This week in Medicare updates—8/31/2022
August 2022 HOP Panel Meeting Materials and Rebroadcast Link
On August 22, CMS published a Download Link containing PDFs of the August 22, 2022 HOP Panel meeting materials and a PDF with a link to the recording from the meeting.
Comment Request: Medicare Part C and Medicare Part D Enrollment Form Interviews
On August 23, CMS published a Comment Request in the Federal Register regarding the following information collection:
- Medicare Part C and Medicare Part D Enrollment Form Interviews
Comments are due by October 24, 2022.
Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Cigna HealthSpring of Florida Submitted to CMS
On August 23, the OIG published a Review of whether select diagnosis codes that Cigna HealthSpring submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by sampling 200 enrollees with at least one diagnosis code that mapped to an HCC for 2015. This resulted in 1,470 HCCs associated with these enrollees. The OIG found that 69 of the 1,470 HCCs were not supported in the medical record, a far lower error rate than the OIG typically finds in these audits. The OIG also found that there were an additional 18 HCCs for which the medical records supported diagnosis codes that Cigna HealthSpring should have submitted to CMS but did not. Therefore, the risk scores for these sampled enrollees should have been based on 1,426 HCCs instead of 1,470, and Cigna HealthSpring received $39,612 in net overpayments for these sampled enrollees.
The OIG recommended that Cigna HealthSpring refund the federal government for the $39,612 in net overpayments and improve its policies and procedures to prevent, detect, and correct noncompliance with federal requirements for diagnosis codes used in risk-adjusted payment calculations. Cigna HealthSpring disagreed with the OIG’s findings and recommendations from the draft report and questioned the OIG’s audit and statistical sampling methodologies. The OIG revised some of its original findings and recommendations but maintained that its methodologies were reasonable and properly executed.
Comment Request: Rate Increase Disclosure and Review Reporting Requirements
On August 24, CMS published a Comment Request in the Federal Register regarding the following information collection:
- Rate Increase Disclosure and Review Reporting Requirements
Comments are due by October 24.
Comment Request: Hospital Notices: IM/DND; more
On August 24, CMS published a Comment Request in the Federal Register regarding the submission of the following information collections for OMB review:
- Hospital Notices: IM/DND
- Medicare Outpatient Observation Notice (MOON)
Comments are due to the OMB desk officer by September 23.
Comment Request: Quality Measures and Administrative Procedures for the Hospital-Acquired Condition Reduction Program; more
On August 24, CMS published a Comment Request in the Federal Register regarding the submission of the following information collections for OMB review:
- Quality Measures and Administrative Procedures for the Hospital-Acquired Condition Reduction Program
- Report of a Hospital Death Associated with Restraint or Seclusion
- Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act
Comments are due to the OMB desk officer by September 23.
Comparison of Average Sales Prices (ASP) and Average Manufacturer Prices (AMP): Results for the First Quarter of 2022
On August 25, the OIG published a Report regarding drugs for which the ASP exceeds the AMP by 5% or more for two consecutive quarters or three of the previous four quarters. When this happens, CMS substitutes 103% of the AMP for the ASP-based reimbursement. In the first quarter of 2022, eight drug codes met this price substitution criteria. Ten additional codes exceeded the 5% threshold but were identified as being in short supply. Another two codes had ASPs exceeding the AMPs by at least 5% in the first quarter of 2022 but didn’t meet other price substitution criteria. The OIG will provide these results to CMS for review.
Updates to Chapter 1 of Medicare Claims Processing Manual to Include Newly Created and Utilized Payer Only Codes
On August 25, CMS published Medicare Claims Processing Transmittal 11571 regarding updates to the manual to include newly created payer only codes. These include condition codes Z0-Z9, ZA, ZB, ZC, ZD-ZZ; occurrence codes AA-AZ; value codes QB, QC, QE-QK, and more.
Effective date: July 1, 2022
Implementation date: September 27, 2022
Exceptions to Average Sales Price (ASP) Payment Methodology - Claims Processing Manual Changes
On August 25, CMS published Medicare Claims Processing Transmittal 11572 regarding updates to language in Chapter 17, Section 20.1.3 and Section 20.3 of the manual. The changes ensure the manual language aligns with recent changes to the add-on percentage for wholesale acquisition cost (WAC)-based payments for new drugs as well as with recent legislation changing payment for infusion drugs furnished through a covered item of durable medical equipment from average wholesale price (AWP) to ASP.
Effective date: October 26, 2022
Implementation date: October 26, 2022
Final Round of Transition of Enrollment and Certification Activities for Various Certified Provider and Supplier Types and Transactions
On August 25, CMS published Medicare Program Integrity Transmittal 11576 regarding the final round of transitioning enrollment applications, changes of ownership, and changes of information functions from the CMS Survey and Operations Group to the MACs and CMS Provider Enrollment and Oversight Group. This round of transitions applies to end-stage renal disease facilities, hospices, and hospitals.
Effective date: September 30, 2022
Implementation date: September 30, 2022
2023 Annual Update of HCPCS Codes for SNF Consolidated Billing (CB) Update
On August 25, CMS published Medicare Claims Processing Transmittal 11573 regarding instructions to the contractors for updating the HCPCS code files for the SNF CB update for 2023.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Sixth General Update to Provider Enrollment Instructions in Chapter 10 of Program Integrity Manual
On August 25, CMS published Medicare Program Integrity Transmittal 11574 regarding updates to Chapter 10 of the manual. These updates provide new or clarifying instructions regarding processing for certain Medicare provider enrollment applications and transactions.
Effective date: June 24, 2022
Implementation date: September 27, 2022
Updated Merit-based Incentive Payment System (MIPS)/MIPS Value Pathways (MVP) HCPCS Codes
On August 25, CMS published One-Time Notification Transmittal 11578 regarding updates on the use of HCPCS codes for MIPS that are specific to MIPS specialty measure sets and the MVPs. These codes allow clinicians to indicate their intent to register for a specific MVP or be scored based on the quality measures within a specialty measure set. The codes are not billable services.
Effective date: January 3, 2023
Implementation date: January 3, 2023
Updates to Community Mental Health Center Cost Report Form
On August 25, CMS published Provider Reimbursement Manual Transmittal 3 regarding updates to the Community Mental Health Center Cost Report form. Changes include revised rounding standards for ratios to include days to days, updated instructions to align with the Protecting Medicare and American Farmers from Sequester Cuts Act of 2021, and more.
Effective date: Cost reporting periods ending on or after August 31, 2022
Preliminary Injunction in Texas v. Becerra
On August 25, CMS published a Memorandum to state survey agency directors regarding court action in response to guidance CMS issued in July pertaining to EMTALA regulations and the effect on state laws governing abortion. Due to a Texas District Court ruling, HHS may not enforce guidance stating that Texas abortion laws are preempted by EMTALA. HHS also may not enforce the guidance’s interpretation of EMTALA as to when an abortion is required and how EMTALA affects state laws governing abortion within the state of Texas or against the members of the American Association of Pro Life Obstetricians and Gynecologists and the Christian Medical and Dental Association.
Effective date: Immediately. Please communicate to all appropriate staff immediately.