This week in Medicare updates—7/19/2023

Updated List of Laboratory Tests Subject to Exceptions to Laboratory Date of Service Policy

On July 10, CMS published the Download Link to the updated list of laboratory tests subject to exceptions to the lab date of service policy.

 

Period of Enhanced Oversight for New Hospices in Arizona, California, Nevada, and Texas

On July 11, CMS published an MLN Fact Sheet regarding information about a period of enhanced oversight for new hospices in Arizona, California, Nevada, and Texas. This affects hospices that received final approval for Medicare enrollment on or after July 13, 2023, or received approval for change of ownership on or after July 13. The fact sheet details when this oversight will start, how long this period will last, and more.

 

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 4th Qtr FY 2023

On July 11, CMS published Medicare Financial Management Transmittal 12123 regarding the updated interest rate for Medicare overpayments and underpayments. The latest private consumer rate has been changed to 11.50%.

Effective date: July 17, 2023

Implementation date: July 17, 2023

 

HCPCS Quarterly Update File

On July 11, CMS revised the July 2023 HCPCS Quarterly Update File. This file was previously revised on May 24.

 

Proposed Decision Memo: Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting

On July 11, CMS published a Proposed Decision Memo regarding the reconsideration of NCD 20.7 for PTA. CMS is proposing to cover PTA and carotid artery stenting (CAS) with embolic protection in patients with asymptomatic carotid artery stenosis ≥ 70% and in patients with symptomatic carotid artery stenosis ≥ 50%. The proposed coverage would expand coverage to individuals who were previously only eligible under clinical trials, allows coverage for beneficiaries at standard surgical risk, removes facility standards and approval requirements, and adds a formal shared decision-making interaction with the individual prior to the procedure. 

CMS is requesting comment on whether this shared decision-making interaction should require the use of a validated shared decision-making tool and whether there are other options to ensure truly informed decision-making. 

Comments are due by August 10.

 

Medicare Dental Coverage Webpage

On July 12, CMS published a new Webpage regarding Medicare dental coverage. The page reviews what Medicare covers, what Medicare doesn’t cover, the meaning of inextricably linked dental services, who can bill for these services, how to submit a claim, and more.

 

Proposed Decision Memo: Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent HIV Infection

On July 12, CMS published a Proposed Decision Memo regarding an NCD for coverage of PrEP using antiretrovirals for persons at high risk of HIV acquisition. CMS proposes covering PrEP to prevent HIV in individuals at high risk for HIV infection, and the determination as to the risk factor will be made by the physician/health care practitioner. CMS is also proposing coverage for up to seven individual counseling visits every 12 months to include HIV risk assessment, HIV risk reduction, and medication adherence. CMS would also cover HIV screening up to seven times annually and a single screening for hepatitis B. 

PrEP is currently covered under Part D but may have cost-sharing and deductibles. This proposal would cover PrEP under Part B as an additional preventive service without requiring Part B coinsurance or meeting the deductible. 

Comments on the proposed decision are due by August 11.

 

Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Excellus Health Plan Submitted to CMS

On July 12, the OIG published a Review of whether select diagnosis codes that Excellus Health Plan submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by sampling 210 unique enrollee years with the high-risk diagnosis codes for which Excellus received higher payments for 2017-2018. The OIG found that diagnosis codes for 202 of the 210 enrollee years did not comply with federal requirements because there was not sufficient support for those codes in the medical records. The OIG estimated that Excellus received approximately $5.4 million in overpayments during the audit period, but due to federal regulations that limit the use of extrapolation in risk adjustment data validation audits, the OIG is recommending a lower refund amount than the estimated $5.4 million.

The OIG recommended that Excellus refund the federal government for $3.1 million in estimated overpayments, identify and return similar overpayments, and continue to examine its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements. Excellus challenged the findings for two enrollee years and did not agree with the OIG’s audit methodology, use of extrapolation, standards for data accuracy, and medical review process. The OIG maintained that its findings and recommendations were valid except for a revision it made to its recommendations based on extrapolated overpayments, as CMS updated regulations for these audits to state overpayments can only be recouped starting with

 

CY 2024 Outpatient Prospective Payment System (OPPS) Proposed Rule

On July 13, CMS published a draft copy of the CY 2024 OPPS Proposed Rule, which is scheduled to be published in the Federal Register on July 31. The rule proposes updating outpatient payment rates by 2.8% for 2024 and proposes updating ambulatory surgical center (ASC) payments by 2.8% as well. One of the most extensive proposals in the rule aims to address gaps in behavioral health coverage in Medicare with the establishment of an Intensive Outpatient Program (IOP) benefit. This benefit would create a distinct outpatient program of psychiatric services for individuals with acute mental illness or substance use disorder. Payment would be made on a per diem basis, and CMS would create two IOP APCs–one for days with three services per day and the other for days with at least four services per day. IOPs may be furnished in hospital outpatient departments, CMHCs, FQHCs, and RHCs. CMS detailed physician certification requirements, coding and billing, and payment rates within the text of the rule.  

Other proposals in the rule include:

• Modifying price transparency requirements by standardizing the machine-readable file format and requiring hospitals to encode their standard charge information in a specific way, place a footer on the hospital homepage that links to the machine-readable file, and ensure that a .txt file is included that features the machine-readable file to make those more accessible to the public
• Continuing to pay for 340B drugs at ASP plus 6%
• Assigning approximately 230 dental codes to clinical APCs
• Adding 26 separately payable dental surgical procedures to the ASC covered procedures list (CPL) and 78 ancillary dental services to the list of covered ancillary services 
• Refining existing coding for remote mental health services to allow for multiple units to be billed daily, creating a new untimed code to describe group psychotherapy, and delaying in-person visit requirements until the end of CY 2024

CMS published a Press Release and Fact Sheet on the rule and a separate Fact Sheet on the price transparency proposals on the same date. Comments will be due by September 11.

 

CY 2024 Medicare Physician Fee Schedule (MPFS) Proposed Rule

On July 13, CMS published a draft copy of the CY 2024 MPFS Proposed Rule, which is scheduled to be published in the Federal Register on August 7. The rule proposes reducing the conversion factor from $33.89 in 2023 down to $32.75 in 2025, a 3.34% decrease. Some of the other proposals in the rule include:

• Delaying the implementation of the new time-based only definition of the “substantive portion” of a split/shared E/M visit through at least the end of CY 2024
• Reintroducing E/M add-on code G2211 for office visits to recognize the additional resource costs for complex patients, although CMS is revising some of the initial policies it had planned to include when this code was first proposed in the CY 2021 MPFS rule
• Implementing several telehealth policies from the Consolidated Appropriations Act of 2023, such as expanding the definition of telehealth practitioners, temporarily expanding the scope of telehealth originating sites, delaying requirements for in-person visits prior to initiating mental health telehealth services, and more
• Paying for telehealth services furnished to people in their homes at the non-facility rate beginning in CY 2024
• Increasing the threshold for the KX modifier to $2,330 (up $10 from the 2023 threshold of $2,320) and conducting targeted medical reviews for any subsequent expenses once a patient’s expenses reach $3,000

The rule also addresses topics such as diabetes screening tests, supervision requirements for remote therapeutic monitoring, dental payment policies, and more. 

CMS published a Press Release and Fact Sheet on the proposed rule, a Fact Sheet on Quality Payment Program changes, and a Fact Sheet on Medicare Shared Savings Program changes on the same date. Comments on the rule are due by September 11.