This week in Medicare updates—7/12/2023
Telehealth Services
On July 5, CMS revised an MLN Fact Sheet on telehealth services (backdated to June 2023) to make extensive updates regarding recent policy changes. The booklet discusses how Medicare defines telehealth, originating sites, and distant sites. It reviews when COVID-19 flexibilities will end for these services and outlines current telehealth requirements. It also reviews the coding for telehealth home health services and the consent requirements for care management and virtual communication services.
2024 Release of ICD-10-CM Codes
On July 5, the CDC published the FY 2024 ICD-10-CM codes and coding guidelines, which are effective October 1, 2023. The update includes 395 new codes, 25 deletions, and 13 revisions. Changes also include instructions to report Z11.52 (encounter for screening for COVID-19) for preoperative COVID-19 screening tests.
July 2023 Update of the Ambulatory Surgical Center (ASC) Payment System
On July 5, CMS published Medicare Claims Processing Transmittal 12122, which rescinds and replaces Transmittal 12099, dated June 22, to correct the ASC payment indicator for HCPCS J9322 in attachment A, table 3 to K5. It also corrects the corresponding number of separately payable drugs in policy section 5.a to 18. The original transmittal was published regarding the July 2023 updates to the ASC payment system. This is the fourth time the transmittal has been revised in the past month.
CMS revised MLN Matters 13216 on the same date to accompany the transmittal.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Broader Medicare Coverage of Leqembi Available Following FDA Approval
On July 6, CMS published a Press Release announcing that broader coverage of the Alzheimer’s drug, Leqembi, is now available under Medicare after the FDA granted traditional approval for the drug on the same date. The FDA found in a Phase 3 trial that Leqembi delayed cognitive decline by 5.3 months compared to a placebo. Medicare will now cover the drug for beneficiaries who have mild cognitive impairment with documented evidence of beta-amyloid plaque on the brain and who have a physician participating in a qualified registry.
CMS published a link to the CMS-facilitated registry as well as additional information for providers on their website.
Adverse Events Toolkits: Medical Review Methodology and Clinical Guidance for Identifying Patient Harm
On July 6, the OIG published two Adverse Events toolkits for hospitals and researchers to use as reference material to understand how the OIG identifies and tracks harm in facilities. One of the documents included, the Medical Record Review Methodology Toolkit, explains the OIG’s methodologies for conducting medical record reviews and includes tips on overcoming common challenges. The other document, the Clinical Guidance Toolkit, serves as a compendium of guidance for assessing the care associated with 29 specific types of conditions and injuries.
Biden Administration Announces New Actions Against Scam Insurance Plans, Surprise Billing, Drug Costs
On July 7, the White House published a Fact Sheet regarding new initiatives by the Biden administration to confront various healthcare coverage and cost issues. As part of this initiative, the administration is targeting facility fees by saying that health plans and providers must make information about facility fees publicly available to consumers as well as other price information about the services and items they provide. The administration also said it is taking action against nonparticipating providers who attempt to evade protections under the No Surprises Act by renaming charges as facility fees.
The fact sheet also stated the administration is cracking down on what it calls the abuse of the “in-network” designation by saying these services are either subject to surprise billing protections if out-of-network or are subject to the ACA’s annual limits on cost-sharing if in-network. The initiatives also target unfair medical debt as well as short-term insurance plans that are essentially scams.
These actions coincide with the release of a report showing that the out-of-pocket spending cap on prescription drugs for Part D enrollees that is slated to start in 2025 will save Medicare enrollees an average of $400 per year. CMS published a Press Release on the drug cost data and other initiatives on the same date.
Proposed Rule: Remedy for 340B Drug Payment Policy for CYs 2018-2022
On July 7, CMS published a Draft Copy of a proposed rule regarding a remedy for the Medicare payment rates for drugs acquired under the 340B program from CYs 2018-2022. The Supreme Court found that Medicare’s rates for those drugs at average sales price (ASP) minus 22.5% was unlawful, and payment was restored to ASP plus 6% effective September 28, 2022. CMS determined that while the unlawful payment rate was in effect, providers received $9 billion less than they otherwise would have. As a remedy for drugs acquired through the 340B program from January 1, 2018 - September 27, 2022, CMS will make a one-time lump-sum payment to each 340B-covered entity hospital that received lower payments. CMS will also make the lump sum payment for the 20% beneficiary copayments for these drugs, and hospitals therefore cannot bill beneficiaries for that coinsurance on remedy payments.
CMS said that hospitals were paid $7.8 billion more for non-drug items and services during CYs 2018-2022 due to the change in the 340B payment policy. In an attempt to maintain budget neutrality, CMS is proposing to reduce future non-drug item and service payments by adjusting the OPPS conversion factor by -0.5% starting in CY 2025 until the adjustment reaches the entire $7.8 billion amount, which CMS estimates will take 16 years.
Comments on this proposed rule are due by September 11. CMS published a Fact Sheet on the rule on July 7. The rule was published in the Federal Register on July 11.
CY 2024 Home Health Prospective Payment System (HH PPS) Proposed Rule
On July 10, CMS published the CY 2024 HH PPS Proposed Rule in the Federal Register. The rule proposes to rebase and revise the home health market basket for the first time since CY 2019, recalibrate PDGM case-mix weights and the LUPA thresholds using CY 2022 data, codify the statutory requirements for negative pressure wound therapy (NPWT) which provide separate payment for the device only, and more.
CMS estimates that the aggregate home health payment update will be -2.2% for CY 2024 due in large part to an estimated 5.1% decrease that is required by statute to account for effects from behavior changes resulting from the switch to PDGM.
CMS published a Fact Sheet on the rule on June 30. Comments are due by August 29.