This week in Medicare updates—3/8/2023

March 8, 2023
Medicare Insider

CMS Fact Sheet on End of COVID-19 Public Health Emergency (PHE)

On February 27, CMS published a Fact Sheet regarding what will happen with certain waivers and flexibilities when the COVID-19 PHE ends. This fact sheet reviews information on COVID-19 vaccines, testing, and treatments; telehealth services; the Hospital at Home program, virtual supervision flexibilities, scope of practice changes, and more.


Advance Care Planning

On February 27, CMS revised an MLN Fact Sheet regarding advance care planning services. CMS added payment information for FQHCs and rural health clinics, clarified documentation and time-based coding requirements, and provided additional resources to the link list at the end of the fact sheet.


CY 2023 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

On February 28, CMS published Medicare Claims Processing Transmittal 11881, which rescinds and replaces Transmittal 11733, dated December 8, 2022, to remove CPT code 0245U from the CY 2023 CLFS Annual Updates, as this code is no longer a part of the gapfill process for 2023. The original transmittal was published regarding instructions for the CY 2023 CLFS.

CMS revised MLN Matters 13023 on the same date to accompany the transmittal. 

Effective date: January 1, 2023

Implementation date: January 3, 2023


Medicare Could Have Saved Up To $216 Million Over Five Years if Program Safeguards Had Prevented At-Risk Payments for Definitive Drug Testing Services

On March 1, the OIG published a Review of Part B payments for definitive drug testing services reported under CPT code G0483. Previous OIG reports and Medicare data identified that these services are at high risk for overpayments. This OIG review found that Medicare paid $704.2 million for definitive drug testing services that were at risk for noncompliance with Medicare requirements, as these payments were for the testing service with the highest reimbursement amount (as reported under G0483) and were made to at-risk providers. When the OIG compared these providers to other providers, the OIG found that these at-risk providers routinely billed for testing 22 or more drug classes under G0483 when other providers did not. The OIG found similar characteristics between the at-risk providers and other providers (types of patients tested, frequency of testing), and because other providers did not bill G0483 at the same rate as the at-risk providers, the OIG suggested the at-risk providers may have been able to bill for definitive drug testing services using codes with lower reimbursement rates. 

The OIG recommends CMS expand program safeguards to prevent and detect at-risk payments to at-risk providers for G0483, review at-risk payments made to at-risk providers during and after the audit period to recover any overpayments, notify providers to identify and return any similar overpayments, and educate providers that received payments that did not comply with Medicare requirements. CMS did not concur with the second and third recommendations but concurred with the first recommendation and identified corrective actions it plans to take.


ICD-10 and Other Coding Revisions to NCDs–July 2023 Update

On March 1, CMS published One-Time Notification Transmittal 11884, which rescinds and replaces Transmittal 11832, dated February 2, to delete three non-covered CPT codes added in error and remove reference to ALERT M38; clarify that C codes are only payable in the ASC setting; and correct effective date of MSN 21.11 to December 31, 2022. The original transmittal was published regarding the regular quarterly updates to ICD-10 conversions and other coding updates for NCDs. 

On February 6, CMS published MLN Matters 13070 to accompany the transmittal.

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


The Inability to Identify Denied Claims in Medicare Advantage Hinders Fraud Oversight

On March 2, the OIG published an Issue Brief regarding an evaluation into Medicare Advantage data and whether the lack of an indicator to identify payment denials in the data hinders efforts to combat fraud, waste, and abuse. CMS requires Medicare fee-for-service and Medicaid records for services to include denied claim indicators.  Medicare Advantage organizations (MAO) do not require indicators to identify a denied claim in MA encounter data, but MAOs are required to submit claim adjustment reason codes when MAOs do not pay the actual amount billed by the provider. The OIG reviewed 2019 MA encounter records to determine how many contained adjustment codes and whether they identified records that may contain payment denials. The OIG also interviewed and sent out questionnaires to involved parties about how they identify payment denials, how the lack of a denied claim indicator could impact audits and oversight work, and to determine why CMS does not require MAOs to submit this indicator. 

The OIG found that the adjustment codes were used on almost all encounter records, but it was not possible to definitively determine which claims were denied using these adjustment codes. Oversight entities who spoke with the OIG said the denied claim indicator would make their efforts much easier and less burdensome. The CMS MA payment group said the indicator is not necessary and raised concerns about the potential burden on MAOs of requiring a denied claim indicator on encounter records. The OIG noted, however, that the private companies which cover most MA enrollees are also involved in Medicaid managed care plans and therefore already have the ability to use denied claim indicators since they are required for Medicaid managed care plans. The OIG therefore recommends CMS require MAOs to definitively indicate on MA encounter data records when they have denied payment for a service on a claim.


Part D Plan Sponsors and CMS Did Not Ensure That Transmucosal Immediate-Release Fentanyl Drugs Were Dispensed Only to Beneficiaries Who Had a Cancer Diagnosis

On March 2, the OIG published a Review of whether Part D plan sponsors and CMS ensured that transmucosal immediate-release fentanyl (TIRF) drugs were dispensed in accordance with Medicare requirements. The OIG found that of the 45,776 prescription drug events (PDE) reviewed, plan sponsors approved 7,552 PDEs for 810 beneficiaries who did not have a cancer diagnosis in their Medicare claims history. This resulted in $86.2 million in unallowable Part D costs. The OIG noted that plan sponsors also approved 2,023 PDEs for TIRF drugs for 176 beneficiaries whose most recent cancer diagnosis was more than one year before the drugs were dispensed, and while this is not technically unallowable, the OIG expressed concern that this could indicate they were at a high risk of being unallowable. Plan sponsors also submitted 889 unallowable PDEs for TIRF drugs even after CMS determined the beneficiaries did not have a cancer diagnosis and were not eligible for TIRF drugs.  

The OIG recommends CMS work with its plan sponsors to delete unallowable PDE records, ensure that plan sponsors obtain sufficient information during the prior authorization process, expand the required PDE data elements to include diagnosis codes, and conduct data analysis on mismatches of information between Medicare claims data and prior authorization information obtained for TIRF drug prescriptions. CMS generally did not agree with the OIG’s audit and conclusions. It stated the OIG’s determination of the amount of unallowable costs was not based on the applicable statute, regulations, or guidance. It also disagreed that the lack of a cancer diagnosis on Medicare claims or the lack of a recent cancer diagnosis does not mean a beneficiary is ineligible for TIRF drugs. CMS noted that while it disagrees with the OIG’s methodology, it takes the misuse of TIRF drugs seriously and is undertaking an additional TIRF audit using methodology aligned with legal requirements for plans. The OIG maintains its audit is valid.