This week in Medicare—8/21/2024
Medicare Improperly Paid Hospitals an Estimated $79 Million for Enrollees Who Had Received Mechanical Ventilation
On August 12, the OIG published a Report on Medicare payment for mechanical ventilation claims between October 2015 and September 2021. After identifying certain compliance issues through previous audits, the OIG set out to evaluate whether Medicare payments to hospitals for inpatient claims with specific Medicare Severity Diagnosis-Related Groups (MS-DRG) for mechanical ventilation complied with Medicare requirements.
The OIG selected a stratified random sample of 250 claims with payments totaling approximately $11 million. The claims were assigned to MS-DRGs 207 or 870 and had a potential procedure length of five to 10 days. Out of the 250 sampled claims, 17 did not comply with Medicare requirements, which resulted in $382,032 in overpayments.
Based on its findings, the OIG estimated that Medicare improperly paid hospitals $79.4 million for all mechanical ventilation claims over the course of the audit period. The OIG recommended for CMS to direct Medicare Administrative Contractors to recover the identified overpayments in the report, as well as educate hospitals on correct coding and hour-counting practices for mechanical ventilation.
A Prescriber’s Guide to Medicare Prescription Drug (Part D) Opioid Policies
On August 12, CMS updated an MLN Fact Sheet on Medicare Part D opioid policies. Effective January 1, 2025, CMS is expanding the definition of an exempted patient being treated for cancer-related pain to include patients undergoing active cancer treatment and cancer survivors. The agency clarified that “cancer survivors” can refer to patients with chronic pain who’ve completed cancer treatment, patients in clinical remission, and patients under cancer surveillance only.
Updated OIG Work Pan
On August 15, the OIG updated its Work Plan with the following new items:
- Healthcare Facilities and Geographic Areas With Potentially Limited Response Capabilities During the 2024 Hurricane Season
- Audit of Medicare Claim Lines for Which Payments Exceeded Charges
- Joint Pain Management Therapies: Hyaluronic Acid Knee Injections
Updates to Chapter 1 of the Medicare Claims Processing Manual (Publication 100-04) to Include Newly Created and Utilized Payer Only Codes
On August 15, CMS published Medicare Claims Processing Transmittal 12789 to add newly created and utilized payer codes to Chapter 1 of the Medicare Claims Processing Manual. The transmittal includes updates to the list of condition codes, value codes, and modifiers.
Effective date: September 16, 2024
Implementation date: September 16, 2024
Quarterly Update to Home Health Grouper
On August 15, CMS published Medicare Claims Processing Transmittal 12793 regarding the January 2025 update to the Home Health Grouper.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes Used for Home Health Consolidated Billing Enforcement
On August 15, CMS published Medicare Claims Processing Transmittal 12794 regarding the January 2025 update to the list of HCPCS codes used to enforce consolidated billing of home health services. This update adds 71 new codes and changes the description for three existing codes.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Influenza Vaccine Payment Allowances – Annual Update for 2024-2025 Season
On August 15, CMS published Medicare Claims Processing Transmittal 12788 regarding the annual update to payment allowances for the influenza vaccine. Part B payment for the vaccine is based on 95% of average wholesale price (AWP) except when furnished in hospital outpatient departments, rural health clinics, or federally qualified health centers, where payment is based on reasonable cost.
The influenza vaccine payment allowances for the 2024-2025 season are available on CMS’ Seasonal Influenza Vaccines Pricing web page.
Effective date: August 1, 2024
Implementation date: September 30, 2024
Annual Clotting Factor Furnishing Fee Update 2025
On August 15, CMS published Medicare Claims Processing Transmittal 12795 regarding the annual update to the clotting factor furnishing fee. The 2025 clotting factor furnishing fee is $0.258 per unit, which is an increase from the 2024 fee of $0.250.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Fourteenth General Update to Provider Enrollment Instructions in Chapter 10 of CMS Publication (Pub.) 100-08
On August 15, CMS published Medicare Program Integrity Transmittal 12796 to clarify certain Medicare provider enrollment policies and revise various model letters. Of note, the transmittal provides guidance to hospices on out-of-state operations, establishing new locations, mergers/acquisitions, and more.
Effective date: September 16, 2024
Implementation date: September 16, 2024
A Social Determinants of Health Risk (SDOH) Assessment in the Annual Wellness Visit (AWV) Policy Update in the Calendar Year (CY) 2024 Physician Fee Schedule Final Rule
On August 15, CMS published Medicare Benefit Policy Transmittal 12786, which rescinds and replaces Transmittal 12599, dated May 2, to clarify that HCPCS code G0136 is processed using the Physician Fee Schedule by revising BRs 13486 - 04.2 and 13486 - 04.4.
The original transmittal was issued to communicate policy updates in the CY 2024 Physician Fee Schedule final rule concerning risk assessments in AWVs.
CMS updated MLN Matters 13468 on the same date to accompany the updated transmittal.
Effective date: January 1, 2024 - Effective date of policy, per CY 2024 PFS Final Rule
Implementation date: October 7, 2024
Medicare Drug Price Negotiation Program: Negotiated Prices for Initial Price Applicability Year 2026
On August 15, CMS published a Press Release and Fact Sheet to announce it has reached an agreement for new, lower prices for all 10 drugs selected for negotiations. The new prices will go into effect for people with Medicare Part D prescription drug coverage beginning January 1, 2026.
CMS previously announced the first 10 drugs covered under Medicare Part D selected for the first cycle of negotiations in August 2023. Nearly nine million Medicare beneficiaries use at least one of the 10 drugs selected for negotiation. CMS projects Medicare beneficiaries will save a total of $1.5 billion in their out-of-pocket costs in 2026.
PrEP for HIV Transition of Coverage: Get Ready Now
On August 15, CMS published a Note in MLN Connects regarding the final national coverage determination (NCD) for preexposure prophylaxis (PrEP) using antiretroviral drugs to prevent HIV. CMS expects to release the final NCD to transition coverage of PrEP for HIV from Part D to Part B in late September of this year.
The agency encourages pharmacies and other parties to prepare for this transition by visiting the PrEP for HIV & Related Preventive Services web page.