This week in Medicare—7/17/2024
Updated FAQ: General Questions Regarding Certain Fraud and Abuse Authorities
On July 8, the OIG published an updated FAQ on general topics regarding certain fraud and abuse authorities. The OIG updated the document to address four additional questions relating to financial assistance policies, advertisements and solicitations, and other pertinent topics.
June 2024 Livanta Claims Review Advisor
On July 8, Livanta published the June 2024 edition of its Claims Review Advisor. This edition addresses the correct reporting of neoplasms on Medicare Part A claims. Livanta provided documentation, query, and coding guidelines related to neoplasms. The guidelines touch on leukemia, lymphoma, solid organ neoplasms, complications, remission, history, and more.
CY 2025 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System (ASC PPS) Proposed Rule
On July 10, CMS published a draft copy of the CY 2025 OPPS and ASC PPS Proposed Rule, which is scheduled to be published in the Federal Register on July 22. CMS proposed a 2.6% update to both OPPS and ASC PPS payment rates for CY 2025, which is slightly less than the 2.8% payment rate update that was finalized for CY 2024 payments.
The rule includes a proposal on implementing Section 4135 of the Consolidated Appropriations Act, 2023, which would provide temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department and ASC settings from January 1, 2025, through December 31, 2027. The provisions related to this proposal involve evidence requirements for medical devices, ways to calculate the payment to stay under the statutory limit of 18% of the OPPS payment for OPPS service or group of services with which the non-opioid treatment for pain relief is furnished, and more.
Other proposals in the rule include the following:
- Maintaining the current rate structure for both intensive outpatient program (IOP) and partial hospitalization program (PHP), and using CY 2023 claims data for rate setting
- Aligning OPPS payment for services furnished remotely by hospital staff to individuals in their homes with those associated with Medicare telehealth and billed under the PFS
- Revising eligibility criteria for the special enrollment period for formerly incarcerated individuals, and refining the definition of “custody” to exclude individuals who are on parole, probation, and home detention, as this would facilitate access to Medicare payment for health care items and services furnished to these patients
- Changing Conditions of Participation for obstetric and emergency services to align with the administration’s goals to improve maternal care and outcomes
CMS published a Fact Sheet and Press Release on the rule on the same date. Comments are due by September 9.
CY 2025 Medicare Physician Fee Schedule (MPFS) Proposed Rule
On July 10, CMS published a draft copy of the CY 2025 MPFS Proposed Rule, which is scheduled to be published in the Federal Register on July 31. The rule proposes reducing the conversion factor from $33.29 in CY 2024 to $32.36 in CY 2025, marking a 2.8% decrease.
Notable proposals in the rule include the following:
- Establishing new HCPCS codes GCTD1, GCTD2, and GCTD3 and payment for caregiver training for direct care services and supports
- Extending certain telehealth flexibilities through 2025, including the waiver allowing federally qualified health centers and rural health clinics to bill for telehealth services.
- Expanding payments for opioid treatment programs for new FDA-approved overdose reversal medications
- Establishing new HCPCS add-on code GIDXX to describe the intensity and complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease performed by a physician with specialized training in infectious diseases
The rule also addresses topics such as supervision, dental services, Part B drugs and biological products, and more.
CMS published a Press Release and Fact Sheet on the proposed rule, as well as a Fact Sheet on Medicare Shared Savings Program changes, on the same date. Comments are due by September 9.
Clarification of Medical Director Board Certification Requirements
On July 10, CMS published a Memorandum to state survey agency directors regarding board certification requirements for dialysis facility medical directors. CMS expects the board certifying the physician to be a nationally recognized professional board, while not explicit on the particular Board from which the certification must be obtained.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 4th Quarter Notification for FY 2024
On July 11, CMS published Medicare Financial Management Transmittal 12715 regarding the updated interest rate for Medicare overpayments and underpayments. The latest private consumer rate has been changed to 11.875%.
Effective date: July 17, 2024
Implementation date: July 17, 2024
New State Codes for Arizona, California, Nevada, and Texas
On July 11, CMS published One-Time Notification Transmittal 12716, which rescinds and replaces Transmittal 12702, dated June 27, to clarify the NCH and CVM implementation timeframe by revising the effective and implementation dates and adding BR 13685.1.1.
The original transmittal was issued to announce new hospice state codes for Arizona, California, Nevada, and Texas.
Effective date: July 1, 2024; July 26, 2024 - NCH and CVM will implement this change to coincide with the NCH weekly and monthly process. Additionally, NCH cannot make a coding change with less than 30 days’ notice
Implementation date: July 1, 2024; July 26, 2024 - NCH and CVM will implement this change to coincide with the NCH weekly and monthly process. Additionally, NCH cannot make a coding change with less than 30 days’ notice
Accommodating 10-Digit Dollar Amounts on All Part A Medicare Summary Notices (MSNs)
On July 11, CMS published Medicare Claims Processing Transmittal 12712 to update how dollar amounts are displayed on all Part A MSNs. The transmittal gives instructions to contractors on accommodating 10-digit dollar amounts by using the See Notes Below functionality.
Effective date: January 1, 2025
Implementation date: January 6, 2025
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the State of Texas
On July 12, CMS published a News Alert to announce additional resources and flexibilities available in response to Hurricane Beryl in Texas. CMS detailed the waivers, special enrollment opportunities, dialysis care, DMEPOS replacements, and other resources available for those impacted by the hurricane.