This week in Medicare updates—12/14/2022
Fall 2022 Semiannual Report to Congress
On December 5, the OIG published the Fall 2022 Semiannual Report to Congress, which reviews OIG work from April 1 - September 30, 2022. The OIG detailed its monetary totals for expected recoveries and highlighted its most significant audit findings from this period.
CY 2023 Provider Enrollment Application Fee Amount
On December 5, CMS published a Notice in the Federal Register to announce the CY 2023 application fee is $688 for institutional providers enrolling or revalidating their enrollment in Medicare, Medicaid, or CHIP, or for providers adding a new practice location.
Dates: The application fee announced in this notice is effective on January 1, 2023.
Labs with Questionably High Billing for Additional Tests Alongside COVID-19 Tests Warrant Further Scrutiny
On December 6, the OIG published a Review of certain diagnostic testing along with COVID-19 tests. These add-on tests included individual respiratory tests (IRT), respiratory pathogen panels (RPP), genetic tests, and allergy tests. The OIG noted that while it is not unusual for labs to bill for multiple types of tests on the same claim, it is concerned about certain patterns of billing involving this type of testing. The OIG examined all Part B claims paid for COVID-19 tests during 2020 with these four add-on tests. It found that 378 labs billed Part B for add-on tests at questionably high levels compared to the 19,199 other labs whose claims were examined. OIG concerns included high-volumes of add-on tests on claims for COVID-19 tests, high payment amounts from including add-on tests, and labs who billed for add-on tests in combination with COVID-19 tests with little variation among patients, suggesting the add-on tests may not have been specific to an individuals’ needs. Payment amounts for claims which included these tests were significantly higher than claims with just COVID-19 tests. The OIG referred the labs in question to CMS for further review.
Implementation of Rural Emergency Hospital (REH) Provider Type
On December 6, CMS published Medicare Claims Processing Transmittal 11729 regarding implementation of the system requirements necessary for the REH provider type. The transmittal includes the new manual language for REHs, payment rates, examples of payment, and more. This transmittal is no longer sensitive and may now be posted to the internet.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Proposed Rule: Advancing Interoperability and Improving Prior Authorization Processes
On December 6, CMS published a draft copy of a Proposed Rule regarding improving interoperability and reducing challenges related to prior authorization. This rule replaces a proposed rule from December 2020 titled “CMS Interoperability and Prior Authorization (85 FR 82586),” and it builds on a final rule published in May 2020 titled “CMS Interoperability and Patient Access (85 FR 25510).” This proposed rule also incorporates feedback CMS received from the December 2020 proposed rule.
The rule is geared overall toward Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans/entities, and Qualified Health Plan issuers on the federal exchanges, as it aims to improve electronic exchange of health care data through various APIs. It also includes proposals to require payers and Medicare Advantage organizations to implement electronic prior authorization and send decisions within 72 hours for expedited requests and seven days for non-urgent requests. It would add a new electronic prior authorization measure for certain hospitals and CAHs participating under the Medicare Promoting Interoperability Program and in MIPS.
The rule also includes five requests for information on the following topics:
- Accelerating the Adoption of Standards Related to Social Risk Factor Data
- Electronic Exchange of Behavioral Health Information
- Improving the Electronic Exchange of Information in Medicare Fee-for-Service
- Advancing the Trusted Exchange Framework and Common Agreement (TEFCA)
- Advancing Interoperability and Improving Prior Authorization Processes for Maternal Health
CMS published a Press Release and Fact Sheet on the rule on the same date. Comments are due by March 13, 2023. The rule was published in the Federal Register on December 13.
Application from the Center for Improvement in Healthcare Quality for Initial CMS Approval of its Critical Access Hospital Accreditation Program
On December 7, CMS published a Notice in the Federal Register to announce that it has received an application from the Center for Improvement in Healthcare Quality for initial recognition as a national accrediting organization for CAHs that wish to participate in Medicare or Medicaid.
Dates: Comments on the application are due by January 6, 2023.
Implementation of the Award for the Jurisdiction M (J-M) Part A and Part B MAC (JM A/B MAC)
On December 8, CMS published One-Time Notification Transmittal 11730 to announce that the Jurisdiction M A/B MAC competition procurement was awarded to Palmetto Government Benefit Administrator, the incumbent contractor for this workload.
Effective date: February 1, 2023
Implementation date: February 1, 2023
Billing Instructions for Home or Residence Services
On December 8, CMS published Medicare Claims Processing Transmittal 11732 regarding billing instructions for a new code family created by combining the E/M visit families titled “Domiciliary, Rest Home, or Custodial Care Services” and “Home Services” into one code family. The change deletes CPT codes 99324-99337 and merges them into CPT codes 99341-99350. These codes are now billable with POS codes 13, 14, 33, and 55 in addition to POS code 12.
CMS published MLN Matters 13004 on the same date to accompany the transmittal.
Effective date: January 1, 2022
Implementation date: January 3, 2022
CY 2023 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On December 8, CMS published Medicare Claims Processing Transmittal 11733 regarding instructions for the CY 2023 CLFS, mapping for new codes for clinical lab tests, and updates for lab costs subject to the reasonable charge payment. Information includes the specimen collection fees for CY 2023 ($8.57 generally, $10.57 for SNFs and home health agencies), updates to the national minimum payment amount, and more.
CMS published MLN Matters 13023 on the same date to accompany the transmittal.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2023
On December 8, CMS published Medicare Claims Processing Transmittal 11734 regarding changes that will be included in the April 2023 quarterly release of the edit module for clinical diagnostic laboratory services. NCDs affected include NCD 190.18 (Serum Iron Studies), NCD 190.22 (Thyroid Testing), and NCDs 190.23 and 190.23B (Lipids Testing).
Effective date: April 1, 2023 - unless noted differently in the requirements
Implementation date: April 3, 2023
HCPCS Codes Subject to and Excluded from CLIA Edits
On December 8, CMS published Medicare Claims Processing Transmittal 11735 regarding new HCPCS codes for 2023 that are subject to and excluded from CLIA edits. It also includes discontinued HCPCS codes.
CMS published MLN Matters 13024 on the same date to accompany the transmittal.
Effective date: April 1, 2023
Implementation date: April 3, 2023
January 2023 Integrated Outpatient Code Editor (I/OCE) Specifications Version 24.0
On December 8, CMS published Medicare Claims Processing Transmittal 11738 regarding the January 2023 updates to the I/OCE.
Effective date: January 1, 2023
Implementation date: January 3, 2023
January 2023 Update to the Hospital Outpatient Prospective Payment System (OPPS)
On December 8, CMS published Medicare Claims Processing Transmittal 11737 regarding the January 2023 updates to the OPPS. Changes include updates to payment for COVID-19 vaccine administration APCs 9397 and 9398, a clarification for CPT code 41899 for dental procedures, the addition of three new devices for pass-through status under the OPPS, and more.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Comment Request: Medicare Prescription Drug Benefit Program
On December 9, CMS published a Comment Request in the Federal Register regarding the following information collection:
- Medicare Prescription Drug Benefit Program
Comments are due by February 7, 2023.
Revisions to Appendix I- Survey Procedures for Life Safety Code Surveys
On December 9, CMS published State Operations Provider Certification Transmittal 209 regarding revisions to Appendix I of the manual due to fire safety requirement changes.
Effective date: October 1, 2022
Implementation date: October 1, 2022
Automation of the Medicare Duplicate Primary Payment (DPP) Process
On December 9, CMS published Medicare Secondary Payer Transmittal 11741, which rescinds and replaces Transmittal 11557, dated August 17, to add a clarifying note to 12687.10; revise 12687.10.2 so that it is specific to VMS and add a new 12687.10.2.1 to reflect a revised MCS requirement; reflect removal of EOB denials in requirement 12687.10.2.1 (formerly 12687.10.2.3); renumber 12687.10.2.2 through 12687.10.2.4; revise 12687.10.3 so that it is specific to FISS and VMS and add a new 12687.10.3.1 for the MCS specific requirement; update 12687.15.1 to remove "Obligated to Accept as Payment in Full" and just reflect the acronym; revise Internet Only Manual (IOM) Pub.100-05, chapter 7, section 20.5.1 to clarify the full claim adjustment requirement (where the Claim Processing Indicator=F) for MCS and associated A/B MACs (Part B); and revise 12687.28.2 to reflect the recently agreed upon Duplicate Primary Payment (DPP) User Acceptance Testing (UAT) problem reporting process. The original transmittal was issued regarding instructions for implementing a newly automated Duplicate Primary Payer (DPP) process.
Effective date: October 1, 2022 - For CWF (requirements/coding/preliminary unit testing); for FISS (design/coding); for MCS (analysis/design/coding); for VMS (analysis & coding); January 1, 2023 - For CWF (testing/implementation); FISS (continued development/testing/implementation); MCS (continued coding/testing/implementation); and VMS (testing & implementation)
Implementation date: October 3, 2022 - For CWF (requirements/coding/preliminary unit testing); for FISS (design/coding); for MCS (analysis/design/coding); for VMS (analysis & coding); January 3, 2023 - For CWF (testing/implementation); FISS (continued development/testing/implementation); MCS (continued coding/testing/implementation); and VMS (testing & implementation)
Update to the Claims Processing Manual Chapter 1, Section 90, to include CAHs for a Portion of a Medicare Advantage (MA) Billing Period
On December 9, CMS published Medicare Claims Processing Transmittal 11731 regarding updates to the manual to include CAHs in the list of directions for hospitals exempt from PPS who bill the MA organization for a portion of the billing period.
Effective date: January 11, 2023
Implementation date: January 11, 2023
Extensions of Certain Temporary Changes to the Low-Volume Hospital Payment Adjustment and the Medicare Dependent Hospital (MDH) Program Under the Inpatient Prospective Payment System (IPPS)
On December 9, CMS published One-Time Notification Transmittal 11740, which rescinds and replaces Transmittal 11660, dated October 21, to revise the implementation date for BRs 12970.3 and 12970.5 from 11/1/2022 to 12/17/2022 and to allow additional time to implement BR 12970.6 (change from 30 days to 45 days). The original transmittal was issued regarding implementation of an extension for the low-volume hospital payment adjustments and MDH programs under the Continuing Appropriations and Ukraine Supplemental Appropriations Act of 2023.
CMS published MLN Matters 12970 on the same date to accompany the transmittal.
Effective date: October 1, 2022
Implementation date: November 1, 2022 - for implementation of the statutory extensions (BRs 12970.1, 12970.2, 12970.4 and 12970.6); December 17, 2022 - for the expiration of the statutory extensions (business requirements 12970.3 and 12970.5)
Incorporation of Recent Provider Enrollment Regulatory Changes into Chapter 10 of the Program Integrity Manual
On December 9, CMS published Medicare Program Integrity Transmittal 11739, which rescinds and replaces Transmittal 11701, dated November 10, to change the effective and implementation dates. The original transmittal was published regarding the incorporation of changes to provider enrollment policies into the manual.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Updated EUA for Bebtelovimab
On December 9, CMS updated its COVID-19 Monoclonal Antibodies Webpage to note that the FDA revised the Emergency Use Authorization (EUA) for bebtelovimab on November 30 to note that it is not expected to neutralize the subvariant omicron strains of COVID-19 and therefore may no longer be administered as a treatment for COVID-19 in any US region. CMS uploaded the updated EUA to the webpage to accompany the announcement.