This week in Medicare—4/17/2024
Updated List of Laboratory Tests Subject to Exceptions to Laboratory Date of Service Policy
On April 5, CMS published the Download Link to the updated list of laboratory tests subject to exceptions to the lab date of service policy.
March 2024 Livanta Claims Review Advisor
On April 8, Livanta published the March 2024 edition of their Claims Review Advisor which covers second-year review findings for reviews completed from November 1, 2022, through October 31, 2023. The review found that 90% of short-stay review claims were approved for appropriate Part A reimbursement.
New COVID-19 Monoclonal Antibody Codes
On April 9, CMS published coding information on its COVID-19 Monoclonal Antibodies webpage for Pemgarda (pemivibart), a monoclonal antibody product created for pre-exposure prophylaxis of COVID-19 in certain adult and adolescent patients. This treatment received an EUA from the FDA effective March 22, 2024.
Providers should bill for Pemgarda with product code Q0224 and administration code M0224.
Manual Update to Section 20.7 in Chapter 23 of Pub. 100-04
On April 9, CMS published Medicare Claims Processing Transmittal 12573, which rescinds and replaces Transmittal 10211, dated July 10, 2020, to correct the link to a form in the final paragraph of Section 20.7 in Chapter 23 of the Claims Processing Manual. regarding changes to the manual to modernize languages regarding ownership of and access to codes established by the AMA, ADA, and NUBC.
Effective date: August 10, 2020
Implementation date: August 10, 2020
FY 2025 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Proposed Rule
On April 10, CMS published a draft copy of the FY 2025 IPPS Proposed Rule, which is scheduled to be published in the Federal Register on May 2. CMS projects a 2.6% increase in operating payment rates based on a projected hospital market basket update of 3.0% reduced by a 0.4% productivity adjustment. CMS projects that disproportionate share hospital (DSH) payments will increase by $560 million for FY 2025.
Other policies proposed in the rule include:
- Starting in FY 2026, CMS would create a mandatory model called the “Transforming Episode Accountability Model” (TEAM) to test whether episode-based payments for five common costly procedures would save money while ensuring the provision of coordinated, high-quality care during surgery as well as through the following 30 days. It also would require referral to primary care services to support continuity of care.
- For the New Technology Add-on Payment (NTAP) program, CMS is proposing to use the start of a fiscal year (October 1) rather than April 1 as the date to determine whether a technology is in its 2- to 3-year newness period. It is also considering increasing the NTAP for certain gene therapies for sickle cell disease from 65% to 75%.
- CMS proposed 252 new, 13 revised, and 36 deleted ICD-10-CM codes for FY 2025. Most of those new codes apply to neoplasms, but there are also new codes for eating disorders, hypoglycemia, sepsis after-care, and more.
The rule also contains proposals involving a variety of quality reporting program changes; separate payment to small independent hospitals for buffer stocks of essential medicines; new social determinants of health data elements for quality reporting; streamlined data reporting for COVID-19, influenza, and RSV; and more.
CMS published a Press Release and Fact Sheet to accompany the rule. It also published a Fact Sheet on TEAM. Comments are due by June 10.
Correction Notice: FY 2024 Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule
On April 10, CMS published a Correction Notice in the Federal Register to correct technical errors from the FY 2024 SNF PPS Final Rule, which was published in the Federal Register on August 7, 2023. These errors include accidentally swapping the categories for the number of codes affected by a proposed surgical option for fractures and errors in the FY 2024 PDPM ICD-10-CM mappings table.
Dates: This correcting document is effective April 10, 2024, and is applicable beginning October 1, 2023.
Implementation of the Award for Jurisdiction 15 (J-15) Part A and Part B MAC
On April 11, CMS published One-Time Notification Transmittal 12574 to announce that CMS awarded the J15 A/B MAC workload to CGS Administrators, LLC, the incumbent contractor for this workload.
Effective date: May 31, 2024 – Part A and B
Implementation date: May 31, 2024 – Part A and B
NCD 20.7 Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting
On April 11, CMS published Medicare National Coverage Determinations Transmittal 12571 and Medicare Claims Processing Transmittal 12571 regarding policy updates for NCD 20.7 that were finalized via the reconsideration process in October 2023. CMS will cover PTA and carotid artery stenting (CAS) with embolic protection in patients with asymptomatic carotid artery stenosis ≥ 70% and in patients with symptomatic carotid artery stenosis ≥ 50%.
This expands coverage to individuals who were previously only eligible under clinical trials, allows coverage for beneficiaries at standard surgical risk, and adds a formal shared decision-making interaction with the individual prior to the procedure.
Effective date: October 11, 2023
Implementation date: May 13, 2024 – MACs; October 7, 2024 – FISS for BR 13512-04.2 for Pub. 100-04
Additional Enforcement of Required County Codes on Home Health Claims
On April 11, CMS published Medicare Claims Processing Transmittal 12577 regarding the creation of an edit in the Medicare FFS systems to ensure required county codes are reported on all home health claims. The creation of this edit follows a recent OIG report which showed that county code reporting on HH PPS claims was incomplete.
The transmittal also includes clarifications to home health billing instructions regarding Notice of Admission timeliness exceptions, charge reporting for telehealth visits, and diagnosis code reporting.
Effective date: October 1, 2024 – Claims processed on or after this date
Implementation date: October 7, 2024
Notice of New Interest Rate for Medicare Overpayments and Underpayments – 3rd Qtr FY 2024
On April 11, CMS published Medicare Financial Management Transmittal 12583 regarding the updated interest rate for Medicare overpayments and underpayments. The latest private consumer rate has been changed to 12.50%.
Effective date: April 17, 2024
Implementation date: April 17, 2024
Medicare Claims Processing Manual Updates to Implement Updates to Inpatient Rehabilitation Facility (IRF) Policy
On April 11, CMS published Medicare Claims Processing Transmittal 12575 regarding updates to the manual pertaining to IRF policy noting the updates to the modification to regulations which allow IRF units to become excluded and paid under the IRF PPS as finalized through the FY 2024 IRF PPS final rule.
Effective date: July 12, 2024
Implementation date: July 12, 2024
Advisory Opinion No. 24-02
On April 11, the OIG published an Advisory Opinion regarding an arrangement where a nonprofit, tax-exempt charitable organization provides financial support to patients with certain medical conditions with a demonstrated financial need. The donors for these funds are pharmaceutical manufacturers who either manufacture or market a drug to treat the specific diseases, but the funds are used to cover costs for a wide range of treatments and the side effects of those treatments. The requestor is seeking an opinion as to whether the arrangement constitutes grounds for the imposition of sanctions under the federal anti-kickback statute or civil monetary penalties related to beneficiary inducements.
The OIG ruled that while the arrangement would generate prohibited remuneration under the anti-kickback statute if the requisite intent was present, it would not impose sanctions in this case because the arrangement includes many features that help reduce the risk of fraud and abuse and because it provides assistance to financially needy patients with rare disorders where the assistance is highly impactful for the patients.
Unlike most Advisory Opinions, this Opinion includes an effective period that lasts only until January 1, 2027. Congress recently enacted new legislation to restructure cost-sharing for Medicare Part D beneficiaries that would cap out-of-pocket costs, and this could reduce the need for the type of cost-sharing subsidies provided under the arrangement.
Revisions to the State Operations Manual (SOM) Appendix B – Home Health Agencies
On April 12, CMS published State Operations Provider Certification Transmittal 219 regarding updates to Appendix B of the SOM due to several updates to the Home Health Agency Conditions of Participation (CoP) that were made through rulemaking processes.
Effective date: April 12, 2024
Implementation date: April 12, 2024