This week in Medicare updates—5/24/2023
DMEPOS Competitive Bidding Program: Temporary Gap Period
On May 15, CMS published an MLN Fact Sheet regarding a temporary gap period in the DMEPOS Competitive Bidding program. All Round 2021 contracts for off-the-shelf back and knee braces will expire on December 31, 2023. A temporary gap period in the program will begin on January 1, 2024, while CMS determines how to move forward. The fact sheet provides instructions on payment rules in effect for Medicare-enrolled DMEPOS suppliers during the gap period.
Medical Record Maintenance & Access Requirements
On May 15, CMS updated an MLN Fact Sheet regarding medical record maintenance and access requirements. Updates include a link to the Consolidated Appropriations Act of 2023 for extended telehealth provisions, information on the elimination of Certificates of Medical Necessity and DME Information Forms, and a reminder for independent diagnostic testing facilities to properly store medical records.
Updated OIG Work Plan
On May 15, the OIG updated its Work Plan with the following new items:
- Opioid Use in Medicare Part D in 2022: Annual Review
- Hospital Identification of Patient Harm Events
- Nursing Home Facility-Initiated Discharges: A Data Brief
Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review
On May 15, CMS published One-Time Notification Transmittal 12037, which rescinds and replaces Transmittal 12032, dated May 10, to clarify that claims will be adjusted/denied if an improper payment is identified and to remove the confidential designation for the transmittal. The original transmittal was issued regarding an instruction to the MACs to perform a 5-claim probe and educate medical review on every SNF in their jurisdiction.
Effective date: June 5, 2023
Implementation date: June 5, 2023
Comparison of Average Sales Prices (ASP) and Average Manufacturer Prices (AMP): Results for the Fourth Quarter of 2022
On May 15, 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 fourth quarter of 2022, 16 drug codes met this price substitution criteria. Seven additional drug codes exceeded the 5% threshold but were identified as being in short supply. Another nine drug codes had ASPs exceeding the AMPs by at least 5% in the fourth quarter of 2022 but didn’t meet other price substitution criteria. The OIG will provide these results to CMS for review.
Final Decision Memo: Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3)
On May 16, CMS posted a Final Decision Memo regarding coverage of seat elevation systems as an accessory for Group 3 power wheelchairs. CMS expanded coverage beyond its proposed decision, especially as it applies to transfers. CMS will cover this equipment for individuals performing weight-bearing transfers with certain elements involved in the transfer, individuals requiring non-weight-bearing transfer in the home, and individuals who reach from the wheelchair to complete one or more mobility-related activities of daily living. The proposed decision covered the equipment only for individuals performing weight-bearing transfers with specific elements involved in the transfer.
CMS will also require the individual to undergo a specialty evaluation performed by a licensed/certified medical professional with specific training and experience in rehabilitation wheelchair evaluations.
CMS published the public comments on the NCA to accompany the final decision memo.
Clinical Laboratory Fee Schedule - Medicare Travel Allowance Fees for Collection of Specimens and New Updates for 2023
On May 16, CMS published Medicare Claims Processing Transmittal 12045, which rescinds and replaces Transmittal 11778, dated January 6, to remove the parenthetical phrase “including Medicare Advantage” under the travel allowance section of the policy. The original transmittal was published regarding the 2023 Medicare travel allowance fees for specimen collection and to clarify various laboratory specimen collection fee policies.
CMS revised MLN Matters 13071 on the same date to accompany the transmittal.
Effective date: January 1, 2023
Implementation date: January 23, 2023
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2023 Update
On May 18, CMS published Medicare Claims Processing Transmittal 12048 regarding updates to the MPFSDB for July 2023. The transmittal includes an attachment at the end detailing the changes to codes, status indicators, and more included in the update.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Update to the Medicare General Information, Eligibility, and Entitlement Manual Chapter 2 to Incorporate Changes from the Consolidated Appropriations Act of 2021 (CAA)
On May 18, CMS published Medicare General Information, Eligibility, and Entitlement Transmittal 12046 regarding updates to Chapter 2 of the manual to incorporate changes from the CAA. These changes include new effective dates for Medicare enrollment so individuals who become eligible for Medicare on or after January 1, 2023, and enroll in Part B during the last three months of their initial enrollment period can have entitlement begin the first day of the month following the month in which they enroll. It also affects entitlement periods for the general enrollment period and adds special enrollment periods to the manual.
Effective date: January 1, 2023
Implementation date: June 21, 2023
Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule
On May 18, CMS published Medicare Benefit Policy Transmittal 12047 regarding educational materials to aid in the implementation of the Medicare payment policies for dental services that were finalized in the CY 2023 PFS Final Rule. The transmittal describes situations in which dental services would be covered; provides definitions for ancillary services, dental services, and dentists; and clarifies how to determine when dental and medical services are inextricably linked.
Effective date: January 1, 2023
Implementation date: June 9, 2023
July 2023 Quarterly Update to HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
On May 18, CMS published Medicare Claims Processing Transmittal 12052 regarding updates to lists of HCPCS codes subject to the CB provision of the SNF PPS. Changes affect certain chemotherapy codes, COVID-19 vaccine and monoclonal antibody codes, and more.
CMS published MLN Matters 13192 on the same date to accompany the transmittal.
Effective date: July 1, 2023
Implementation date: July 3, 2023
July 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On May 18, CMS published Medicare Claims Processing Transmittal 12053 regarding the July update to the OPPS. Changes include 15 new PLA codes, 20 new CPT Category III codes, a variety of new HCPCS codes for gastroenterology procedures, and more.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Medicare Claims Processing Manual Update to Chapter 12 for Code Updates and Substantive Portion Definition Finalized Through Rule-Making Processes
On May 18, CMS published MLN Matters 13064 regarding information on updates to the manual to reflect changes made through CY 2020 and 2021 final rules to items such as E/M code family merging, prolonged services, nursing facility visits, and more.
The article accompanies Medicare Claims Processing Transmittal 11842, which was published on February 9. The MLN does not contain new information but provides links to sections of the manual which contain the changes to various policies or billing processes.
Effective date: January 1, 2023
Implementation date: May 9, 2023
The Risk of Misuse and Diversion of Buprenorphine for Opioid Use Disorder Appears to Be Low in Medicare Part D
On May 18, the OIG published a Data Brief regarding the risk of misuse and diversion of buprenorphine in Medicare Part D in 2021. This data may hold future relevance, as Congress repealed a requirement from the Drug Addiction Treatment Act (DATA) in 2022 that previously required providers to obtain a waiver through SAMHSA to prescribe or administer buprenorphine in office-based settings. Providers were also limited in the number of patients they could treat. Because this data brief examines buprenorphine prior to the repeal of this waiver, this data may be compared in the future to data from after the repeal of the waiver.
The data brief showed that in 2021, almost all Part D enrollees who received buprenorphine for the treatment of opioid use disorder received the recommended amounts. Most prescribers ordered buprenorphine for a limited number of Part D enrollees and very few providers had patterns that raised concern. The OIG said these findings support the repeal of the DATA waiver, as the risk of misuse and diversion of buprenorphine is low, and repealing the waiver may increase access to necessary treatment.
Use of CR Modifier, DR Condition Code After End of PHE
On May 18, CMS published a reminder in MLN Connects regarding the use of the CR modifier and DR condition code after the end of the PHE. These should only be used during a PHE when a formal waiver is in place except for two exceptions, which apply to specific scenarios for DMEPOS suppliers and SNF and swing-bed providers.
FAQ: CMS Waivers, Flexibilities, and the End of the COVID-19 PHE
On May 19, CMS updated an FAQ regarding the end of CMS waivers and flexibilities for the COVID-19 PHE. CMS added questions 21-24 on page 9 regarding whether hospitals can bill for PT, OT, SLP, DSMT, or MNT provided via telehealth, Medicare payment for a subsequent nursing facility or subsequent inpatient visit when furnished via telehealth, and enforcement discretion for teaching physicians using virtual presence and billing for services involving residents in residency training sites outside of an MSA after the PHE ends.