This week in Medicare updates—5/10/2023

May 10, 2023
Medicare Insider

Guidance for the Expiration of the COVID-19 Public Health Emergency (PHE)

On May 1, CMS published a Memorandum to state survey agency directors regarding preparations for the end of the COVID-19 PHE and the termination of waivers associated with the PHE. The memo reviews waivers by provider type, what actions providers and surveyors must take in response to the end of these waivers, and when CMS expects providers to be in compliance with these changes. 

Effective date: Immediately. Please communicate to all appropriate staff within 30 days.


Extending the Medicare Diabetes Prevention Program’s (MDPP) Expanded Model Emergency Policy Through CY 2023

On May 2, CMS published a Policy Extension Notice in the Federal Register to extend certain MDPP flexibilities through December 31, 2023, instead of ending those when the PHE expires on May 11. This will allow MDPP suppliers to continue providing virtual services through the end of the year.

Dates: Effective on May 2, 2023, the PHE flexibilities described under 42 CFR 410.79(e) are extended through 11:59 p.m. EST on December 31, 2023.


Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance

On May 2, CMS published Medicare Claims Processing Transmittal 12013, which rescinds and replaces Transmittal 11917, dated March 21, to add new ASP insulin administered by DME pump effective July 1, 2023, to business requirements 13014.2 and 13014.7. The original transmittal was published regarding the implementation of the changes to insulin pricing and provider/supplier payments.

CMS revised an associated MLN Fact Sheet on May 3 to accompany the transmittal. The fact sheet now includes HCPCS codes J1811 and J1813 under the billing instructions for July 2023 or later.

Effective date: July 1, 2023

Implementation date: July 3, 2023


HCPCS Quarterly Update File

On May 3, CMS published the July 2023 HCPCS Quarterly Update File to its website for download.


Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided Via Telehealth, During the First Year of the COVID-19 PHE

On May 4, the OIG published a Review of whether providers met Medicare requirements and guidance when billing for psychotherapy services, including services provided via telehealth. The OIG found that 128 of the 216 sampled enrollee days did not meet Medicare requirements for these services. Errors included missing documentation for time on psychotherapy claims, incomplete or missing treatment plans, incorrect number of services or incorrect CPT code billed, and more. The OIG estimates that over half of what Medicare paid for psychotherapy services covered by the audit was improper ($580 million in improper payments out of $1 billion reviewed in the audit). Of the $580 million in improper payments, $348 million was attributed to telehealth, and $232 million was attributed to non-telehealth services. 

The OIG recommends CMS recover improper payments, implement system edits for psychotherapy services to prevent payments for incorrectly billed services, strengthen educational efforts to make providers aware of requirements for psychotherapy services, and more. CMS concurred with some of the recommendations.


Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review

On May 4, CMS published One-Time Notification Transmittal 12015 regarding instructions to the MACs to perform a five-claim probe and educate medical review on every SNF in their jurisdiction. This is part of an effort to reduce improper payments, as the transmittal notes that the CERT program projects the improper payment rate for SNFs will increase by 7.79% from 2021 to 2022. 

Effective date: June 5, 2023

Implementation date: June 5, 2023


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

On May 4, CMS published One-Time Notification Transmittal 12017 regarding the regular quarterly updates to ICD-10 conversions and other coding updates for NCDs. This round of updates affects NCD 20.20 (External Counterpulsation Therapy for Severe Angina), NCD 90.2 (Next Generation Sequencing), and NCD 210.1 (Prostate Screening Tests).

Effective date: August 7, 2023 - BRs 1&2; October 1, 2023 - BR 3 only

Implementation date: August 7, 2023 - BRs 1&2; October 2, 2023 - BR 3 only - for DOS on and after 1/1/2023


Update the Process for Home Dialysis Payment Adjustment (HDPA) and Performance Payment Adjustment (PPA) for End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model Part A Claims

On May 4, CMS published Demonstrations Transmittal 12020 regarding a correction to a process for adjusting ESRD ETC model payments. There are two payment adjustments: the HDPA and the PPA. This transmittal creates a field that enables the process for the PPA.  

CMS published MLN Matters 13180 on the same date to accompany the transmittal. 

Effective date: October 1, 2023

Implementation date: October 2, 2023


Quarterly Update to Clinical Laboratory Fee Schedule (CLFS) & Laboratory Services Subject to Reasonable Charge Payment

On May 4, CMS published Medicare Claims Processing Transmittal 12021 regarding the quarterly update to the CLFS. This quarter’s changes include a note about the HCPCS codes expiring with the COVID-19 PHE (G2023, G2024, U0003, U0004, and U0005), new proprietary laboratory analysis (PLA) codes, and more. 

CMS published MLN Matters 13195 on the same date to accompany the transmittal. 

Effective date: July 1, 2023

Implementation date: July 3, 2023