This week in Medicare updates—1/4/2023
Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier
On December 19, CMS published an MLN Fact Sheet regarding the Part B inflation rebate and 340B drugs. The Inflation Reduction Act of 2022 established a Part B inflation rebate where manufacturers for certain single source drugs and biologicals will provide a rebate for drugs where prices are increasing faster than the rate of inflation. The 340B drugs are excluded from Part B inflation rebates, and they will be identified by the JG and TB modifiers that are required for use no later than January 1, 2024.
Ordering External Breast Prostheses & Supplies
On December 19, CMS revised an MLN Fact Sheet on breast prostheses and supplies to add coding information and tips on documentation to help avoid improper payments.
Clinical Laboratory Fee Schedule
On December 19, CMS revised an MLN Fact Sheet on the clinical laboratory fee schedule to update a URL and update specimen collection and flat-rate travel amounts for 2023.
Medicare Part B Spending on Lab Tests Increased in 2021
On December 19, the OIG published a Review of Part B spending on lab tests in 2021. The OIG found that Part B spending increased from $8 billion in 2020 to $9.3 billion in 2021. This 17% increase was the largest change in spending since the OIG began reviewing Part B spending on lab tests in 2014. The OIG attributed the increase in spending to increased volume for COVID-19 tests, continued growth of high-priced genetic tests, and an increased volume for panel and chemistry tests.
Electronic Correspondence Referral System (ECRS) Restoration of Patient Relationship Code 18, Update to Medicare Secondary Payer (MSP) Inquiry Transactions for Deceased Beneficiaries, and Clarification of Existing ECRS User Guide Policy Based on MAC Feedback
On December 21, CMS published Medicare Secondary Payer Transmittal 11754 regarding various modifications to the ECRS Web User Guide. Changes made cover restoring the usage of Patient Relationship Code (18) defined as Parent; clarifying when a Medicare Secondary Payer (MSP) inquiry transaction for a deceased beneficiary may be added; and clarifying the usage of specific reason and action codes, hierarchy, MSP Type G (Disabled), MSP Type B (End Stage Renal Disease (ESRD), and matching criteria for inquiries and transactions.
Effective date: January 23, 2023
Implementation date: January 23, 2023
January 2023 Update of the Ambulatory Surgical Center (ASC) Payment System
On December 21, CMS published Medicare Claims Processing Transmittal 11762 regarding the January 2023 updates to the ASC payment system. Changes include three new devices for pass-through status, clarification of the policy for reporting HCPCS code C9777, 26 new procedures that are now separately payable in the ASC setting, and more.
CMS published MLN Matters 13041 on the same date to accompany the transmittal.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Provider Education for Prior Authorization (PA) Process for Facet Joint Interventions in Hospital Outpatient Department (OPD) Setting
On December 21, CMS published One-Time Notification Transmittal 11753 regarding instructions to the A/B MACs to provide education for providers regarding the PA process for facet joint interventions in hospital outpatient departments. Facet joint intervention procedures are the most recent addition to CMS’ PA for HOPD services list. The transmittal includes drafts of the letters MACs are being instructed to send out regarding the education on the PA process for this service.
Effective date: February 15, 2023
Implementation date: February 15, 2023
Update to Chapter 18, Section 170.1, and Chapter 31, Section 270.2 of the Claims Processing Manual to Add New Codes for Certain NCDs
On December 21, CMS published Medicare Claims Processing Transmittal 11759 regarding updates to the manual to add in new ICD-10-CM codes due to changes to NCD 20.4 (Implantable Automatic Defibrillators) and new CPT codes for NCD 210.10 (Screening for Sexually Transmitted Infections and High-Intensity Behavioral Counseling).
Effective date: January 23, 2023
Implementation date: January 23, 2023
Significant Updates to Medicare Secondary Payer Manual, Chapters 1 and 2
On December 21, CMS published Medicare Secondary Payer Transmittal 11755 regarding a wide range of updates to Chapters 1 and 2 of the manual to update verbiage, policy, and operational procedures. The transmittal includes approximately 70 pages of changes to the manual, which are highlighted in red.
Effective date: January 23, 2023
Implementation date: January 23, 2023
Hospital and Hospital Health Care Complex Cost Report Updates
On December 29, CMS published Provider Reimbursement Manual Transmittal 18 regarding a plethora of updates to the Hospital and Hospital Health Care Complex cost report. The transmittal has over 800 pages of changes across a range of worksheets and implements various changes due to recent legislation, the FY/CY 2023 final payment system rules, and more.
Effective date: Cost reporting periods beginning on or after October 1, 2022
Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter as Certain Colorectal Cancer Screening Tests
On December 29, CMS published One-Time Notification Transmittal 11772, which rescinds and replaces Transmittal 11622, dated September 29, to remove Part A MACs from business requirements 12656.1, 12656.2, and 12656.3. The original transmittal was published regarding the implementation of a gradual reduction in coinsurance for certain colorectal cancer screening procedures as mandated by the Consolidated Appropriations Act of 2021.
CMS revised MLN Matters 12656 on the same date to accompany the transmittal.
Effective date: January 1, 2022
Implementation date: October 3, 2022 - Coding; January 3, 2023 - Testing and Full Implementation
National Coverage Determination (NCD) 110.24: Chimeric Antigen Receptor (CAR) T-Cell Therapy
On December 30, CMS published Medicare Claims Processing Transmittal 11774, which rescinds and replaces Transmittal 11721, dated November 28, to revise the implementation date and to (1) remove duplicate BR 12928.3 and replace with the intended language, (2) clarify 1 unit per HCPCS code in BRs 12928.7, 12928.8, 12928.8.1, (3) clarify modifier -Q1 not -Q0 in BRs 12928.10, 12928.11, (4) change date to October 1, 2021 in BR 12928.11, (5) remove Part A from BR 12928.8.1, (6) where discussing NCD 310.1 replace 'FDA-approved' with 'qualifying clinical trial'. This correction also revises the IOM, the background section of the requirements, and the NCD excel file. The original transmittal was published regarding updated instructions on how to process claims in the Part B physician office and independent clinics for CAR T-Cell therapy.
Effective date: January 1, 2022
Implementation date: January 31, 2023