This week in Medicare—12/18/2024
CMS Announces its Framework for Improving Healthcare Delivery and Care Experience
On December 9, CMS announced its new Framework for improving healthcare delivery and care experience. CMS’ five-year strategy is designed to address administrative burdens and other frictions in its programs and the healthcare industry as a whole.
Updates of Chapter 4 and Exhibits in Publication (Pub.) 100-08, Including the Unified Program Integrity Contractor (UPIC) and Medical Review Accuracy Contractor (MRAC) Coordination Process
On December 12, CMS published Medicare Program Integrity Transmittal 13000, which rescinds and replaces Transmittal 12954, dated November 8, to revise contact information in Exhibit 47.
The original transmittal was issued to update guidance on the UPIC and MRAC coordination process in Chapter 4 and communicate new contact information.
Effective date: December 10, 2024
Implementation date: December 10, 2024
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 31.1, Effective April 1, 2025
On December 12, CMS published Medicare Claims Processing Transmittal 12998 regarding the regular quarterly updates to the NCCI PTP edits. The final file should be available on or around February 14.
Effective date: April 1, 2025
Implementation date: April 7, 2025
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) – April 2025
On December 12, CMS published Medicare Claims Processing Transmittal 12993 regarding instructions for downloading the quarterly update to the DMEPOS CBP.
Effective date: April 1, 2025
Implementation date: April 7, 2025
April 2025 Update to the MS-DRG Grouper and Medicare Code Editor (MCE) Version 42.1
On December 12, CMS published Medicare Claims Processing Transmittal 12995 regarding instructions to contractors to update the MS-DRG Grouper and MCE to version 42.1 for the April 2025 update.
Effective date: April 1, 2025
Implementation date: April 7, 2025
April 2025 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On December 12, CMS published Medicare Claims Processing Transmittal 12994 regarding the quarterly updates to the ASP and Not Otherwise Classified drug pricing files for Part B drugs.
Effective date: April 1, 2025
Implementation date: April 7, 2025
Implementation of Changes in the ESRD PPS and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for CY 2025
On December 12, CMS published Medicare Benefit Policy Transmittal 12999, which rescinds and replaces Transmittal 12962, dated November 14, to revise the background section, Attachment A, and BR 13865.4.
The original transmittal was issued to implement rate updates and policies for the ESRD PPS for 2025.
Effective date: January 1, 2025
Implementation date: January 6, 2025
OIG Advisory Opinion No. 24-10
On December 12, the OIG published an Advisory Opinion on a proposed arrangement involving a medical and dental supplies distributor expanding its existing customer loyalty program. The requestor’s customers currently earn points on purchases of dental-related items and services and redeem them to reduce the price of other dental-related items and services. In addition to earning redeemable points, the customers are assigned to a tiered membership level based on annual spending amounts on these items and services. Each membership level has unique benefits (e.g., priority scheduling for in-office services, extended labor warranties, and rental equipment discounts).
Under the proposed arrangement, the requestor would expand its existing customer loyalty program to allow points to be earned on purchases from certain of its other subsidiaries, including those that are at least 50% owned by the requestor. The participating entities would ultimately report to the same upper management, often use the same brand names, utilize common resources, and share common aims to meet the needs of similar customer types. The requestor asked for an opinion as to whether this arrangement would be grounds for the imposition of sanctions under the federal anti-kickback statute and/or beneficiary inducements civil monetary penalty (CMP).
The OIG determined that the proposed arrangement would generate prohibited remuneration under the federal anti-kickback statute if the requisite intent were present, but it would not impose sanctions.
Revisions to the State Operations Manual (SOM) Appendix X, Transplant Program Interpretive Guidelines and Survey Procedures and Chapter 9 - Exhibits
On December 13, CMS published State Operations Provider Certification Transmittal 227 to revise Appendix X to provide better clarification to contractors on transplant program survey procedures.
CMS added Exhibit 357 to Chapter 9 of the manual for state agency use for inactive transplant programs.
Effective date: December 13, 2024
Implementation date: December 14, 2024
Revisions to State Operations Manual (SOM) Appendix Q – Core Guidelines for Determining Immediate Jeopardy
On December 13, CMS published State Operations Provider Certification Transmittal 228 regarding revisions to Appendix Q in the manual, which details core guidelines for determining immediate jeopardy. Of note, CMS revised Subpart XI to expand CLIA-specific guidance.
Effective date: December 13, 2024
Implementation date: December 13, 2024
January 2025 Alpha-Numeric HCPCS File
On December 13, CMS updated the January 2025 Alpha-Numeric HCPCS File.
Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32 Sections 90, 190.2 and 300.2 for Coding Revisions to the National Coverage Determinations (NCDs) - April 2025 (1 of 2) CR 13818
On December 13, CMS published Medicare Claims Processing Transmittal 12990 to update the manual to reflect the ICD-10 coding updates to specific NCDs listed in One-Time Notification Transmittal 12903, dated October 24.
Effective date: September 30, 2024 - See Individual Business Requirements for Effective Dates
Implementation date: March 13, 2025