This week in Medicare—8/28/2024
The Recovery and Adjustment of Medicare Claims where the Department of Veteran Affairs (VA) also Made Payment Using the Medicare Duplicate Payment (DP) Process
On August 19, CMS published Medicare Secondary Payer Transmittal 12800, which rescinds and replaces Transmittal 12780, dated August 9, to upload an updated VADP file layout attachment.
The original transmittal was issued to provide updates to the Medicare Secondary Payer DP process to handle the recovery of duplicate payments when both Medicare and the VA made payments for the same services.
Effective date: January 1, 2025 - For CWF (requirements/coding/preliminary unit testing); for FISS (design/coding); for MCS (analysis/design/coding); for VMS (analysis & coding); April 1, 2025 - For CWF (testing/implementation); FISS (continued development/testing/implementation); MCS (continued coding/testing/implementation); and VMS (testing & implementation)
Implementation date: January 6, 2025 - For CWF (requirements/coding/preliminary unit testing); for FISS (design/coding); for MCS (analysis/design/coding); for VMS (analysis & coding); April 7, 2025 - For CWF (testing/implementation); FISS (continued development/testing/implementation); MCS (continued coding/testing/implementation); and VMS (testing & implementation)
Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) National Coverage Determination (NCD) 110.23
On August 21, CMS published Medicare National Coverage Determinations Transmittal 12781, which rescinds and replaces Transmittal 12627, dated May 9, and to update BRs 13604-04.2 and 13604-04.3 and remove BRs 13604-04.3.1 and 13604-04.4. The transmittal adds two ICD-10-PCS codes to the coding instructions for HSCT for MDS under NCD 110.23.
CMS also published Medicare Claims Processing Transmittal 12781, which rescinds and replaces Transmittal 12627, dated May 9, to detail the aforementioned changes.
The original transmittals were issued to announce expanded coverage for allogeneic HSCT using bone marrow, peripheral blood, or umbilical cord blood stem cell products for Medicare patients with MDS. CMS issued a final decision regarding this expanded coverage in March 2024.
CMS revised MLN Matters 13604 on the same date to accompany the transmittals.
Effective date: March 6, 2024
Implementation date: October 7, 2024
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for FY 2025
On August 21, CMS published Medicare Claims Processing Transmittal 12809 regarding the implementation of changes for IPFs as finalized in the FY 2025 IPF PPS final rule. This includes updates to payment rates, quality programs, and more.
CMS published MLN Matters 13766 on the same date to accompany the transmittal.
Effective date: October 1, 2024
Implementation date: October 7, 2024
Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations for the Medicare Benefit Policy Manual Chapter 15, Section 50.4.4.2
On August 21, CMS published Medicare Benefit Policy Transmittal 12801 regarding updated coverage requirements for pneumococcal vaccinations. CMS updated the Medicare coverage requirements to align with recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP). The updated requirements include information on vaccine administration, clinical guidance, underlying conditions, and more.
CMS published MLN Matters 12750 on the same date to accompany the transmittal.
Effective date: June 27, 2024
Implementation date: November 25, 2024
Instructions for Retrieving the January 2025 Medicare Physician Fee Schedule Database (MPFSDB) Files Through the CMS Mainframe Telecommunications System
On August 22, CMS published Medicare Claims Processing Transmittal 12802 regarding instructions for the Medicare contractors to download, test, and implement the annual January MPFSDB update files.
Effective date: January 1, 2025
Implementation date: January 6, 2025
New Waived Tests
On August 22, CMS published Medicare Claims Processing Transmittal 12808 to inform contractors of a new test approved by the FDA as a waived test under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The HCPCS code for the newly approved test is 87521QW, and it must have modifier QW to be recognized as a waived test.
Effective date: October 1, 2024
Implementation date: October 7, 2024
FY 2025 IPPS and Long-Term Care Hospital (LTCH) PPS Changes
On August 22, CMS published Medicare Claims Processing Transmittal 12805 regarding the implementation of policies and rate changes finalized through the FY 2025 IPPS and LTCH PPS final rule. The transmittal instructs the MACs on which files and systems to update with these changes and provides links to where the data files, tables, and implementation files can be accessed.
Effective date: October 1, 2024
Implementation date: October 7, 2024
Revisions and Clarifications for Survey and Certification Activities for the Outpatient Physical Therapy (OPT)/Speech-Language Pathology (SLP) Programs
On August 23, CMS published a Memorandum to state survey agency directors regarding survey and certification expectations for OPT/SLP programs related to extension locations. CMS provided additional guidance for the following four areas:
- Primary site and extension location surveys
- Surveying all extension locations
- Surveying all Conditions of Participation at extension locations
- Extension locations beyond the 30-mile radius
The agency is currently in the process of revising Chapter 2 of the Medicare State Operations Manual to reflect these changes.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the State/CMS Location training coordinators within 30 days of this memorandum.
OIG Advisory Opinion No. 24-07
On August 23, the OIG published an Advisory Opinion regarding a proposed arrangement involving a patient assistance program (PAP) operated by a nonprofit grant-making organization. The nonprofit was created by the net proceeds of the sale of a nonprofit hospital, and its mission is to improve the health and wellbeing of residents located in the rural former service area of the hospital. The requestor reported that many Medicare enrollees who reside in the service area are low-income and often forgo filling their prescriptions due to the cost of doing so.
Under the proposed arrangement, the requestor would establish a PAP through which it would subsidize participating patients’ cost-sharing obligations (deductibles, copayments, etc.) for all FDA-approved prescription medications used to treat diabetes and covered by Medicare Part D. The PAP would provide this financial assistance to patients in the service area who meet specific criteria on a first-come, first-served basis for so long as funding remains available in a given calendar year. The requestor is seeking an opinion as to whether this arrangement constitutes grounds for the imposition of sanctions under the federal anti-kickback statute or civil monetary penalties related to beneficiary inducements.
The OIG ruled that although the arrangement would generate prohibited remuneration under the anti-kickback statute and beneficiary inducements civil monetary penalty if the requisite intent were present, it would not impose sanctions.