This week in Medicare updates—10/6/2021

October 6, 2021
Medicare Insider

Boosters Approved at No Cost to Medicare Beneficiaries 

On September 24, CMS published a Press Release to announce it will pay for the booster dose of the Pfizer COVID-19 vaccine, which received FDA authorization in September, for Medicare beneficiaries. As with the first two doses of the vaccine, beneficiaries will not pay for the vaccine or administration, and there is no applicable copayment, coinsurance, or deductible.


Final Decision Memo for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches 

On September 27, CMS published a Final Decision Memo regarding changes to NCD 240.2.2 (Home Oxygen Use to Treat Cluster Headache) and NCD 240.2 (Home Use of Oxygen). CMS is removing NCD 240.2.2 to end coverage with evidence development and allow the MACs to make coverage determinations for the use of home oxygen for cluster headaches. CMS is also modifying NCD 240.2 to expand patient access to oxygen/oxygen equipment in the home and to permit contractors to cover home oxygen and oxygen equipment in treating cluster headaches and other acute conditions. 


SNF Enforcement Discretion Relating to Certain Pharmacy Billing

On September 27, CMS updated its SNF Enforcement Discretion COVID-19 page to note that it will exercise enforcement discretion for SNF consolidated billing provisions related to flu and pneumococcal vaccines to allow Medicare-enrolled immunizers to bill directly and receive direct reimbursement from Medicare for vaccinating SNF residents during the COVID-19 PHE. The products and administration for these vaccinations should all be billed to Medicare. This enforcement discretion is effective September 20, 2021.


ICD-10 and Other Coding Revisions to NCDs--January 2022

On September 28, CMS published One-Time Notification Transmittal 11025, which rescinds and replaces Transmittal 10963, dated August 19, 2021, to make a number of changes, including adding back ICD-10 diagnosis codes inadvertently removed.  The original transmittal was published regarding the regular ICD-10 conversions and coding updates specific to NCDs. 

CMS revised MLN Matters 12399 to accompany the transmittal. 

Effective date: January 1, 2022 - Unless otherwise noted in requirements

Implementation date: September 20, 2021 - MACs; January 3, 2022 - shared system maintainers


Medicare Advantage Value-Based Insurance Design (VBID) Model CY 2022 Model Participation

On September 29, CMS published a Fact Sheet regarding participation in the Medicare Advantage VBID Model for 2022. Participation has increased from 19 participating Medicare Advantage Organizations (MAO) in 2021 to 34 participating MAOs in 2022. CMS projects that 7.8 million beneficiaries will be enrolled in participating plans in 2022, an increase from 4.6 million in 2021. The VBID Model began in January 2017 and will continue through December 2024. 


CMS Updates COVID-19 Vaccine Billing and Coding Information

On September 29, CMS updated its COVID-19 Vaccines and Monoclonal Antibodies page to include coding information for the Pfizer Covid-19 vaccine (Ready to use) and Moderna Low-Dose COVID-19 vaccine product and administration. Neither product’s codes are currently effective. CMS also added a link to the updated Pfizer EUA, dated September 22, 2021.


Requirements Related to Surprise Billing Part II

On September 30, HHS published a draft copy of an Interim Final Rule with Request for Comment regarding implementation of the No Surprises Act, which is intended to protect patients from surprise medical bills. This rule focuses on implementing the independent dispute resolution process providers and plans will use to address any outstanding reimbursement disputes. It also discusses good faith estimate requirements for uninsured individuals, patient-provider dispute resolution processes for uninsured individuals, and external review provisions. As part of the independent dispute resolution process, providers and payers will have a 30-day open negotiation period to determine a payment. If stakeholders cannot determine a payment during that time, they will enter the dispute resolution process, which will be conducted by a certified independent dispute resolution entity which has been jointly selected by stakeholders and authorized by CMS. 

CMS published a Fact Sheet for consumers, a Fact Sheet for providers, and a Press Release on the rule on the same date. The rule is scheduled to be published in the Federal Register on October 7.


Public Reporting of Organ Procurement Organizations’ (OPO) Performance Measures

On September 30, CMS published a Memorandum to state survey agency directors regarding public reporting of OPO performance outcomes. CMS provided a summary of what the report will include and linked to the webpage where annual assessments and a data user guide will be made available. 

Effective date: Immediately. This information should be communicated to all survey and certification staff, their managers, and the state/CMS location training coordinators within 30 days of this memorandum. 


Adjustment to the Amount in Controversy Threshold Amounts for CY 2022

On September 30, CMS published a Notice in the Federal Register to announce the annual adjustment in the amount in controversy threshold amounts. The CY 2022 amount in controversy thresholds are $180 for ALJ hearings and $1,760 for judicial review.

Dates: This annual adjustment takes effect January 1, 2022.


Revisions to Chapters 13, 18, and 32 to Update Coding

On October 1, CMS published Medicare Claims Processing Transmittal 11021 regarding updates to Chapters 13, 18, and 32 of the manual to update the codes/code descriptions and certain coding instructions in those chapters.  The transmittal states there are no regulatory, legislative or statutory requirements changed, due to the extensive coding changes, the revisions should be reviewed for pertinent coding and billing requirements that have changed. 

Effective date: October 29, 2021 - Unless otherwise specified, the effective date is the date of service

Implementation date: October 29, 2021 - Unless otherwise specified, the effective date is the date of service