This week in Medicare—8/7/2024
Beneficiaries Dually Eligible for Medicare & Medicaid
On July 29, CMS updated an MLN Booklet regarding dually eligible beneficiaries. The updates consist of a new section on Qualified Medicare Beneficiary billing prohibitions. The booklet is backdated to June 2024.
CMS Releases 2025 Part D Bid Information and Announces Premium Stabilization Demonstration
On July 29, CMS published a Press Release to announce the base beneficiary premium will be $36.78 in 2025, which is $2.08 more than 2024. CMS said it will release preliminary average Part D premiums later this summer.
In addition to the preliminary Part D bid information, CMS announced a voluntary Part D Premium Stabilization Demonstration, which will test whether additional premium stabilization and revised risk corridors for stand-alone prescription drug plans increase the efficiency and economy of services under the Part D program. The demonstration will last for a single year (CY 2025), and sponsors were required to inform CMS of their participation by August 5, 2024.
CMS published a Fact Sheet and new Rate Information to accompany the press release.
FY 2025 Hospice Payment Rate Update Final Rule
On July 30, CMS published a draft copy of the FY 2025 Hospice Payment Rate Update Final Rule, which is scheduled to be published in the Federal Register on August 6. CMS finalized a 2.9% increase in hospice payments for 2025 (0.3% higher than the proposed rule) and an aggregate cap amount of $34,465.34.
The rule also includes corrections to language discrepancies between the Conditions of Participation and the payment requirements involving medical directors and physician designees. CMS will change the CoPs to add the physician member of the hospice interdisciplinary group (IDG) as an individual who may review clinical information for each patient and provide written certification that a patient’s life expectancy is six months or less. CMS will also change the term “physician designated by” in the CoPs to state “physician designee” as written in the payment requirements. The rule also clarifies requirements related to the election statement and notice of election (NOE), but these clarifications don’t change any current policy.
CMS published a Fact Sheet on the rule on the same date. The rule is effective October 1.
FY 2025 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule
On July 31, CMS published a draft copy of the FY 2025 SNF PPS Final Rule, which is scheduled to be published in the Federal Register on August 6. CMS finalized a 4.2% update to the SNF PPS payment rates (0.1% higher than the proposed rule) and will update the SNF market basket base year to the new base year of 2022.
The rule also finalized proposals to expand CMS’ ability to impose per instance and per day civil monetary penalties for health and safety deficiencies at nursing homes, and it includes several changes to PDPM ICD-10 code mappings to allow for more accurate and appropriate primary diagnoses the meet criteria for skilled intervention during Part A SNF stays.
CMS published a Fact Sheet on the rule on the same date. The rule is effective October 1.
FY 2025 Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS) Final Rule
On July 31, CMS published a draft copy of the FY 2025 IPF PPS Final Rule, which is scheduled to be published in the Federal Register on August 7. CMS finalized a 2.5% update to total estimated payments to IPFs in FY 2025 (0.1% lower than the proposed rule). As required by the CAA of 2023, CMS is revising the methodology for determining payment rates under the IPF PPS and is revising the IPF PPS patient-level adjustment factors, including MS-DRG assignments of the patient’s principal diagnosis, selected comorbidities, patient age, and a variable per diem adjustment.
CMS also finalized an update to the wage index using the core-based statistical area labor market areas as defined in the OMB Bulletin 23-01 and will phase in these changes by FY 2027 for providers who will transition from rural to urban based on this update. The rule also increases electroconvulsive therapy payment per treatment to $661.52, a significant change from the 2024 rate of $385.58.
CMS published a Fact Sheet on the final rule on the same date. The rule is effective October 1.
FY 2025 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Final Rule
On July 31, CMS released a draft copy of the FY 2025 IRF PPS Final Rule, which is scheduled to be published in the Federal Register on August 6. CMS finalized a 3.0% update to IRF PPS payments. CMS finalized associated updates to prospective payment rates, the outlier threshold, case-mix group relative weights and average length of stay values, and more. The rule also finalized an update to the IRF PPS wage index using the core-based statistical areas as defined in the OMB Bulletin 23-01 and provides a three-year transition for those IRFs who lose the rural adjustment due to their labor market area transitioning from rural to urban.
CMS published a Fact Sheet on the final rule on the same date. The rule is effective October 1.
FY 2025 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Final Rule
On August 1, CMS published a draft copy of the FY 2025 IPPS Final Rule, which is scheduled to be published in the Federal Register on August 28. CMS projects a 2.9% increase in operating payment rates, which is higher than the 2.6% projection in the proposed rule, and overall inpatient payments to hospitals are projected to increase by $2.9 billion.
CMS finalized a mandatory five-year payment model which will begin in January 2026 called the “Transforming Episode Accountability Model” (TEAM) to test whether episode-based payments for five common costly procedures would save money while ensuring the provision of coordinated, high-quality care during and after surgery. The procedures in the model include:
- Lower extremity joint replacement
- Surgical hip femur fracture treatment
- Spinal fusion
- Coronary artery bypass graft
- Major bowel procedures
Hospitals will be required to participate if they are located within certain Core-Based Statistical Areas (CBSA) and are paid under the IPPS. Those CBSAs and the correlated geographic areas will be listed in tables accompanying the IPPS final rule.
Other policies finalized in the rule include:
- For the New Technology Add-on Payment (NTAP) program, using the start of a fiscal year (October 1 rather than April 1 as the date to determine whether a technology is in its two- to three-year newness period. It is also increasing the NTAP for certain gene therapies for sickle cell disease from 65% to 75%
- Updating the status of seven ICD-10-CM codes describing housing instability or inadequacy from non-complication/comorbidities (non-CC) to CCs
- Creating a separate payment to small independent hospitals for buffer stocks of essential medicines
CMS published a Press Release and Fact Sheet to accompany the rule. It also published a Fact Sheet and FAQ on TEAM. The rule is effective October 1 unless otherwise specified.
Revisions to the Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-Coverage (ABN)
On August 1, CMS published Medicare Claims Processing Transmittal 12758 regarding minor revisions to language in Chapter 30 (Financial Liability Protections) of the manual concerning the SNF ABN form. There are also revisions to the SNF ABN and the SNF ABN form instructions.
Effective date: October 2, 2024
Implementation date: October 2, 2024
Updated Coding List Included in CRs 11914 and 11915
On August 1, CMS published Demonstrations Transmittal 12755 regarding updates to the CPT codes included in Change Requests (CR) 11914 and 11915, which were published in 2021 for the Kidney Care Choices Demonstration Model. This transmittal replaces retired CPT codes 99354-99355 in those CRs with the new code 99417 for prolonged E/M visits.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Manual Update for Billing Code G0444 for Annual Depression Screening
On August 1, CMS published Medicare Claims Processing Transmittal 12763 regarding updates to manual language to include telehealth place of service codes for HCPCS code G0444 for Annual Depression Screening. It also includes an update to the language for CARC code 96 when used to deny payment for G0444.
Effective date: January 1, 2025
Implementation date: January 6, 2025
October 2024 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On August 2, CMS published Medicare Claims Processing Transmittal 12766, which rescinds and replaces Transmittal 12693, dated June 20, to remove several BRs since the DME MACs are now able to download the pricers from the cloud. The affected BRs are listed in the transmittal.
The original transmittal was issued 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
July 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On August 2, CMS published Medicare Claims Processing Transmittal 12765, which rescinds and replaces Transmittal 12665, dated May 31, to update information about drugs, biological, and radiopharmaceuticals in a variety of tables. Changes affect long descriptors, status indicators, the number of products that will have their pass-through status end, and more.
The original transmittal was issued regarding the July 2024 update to the OPPS.
CMS revised MLN Matters 13632 on the same date.
Effective date: July 1, 2024
Implementation date: July 1, 2024
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, and Hospice Pricer for FY 2025
On August 2, CMS published Medicare Claims Processing Transmittal 12759 regarding the FY 2025 updates to the hospice payment rates, wage index, aggregate cap amount, and pricer.
CMS published MLN Matters 13707 on the same date to accompany the transmittal.
Effective date: October 1, 2024
Implementation date: October 7, 2024
ICD-10 and Other Coding Revisions to NCDs and Update to the Appropriate Use Criteria (AUC) Program—January 2025
On August 2, CMS published One-Time Notification Transmittal 12757 regarding the quarterly updates to codes for NCDs. The NCDs affected in this update include NCD 20.33 (TMVR/TEER) and NCD 210.10 (STIs). The transmittal also will end the use of the AUC program modifiers effective January 1, 2025.
CMS published MLN Matters 13706 on the same date to accompany the transmittal.
Effective date: January 1, 2025 – see BR 2 & 3 for different effective dates
Implementation date: January 6, 2025