This week in Medicare updates—3/22/2023
Medicare Secondary Payer (MSP): Don’t Deny Services & Bill Correctly
On March 13, CMS published an MLN Fact Sheet regarding billing procedures for Medicare patients with open MSP records. The fact sheet discusses how to determine payer order, how to bill MSP non-group health plan (NGHP) claims with group health plan and NGHP involvement, how to bill when there’s Worker’s Compensation Medicare Set-Aside (WCMSA), and more.
Implementation of Rural Emergency Hospital (REH) Provider Type
On March 13, CMS published Medicare Claims Processing Transmittal 11900, which rescinds and replaces Transmittal 11729, dated December 6, 2022, to remove Chapter 3, Addendum A - Provider Specific File, which should not have been included with the instruction. The original transmittal was issued regarding implementation of the system requirements necessary for the REH provider type.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Clinical Laboratory Fee Schedule (CLFS) Annual Payment Determination Process
On March 13, CMS published an Infographic regarding the CLFS annual payment determination process. The infographic includes a timeline of the process as well as links to the regulatory sources dictating the process.
Medicare Improperly Paid Physicians for Epidural Steroid Injection Sessions
On March 13, the OIG published a Review regarding whether Medicare paid physicians for epidural steroid injection sessions in accordance with Medicare requirements. The OIG had conducted prior audits which determined Medicare did not always pay for spinal facet-joint denervation and injection sessions in accordance with federal requirements. This audit found that Medicare improperly paid physicians $3.6 million on behalf of beneficiaries who received more epidural steroid injection sessions than were permitted by the coverage limitations in applicable local coverage determinations (LCD). The OIG found that neither CMS nor the MACs’ oversight was adequate to prevent or detect these payments. After the audit period (January 1, 2019 - December 31, 2020), all MAC jurisdictions updated LCDs with revised coverage limitations that were specific to these injections.
The OIG recommends CMS direct the MACs to recover the improper payments, direct providers to identify and return any similar overpayments, assess the effectiveness of the oversight mechanisms put in place after the audit period, and direct MACs to review a sample of claims for injection sessions between the end of the audit period and the start of the revised coverage limitations to identify and recover any improper payments. CMS concurred with the recommendations.
Durable Medical Equipment (DME) Competitive Bidding Program (CBP) Fact Sheets
On March 14, CMS published a variety of fact sheets regarding various aspects of DME CBP. These include:
- DME CBP Repairs and Replaces of Off-the-Shelf Back and Knee Braces
- DME CBP Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists
- DME CBP Hospitals That Are Not Contract Suppliers
- DME CBP Traveling Beneficiary
- DME CBP Referral Agents
Some Skin Substitute Manufacturers Did Not Comply with New Average Sales Price (ASP) Reporting Requirements
On March 14, the OIG published a Data Brief examining whether skin substitute manufacturers were complying with new ASP reporting requirements. These requirements were established by the Consolidated Appropriations Act of 2021, which required manufacturers of skin substitutes to begin reporting ASPs to CMS as of the first quarter of 2022. The OIG noted that it is vital to have accurate ASP data, as that data is directly used to calculate Part B payments. CMS found that manufacturers did not report ASP data for 30 of the 68 skin substitutes included in the review. This missing data could lead to tens of millions of dollars in potential savings each quarter.
The OIG noted, however, that CMS faces several hurdles in implementing the ASP-based reimbursement for skin substitutes, and it highlighted that CMS recently held a town hall on skin substitutes to address stakeholder concerns and discuss potential payment approaches.
Correction Notice: CY 2023 Medicare Physician Fee Schedule Final Rule
On March 14, CMS published a Correction Notice in the Federal Register regarding corrections to errors in the CY 2023 Medicare Physician Fee Schedule Final Rule. In addition to various typographical corrections, CMS is correcting the time thresholds for reporting prolonged inpatient or observation services under G0316 when reported with codes 99223 (initial hospital visit), 99233 (subsequent hospital visit), and 99236 (same-day admit/discharge). The time threshold for each of these three scenarios has been lowered by 15 minutes.
Dates: This document is effective March 15, 2023, and is applicable beginning January 1, 2023.
Updated OIG Work Plan
On March 15, the OIG updated its Work Plan with the following new items:
HHS Releases Initial Guidance for Medicare Drug Price Negotiation Program for Price Applicability Year 2026
On March 15, CMS published a Memorandum regarding implementation of the Medicare Drug Price Negotiation Program. The guidance covers how Medicare intends to use its new authority to negotiate lower prices on selected high-cost drugs with drug companies. CMS plans to publish a list of selected drugs for each initial price applicability year, enter into agreements with manufacturers of selected drugs, and negotiate maximum fair prices (MFP) for these drugs. CMS will then publish MFPs for the drugs and will enforce civil monetary penalties when necessary.
CMS is soliciting comments on a variety of topics included in the memorandum, such as terms and conditions for the manufacturer agreement, methods for applying MFP across different dosages and strengths of a drug, dispute resolution processes, and more. Comments are due by April 14.
CMS published a Fact Sheet and Press Release to accompany the memorandum. On March 17, CMS also published a Comment Request in the Federal Register regarding this guidance.
CMS Announces Savings on 27 Part B Drugs Via Medicare Prescription Drug Inflation Rebate Program
On March 15, CMS published a Press Release to announce lower Part B beneficiary coinsurances for 27 Part B drugs as part of the Medicare Prescription Drug Inflation Rebate Program. This lower Part B coinsurance will go into effect on April 1, 2023. The drugs impacted by the coinsurance adjustment may change quarterly.
CMS published a List of the drugs impacted for the April 1 - June 30, 2023 quarter and a Fact Sheet on the program on the same date.
Implementation of Consolidated Appropriations Act of 2023, Section 4143: Waiver of Cap on Annual Payments for Nursing and Allied Health Education Payments
On March 16, CMS published One-Time Notification Transmittal 11904 regarding implementation of a section of the Consolidated Appropriations Act of 2023, which adjusts payment caps for nursing and allied health education payments.
Effective date: December 29, 2022
Implementation date: December 28, 2023
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 29.2, Effective July 1, 2023
On March 16, CMS published Medicare Claims Processing Transmittal 11909 regarding the quarterly updates to the NCCI PTP edits for the quarter beginning in July 2023.
Effective date: July 1, 2023
Implementation date: July 3, 2023
April Quarterly Update for 2023 DMEPOS Fee Schedule
On March 16, CMS published Medicare Claims Processing Transmittal 11910 regarding the quarterly update to the DMEPOS fee schedule. The update includes the addition of eleven new codes and the addition of fee schedule amounts for a variety of new and revised codes.
CMS published MLN Matters 13153 on the same date to accompany the transmittal.
Effective date: April 1, 2023
Implementation date: April 3, 2023
Instructions Relating to the Evaluation of Section 1115 Waiver Days in the Calculation of Disproportionate Share Hospital (DSH) Reimbursement
On March 16, CMS published One-Time Notification Transmittal 11912 regarding updated directions related to the evaluation of Section 1115 waiver days in the calculation of DSH reimbursement for open cost reports currently under administrative appeal.
Effective date: April 17, 2023
Implementation date: May 17, 2023
Update to the Manual to Clarify Supervision Requirements for Diagnostic Tests
On March 16, CMS published Medicare Benefit Policy Transmittal 11901 regarding a clarification to existing manual language to note that nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), certified registered nurse anesthetists (CRNA), and physician assistants (PA) may supervise performance of diagnostic tests.
Effective date: January 1, 2021
Implementation date: May 17, 2023
Update to the Claims Processing Manual, Chapter 18 Sections 50.3-50.4, and Chapter 32 Sections 130.1, 170.2 for Coding Revisions to NCDs
On March 16, CMS published Medicare Claims Processing Transmittal 11902 regarding updates to two chapters in the manual to account for coding changes published in Change Requests 13070. That transmittal included end dates for five codes in reference to NCD 20.20 and added codes to NCDs 210.1 and 150.10.
Effective date: April 17, 2023
Implementation date: April 17, 2023
April 2023 Update of the Ambulatory Surgical Center (ASC) Payment System
On March 16, CMS published Medicare Claims Processing Transmittal 11903 regarding the April 2023 update to the ASC payment system. This update includes new HCPCS codes for drugs and biologicals, corrections to the January 2023 ASC code pair file, and more.
CMS published MLN Matters 13143 on the same date.
Effective date: April 1, 2023
Implementation date: April 3, 2023
Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations for the Medicare Benefit Policy Manual Chapter 15, Section 50.4.4.2
On March 16, CMS published Medicare Benefit Policy Transmittal 11905 regarding updates to coverage for pneumococcal vaccinations. Effective October 19, 2022, CMS updated Medicare coverage requirements for these vaccines to align with ACIP recommendations. This transmittal updates the manual with those coverage changes.
Effective date: October 19, 2022
Implementation date: April 17, 2023
HCPCS Quarterly Update
On March 17, CMS published the April 2023 HCPCS Quarterly Update files for download to its website.