This week in Medicare updates—4/6/2022
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
On March 24, CMS revised Special Edition MLN Matters 19006, which was originally published on February 27, 2019, to note that for CDLTs that are not ADLTs, the data reporting is delayed by one year and must now be reported from January 1, 2023 - March 31, 2023. CMS clarified language about reporting periods throughout the article. The original article was published to discuss ways laboratories can meet the requirements under Section 1834A of the Social Security Act for the Medicare Part B Clinical Laboratory Fee Schedule (CLFS).
Advanced Practice Registered Nurses, Anesthesiologist Assistants, & Physician Assistants
On March 28, CMS revised an MLN Booklet regarding qualifications and Medicare billing and payment guidelines for Advanced Practice RNs (APRN), Anesthesiologist Assistants (AA), and Physician Assistants (PA). The changes incorporate updates made through the rule-making processes regarding services these health care professionals may provide as well as how to bill for those services and what type of payment they would receive.
CMS Office of the Actuary Releases 2021-2030 Projections of National Health Expenditures
On March 28, CMS published a Press Release regarding the 2021-2030 National Health Expenditure (NHE) report, which presents health spending and enrollment projections for the coming decade. The report showed that near-term expected trends in health spending and insurance enrollments are significantly influenced by the COVID-19 PHE. It found that while there was an increased demand for patient care in 2021, the growth in national health spending slowed from 9.7% in 2020 down to 4.2% in 2021, likely as supplemental funding for public health activity and federal programs related to the COVID-19 pandemic kicked in. The report also showed that Medicare spending growth is projected to average 7.2% over 2021-2030, the fastest rate of all major payers. Medicare spending is projected to exceed $1 trillion for the first time in 2023.
Claims Processing Instructions for the New Pneumococcal 20-valent Conjugate Vaccine Code 90677
On March 29, CMS published Medicare Claims Processing Transmittal 11329, which rescinds and replaces Transmittal 11163, dated December 21, 2021, to revise business requirement 12439.12 to instruct the MACs to adjust rejected claims with HCPCS code 90671 with dates of service from July 16, 2021 - March 31, 2022. The original transmittal was published regarding instructions to update the MCS, CWF, and FISS to include the new pneumococcal 20-valent conjugate vaccine code (90677).
CMS revised MLN Matters 12439 on the same date to accompany the transmittal.
Effective date: July 1, 2021 - for HCPCS code 90677; July 16, 2021 - for HCPCS code 90671
Implementation date: April 4, 2022
Claims Processing Instructions for the New Hepatitis B Vaccine Code 90759
On March 29, CMS published Medicare Claims Processing Transmittal 11322 regarding instructions to update the CWF and FISS to include the new Hepatitis B vaccine code (90759) for claims with dates of service on or after January 11, 2022.
Effective date: January 11, 2022 - Unless otherwise specified, the effective date is the date of service.
Implementation date: July 5, 2022
Mental Health Visits via Telecommunications for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)
On March 30, CMS published Special Edition MLN Matters 22001 regarding regulatory changes and billing information for mental health visits in RHCs and FQHCs. The article reviews the regulatory changes made in the 2022 Medicare Physician Fee Schedule Final Rule, provides examples on how RHCs and FQHCs should bill mental health visits via telecommunications, outlines in-person mental health visit requirements, and discusses exceptions for the requirement for an in-person visit every 12 months.
Psychotherapy Services Billed by a New York City Provider Did Not Comply with Medicare Requirements
On March 30, the OIG published a Review of whether a New York City provider complied with Medicare requirements when billing for psychotherapy services. The OIG chose this provider based on analysis of Medicare claims data for Part B psychotherapy services, which showed that this provider was among the highest reimbursed in the nation in 2019. The OIG reviewed a random sample of 100 beneficiary days and did not determine whether the services were medically necessary. The OIG found that the provider did not comply with Medicare requirements for any of the 100 sampled beneficiary days. Issues included beneficiary treatment plans which were not provided or did not contain required elements (e.g., frequency or duration of services), services billed to Medicare that did not meet incident-to requirements or were conducted by a therapist who was not licensed or registered in New York state, and a lack of documentation for time spent on therapy services and treatment notes. There was also no evidence that beneficiaries’ treatment plans were signed by the treating physician for 96 of the sampled beneficiary days. The OIG estimated that this provider received $1.1 million in Medicare overpayments for psychotherapy services.
The OIG recommends the provider refund the estimated $1.1 million overpayment and identify and return any overpayments in accordance with the 60-day rule. It also recommended that the provider develop policies and procedures and provide training to its therapists to ensure that psychotherapy services comply with Medicare requirements.
FY 2023 Hospice Payment Rate Update Proposed Rule
On March 30, CMS published a draft version of the FY 2023 Hospice Payment Rate Update Proposed Rule, which is scheduled to be published in the Federal Register on April 4. Proposals include a 2.7% increase in hospice payments for 2023 and a proposed aggregate cap amount of $32,142.65. CMS also proposes to establish a permanent, budget neutral approach to smooth year-to-year changes to the hospice wage index by proposing a permanent cap on negative wage index changes greater than a 5% decrease from the previous year. The rule includes an update on the development of a patient assessment instrument (HOPE) as well as other quality reporting program changes.
CMS published a Fact Sheet on the proposed rule on the same date. Comments on the proposed rule are due by May 31.
FY 2023 Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS) Proposed Rule
On March 31, CMS published a draft copy of the FY 2023 IPF PPS Proposed Rule, which is scheduled to be published in the Federal Register on April 4. CMS proposes an IPF payment rate update of 2.7%, but the additional update to the outlier threshold would reduce the aggregate payments by 1.2%, resulting in an estimated total increase in IPF payments of 1.5% for FY 2023. In what CMS called an effort to mitigate instability in IPF payments due to possible significant wage index decreases, CMS is proposing to cap negative wage index changes at no greater than a 5% decrease from the previous year for FYs 2023 and beyond. The rule also includes a request for information regarding efforts to address healthcare disparities and advance healthcare equity. There are no proposed changes to the IPF Quality Reporting Program.
CMS published a Fact Sheet on the proposed rule on the same date. Comments are due by May 31.
FY 2023 Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS)
On March 31, CMS published a draft copy of the FY 2023 IRF PPS Proposed Rule, which is scheduled to be published in the Federal Register on April 6. CMS estimates the total IRF PPS payments will increase by 2.0% for FY 2023 based on a 2.8% update to IRF PPS payment rates combined with a 0.8% decrease due to outlier threshold adjustments. In what CMS called an effort to mitigate instability in IRF payments due to possible significant wage index decreases, CMS is proposing a permanent 5% cap on wage index changes. CMS is requesting comments on the methodology used to update the rural, low-income, and teaching status IRF facility level adjustments. It also is requesting comment on incorporating discharge to home health in the IRF transfer policy based on an OIG recommendation.
CMS published a Fact Sheet on the proposed rule on the same date. Comments are due by May 31.
Medicare Part D and Beneficiaries Could Realize Significant Spending Reductions with Increased Biosimilar Use
On March 31, the OIG published a Data Brief regarding biosimilar utilization and spending in Part D. The OIG found that in 2019, biosimilars’ reference products were used about five times more frequently than biosimilars in Part D. It estimated that increased use of biosimilar products could have reduced Part D spending by 18% if all biosimilars were used as frequently as the most-used biosimilars. The OIG noted that not all plan formularies covered biosimilars, and those that did cover biosimilars rarely encouraged their use over reference products. The OIG is publishing the data brief now given the expected launches for biosimilars for Humira and Enbrel in 2023, as it said there is a potential to significantly reduce costs for Part D and beneficiaries if those biosimilars are used more widely.
The OIG recommends that CMS encourage plans to increase access to and use of biosimilars in Part D as well as monitor biosimilar coverage on formularies to identify concerning trends.
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) - July 2022
On April 1, CMS published Medicare Claims Processing Transmittal 11316 regarding the quarterly updates to the DMEPOS CBP files.
Effective date: July 1, 2022
Implementation date: July 5, 2022