This week in Medicare—11/15/2023
Proposed Rule: CY 2025 Policy and Technical Changes to the Medicare Advantage (MA) Program
and Medicare Prescription Drug Benefit Programs
On November 6, CMS published a draft copy of a Proposed Rule regarding policy and technical changes to MA plans, Part D plans, and Programs of All-Inclusive Care for the Elderly (PACE).
To improve MA beneficiaries’ access to behavioral healthcare, CMS proposed to add a range of behavioral healthcare providers under one category—“Outpatient Behavioral Health”—as a facility-specialty for which it would set MA plan network adequacy standards. Specialists under this category would include marriage and family therapists, mental health counselors, and others. CMS also proposed to add Outpatient Behavioral Health to the list of the specialty types that will receive a 10% credit if the MA plan organization’s contracted network of providers includes one or more telehealth providers of that specialty type who provide additional telehealth benefits for covered services.
To stop anticompetitive steering, CMS proposed to set a fixed compensation amount that agents and brokers can be paid regardless of the plan the beneficiary enrolls in. The proposed national MA agency/broker compensation amount is $642.
Other notable changes in the proposed rule include the following:
- Issuing an annual “Mid-Year Enrollee Notification of Unused Supplemental Benefits” to each enrollee that includes a list of supplemental benefits not accessed during the first six months of the year
- Increasing the percentage of dually eligible managed care enrollees who receive integrated Medicare and Medicaid Services
The rule was published in the Federal Register on November 15, and comments are due by January 5, 2024. CMS also released a Press Release and Fact Sheet on the proposed rule.
Part B Payment Amounts for Two Drugs Included Noncovered Self-Administered Versions in 2022
On November 6, the OIG published an Issue Brief regarding whether noncovered self-administered drugs have been included in calculations to set Part B payment amounts and whether those drugs should be excluded. The OIG determined that CMS correctly removed noncovered self-administered versions of Orencia and Cimzia when calculating 2022 payment amounts. The OIG also discovered that while payment amounts for Fasenra and Xolair included noncovered self-administered versions in 2022, those versions did not substantially affect per-injection payment amounts. CMS is required to remove self-administered versions of Fasenra and Xolair from payment amount calculations in subsequent quarters if the exclusion would result in lower payment amounts.
General Compliance Program Guidance
On November 6, the OIG published a General Compliance Program Guidance reference guide, fulfilling its promise from earlier this year to start publishing these types of compliance resources for the first time since 2008. The guidance booklet is available for full download or is available on the OIG website and has been broken up into separate sections. This resource provides information about relevant federal laws, compliance program infrastructure, OIG resources, and more. It is not, however, binding information and is voluntary guidance about general program risks and structure.
January 2024 Update to HCPCS Files
On November 6, CMS published the Download Link for the January 2024 update to the HCPCS files.
Medicare, Medicaid, and Children’s Health Insurance Programs (CHIP) Provider Enrollment Application Fee Amount for CY 2024
On November 7, CMS published a Notice in the Federal Register to announce the CY 2024 application fee for provider enrollment or practice location enrollment in Medicare, Medicaid, and CHIP. The fee in 2024 will be $709.
This fee is effective on January 1, 2024.
Manual Updates for Coverage of Intravenous Immune Globulin (IVIG) for Treatment of Primary Immune Deficiency Diseases in the Home
On November 8, CMS published Medicare Benefit Policy Transmittal 12352 regarding updates to the manual to incorporate changes from the Consolidated Appropriations Act of 2023 for IVIG treatment in the home. CMS is establishing a permanent bundled payment effective January 1, 2024, for items and services related to administration of IVIG in a patient’s home for the treatment of primary immune deficiency diseases.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Addition of “Birthing-Friendly” Designation Icon to Care Compare Online Tool
On November 8, CMS published a Press Release to announce the addition of a “Birthing-Friendly” designation icon to its Care Compare Online Tool. The new designation describes high-quality maternal care. To earn this designation, organizations must report their Maternal Morbidity Structural Measure progress to the Hospital Inpatient Quality Reporting Program. The measure determines if a hospital participates in a state- or nationwide perinatal quality improvement collaborative program and if it implements evidence-based care to improve maternal health.
Lymphedema Compression Treatment Items: Implementation
On November 9, CMS published Medicare Claims Processing Transmittal 12359, which rescinds and replaces Transmittal 12164, dated July 28, to reflect the final policies in the CY 2024 Home Health PPS Final Rule. Revisions update BRs 13286.1, 13286.1.1, 13286.7, 13286.8, 13286.8.1, 13286.8.1.1, and 13286.9 to reflect the new HCPCS attachment. Revisions also add BR 13286.1.2 and update Chapter 20, section 181 of the IOM as well as the background and policy sections. The transmittal is no longer sensitive and may now be posted to the internet. CMS is adding lymphedema compression garments into the DMEPOS benefit category, which was established through the Consolidated Appropriations Act of 2023. The transmittal walks through all the nuances of billing for this service.
CMS published MLN Matters 13286 to accompany the transmittal. CMS also updated an MLN Fact Sheet on the Intravenous Immune Globulin Demonstration with details about these changes.
Effective date: January 1, 2024
Implementation date: January 2, 2024
ICD-10 and Other Coding Revisions to NCDs–January 2024 Update
On November 9, CMS published One-Time Notification Transmittal 12355, which rescinds and replaces Transmittal 12184, dated August 3, to revise NCD 210.1 BR 13278.3 to remove FISS, add A/B MACs, and instruct MACs to adjust claims, and NCD 90.2, BR 13278.2 to replace CPT 81455 with CPT 81479 with associated diagnosis codes for solid organ neoplasms, and to revise BRs 13278.4 and the implementation date. The original transmittal was published regarding the regular quarterly updates to ICD-10 conversions and other coding updates for NCDs.
CMS revised MLN Matters 13278 to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: BR 2 (addition of CPT 81469 and diagnosis codes) 10 days from issuance; January 2, 2024 – BR 1, BR 2 (addition of CPT 0397U), BR 3
Incorporation of Recent Provider Enrollment Regulatory Changes into Chapter 10 of the Program Integrity Manual
On November 9, CMS published Medicare Program Integrity Transmittal 12356 regarding the incorporation of provider enrollment changes for marriage and family therapists and mental health counselors into the manual. These changes were established via the CY 2024 Medicare Physician Fee Schedule Final Rule.
CMS published MLN Matters 13331 to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
CMS Can Do More to Leverage Medicare Claims Data to Identify Unreported Incidents of Potential Abuse or Neglect
On November 9, the OIG published a Review regarding CMS’ use of Medicare data to identify incidents of potential abuse or neglect. In this audit, the OIG said it reviewed claims to determine whether there was evidence of potential abuse or neglect, who perpetrated those incidents, where those incidents occurred, and whether law enforcement was alerted. The OIG sampled 100 claims containing diagnosis codes indicating treatment of injuries that potentially resulted from abuse or neglect, and it found that 93 of those claims had medical records that contained evidence of potential abuse or neglect. The majority of those claims indicated potential abuse or neglect by a family member, spouse, or significant other, but the OIG was concerned that 14 of the 93 claims showed the perpetrator was a healthcare worker. It also found that 17 of the 93 claims were related to incidents that occurred in medical facilities and 18 were related to incidents that were not reported to law enforcement.
The OIG recommends CMS conduct data analyses to identify trends and high-risk areas in Medicare claims containing diagnosis codes indicating potential abuse or neglect, provide results of the analyses to relevant programs/organizations for further reviews, develop and share guidance and best practices with providers to help ensure incidents are reported in compliance with state mandatory reporting laws, and consider addressing existing Conditions of Participation requirements for reporting abuse or neglect of Medicare enrollees if necessary. CMS concurred with the recommendations.
Correction Notice: FY 2024 IPPS Final Rule
On November 9, CMS published a Correction Notice in the Federal Register to correct errors from the FY 2024 IPPS Final Rule. This notice corrects the omission of comment and response related to the request for MS-DRG reassignment of cases reporting spinal fusion procedures utilizing an aprevo™ customized interbody fusion device.
Effective date: This correcting document is effective November 9, 2023
Applicability date: This correcting document is applicable for discharges beginning October 1, 2023