This week in Medicare updates—6/7/2023
Annual Updates to the Annual Cap on Patient Engagement Tools and Supports Under 42 CFR §1001.952(hh)
On May 31, the OIG updated its Safe Harbor Regulations page to update the annual monetary cap on patient engagement tools and supports under a safe harbor. The cap for 2023 is $570, an 8.2% increase from 2022.
Medicare Paid Millions More for Physician Services at Higher Nonfacility Rates Rather Than at Lower Facility Rates While Enrollees Were Inpatients of Facilities
On May 31, the OIG published a Review of whether Medicare paid the proper rate for physician services furnished to enrollees while they were inpatients of a SNF or a hospital. The OIG conducted the review out of concern that practitioners may not always follow CMS regulations/guidance for reporting place of service (POS) codes on claim lines, which would create a risk for overpayments for physician services when furnished to inpatients of a SNF or hospital if the incorrect POS code is reported, as physician services are paid at different rates when furnished in a facility vs nonfacility setting.
The OIG found that Medicare sometimes paid the higher nonfacility rates rather than the lower facility rates for physician services when enrollees were inpatients at a SNF or hospital. Medicare made overpayments totaling nearly $22.5 million during the two-year audit period by paying the nonfacility rate for services coded as furnished in a nursing facility or SNF setting without Part A coverage while enrollees were Part A SNF inpatients. Medicare also paid an additional $22 million for physician service claim lines coded as furnished in a nonfacility setting. CMS said neither statute nor CMS regulation addresses specific situations in which a SNF or hospital inpatient leaves to receive a physician service in a nonfacility setting.
The OIG recommends CMS recover the $22.5 million in overpayments, establish and apply CWF edits to detect instances in which practitioners incorrectly use the nonfacility POS code for a SNF while an enrollee is a Part A SNF inpatient, take steps to revise regulations to ensure Medicare appropriately pays for physician services in these situations, consider developing a mechanism for facilities to indicate when an inpatient leaves a facility and returns the same day, and provide additional education to practitioners on the appropriate use of POS codes. CMS concurred with most recommendations and said it would consider the OIG’s findings and other available information to determine whether it should take further regulatory steps to prevent these situations.
Final Rule: Policy and Regulatory Changes to the Omnibus COVID-19 Health Care Staff Vaccination Requirements
On May 31, CMS published a draft copy of a Final Rule regarding the removal of a federal requirement for healthcare staff to be vaccinated against COVID-19 now that the COVID-19 PHE has ended. The rule requires SNF, long-term care (LTC), and Intermediate Care Facilities for Individuals with Intellectual Disabilities to continue to provide COVID-19 educational information and vaccines to their residents, clients, and staff. CMS will continue to encourage ongoing COVID-19 vaccination through quality reporting and value-based incentive programs in the near future. It will, however, now treat COVID-19 vaccination more like vaccination for other infectious diseases such as influenza.
The rule will be published in the Federal Register on June 5, at which time effective dates for regulations within the final rule will also be released.
CMS Announces Plan to Ensure Availability of New Alzheimer’s Drugs
On June 1, CMS published a Press Release regarding how Medicare coverage for a new Alzheimer’s drug (Leqembi) will work if the drug receives traditional approval from the FDA. The FDA will be holding a committee meeting on June 9 to discuss the results of a trial for that drug, and if the FDA grants traditional approval, broader Medicare coverage of the drug will begin on the same day as the approval.
Audiologists May Provide Certain Diagnostic Tests Without a Physician Order
On June 1, CMS published One-Time Notification Transmittal 11935 regarding the implementation of a policy from the CY 2023 Physician Fee Schedule final rule which will allow audiologists to furnish diagnostic and balance assessment services without requiring a physician order, effective July 1, 2023. The rule also allows physicians and non-physician practitioners (NPP) (including PAs, NPs, and CNSs) to provide these services. Patients are allowed one visit every 12 months to an audiologist without a physician or NPP order. This service should be billed with the AB modifier and the audiologist’s NPI as the rendering provider on the line of service.
CMS published MLN Matters 13055 on the same date to accompany the transmittal.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Keystone Health Plan East Submitted to CMS
On June 2, the OIG published a Review of whether select diagnosis codes that Keystone Health Plan East submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by sampling 270 unique enrollee years with the high-risk diagnosis codes for which Keystone received higher payments for 2016 and 2017. The OIG found that diagnosis codes for 205 of the 270 enrollee years did not comply with federal requirements because there was not sufficient support for those codes in the medical records. These errors resulted in $550,391 in net overpayments.
The OIG recommended that Keystone refund the federal government for the $550,931 in overpayments, identify and return similar overpayments, examine its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements, and ensure it collects medical records for audits of risk adjustment data in compliance with CMS requirements. Keystone disagreed with some of the findings and recommendations in the report, and the OIG reduced the number of sampled enrollee-years in error down from 207 to 205 based on additional documentation provided. The OIG stood by the remainder of its findings and recommendations.
Update to Section 50 of Medicare Managed Care Manual on Renewal Options and Crosswalks
On June 2, CMS published Medicare Managed Care Transmittal 127 regarding updated sections in the manual to better reflect the codification of certain longstanding policies via the CY 2022 and 2023 Medicare Advantage and Part D final rules. This includes information about beneficiary enrollment upon a D-SNP non-renewing for the following contract year, a reiteration of the definition of a crosswalk, and more.
Effective date: January 1, 2023 - however, please note that CMS was advised by OGC that they should not be including retroactive effective dates
Implementation date: January 1, 2023 - however, please note that CMS was advised by OGC that they should not be including retroactive effective dates
New Claims Modifier Requirement for Drugs and Biologicals From a Single-Dose Container or Single-Use Package
On June 2, CMS published Medicare Claims Processing Transmittal 12067 regarding the implementation of the JZ modifier for claims for drugs and biologicals from single-dose containers or packages when no amount is discarded. The transmittal contains information on when the various phase-in elements of the policy are effective and when providers and suppliers are required to report the JZ and JW modifiers. The JZ modifier is required for use effective July 1, 2023, but contractor editing for this will not be effective until October 1. Claims editing will begin on October 2.
Effective date: January 1, 2023
Implementation date: July 3, 2023 (-JZ)
July Quarterly Update for 2023 DMEPOS Fee Schedule
On June 2, CMS published Medicare Claims Processing Transmittal 12068 regarding the quarterly update to the DMEPOS fee schedule. This update includes information on supplier education for power wheelchair repair, revisions to the process for establishing national fee schedule amounts, and more.
Effective date: July 1, 2023
Implementation date: July 3, 2023