This week in Medicare updates—2/8/2023
Final Rule: Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, PACE, Medicaid Fee-for-Service, and Medicaid Managed Care Programs for 2020 and 2021
On January 30, CMS published a draft copy of a Final Rule regarding the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program, which is the program CMS uses to audit and provide oversight of MA program payments. Despite numerous studies and audits from both the OIG and CMS showing that MA enrollees’ medical records do not always support diagnoses reported by MA organizations (MAO), no risk adjustment overpayments have been collected from MAOs since payment year 2007.
In October 2018, CMS published a rule proposing to use extrapolation to collect overpayments from payment year 2011 to present day. In this final rule, CMS finalized a policy where it will only collect non-extrapolated overpayments identified in CMS RADV audits and OIG audits for payment years 2011-2017. It will use extrapolation for payment year 2018 RADV audits and beyond. CMS did not adopt any specific sampling or extrapolation audit methodology in the rule, but it said whichever method it chooses will be focused on MAO contracts that have been identified as being at the highest risk for improper payments. The rule also finalized a policy whereby CMS will not apply the FFS adjustment factor in RADV audits.
CMS published a Press Release and Fact Sheet on the rule on the same date. The rule was published in the Federal Register on February 1. The rule is effective on April 3.
Office of Management and Budget (OMB) Announces End Date for COVID-19 Public Health Emergency (PHE)
On January 30, the OMB published a Statement of Administration Policy announcing that the Biden administration plans to end the COVID-19 PHE on May 11. The statement was issued in response to two Congressional bills proposing a more immediate end to the PHE. The PHE was last extended on January 11, which brings it up for renewal again on April 11.
Retired NCD: Ambulatory EEG Monitoring
On January 31, CMS updated an NCD to note that the ambulatory EEG monitoring policy (NCD 160.22) has been retired effective January 1, 2023. Coverage determinations for this service will now be made by the MACs.
2024 Medicare Advantage and Part D Advance Notice
On February 1, CMS published the 2024 Medicare Advantage and Part D Advance Notice regarding Medicare Advantage capitation rates and Parts C and D payment policies for CY 2024. CMS is proposing to revise the Part C risk adjustment model by restructuring condition categories using ICD-10 instead of ICD-9 and by focusing on revisions for conditions that are subject to more coding variation. The advance notice also outlined changes for Part D that were made by the Inflation Reduction Act, such as reducing cost-sharing for insulin, eliminating cost-sharing for recommended preventive vaccines, eliminating cost-sharing for Part D prescription drugs in the catastrophic phase, and more.
CMS published a Fact Sheet and Press Release on the Advance Notice on the same date. Comments on proposals are due by March 3. The final rate announcement will be published no later than April 3.
Updated Fact Sheets on COVID-19 Public Health Emergency (PHE) Waivers
On February 1, CMS updated a series of Fact Sheets about COVID-19 PHE waivers in light of the recent announcement that the Biden administration plans to end the PHE on May 11. These fact sheets are located on the Coronavirus Waivers & Flexibilities webpage and are not dated on the main page but have all been revised as of February 1. They detail which flexibilities will remain after the PHE and which will not. The Hospitals and CAHs, ASCs, and CMHCs fact sheet discusses the end of the Hospital Without Walls program as well as the end of several telehealth flexibilities that were permitted during the PHE.
CMS said in an email that it will continue to provide resources and guidance via its Current Emergencies webpage as the PHE winds down.
Revoked Emergency Use Authorization (EUA) for Evusheld
On February 2, CMS updated its COVID-19 Monoclonal Antibodies Webpage to announce that the FDA revoked the EUA for Evusheld, a pre-exposure prophylactic treatment for COVID-19, effective January 26, 2023. Data shows this treatment is no longer effective against the current SARS-CoV-2 variants in the United States. There are no other currently authorized pre-exposure prophylactic treatments authorized for use at this time.
Quarterly Update to Clinical Laboratory Fee Schedule (CLFS) & Laboratory Services Subject to Reasonable Charge Payment
On February 2, CMS published Medicare Claims Processing Transmittal 11829 regarding the quarterly update to the CLFS. This quarter’s changes include a note about the delay for the data reporting period for clinical diagnostic laboratory tests (CDLT) to January 1, 2024 as stipulated by the Consolidated Appropriations Act of 2023, two new codes for proprietary laboratory analysis (PLA), and more.
CMS published MLN Matters 13082 on the same date to accompany the transmittal.
Effective date: April 1, 2023
Implementation date: April 3, 2023
Correction of Split (or Shared) Critical Care Billing Requirement in Section 30.6.12.5 of Chapter 12 of the Medicare Claims Processing Manual
On February 2, CMS published Medicare Claims Processing Manual 11828 regarding a correction to an error in the billing instructions for CPT code 99292 when critical care is delivered as a split (or shared) visit. CMS is correcting the instructions to say that CPT code 99292 can be billed after 104 (not 75) or more cumulative total minutes were spent providing critical care.
Effective date: January 1, 2023
Implementation date: March 3, 2023
Patient Responsibility Reporting with Medicare Secondary Payer (MSP)
On February 2, CMS published One-Time Notification Transmittal 11833 regarding processing claims where Medicare is a secondary payer. The transmittal instructs the multi-carrier system (MCS) on how to use CARC 23 to report prior payer adjudication in the case of a secondary claim. When the impact is reported at the claim level, OA 23 is used at the claim level. If the impact is reported at the service line level, OA 23 is used at the service line level once per service line.
Effective date: July 1, 2023
Implementation date: July 3, 2023
New Biweekly Interim Payments for Domestic N95 Respirator Procurement Cost Reimbursement
On February 2, CMS published Medicare Claims Processing Transmittal 11836 regarding instructions for the claims processing systems to prepare for implementing the new bi-weekly interim payments for domestic N95 respirator procurement cost reimbursements. Payment adjustments will be made under the IPPS and OPPS for additional resource costs that hospitals face in procuring domestic NIOSH-approved surgical N95 respirators for cost reporting periods beginning on or after January 1, 2023.
CMS published MLN Matters 13052 on the same date to accompany the transmittal.
Effective date: January 1, 2023 - effective for cost reporting periods beginning on or after January 1, 2023
Implementation date: July 3, 2023
ICD-10 and Other Coding Revisions to NCDs–July 2023 Update
On February 2, CMS published One-Time Notification Transmittal 11832 regarding the regular quarterly updates to ICD-10 conversions and other coding updates for NCDs. The NCDs affected by this round of updates include NCD 20.4, NCD 20.7, NCD 20.20, NCD 150.3, and more.
Effective date: July 1, 2023 - Unless otherwise stated in individual business requirements
Implementation date: March 3, 2023 - MAC local edits; July 3, 2023 - Shared System Maintainers
Revisions to the State Operations Manual (SOM) Appendix M - Hospice
On February 3, CMS published State Operations Provider Certification Transmittal 210 regarding revisions to Appendix M of the manual based on recent regulatory changes and changes to the survey protocol for hospice surveyors.
Effective date: February 3, 2023
Implementation date: February 3, 2023
Revisions to the State Operations Manual (SOM) Appendix PP
On February 3, CMS published State Operations Provider Certification Transmittal 211 regarding technical corrections to Appendix PP of the manual. These corrections include corrected endnote numbering and references, updated broken web links, and deleted duplicated regulatory text.
Effective date: October 21, 2022
Implementation date: October 24, 2022