This week in Medicare—1/3/2024
CMS Releases Final Evaluation Report on Comprehensive Primary Care Plus Model
On December 15, CMS released its final Evaluation Report on the Comprehensive Primary Care Plus (CPC+) Model. CPC+ was a primary care payment and delivery reform model that launched in 2017 and ran for five years, supporting practices at varying levels of readiness in two tracks.
The report focuses on the model’s fifth year and its impact on care provision and expenditures. CPC+ practices reported reductions in outpatient emergency department visits, acute inpatient hospitalizations, and acute inpatient expenditures. However, after accounting for increased expenditures in other areas and enhanced CPC+ payments, CMS found that these reductions were not sufficient enough to reduce total Medicare expenditures or achieve net savings in either track.
Medigap-Related Advisory Opinions
On December 18 and 20, the OIG published Advisory Opinion 23-09 and Advisory Opinion 23-10 regarding the use of “preferred hospital” networks as part of Medigap policies. The requestors were looking to see if insurance companies could contract with a preferred hospital network to provide discounts on the otherwise applicable Medicare inpatient deductibles for policyholders and, in turn, the insurance company would provide a premium credit of $100 off the next renewal premium to policyholders who use a network hospital for an inpatient stay. The requestors were seeking opinions as to whether these arrangements would be grounds for the imposition of sanctions under the anti-kickback statute and beneficiary inducements civil monetary penalty.
In both cases, the OIG ruled favorably for the requestors and said that while the proposed arrangements would generate prohibited remuneration under the antikickback statute and beneficiary inducements civil monetary penalty, the OIG would not impose administrative sanctions in these cases because the arrangements would be unlikely to increase costs for federal healthcare programs, are unlikely to lead to inappropriate utilization of healthcare services, and would be unlikely to impact competition or patient choices.
Ambulance Inflation Factor (AIF) for CY 2024 and Productivity Adjustment
On December 19, CMS published Medicare Claims Processing Transmittal 12414, which rescinds and replaces Transmittal 12268, dated September 28, to remove BR 13400.3 about contractors sending confirmation via email to a specific CMS email to state that they received each file. The original transmittal was issued regarding an update to the manual to list the AIF for 2024, which is 2.6%.
Effective date: January 1, 2024
Implementation date: January 2, 2024
New Waived Tests
On December 19, CMS published Medicare Claims Processing Transmittal 12415, which rescinds and replaces Transmittal 12381, dated November 24, to update the background section to revise the QW code information among the 80 tests and to add 24 new waived tests with their corresponding QW codes approved by the FDA as of December 5. The changes also include updates to the attachment and CR summary. The original transmittal was issued regarding the new CLIA-waived lab tests.
CMS revised MLN Matters 13455 to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92
On December 19, CMS published Medicare Claims Processing Transmittal 12423, Medicare Benefit Policy Transmittal 12425, and Medicare General Information, Eligibility, and Entitlement Transmittal 12425 regarding the implementation of condition code 92 for IOP services and enforcement of associated billing requirements. These instructions affect providers at hospital outpatient departments, critical access hospitals, community mental health centers, and any other providers billing MACs for IOP services. The transmittals outline how to bill condition code 92, requirements for patient eligibility for these services, covered services, reasons for denials, and more.
CMS published MLN Matters 13496 and MLN Matters 13222 to accompany the transmittals.
Effective date: January 1, 2024
Implementation date: January 2, 2024
January 2024 Update of the OPPS
On December 21, CMS published Medicare Claims Processing Transmittal 12421 regarding the January 2024 update to the OPPS. This includes updates to COVID-19 vaccine codes and APCs, new device pass-through categories, the addition of 10 procedures to the inpatient-only list, and more.
Effective date: January 1, 2024
Implementation date: January 2, 2024
January 2024 Update of the OPPS for Supervision Changes
On December 21, CMS published Medicare Benefit Policy Transmittal 12421 regarding the January 2024 update to the OPPS. This transmittal specifically addresses the change to the manual related to the supervision of pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, which may be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist as of January 1, 2024.
Effective date: January 1, 2024
Implementation date: January 2, 2024
January 2024 I/OCE Update
On December 21, CMS published Medicare Claims Processing Transmittal 12419 regarding the regular quarterly update to the I/OCE.
Effective date: January 1, 2024
Implementation date: January 2, 2024
April 2024 Quarterly ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On December 21, CMS published Medicare Claims Processing Transmittal 12422 regarding the quarterly updates to the ASP and Not Otherwise Classified drug pricing files for Part B drugs.
Effective date: April 1, 2024
Implementation date: April 1, 2024
Implement Edits to Prevent Payment of Complexity Add-On Code G2211 When Associated Office/Outpatient E/M Visit Is Reported With Modifier 25
On December 21, CMS published Medicare Claims Processing Transmittal 12424, which rescinds and replaces Transmittal 12370, dated November 21, to update BR 13272.4 to replace CARC P14 with CARC 234. The original transmittal was published regarding the implementation of the G2211 add-on code, which was finalized in the CY 2024 Medicare Physician Fee Schedule final rule.
CMS revised MLN Matters 13272 to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
CY 2024 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On December 21, CMS published Medicare Claims Processing Transmittal 12426, which rescinds and replaces Transmittal 12389, dated November 30, to update the CY 2024 CLFS Annual Updates attachment. The original transmittal was issued regarding the annual update for the CLFS, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment.
CMS revised MLN Matters 13467 to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Provider Education for the Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility Services (IRF)
On December 21, CMS published One-Time Notification Transmittal 12428 regarding instructions to the JL MAC to provide education for IRF providers regarding the RCD process for IRFs who are physically located in and bill to Pennsylvania. This will then expand to other IRF providers who bill to JL.
Effective date: January 24, 2024
Implementation date: January 24, 2024
Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Opioid Treatment Programs (OTP)
On December 21, CMS published Medicare Benefit Policy Transmittal 12418 and Medicare Claims Processing Transmittal 12418 regarding revisions to the manuals to reflect changes made to OTPs via the CY 2024 Physician Fee Schedule Final Rule and the CY 2024 OPPS Final Rule. This includes changes to episode requirements, information on HCPCS code G0137, and more.
Effective date: January 1, 2024
Implementation date: January 24, 2024
January 2024 Update of the Ambulatory Surgical Center (ASC) Payment System
On December 21, CMS published Medicare Claims Processing Transmittal 12420 regarding the January 2024 updates to the ASC payment system. This includes the addition of dental codes, the addition of 41 new separately payable procedures to the ASC-covered procedure list, device pass-throughs, and more.
CMS published MLN Matters 13841 to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Reprocessing for Improperly Denied Vagus Nerve Stimulator Claims
On December 21, CMS published a Note in MLN Connects regarding a claims processing issue with the transitional pass-through payment for vagus nerve stimulators reported with HCPCS code C1827 in combination with CPT code 64568. CMS said it reopened all claims submitted for C1827 with dates of service starting January 1, 2023, and reprocessed them if necessary. The note states that providers with any physician claims in ASCs that were improperly denied should alert their MACs.
January 2024 OPPS Addendum A and B Files
On December 21, CMS published the January 2024 OPPS Addendum A and B files for download.
Medicare Part B Spending on Clinical Diagnostic Laboratory Tests in 2022
On December 22, the OIG published a Data Snapshot regarding Part B spending on clinical diagnostic lab tests in 2022. The OIG conducts an annual analysis in this area due to a requirement from the Protecting Access to Medicare Act (PAMA) of 2014, which requires that Part B payment rates align with rates paid by private payors. The OIG found that Part B spending on clinical diagnostic lab tests decreased by 10% in 2022, an aberration from a typical rise year-over-year in spending on these tests. Payment rates for these tests did not change from 2021 to 2022, so the OIG attributes the changes in spending due primarily to changes in volume of tests. The OIG noted a 26% decrease in spending on genetic tests and a 14% decrease in spending on COVID-19 tests in 2022.
Proposed Rule: Establishment of Appeal Processes for Certain People with Medicare
On December 27, CMS published a Proposed Rule in the Federal Register regarding the establishment of three appeal processes for certain Medicare beneficiaries.
CMS is proposing an expedited appeals process for eligible beneficiaries who disagree with a hospital’s decision to reclassify their inpatient status to outpatient receiving observation services while they are still in the hospital. These beneficiaries would be able to file an appeal with a Beneficiary and Family Centered Care - Quality Improvement Organization. In addition, the agency is proposing a standard appeals process for eligible beneficiaries who do not file an expedited appeal that would allow them to pursue an appeal regarding the hospital’s decision to reclassify their status. The proposed standard process would largely follow the same procedures as the proposed expedited process.
CMS is also proposing a retrospective appeals process that applies to beneficiaries with hospital admissions on or after January 1, 2009, involving status changes before the implementation of the other proposed prospective appeals processes. Beneficiaries would have a full year from the implementation date of the final rule to gather any related documentation and file an appeal request.
CMS also published a Fact Sheet on the proposed rule.
Comments on the rule are due by February 26, 2024.
Advisory Opinion No. 23-11
On December 27, the OIG published an Advisory Opinion regarding an arrangement in which the manufacturer of a device used to treat heart failure would subsidize patient cost-sharing for patients participating in a clinical trial involving the device. The manufacturer requested an opinion as to whether this would be grounds for the imposition of sanctions under the anti-kickback statute or the beneficiary inducements civil monetary penalties. The OIG said that while the arrangement may implicate both the anti-kickback statute and the beneficiary inducements civil monetary penalties, it would not impose sanctions in this case, as the arrangement is a reasonable means of promoting enrollment in the study, helps ensure the blind nature of the study, has various factors that distinguish it from problematic seeding arrangements, and more.
CLIA Fees: Histocompatibility, Personnel, and Alternative Sanctions for Certificate of Waiver Laboratories
On December 28, CMS published a Final Rule in the Federal Register in conjunction with the CDC regarding updates to CLIA fees and clarification on certain CLIA fee regulations. The rule implements a process for sustainable funding for the CLIA program through a biennial two-part increase of CLIA fees. It also incorporates limited/specific lab fees including fees for follow-up surveys, substantiated complaint surveys, and revised certificates. The rule finalized the distribution of administrative overhead costs of test complexity determinations for waived tests and test systems with a nominal increase in Certificate of Waiver fees. The rule includes amendments for histocompatibility and personnel regulations under CLIA that are obsolete and amendments to provisions governing alternative sanctions.
CMS published a Memorandum on the rule on the same date.
These regulations are effective January 27, 2024, except for certain instructions as noted in the rule.
Update to the Medicare Claims Processing Manual, Chapter 18, Sections 20.2, 60.3, and Chapter 32, Sections 50.4.1, 200.2 for Coding Revisions to the NCDs – April 2024 CR 13391
On December 28, CMS published Medicare Claims Processing Transmittal 12435 regarding updates to two chapters of the manual to add ICD-10 codes to NCD 220.4 (Mammograms), 210.3 (Colorectal Cancer Screening), 160.24 (Deep Brain Stimulation), and 160.18 (Vagus Nerve Stimulations).
Effective date: January 29, 2024
Implementation date: January 29, 2024
2024 Therapy Code List and Dispositions
On December 28, CMS published a Download Link for the 2024 Therapy Code List and Dispositions. The files have a list of codes that indicate whether they are sometimes or always therapy services.
Update to the Medicare Secondary Payer Manual, Chapter 2, Section 40.2 to Clarify the Liability Insurance Settlement Provisions
On December 28, CMS published Medicare Secondary Payer Transmittal 12436 regarding updates to Chapter 2, Section 40.2, paragraph E of the manual to clarify that a provider, physician, or other supplier may maintain a claim or lien against the liability insurance or beneficiary’s liability insurance settlement once the Medicare timely filing period has lapsed.
Effective date: January 29, 2024
Implementation date: January 29, 2024
Implementation of the New Home Intravenous Immune Globulin (IVIG) Items and Services Payment
On December 28, CMS published Medicare Claims Processing Transmittal 12437, which rescinds and replaces Transmittal 12252, issued November 2, to update BR 13217.7. The contractor shall reject claims for services (Q2052) when the place of service is not one of the following: 12, 13, 14, 32, or 33, and to add POS codes 04, 54, 55, and 56. The transmittal is no longer sensitive and is now being published on the internet. The original transmittal was issued to implement the new IVIG payment effective January 1, 2024.
Effective date: January 1, 2024
Implementation date: January 1, 2024