This week in Medicare—5/8/2024
HCPCS Quarterly Update File
On May 2, CMS published the July 2024 HCPCS Quarterly Update File to its website for download.
Enhancements to Home Health Consolidated Billing Edits
On May 2, CMS published Medicare Claims Processing Transmittal 12608 to ensure systems edits enforcing home health consolidated billing are accurate and consistent with existing payment policies. The transmittal adds code F6 (epileptologists) to the list of physician specialty codes that cause the Common Working File to bypass this edit and the informational unsolicited response (IUR) for therapy services. It also corrects the home health consolidated billing edit and IUR for supply services to be based on the last billable service date for that period.
Effective date: October 1, 2024 - Claims processed on or after this date.
Implementation date: October 7, 2024
Extension of Payment Period for Pennsylvania Rural Health Model
On May 2, CMS published Demonstrations Transmittal 12622 to extend the existing termination date of the Pennsylvania Rural Health Model to December 31, 2026.
Effective date: October 1, 2024
Implementation date: October 7, 2024
Primary Care First (PCF) Model: Updated Appendix B - Prohibited HCPCS Codes
On May 2, CMS published Demonstrations Transmittal 12620 to update the list of PCF Appendix B Prohibited HCPCS codes. Of note, HCPCS add-on code G2211 (Prolonged evaluation and management with direct patient contact) is being removed from Appendix B. PCF participants can bill this code and receive payment as per the CY 2024 Physician Fee Schedule final rule, effective January 1, 2024. Contractors are to accept claims containing this new add-on code in accordance with its effective date.
Effective date: January 1, 2024
Implementation date: October 7, 2024
File Conversions Related to the Spanish Translation of the HCPCS Descriptions
On May 2, CMS published Medicare Claims Processing Transmittal 12596 regarding directions to contractors to implement the regular quarterly changes to the Spanish translations of HCPCS descriptions.
Effective date: July 1, 2024
Implementation date: July 1, 2024
A Social Determinants of Health Risk (SDOH) Assessment in the Annual Wellness Visit (AWV) Policy Update in the Calendar Year 2024 Physician Fee Schedule Final Rule
On May 2, CMS published Medicare Claims Processing Transmittal 12599 and Medicare Benefit Policy Transmittal 12599 regarding policy updates in the CY 2024 Physician Fee Schedule final rule concerning SDOH risk assessments in AWVs.
When furnished as an additional element of the AWV, the SDOH risk assessment is optional at the discretion of the clinician and beneficiary, and separately payable with no beneficiary cost-sharing when furnished as part of the same visit with the same date of service as the AWV. When providing the SDOH risk assessment in this scenario, report HCPCS code G0136 for the SDOH risk assessment with Modifier –33, with the same date on the same claim as G0438 or G0439. The transmittal also discusses eligible health professionals, frequency limitations, and more.
CMS published MLN Matters 13486 on the same date to accompany the transmittal.
Effective date: January 1, 2024 - Effective date of policy, per CY 2024 PFS Final Rule
Implementation date: October 7, 2024
Update to Several Sections of the Internet-only Manual (IOM) Publication (Pub.) 100-04, Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements
On May 2, CMS published Medicare Claims Processing Transmittal 12601 to update Chapter 23, sections 20.9, 20.9.1.1, 20.9.3.1, and 20.9.3.2 of the Medicare Claims Processing Manual. When a provider or supplier submits a claim for any of the codes specified in the transmittal (i.e., 77427, 92012-92014, and 99201-99499) with modifier 59 or the XE, XP, XS, or XU modifiers, the contractor will process the claim as if the modifier were not present.
Effective date: June 4, 2024
Implementation date: June 4, 2024
Expand Diabetes Screening and Diabetes Definitions Policy Update in the Calendar Year 2024 Physician Fee Schedule (PFS) Final Rule
On May 2, CMS published Medicare Benefit Policy Transmittal 12600 to ensure contractors are aware of updates to diabetes screening policies and definitions in the CY 2024 PFS final rule.
Medicare now covers the Hemoglobin A1C (HbA1c) test for diabetes screening. Diabetes screening frequency limitations are now simplified to no more often than twice within the 12 months following the date of the individual’s most recent screening test. Medicare no longer distinguishes diabetes screening frequency limitations based on a prior diagnosis of pre-diabetes.
The regulatory definition of diabetes for the purposes of diabetes screening, medical nutrition therapy, and diabetes outpatient self-management training services has been simplified to, “Diabetes mellitus, a condition of abnormal glucose metabolism.”
CMS published MLN Matters 12487 on the same date to accompany the transmittal.
Effective date: January 1, 2024 - Effective date per CY 2024 PFS policy effective date
Implementation date: October 7, 2024
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On May 2, CMS published Medicare Claims Processing Transmittal 12606 regarding the quarterly update to the CLFS. This quarter’s changes include a note on delayed reporting requirements, the deletion of CPT codes 0204U and 0353U, and more.
CMS published MLN Matters 13613 on the same date to accompany the transmittal.
Effective date: July 1, 2024
Implementation date: July 1, 2024
Internet-Only Manual (IOM) Updates for Split (or Shared) Evaluation and Management (E&M) Visits
On May 3, CMS published Medicare Claims Processing Transmittal 12604 to update Chapter 12 of the Medicare Claims Processing Manual to conform with policies in the CY 2024 Medicare Physician Fee Schedule final rule regarding split/shared E&M services. The transmittal defines a split or shared visit and clarifies what a “substantive portion” is for various settings.
CMS published MLN Matters 13592 on the same date to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: August 1, 2024
HHS Releases New Data Showing Over 10 Million People with Medicare Received a Free Vaccine Because of the President’s Inflation Reduction Act; Releases Draft Guidance for the Second Cycle of Medicare Drug Price Negotiation Program
On May 3, CMS published Draft Guidance on the implementation of the Medicare Drug Negotiation Program for initial price applicability year 2027. This draft guidance outlines new requirements for the second cycle of negotiations, which begins in 2025 and will result in maximum fair prices (MFP) effective for 2027.
The negotiations on the first set of 10 prescription drugs are successfully underway, and this second cycle of negotiations will include up to 15 additional drugs selected for negotiation, increasing access to innovative, life-saving treatments for people with Medicare and lowering costs. CMS will announce the drugs selected for potential negotiation for 2027 by February 1, 2025.
The draft guidance also outlines policies on how manufacturers must ensure eligible Medicare beneficiaries have access to negotiated MFPs for 2026 and 2027, including the procedures that may apply to drug companies, Medicare Part D plans, pharmacies, mail order services, and other dispensing entities that dispense drugs covered under Medicare Part D.
Comments received by July 2 will be considered in the development of final guidance. CMS plans to issue final guidance later this year on the second cycle of negotiations
CMS published a Press Release and Fact Sheet on the guidance on the same date. The press release also details new data on the impact of the Inflation Reduction Act on vaccine uptake and associated costs. CMS shared the following information:
- Over 10 million Part D enrollees received a free vaccine in 2023, compared to 3.4 million in 2021
- Approximately 3.9 million Medicare enrollees received a shingles vaccine in 2023, compared to 2.7 million in 2021
- Nearly 1.5 million Medicare enrollees received a Tdap vaccine in 2023, compared to 700,000 enrollees in 2021
- Approximately 6.5 million Part D enrollees accessed an RSV vaccine free of charge in 2023
Revisions to the State Operations Manual (SOM) Chapter 10 –Informal Dispute Resolution (IDR) and Enforcement Procedures for Home Health Agencies (HHA) and Hospice Programs
On May 3, CMS published a Memorandum to state survey agency directors regarding the IDR process for HHAs and hospice programs. CMS is revising guidance in Chapter 10 of the State Operations Manual to provide IDR procedures for these provider types. Revisions also include guidance for State Agencies and CMS Survey & Operations Group Locations on recommending and imposing HHA alternative sanctions and hospice enforcement remedies.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.