Knowledge Base Article
August 2024 Monthly Medicare Updates
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August 2024 Monthly Medicare Updates
Friday, August 30, 2024
Medicare Transmittals & MLN Articles
August 5, 2024: MLN MM13706: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2025 Update
Make sure key stakeholders are aware of new codes and recent coding changes that will be effective January 1, 2025. Change Request (CR) 13706 includes the following NCDs and NCD specific updates:
- 20.33 TMVR/TEER: Effective January 1, 2025, any existing edits that require ICD-10 I34.0 and I34.1 be listed as primary will be deleted, along with clinical trial ICD-10 Z00.6 as secondary. These codes can appear in any position, and
- 210.10 STIs: June 30, 2024 is the end date for CPT 0353U. Effective July 1, 2024 add CPT 0455U (used for combined chlamydia and gonorrhea testing).
Also, CR 13706 removed the delayed termination of the Appropriate Use Criteria (AUC) Program modifiers with an effective date for the AUC modifier removal noted as being January 1, 2025. https://www.cms.gov/files/document/mm13706-icd-10-other-coding-revisions-national-coverage-determinations-january-2025-update.pdf
August 6, 2024: MLN MM13707: Hospice Payments: FY 2025 Update
This article provides information about payment rates, inpatient and aggregate caps, and wage index updates effective October 1, 2024. https://www.cms.gov/files/document/mm13707-hospice-payments-fy-2025-update.pdf
August 6, 2024: MLN MM13632: Hospital Outpatient Prospective Payment System: July 2024 Update - Revised
In this second iteration of this MLN article, CMS updated the number of certain drugs, biologicals, and radiopharmaceuticals and added new subsections g and j in Section 7. Substantive content changes are in dark red. https://www.cms.gov/files/document/mm13632-hospital-outpatient-prospective-payment-system-july-2024-update.pdf
August 19, 2024: MLN MM13486: Annual Wellness Visit: Social Determinants of Health Risk Assessment - Revised
This article was initially released May 3, 2024. In this update CMS has clarified that MACs will process G0136 using the Physician fee Schedule. https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf
August 21, 2024: MLN MM13750: Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations Policy
Make sure your billing staff knows about updated Medicare coverage requirements for pneumococcal vaccinations and changes to align with the Advisory Committee on Immunization Practices (ACIP) recommendations for pneumococcal vaccination coverage. https://www.cms.gov/files/document/mm13750-revisions-medicare-part-b-coverage-pneumococcal-vaccinations-policy.pdf
August 22, 2024: MLN MM13766: Inpatient Psychiatric Facilities Prospective Payment System: FY 2025 Updates
This article highlights key information for your billing staff for FY 2025, for example the refinements to adjustment factors and electroconvulsive therapy (ECT) payment per treatment. https://www.cms.gov/files/document/mm13766-inpatient-psychiatric-facilities-prospective-payment-system-fy-2025-updates.pdf
August 26, 2024: MLN MM13757: New Waived Tests
Make sure your billing staff knows about Clinical Laboratory Improvement Amendments (CLIA) requirements, the one new CLIA-waived test approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13757-new-waived-tests.pdf
August 29, 2024: MLN MM13734: Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2025 Changes
This thirteen-page article provides updates that will be effective October 1, 2024. For example, regarding the Hospital-Acquired Condition (HAC) Reduction Program, CMS expects to issue the final list of hospitals that are subject to the HAC Reduction Program for FY 2025 to MACs in mid-September 2024. https://www.cms.gov/files/document/mm13734-inpatient-long-term-care-hospital-prospective-payment-system-fy-2025-changes.pdf
Coverage Updates
August 5, 2024: CMS Prior Authorization and Pre-Claim Review Initiatives Update
CMS is removing CPTs 64492 and 64494 from the list of codes that require prior authorization as a condition of payment. According to the revised Local Coverage Determinations for Facet Joint Interventions, three or four-level procedures are not medically necessary and non-covered. Therefore, the decision on the prior authorization request will always be non-affirmative, so submitting the request would be unnecessary. The full list of HCPCS codes has been updated to reflect this change. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
August 7, 2024: Final Notice – Transitional Coverage for Emerging Technologies (TCET) (CMS-3421-FN)
CMS announced in the August 8, 2024, edition of MLN connects that CMS has issued a final procedural notice outlining a Medicare coverage pathway to achieve more timely and predictable access to certain new medical technologies for people with Medicare. The new TCET pathway for certain FDA-designated Breakthrough Devices increases the number of National Coverage Determinations (NCDs) that CMS will conduct per year and supports both improved patient care and innovation by providing a clear, transparent, and consistent coverage process while maintaining robust safeguards for the Medicare population.
Link to August 8, 2024, MLN Connects: https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-08-08-mlnc
August 21, 2024: MLN MM13604: National Coverage Determination 110.23: Allogeneic Hematopoietic Stem Cell Transplantation – Revised
This MLN article was revised to add two procedure codes to the coding instructions (XW133C8 and XW143C8). https://www.cms.gov/files/document/mm13604-national-coverage-determination-11023-allogeneic-hematopoietic-stem-cell-transplantation.pdf
Compliance Education Updates
August 12, 2024: OIG Report: Medicare Improperly Paid Hospitals an Estimated $79M for Enrollees Who Had Received Mechanical Ventilation
OIG performed this audit due to prior OIG audits finding hospitals did not fully comply with Medicare requirements for MS-DRGs that require enrollees to have received 96 or more consecutive hours (i.e., 4 days or more) of mechanical ventilation. This audit specifically evaluated if claims reporting a mechanical ventilation start date that was 5 to 10 days before the enrollee discharge date were at risk for billing errors. The audit included inpatient claims with dates of service from October 2015 through September 2021 that were grouped to MS-DRGs 207 and 870. They found that for 17 of 250 sampled claims hospitals did not comply with requirements. Based on this finding, the OIG estimated that Medicare improperly paid hospitals $79.4M for the audit period. CMS concurred with OIG recommendations to recover the identified overpayments and continue to educate providers to reinforce requirements for billing mechanical ventilation. https://oig.hhs.gov/documents/audit/9957/A-09-22-03002.pdf
August 2024: MLN Fact Sheet MLN2886155: A Prescriber’s Guide to Medicare Prescription Drugs (Part D) Opioid Policies – Revised
This MLN Fact Sheet was revised in August to add information on the expansion of the exempted patient definition. 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,
- Cancer survivors:
- With chronic pain who’ve completed cancer treatment,
- In clinical remission, and
- Under surveillance only.
MLN Booklet MLN909188: Chronic Care Management Services – Revised
Earlier in May 2024, this MLN Booklet was revised to add new codes describing chronic pain management and treatment and added information about other care management services. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
Other Updates
August 1, 2024: FY 2025 Hospital IPPS and LTCH PPS Final Rule (CMS-1808-F)
For FY 2025, the increase in operating payment rates for acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) program and are meaningful electronic health record (EHR) users is 2.9%.
Link to Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2025-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0
August 13, 2024: CMS Memorandum: Updated Model Signage for the Emergency Medical Treatment and Labor Act (EMTALA)
In the memorandum summary, CMS notes that they are “dedicated to safeguarding the health and safety of millions of individuals, a commitment that includes enforcing federal laws including EMTALA.” Further, CMS regulations require Medicare-participating hospitals to post signage outlining patients’ rights under EMTALA in the emergency department and areas where patients will be examined or treated, or wait to be examined or treated, for emergency medical conditions (EMCs). CMS is releasing updated model signage that hospitals may use to meet this obligation.” https://www.cms.gov/files/document/qso-24-17-emtala.docx
August 13, 2024: CMS Posts Content for Health Care Providers in Preparation of Coverage Transition from Part D to Part B of Antiretroviral Drugs to Prevent HIV
CMS is encouraging pharmacies and other affected parties to prepare now for this expected transition. They expect to release the final National Coverage Determination (NCD) in late September 2024. Coverage under Part B will begin once the final NCD is released. https://www.cms.gov/medicare/coverage/prep
August 15, 2024: HHS Press Release: Negotiating for Lower Drug Prices Works, Saves Billions
HHS announced agreements for new lower prices for 10 drugs that are “some of the most expensive and most frequently dispensed drugs in the Medicare program and are used to treat conditions such as heart disease, diabetes, and cancers.” New prices go into effect January 1, 2026 for people with Medicare Part D prescription drug coverage. CMS will continue to select up to 15 more drugs for 2027 and 2028, and up to 20 more drugs each year after that, as required by the Inflation Reduction Act (IRA).
Additional resources were included in the Thursday, August 15, 2024 edition of MLN Connects at https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-08-15-mlnc
August 2024: CMS FAQs about Add-on HCPCS Code G2211
CMS has published an FAQ document about office/outpatient (O/O) evaluation and management (E/M) visit complexity add-on HCPCS code G2211 (visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)). https://www.cms.gov/files/document/hcpcs-g2211-faq.pdfThis material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.
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