This week in Medicare—10/11/2023
Correction Notice: FY 2024 IPPS Final Rule
On October 4, CMS published a Correction Notice in the Federal Register to correct errors from the FY 2024 IPPS Final Rule, which was published on August 28. Errors include incorrect ICD-10-PCS codes, errors with procedure code combinations in a table of ICD-10-PCS code pairs added to Version 41 ICD-10 MS-DRGs 001 and 002, errors with wage data in several tables posted to the CMS website, and more.
This correcting document is effective October 1, 2023.
Correction Notice: FY 2024 SNF PPS Final Rule
On October 4, CMS published a Correction Notice in the Federal Register to correct errors from the FY 2024 SNF PPS Final Rule. Errors include incorrect wage index data, errors in PDPM ICD-10 mappings, and more.
This document is effective October 1, 2023.
Correction Notice: FY 2024 Inpatient Psychiatric Facility (IPF) PPS Final Rule
On October 4, CMS published a Correction Notice in the Federal Register to correct errors from the FY 2024 IPF PPS Final Rule. Errors include missing links, changes to footnotes, updates to cost amounts that were incorrectly calculated, and more.
This document is effective October 1, 2023.
Correction Notice: FY 2024 Inpatient Rehabilitation Facility (IRF) PPS Final Rule
On October 4, CMS published a Correction Notice in the Federal Register to correct errors from the FY 2024 IRF PPS Final Rule. Errors include issues related to incorrect wage data, updated percentages, typos, and more.
This document is effective October 1, 2023.
CMS Sickle Cell Disease Action Plan
On October 5, CMS published a link to an Action Plan to outline its efforts to improve health outcomes, eliminate barriers, and reduce health disparities for people living with Sickle Cell Disease. The Action Plan targets four areas where CMS aims to make changes for this population:
- Expanding coverage and access
- Improving quality and the continuum of care
- Advancing equity and engagement
- Examining data and analytics
CMS highlighted efforts via the Physician Fee Schedule rules, Innovation Center models, NCD updates, and more to improve care for those living with Sickle Cell Disease.
Update to Medicare Benefit Policy Manual and Medicare Claims Processing Manual to Implement Consolidated Appropriations Act 2023 Changes for Skilled Nursing Facilities (SNF)
On October 5, CMS published Medicare Claims Processing Transmittal 12283 and Medicare Benefit Policy Transmittal 12283 regarding updates to both manuals to add marriage and family therapists and mental health counselors to the list of practitioners whose services are excluded from SNF consolidated billing.
Effective date: January 8, 2024
Implementation date: January 8, 2024
Patient Driven Payment Model (PDPM) Corrections to Interrupted Stay Edits
On October 5, CMS published One-Time Notification Transmittal 12286 regarding updates to claims processing edits when there is an interrupted stay. These updates apply to SNF billing on TOB 21X and swing bed billing on TOB18X. The transmittal also updates an ambulance edit when billing during an interrupted stay.
Effective date: April 1, 2024
Implementation date: April 1, 2024
Deleting Medicare Claims Processing Manual Chapter 4, Section 190, Payer Only Codes Utilized by Medicare
On October 5, CMS published Medicare Claims Processing Transmittal 12284 regarding the deletion of duplicate material in the manual. This material is being deleted from Section 190 of Chapter 4 (Payer Only Codes Utilized by Medicare), as it is already printed in Section 190 of Chapter 1.
Effective date: November 6, 2023
Implementation date: November 6, 2023
Diagnosis Code Update for Add-On Payments for Blood Clotting Factor Administered to Hemophilia Inpatients
On October 5, CMS published Medicare Claims Processing Transmittal 12290 regarding updates to the list of diagnosis codes used to allow add-on payments for blood clotting factors under the IPPS. These updates are retroactive to October 2022 and affect diagnosis codes for Von Willebrand disease.
Effective date: October 1, 2022
Implementation date: April 1, 2024
Requirements for a Provider Direct Mailing and Education & Outreach for Behavioral Health Initiatives
On October 5, CMS published One-Time Notification Transmittal 12285 regarding outreach and education for physicians and non-physician practitioners on Medicare-covered behavioral health services as established by the Consolidated Appropriation Act of 2023. The transmittal includes directions to the MACs on how to conduct this outreach and a sample version of the letter MACs are supposed to send to physicians and non-physician practitioners about this.
Effective date: November 6, 2023
Implementation date: November 6, 2023
Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Aetna, Inc. Submitted to CMS
On October 5, the OIG published a Review of whether select diagnosis codes that Aetna submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by sampling 210 unique enrollee-years with the high-risk diagnosis codes for which Aetna received higher payments for 2015 and 2016. The OIG found that diagnosis codes for 155 of the 210 enrollee years did not comply with federal requirements because there was not sufficient support for those codes in the medical records. These errors resulted in $632,070 in net overpayments. The OIG estimates that on the basis of the sample, Aetna received at least $25.5 million in net estimated overpayments for 2015-2016.
The OIG recommends Aetna refund the federal government for the $632,070 in overpayments, identify and return similar overpayments, and examine its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded to comply with federal requirements. The OIG also found many instances of situations where diagnosis codes could have been miskeyed because numbers were transposed or other data entry errors occurred. The OIG recommends Aetna review those years to determine whether the medical records support the diagnoses on those claims. Aetna did not concur with the OIG’s recommendations and challenged some of its findings. The OIG reduced the number of enrollee years in error from 156 down to 155, but it stood by the remainder of its findings.
Updated Novavax COVID-19 Vaccine Information
On October 6, CMS published an MLN Connects notice following the FDA’s decision to amend the EUA for the Novavax COVID-19 vaccine, Adjuvanted, to include the 2023-2024 formula for patients 12 and older. This EUA is effective October 3.
The vaccine should be reported by CPT code 91304, and the administration of the vaccine should be reported by CPT code 90480. Payment for CPT code 91304 is $148.20. Medicare also will no longer pay for CPT codes 0041A, 0042A, and 0044A effective October 3.