This week in Medicare—6/26/2024
CMS Updates Information on New Hospital Price Transparency Requirements Commencing July 1, 2024
On June 5, CMS published an updated FAQ with additional information to help hospitals understand and meet the new price transparency requirements that will take effect on July 1.
July 2024 Update to the HCPCS files
On June 10, CMS updated the Download Link for the July 2024 update to the HCPCS files.
CMS Releases 2023-2032 National Health Expenditure Projections
On June 12, CMS published a Press Release regarding a report from CMS’ Office of the Actuary on projections of national health expenditures (NHE) and health insurance enrollment for 2023-2032. The agency projected average annual Medicare expenditure growth to be 7.4% between 2023 and 2032.
Of note, CMS projected an average spending growth rate of 5.7% for hospitals and 5.6% for physician and clinical services within this period. In addition, CMS projected an average annual growth rate of 6.0% in retail prescription drug spending.
FY 2025 Annual Update to the Medicare Code Editor (MCE) and ICD-10-PCS
On June 13, CMS published Medicare Claims Processing Transmittal 12688 regarding the implementation of changes to ICD-10-CM and PCS codes in the MCE for FY 2025.
Effective date: October 1, 2024
Implementation date: October 7, 2024
Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 150.3 for Coding Revisions to the National Coverage Determinations (NCDs)
On June 13, CMS published Medicare Claims Processing Transmittal 12683 to add ICD-10 procedure codes 0DB84ZZ, 0DB93ZZ, 0DBB3ZZ, 0D164ZB, and 0F194Z3 for NCD 100.1 (Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity) to chapter 32 of the Medicare Claims Processing Manual.
Effective date: January 1, 2020
Implementation date: July 15, 2024
Manual Update Pub. 100-02 Medicare Benefit Policy, Chapter 15, Section 110.8 DMEPOS Benefit Category Determinations
On June 13, CMS published Medicare Benefit Policy Transmittal 12684 to update section 110.8 in chapter 15 of the Medicare Benefit Policy Manual with additional DMEPOS items and their national benefit category determinations.
CMS published MLN Matters 13651 on the same date to accompany the transmittal.
Effective date: January 1, 2024 - for 3 orthotic brace determinations; April 1, 2024 - For all other items, equipment and devices
Implementation date: July 15, 2024
July 2024 Update of the Ambulatory Surgical Center [ASC] Payment System
On June 13, CMS published Medicare Claims Processing Transmittal 12673 regarding the July 2024 updates to the ASC payment system. Changes include 23 new skin substitute HCPCS codes, 17 new separately payable drugs and biological HCPCS codes, and more.
CMS published MLN Matters 13656 on the same date to accompany the transmittal.
Effective date: July 1, 2024
Implementation date: July 1, 2024
July Quarterly Update for 2024 DMEPOS Fee Schedule
On June 13, CMS published Medicare Claims Processing Transmittal 12685 regarding the quarterly update to the DMEPOS fee schedule. This update includes fee schedule amounts for HCPCS Level II codes K1007 and E2298.
CMS published MLN Matters 13658 on the same date to accompany the transmittal.
Effective date: July 1, 2024 - except for fee schedules for HCPCS codes E2298 and K1007 effective April 1, 2024
Implementation date: July 1, 2024
CMS Could Strengthen Program Safeguards To Prevent and Detect Improper Medicare Payments for Short Inpatient Stays
On June 13, the OIG published a Report on CMS’ safeguards for preventing and detecting improper payment for short inpatient stays. The OIG conducted this report after hospitals continued to bill for many short inpatient stays that were potentially inappropriate under the two-midnight rule, despite being aware of this issue through previous audit findings.
The OIG interviewed CMS officials and one Beneficiary and Family Centered Care—Quality Improvement Organization (BFCC-QIO) to gain information for this report. The audit covered $19.7 billion in Part A claims with dates of service from January 1, 2016, through December 31, 2020, for 2.5 million short inpatient stays at 3,340 acute care hospitals.
The audit revealed the following weaknesses in CMS’ established program safeguards:
- CMS did not have claim information to identify short inpatient stays for which the admitting practitioner expected a longer stay and the longer stay did not occur because of an unforeseen circumstance. In addition, CMS had inadequate claim information to identify short inpatient stays with inpatient-only procedures.
- CMS did not have pre-payment edits for claims at risk of noncompliance with the two-midnight rule.
- CMS did not have adequate policies and procedures to review claims at risk for noncompliance with the two-midnight rule and recover overpayments.
The OIG determined that these weaknesses occurred because CMS relied primarily on post-payment reviews conducted by BFCC-QIOs to ensure compliance with the two-midnight rule. Although BFCC-QIOs denied $49.2 million in improper payments during the audit period, this amount was only 0.6% of the $7.8 billion in improper payments for inpatient stays estimated by CMS’ CERT reviews.
The OIG provided CMS and its contractors with four recommendations to strengthen program safeguards. Although CMS did not explicitly concur or disagree with the recommendations, it agreed to take the report findings into consideration as it determines appropriate next steps.
Medicare Prescription Drug Benefit Program: Health Information Technology Standards and Implementation Specifications Final Rule
On June 17, CMS published a Final Rule in the Federal Register regarding Part D health information technology standards and implementation specifications. The rule addresses policies that had not been addressed in the CY 2025 Medicare Advantage Policy and Technical Changes final rule, which was published on November 15, 2023.
This rule requires Part D sponsors, prescribers, and dispensers of covered Part D drugs to comply with electronic prescribing standards that CMS has either adopted directly or is requiring by cross-referencing standards ONC adopts for electronically transmitting prescriptions and prescription-related information.
These regulations are effective July 17, 2024.
Advisory Opinion No. 24-03
On June 17, the OIG published an Advisory Opinion regarding an arrangement in which a manufacturer of a gene therapy product for severe genetic diseases would provide assistance for qualifying patients with certain travel, lodging, meals, and associated expenses. Patients must receive this treatment at specific treatment centers and may have to stay there for at least 4-6 weeks. This assistance would only be offered only to low-income patients whose insurance would not cover these costs. The requestor asked for an opinion as to whether this arrangement would be grounds for the imposition of sanctions under the civil monetary penalties for beneficiary inducements or the anti-kickback statute.
The OIG determined that while the arrangement implicates the anti-kickback statute, it would not impose administrative sanctions on the requestor in this case for a variety of reasons discussed in the Opinion. The OIG also said the arrangement does not generate prohibited remuneration under the beneficiary inducements civil monetary penalty, as it meets the Promotes Access to Care Exception.
CMS to Close Program Addressing Medicare Funding Issues Resulting from Change Healthcare Cyber-Attack
On June 17, CMS published a Press Release to announce that it will end the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) as of July 12. CMS said that as of the date of publishing the press release, it had already recovered over 96% of the CHOPD payments. It issued more than $2.55 billion in accelerated payments to over 4,200 Part A providers and more than $717.18 million in payments to Part B suppliers.
Updated OIG Work Plan
On June 17, the OIG updated its Work Plan with the following new items:
- Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care
- Audit of CMS Contract Closeout Process
- Audits of Medicare Part C Supplemental Benefits
- Audit To Determine Whether CMS Oversight of Its Preclusion List Ensured That Certain Revoked Providers Did Not Receive Payment for Medicare Part C and Part D Services
- Durable Medical Equipment Fraud and Safeguards in Medicare
- Medicare Enrollees Leaving Hospitals Against Medical Advice
- Medicare Payments for Lower Extremity Peripheral Vascular Procedures
- Assessment of the Special Focus Facility Program for Nursing Homes
Revised Guidance for Long-Term Care Facility Assessment Requirements
On June 18, CMS published a Memorandum to state survey agency directors regarding new regulations for facility assessments that were finalized through a rule on minimum staffing standards for long-term care facilities that was published on May 10. The memorandum updates guidance for state survey agencies and long-term care facilities to comply with the increased standards that were finalized via the rule-making process.
Effective date: August 8, 2024
Changes to the Laboratory NCD Edit Software for October 2024
On June 20, CMS published Medicare Claims Processing Transmittal 12691 regarding the regular quarterly changes for the October 2024 quarterly release of the clinical diagnostic lab services edit module.
CMS published MLN Matters 13672 on the same date to accompany the transmittal.
Effective date: October 1, 2024 – unless noted differently in requirements
Implementation date: October 7, 2024
Advisory Opinion No. 24-04
On June 20, the OIG published an Advisory Opinion regarding an arrangement involving a three-year program to refund, waive, or delay requiring a payment receipt for a drug in the event of an insurance reimbursement denial or delay. Treatment centers have been hesitant to purchase the drug, a potentially curative treatment for a rare pediatric disorder, due to concerns about financial liability. The refund program is an attempt to ameliorate those concerns. The requestor asked for an opinion as to whether this arrangement would be grounds for the imposition of sanctions under the anti-kickback statute or beneficiary inducements civil monetary penalties.
The OIG said that the arrangement does not generate prohibited remuneration under the beneficiary inducements civil monetary penalty, and while it could potentially generate prohibited remuneration under the anti-kickback statute, the OIG would not impose administrative sanctions in this case.
October 2024 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On June 20, CMS published Medicare Claims Processing Transmittal 12693 to supply the ASP and Not Otherwise Classified (NOC) drug pricing files for Part B drugs to the contractors.
Effective date: October 1, 2024
Implementation date: October 7, 2024
NCA for Transcatheter Tricuspid Valve Replacement
On June 20, CMS published a Tracking Sheet to initiate a National Coverage Analysis (NCA) into coverage for transcatheter tricuspid valve replacements (TTVR). This NCA will be limited to coverage for TTVR as a treatment for tricuspid regurgitation.
By publishing the tracking sheet, CMS started a 30-day public comment period. Comments are due by July 20.
OPPS Addendum A and B
On June 20, CMS published download links for the July 2024 updates to OPPS Addendum A and Addendum B.
Expand Diabetes Screening and Diabetes Definitions Policy Update in the Calendar Year 2024 Physician Fee Schedule (PFS) Final Rule
On June 21, CMS published Medicare Benefit Policy Transmittal 12694 and Medicare Claims Processing Transmittal 12694, which rescind and replace Benefit Policy Transmittal 12600 and Claims Processing Transmittal 12600, dated May 2, to correct an outpatient consistency edit in BR 13487-04.7, as well as to provide clarifications and instructions to the MACs on claims processing prior to the implementation date of this CR. The correction also updates the effective and implementation dates, updates the policy section, and revises BRs 13487-04.1, -04.2.1, -04.9, and -04.11. All revisions are associated with the Claims Processing Manual only. They do not apply to the Benefit Policy Manual.
The original transmittal was issued to ensure contractors are aware of updates to diabetes screening policies and definitions in the CY 2024 PFS final rule.
CMS revised MLN Matters 12487 on the same date to accompany the transmittals.
Effective date: January 1, 2024 - Per CY 2024 PFS policy effective date
Implementation date: October 7, 2024