This week in Medicare updates--1/25/2023
CMS Statement on FDA Accelerated Approval of Lecanemab
On January 6, CMS published a Press Release regarding the FDA’s accelerated approval of Lecanemab, a monoclonal antibody that will be used as an Alzheimer’s Disease treatment. Because of the FDA accelerated approval, coverage of Lecanemab now falls under the already existing NCD 200.3 for this type of treatment. Should Lecanemab receive traditional FDA approval in the future, CMS will broaden coverage of the product accordingly.
January 2023 Integrated Outpatient Code Editor (I/OCE) Specifications Version 24.0
On January 10, CMS published Medicare Claims Processing Transmittal 11781, which rescinds and replaces Transmittal 11738, dated December 8, 2022, to replace the summary of data changes attachment. The original transmittal was published regarding the January 2023 updates to the I/OCE.
Effective date: January 1, 2023
Implementation date: January 3, 2023
HHS Announces Dates for First Year of the Inflation Reduction Act’s Medicare Drug Price Negotiation Program
On January 11, CMS published a Press Release and Memorandum regarding the timeline for the Medicare Drug Price Negotiation Program under the Inflation Reduction Act. The first 10 Medicare Part D drugs selected for the program will be announced on September 1, 2023. The negotiated maximum fair prices for these drugs will be announced by September 1, 2024. Prices will be effective starting January 1, 2026. The memo has more details about the intricacies of implementing this policy.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr FY 2023
On January 11, CMS published Medicare Financial Management Transmittal 11784 regarding the updated interest rate for Medicare overpayments and underpayments. The latest private consumer rate has been changed to 11.25%.
Effective date: January 18, 2023
Implementation date: January 18, 2023
FAQs on JW and JZ Modifier Policy
On January 12, CMS published an FAQ document regarding use of the JW and JZ modifiers, which will be used to report drug wastage. The FAQs address the overall policy, how the modifiers apply, billing concerns, and more.
January 2023 Update of the Ambulatory Surgical Center (ASC) Payment System
On January 17, CMS published Medicare Claims Processing Transmittal 11786, which rescinds and replaces Transmittal 11762, dated December 21, 2022, to add CPT codes 50970, 50972, and 50974 to Attachment A, table 2; delete code Q4228 from Attachment A, table 10; and to revise policy section B.1.a. The original transmittal was published regarding the January 2023 updates to the ASC payment system.
CMS published MLN Matters 13041 on the same date to accompany the transmittal.
Effective date: January 1, 2023
Implementation date: January 3, 2023
Updates to Face-to-Face Encounter and Written Order Prior to Delivery List
On January 17, CMS published a Notice in the Federal Register regarding updates to the list of HCPCS codes of DMEPOS items for which a face-to-face encounter and written order prior to delivery is required. The list includes 46 K-codes for power mobility devices and seven HCPCS codes for other items.
Dates: The implementation is effective on April 17, 2023.
Updated OIG Work Plan
On January 17, the OIG updated its Work Plan with the following new items:
- OIG Toolkit on Analyzing Telehealth Claims To Assess Program Integrity Risks
- Assessment of CMS's Early Use of Payroll-Based Journal Data To Improve Enforcement of Nursing Home Staffing Standards
- Access to Providers Prescribing or Dispensing Medications for Opioid Use Disorder in Medicare and Medicaid
- Assessment of the Special Focus Facility Program for Nursing Homes
- Medicare Advantage Organizations' Efforts To Reduce Racial and Ethnic Health Disparities
Updates to Strengthen Nursing Home Safety and Transparency
On January 18, CMS published a Memorandum to state survey agency directors regarding actions to reduce the inappropriate use of antipsychotic medications and to bring greater transparency about nursing home citations to families. In November 2022, the OIG published a report regarding concerning numbers of schizophrenia diagnoses in nursing homes that it suspected could be used to skirt monitoring of antipsychotic use in these facilities. In this memo, CMS announced it will be conducting audits of schizophrenia coding in the MDS data and will adjust Nursing Home Care Compare quality measure star ratings for facilities whose audits reveal inaccurate coding. CMS will also now post citations under informal dispute on the Nursing Home Care Compare website to provide more transparency to beneficiaries and their families about potential issues at these facilities.
CMS published a Press Release to accompany the memo on the same date.
Effective date: Immediately. Please communicate to all appropriate staff.
Revisions to Medicare Financial Management Manual to Regarding Debt Collection References
On January 19, CMS published Medicare Financial Management Transmittal 11787 regarding revisions to the manual to remove references to the now-retired Debt Collection System, add the HIGLAS Debt Management Module debt referral and Return to Agency related instructions, and revise debt close-out instructions.
Effective date: April 21, 2023
Implementation date: April 21, 2023
Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Opioid Treatment Programs (OTP) and Additional Claims Modifier for Audio-Only Services
On January 19, CMS published Medicare Benefit Policy Transmittal 11792 and Medicare Claims Processing Transmittal 11792 regarding revisions to the manuals to incorporate changes to OTP policies and claims modifiers as finalized in the CY 2023 Physician Fee Schedule Final Rule. This includes policies related to OTP mobile units, types of professionals who may furnish OTP services, an allowance to furnish the OTP intake add-on code via two-way audio-video communication in certain circumstances, and more.
Effective date: January 1, 2023
Implementation date: February 1, 2023
Updates of Chapters 4 and 8 in Medicare Program Integrity Manual, Including an Update to the Statistical Sampling Process, in Addition to Various Other Minor Updates
On January 19, CMS published Medicare Program Integrity Transmittal 11797 regarding updates to the manual to align with updates to the UPIC and Investigations Medicare Drug Integrity Contractor processes. This includes timelines regarding sending documentation, the use of statistical sampling, and more.
Effective date: February 21, 2023
Implementation date: February 21, 2023
Medicare Claims Processing Manual Updates for Ambulatory Surgical Centers (ASC)
On January 19, CMS published Medicare Claims Processing Transmittal 11793 regarding updates to the manual to incorporate policies from the ASC PPS final rule. The changes do not change or introduce any new policies–they simply manualize existing policies created or altered via the rule-making process.
Effective date: February 21, 2023
Implementation date: February 21, 2023
Revisions to Processing of Home Health Disaster-Related Claims and Contractor-Initiated Adjustments
On January 19, CMS published Medicare Claims Processing Transmittal 11796 to clarify home health agency (HHA) billing instructions to specify the correct situation for reporting condition code DR. This should only be reported when OASIS submission has been waived. The transmittal also modifies claims processing systems to ensure claims with condition code DR process correctly and to ensure the claims processing systems no longer send contractor-initiated adjustments with no covered visits to the Pricer.
CMS published MLN Matters 13020 on the same date to accompany the transmittal.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Better Protections Needed at Nursing Homes for Future Public Health Emergencies
On January 19, the OIG published a Data Brief, which is the second report in a three-part series of evaluations focusing on the impact of COVID-19 on Medicare beneficiaries in nursing homes. This data brief focused on rates of COVID-19 in nursing homes in 2020 and the characteristics of nursing homes with extremely high infection rates. The OIG found that more than 1,300 nursing homes had extremely high infection rates (75% or more residents infected) during 2020, and the surge in the fall of 2020–well after it was known that nursing homes were vulnerable–was worse than that in the spring of 2020. For-profit nursing homes made up 77% of the nursing homes with extremely high infection rates. Areas with high COVID-19 transmission rates did not always correlate to nursing homes in that area having high infection rates. Other characteristics varied by surge.
The OIG noted that this data shows that significant changes are needed to protect residents and better prepare nursing homes for future surges. The OIG recommends CMS re-examine current nursing staff requirements and revise them if necessary, improve how surveys identify infection control risks to nursing home residents and strengthen guidance on assessing the scope and severity of those risks, target nursing homes in most need of infection control intervention, and provide enhanced oversight and assistance to these facilities as appropriate.
January 2023 Update to the Hospital Outpatient Prospective Payment System (OPPS)
On January 20, CMS published Medicare Claims Processing Transmittal 11801, which rescinds and replaces Transmittal 11737, dated December 8, 2022, to update tables 5, 6, and add table 20 in order to update the pass-through status of five devices that will be extended pass-through status for a one-year period beginning on January 1, 2023. The original transmittal was published regarding the January 2023 updates to the OPPS.
CMS revised MLN Matters 13031 to accompany the transmittal.
Effective date: January 1, 2023
Implementation date: January 3, 2023