This week in Medicare—11/29/2023
FY 2023 Improper Payments
On November 15, CMS published a Fact Sheet regarding improper payment data for FY 2023. The Medicare Fee-for-Service (FFS) estimated improper payment rate was 7.38%, marking the seventh consecutive year that the figure has been below the 10% statutory threshold for compliance. The Part C rate (6.01%) and Part D rate (3.72%) were also below the 10% statutory threshold.
The fact sheet provides additional details on what Medicare considers to be an improper payment, what these rates mean, and how CMS works to combat improper payments across each federal healthcare program. More detailed data is available in the FY 2023 HHS Agency Financial Report.
Updated OIG Work Plan
On November 15, the OIG updated its Work Plan with the following new items:
- Medicare Payments Compared to the Prices Available to Consumers and Suppliers for Continuous Glucose Monitors and Sensors
- Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the First Quarter 2024
- Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Fourth Quarter 2023
- Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Third Quarter 2023
- Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Second Quarter 2023
- Case Study: Preparedness and Response for Disruptions in Health Care in Select Communities During and After Hurricanes Fiona and Ian
- Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2022 Average Sales Prices
- Medicare Part D Formulary Coverage of Humira Biosimilars
- Audit of Emergency Preparedness, Infection Prevention and Control, and Life Safety at Intermediate Care Facilities for Individuals With Intellectual Disabilities
- Audit of Nursing Homes' Nurse Staffing Hours Reported in CMS's Payroll-Based Journal
- Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes
- Audits of Medicare Part C Health Risk Assessment Diagnosis Codes
Updates to Chapter 1 of the Medicare Claims Processing Manual to Include Newly Created and Utilized Payer Only Codes
On November 16, CMS published Medicare Claims Processing Transmittal 12361 regarding an update to the manual to include newly created and utilized payer-only codes. These include bypass codes for the shared systems Medicare deductible and coinsurance, MAC Medicare deductible and coinsurance bypass codes, Medicare SNF 3-day inpatient hospital stay bypass codes, and more.
Effective date: August 1, 2023
Implementation date: December 19, 2023
NCD 220.6.20 – Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease
On November 16, CMS published Medicare National Coverage Determinations Transmittal 12364 and Medicare Claims Processing Transmittal 12364 regarding the removal of NCD 220.6.20 to end coverage with evidence development for PET beta-amyloid imaging following CMS’ decision last month to end the NCD and hand coverage determinations over to the MACs.
CMS published MLN Matters 13429 on the same date to accompany the transmittals.
Effective date: October 13, 2023
Implementation date: December 19, 2023 – A/B MACs; April 1, 2024 – CWF, MCS, FISS
Guiding an Improved Dementia Experience (GUIDE) Model Implementation
On November 16, CMS published Demonstrations Transmittal 12365 regarding the implementation of the GUIDE Model, which is a demonstration that will test payment and service delivery models for people with dementia and their caregivers. The transmittal includes a list of G-codes and diagnosis codes to use when billing for the model.
Effective date: April 1, 2024 – Analysis, Design & Coding; July 1, 2024 – Testing and Implementation
Implementation date: April 1, 2024 – Analysis, Design & Coding; July 1, 2024 – Completion of Coding, Testing and Implementation
Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for CY 2024
On November 16, CMS published Medicare Claims Processing Transmittal 12267 regarding the update to the FQHC PPS base rate and the geographic adjustment factors (GAF) for 2024. The FQHC base rate in 2024 will be $195.99, a 4.7% increase from 2023.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Update to the Rural Health Clinic (RHC) All-Inclusive Rate (AIR) Payment Limit for CY 2024
On November 16, CMS published Medicare Claims Processing Transmittal 12288 regarding the 2024 update to the RHC AIR payment limit. For independent RHCs and provider-based RHCs in a hospital with 50 or more beds, the payment limit per visit is $139. Other payment limit provisions are discussed in the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Hospital Price Transparency – Data Dictionary GitHub
On November 16, CMS published a Repository where hospitals can access templates and technical instructions for price transparency standard charge information. CMS finalized new price transparency requirements in the CY 2024 OPPS Final Rule which require hospitals to adopt a CMS template layout and encode their standard charge information using the technical specifications and data dictionary on this new repository.
Implementation of Rural Emergency Hospital (REH) Provider Type
On November 17, CMS published Medicare Claims Processing Transmittal 12369, which rescinds and replaces Transmittal 12321, dated October 18, to revise the policy section, clarifying the REH monthly facility amount and provider reporting period. The original transmittal was issued regarding the implementation of the system requirements necessary for the REH provider type.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Final Rule: Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities (SNF) and Nursing Facilities (NF)
On November 17, CMS published a Final Rule in the Federal Register regarding the implementation of a section in the Affordable Care Act that requires disclosure of certain ownership, managerial, and other information regarding SNFs and NFs. The rule would require SNFs and NFs to disclose data about trustees and additional disclosable parties upon initial enrollment and revalidation. SNFs would also have to report information as part of any change of ownership within specific timeframes. The rule also provides definitions of private equity companies and real estate investment trusts, which would then allow SNFs to disclose whether each direct and indirect owning or managing entity is a private equity company or real estate investment trust. CMS is revising Form CMS-855A to accommodate this additional data.
CMS published a Press Release, Fact Sheet, and MLN Fact Sheet on the rule on the same date. The rule is effective January 16, 2024.
Guidance for Federal Monitoring Surveys (FMS)
On November 20, CMS published a Memorandum to state survey agency directors regarding guidance on federal monitoring surveys for long-term care facilities. The memo identifies the FY 2024 and FY 2025 focus concerns (including nurse staffing, unnecessary psychotropic medication, and facility-initiated discharges) and provides guidance on how CMS location staff will conduct FMS. It also discusses the statutorily required number of long-term care FMS for health and life safety code/emergency preparedness.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.
Consumer Alert: Remote Patient Monitoring
On November 21, the OIG published a Consumer Alert regarding a fraud scheme involving remote patient monitoring (RPM). The scam involves signing Medicare beneficiaries up for RPM regardless of medical necessity via phone solicitation, internet ads, or TV advertising. The OIG included instructions on how beneficiaries should protect themselves from this scheme.
Implement Edits to Prevent Payment of Complexity Add-On Code G2211 When Associated Office/Outpatient E/M Visit Is Reported With Modifier 25
On November 21, CMS published Medicare Claims Processing Transmittal 12370 regarding the implementation of the G2211 add-on code, which was finalized in the CY 2024 Medicare Physician Fee Schedule final rule. While this code is now separately payable, it isn’t payable when the office/outpatient visit is reported with modifier 25. This transmittal implements an edit that will prevent MACs from improperly paying for G2211 in that situation. The transmittal is no longer sensitive and may now be posted to the internet.
CMS published MLN Matters 13272 on the same date to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
January 2024 Update to HCPCS Files
On November 21, CMS updated the Download Link for the January 2024 update to the HCPCS files.
January 2024 Annual Rural Emergency Hospital (REH) Monthly Facility Payment Amount
On November 22, CMS published Medicare Claims Processing Transmittal 12373 regarding the annual update to the additional REH monthly facility payment amount for CY 2024.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Implementation of Changes in the ESRD PPS and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for CY 2024
On November 22, CMS published Medicare Benefit Policy Transmittal 12371 regarding the implementation of rate updates and policies for the ESRD PPS for 2024. The transmittal also includes updates to payment for renal dialysis services provided to patients with AKI in ESRD facilities.
CMS published MLN Matters 13445 on the same date to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Summary of Policies in the CY 2024 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
On November 22, CMS published Medicare Claims Processing Transmittal 12372 regarding the implementation of policies finalized in the CY 2024 MPFS Final Rule. It also includes the telehealth originating site facility fee payment amount.
CMS published MLN Matters 13452 on the same date to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Diagnosis Code Update for Add-On Payments for Blood Clotting Factor Administered to Hemophilia Inpatients
On November 24, CMS published Medicare Claims Processing Transmittal 12380, which rescinds and replaces Transmittal 12290, dated October 5, to update BR 13381.3 to remove HCPCS J7191 and J7199 and to add HCPCS J7177, J7178, and J7214. The original transmittal was published regarding updates to the list of diagnosis codes used to allow add-on payments for blood clotting factors under the IPPS.
CMS revised MLN Matters 13381 to accompany the transmittal.
Effective date: October 1, 2022
Implementation date: April 1, 2024
New Waived Tests
On November 24, CMS published Medicare Claims Processing Transmittal 12381 regarding the new CLIA-waived lab tests.
CMS published MLN Matters 13455 on the same date to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024