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Medicare Transmittals & MLN Articles

November 5, 2024: MLN MM13818: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2025 Update (CR 1 of 2)

CMS advises making sure your billing staff knows about newly available codes, recent coding changes, and National Coverage Determination (NCD) coding information. https://www.cms.gov/files/document/mm13818-icd-10-other-coding-revisions-national-coverage-determinations-april-2025-update-cr-1-2.pdf

November 5, 2024: MLN MM13828: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2025 Update (CR 2 of 2)

CMS advises making sure your billing staff know about the same updates as in MLN article (MM13818). https://www.cms.gov/files/document/mm13828-icd-10-other-coding-revisions-national-coverage-determinations-april-2025-update-cr-2-2.pdf

November 6, 2024: MLN MM13858: New Waived Tests

This article provides information about the new waived test approved by the FDA that will be effective January 1, 2025. https://www.cms.gov/files/document/mm13858-new-waived-tests.pdf

November 8, 2024: MLN MM13796: Medicare Deductible, Coinsurance, & Premium Rates: CY 2025 Update

This article includes Medicare Part A and Part B deductible, Part A and Part B coinsurance rates, and Part A and Part B premiums effective January 1, 2025. https://www.cms.gov/files/document/mm13796-medicare-deductible-coinsurance-premium-rates-cy-2025-update.pdf

November 22, 2024: MLN MM13846: Medicare Change of Status Notice Instructions (Expedited Determinations When a Patient is Reclassified from an Inpatient to an Outpatient Receiving Observation Services)

Hospitals (including Critical Access Hospitals) need to make sure your staff knows about:

• Appeal rights for eligible Medicare patients reclassified from an inpatient to outpatient receiving observation services,
• Medicare Change of Status Notice (MCSN) delivery requirements, and
• New Section 450 to the Medicare Claims Processing Manual, Chapter 30.

https://www.cms.gov/files/document/mm13846-medicare-change-status-notice-instructions.pdf

November 25, 2024: MLN MM13887: Medicare Physician Fee Schedule Final Rule Summary: CY 2025

Make sure your billing staff knows about change to the following services:

• Telehealth,
• Caregiver training,
• Therapy,
• Cardiovascular risk assessment and management,
• Evaluation and management (E/M),
• Behavioral Health,
• Advanced Primary Care Management (APCM),
• Global Surgery Payment, and
• Dental and Oral Health.

  https://www.cms.gov/files/document/mm13887-medicare-physician-fee-schedule-final-rule-summary-cy-2025.pdf

   

  Coverage Updates

  November 15, 2024: CMS National Coverage Determination (NCD) Dashboard Updated

  As of November 14, 2024, there are eight topics on the NCD wait list, four open NCDs, and two NCDs finalized in the past twelve months. https://www.cms.gov/files/document/ncddashboard2024.pdf

   

  Compliance Education Updates

  November 2024: MLN Booklet (MLN907166) Global Surgery Revised

  This booklet has been reviewed to add information about modifiers and about new G-code, HCPCS code G0559, for post-operative care services provided by a practitioner other than the one who performed the surgical procedure (or another practitioner in the same group practice). https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

   

  Other Updates

  November 1, 2024: Calendar Year (CY 2025 Medicare Physician Fee Schedule (PFS) Final Rule

  CMS finalized their proposal to establish coding and payment under the PFS for a new set of Advanced Primary Care Management Services (APCM) described by three new HCPCS G-codes (G0556, G0557, G0558). The finalized APCM incorporates elements of several existing care management and communication technology-based services. However, unlike existing care management codes, there are no time-based thresholds included in the service elements, which is intended to reduce the administrative burden associated with coding and billing. Instead, the new APCM codes are stratified into three levels based on an individual’s number of chronic conditions and status as a Qualified Medicare Beneficiary, reflecting the patient’s medical and social complexity. You can read additional high level summary of this final rule in a related CMS Fact Sheet at https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-final-rule and CMS Press Release at https://www.cms.gov/newsroom/press-releases/hhs-finalizes-physician-payment-rule-strengthening-person-centered-care-and-health-quality-measures

  November 1, 2024: CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (1809-FC)

  CMS is finalizing an update to OPPS payment rates of 2.9% for hospitals that meet applicable quality reporting requirements. Policies in this final rule will affect approximately 3,500 hospitals and approximately 6,100 ASCs.

   

  Following are the changes being made to the Medicare Inpatient Only (IPO) Procedure list effective January 1, 2025 as listed in Table 138 in the final rule:

   

  CPT Codes to be Added to IPO List

• 0894T (Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device decannulation of the liver allograft following normothermic perfusion)
• 0895T (Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary)
• 0896T (Connection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour, including physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile PH, bile glucose, biliary bicarbonate, lactate levels, macroscopic

   

  CPT Removed from the IPO List

• 22848 (Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)

You can read a high level summary of this final rule in a related CMS Press Release at https://www.cms.gov/newsroom/press-releases/cms-announces-new-policies-reduce-maternal-mortality-increase-access-care-and-advance-health-equity.

November 1, 2024: Calendar Year 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule (CMS-1805-F)

For CY 2025, CMS is increasing the ESRD PPS base rate to $273.82, which CMS expects will increase total payments to all ESRD facilities, both freestanding and hospital-based, by approximately 2.7%. This final rule also includes changes to the methodology for calculating the ESRD facility wage index, changes to the Low-Volume Payment Adjustment (LVPA) methodology, and several changes to the ESRD outlier policy. You can read more in a related CMS Fact Sheet at https://www.cms.gov/newsroom/fact-sheets/calendar-year-2025-end-stage-renal-disease-esrd-prospective-payment-system-pps-final-rule-cms-1805-f.

November 4, 2024: CMS Update to Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Initiative

CMS is changing the review timeframe for standard prior authorization decision from 10 business days to 7 calendar days for requests submitted on or after January 1, 2025. The timeframe for expedited requests remains 2 business days. 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

Note, this change in the review timeframe will also go into effect for the Prior Authorization Process for Certain DMEPOS Items and Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport Initiative.

November 8, 2024: CMS Fact Sheet: 2025 Medicare Parts A & B Premiums and Deductibles

CMS published a Fact Sheet that includes the 2025 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2025 Medicare Part D income-related monthly adjustments. The standard Part B premium will be $185.00 for 2025, an increase of $10.30 from $174.70 in 2024. The following table provides a comparison of Part A deductible, and coinsurance amounts for CY 2024 and CY 2025 by type of cost sharing.

https://www.cms.gov/newsroom/fact-sheets/2025-medicare-parts-b-premiums-and-deductibles

November 2024: Acentra Health Case Review Connections: Appeals Update – Safe Discharges

Acentra Health notes the following in their November edition of Case Review Connections for Acute Care:

“What are the key factors you are looking at for a safe discharge plan? What if a member needs a higher level of care, but there is no movement on finding a discharge plan?

Key considerations for a safe discharge plan:

• Secure a skilled nursing facility (SNF) bed, if applicable.
• If the beneficiary is going home, ensure they can safely return alone.
• Confirm that home health care is arranged.
• Ensure durable medical equipment (DME) is ordered and will arrive before discharge.

All arrangements needed for the discharge must be confirmed and not pending when the appeal is filed.”  https://acentraqio.com/bene/newsletter/november2024acute

MLN Fact Sheet: Rural Emergency Hospitals (MLN2259384)

This MLN Fact Sheet was updated in November to add new information on Indian Health Services Hospitals and CY 2025 payment amount. https://www.cms.gov/files/document/mln2259384-rural-emergency-hospitals.pdf

In mid-November, the Comprehensive Error Rate Testing (CERT) published the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data (https://www.cms.gov/files/document/2024-medicare-fee-service-supplemental-improper-payment-data.pdf). This report supplements the FY 2024 HHS Agency Final Report for Fiscal Year 2024, highlights common causes of improper payments, and includes tables allowing you to drill down into the review findings.

Estimated Improper Payment Rates

Calculation for the FY 2024 Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2022 through June 30, 2023. As compared to FY 2020 and 2021, the improper payment rate is trending up.

Table 1

“It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).

Unfortunately, like last year, “insufficient documentation” continues to be the main cause of improper payments. The CERT defines “insufficient documentation” as when the medical record documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that the billed services were provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.

While the CERT data reports on improper payments in various settings (i.e., skilled nursing facilities, hospital outpatient, hospice), this article focuses on Part A (Hospital IPPS) findings.

“0 or 1 day” Length of Stay Claims

A compare of improper payments rates for Part A hospital claims by length of stay (LOS) has been a part of this annual report since the October 1, 2013 implementation of the Two-Midnight Rule. Table 1 trends short stays findings from the initial year this information was included in the CERT report.

Table 2

In addition, to the CERT’s focus on claims by length of stay, short stays (“0 of 1 Day” Stays) short stays are also actively being reviewed by the OIG as part of their Work Plan (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp) and Livanta, the National Medicare Claim Review Contractor (https://livantaqio.com/en/ClaimReview/index.html), who reviews short stay claims across the nation on a monthly bases.  

Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS

Table D4 of the CERT report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories.

For fourteen of the top 20 DRG types, the type of error with the highest percentage was error type medical necessity. A claim is placed in this category when the CERT contractor reviewer receives adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. The following three DRG types had the highest percent of errors attributed to medical necessity:

• DRG Pair 551 and 552 (Medical Back Problems): 99.6% error attributed to medical necessity.
• DRG 884 (Organic Disturbances & Intellectual Disability): 93.1% error attributed to medical necessity.
• DRG Pair 469 and 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity): 92.8% error attributed to medical necessity.

   

  Top Root Causes of Improper Payments

  The 2024 CERT report includes the same top three service types with the highest improper payments in the Part A (Hospital IPPS) setting as in the 2023 report. Each of the three service types also have the same top root cause for improper payments in FY 2023 and FY 2024.

   

  In the 2024 report, the CERT identified the following new root causes of improper payments not noted listed in the 2023 report.

   

  New Root Causes for DRG 469 and 470

• Documentation to support conservative treatment for the billed surgical procedure(s) – missing,
• Preoperative surgeon’s office notes – missing,
• Documentation to support conservative treatment for the billed surgical procedure(s) – inadequate, and
• Radiographs to support medical necessity for the billed surgical procedure(s) – inadequate.

   

  New Root Cause for DRGs 273 and 274

• Documentation to support medical necessity for the procedure – Missing.

   

  New Root Causes for DRGs 266 and 267

• NCD requirements, other documentation required for payment – Missing, and
• Incorrect secondary diagnosis code – DRG change.

   

  Moving Forward

  Moving forward, here are ideas and resources to help in your efforts to prevent claims errors:

• Visit the CERT Provider Website (https://c3hub.certrc.cms.gov/) to find information about the CERT, how to submit records, view sample request letters and much more,
• Become familiar with National and Local Coverage Determinations and Local Coverage Articles that detail indications and limitations of coverage for applicable services. For example, CMS has published two resources related to Major Hip and Knee replacement:
  • MLN Product: Medicare Compliance Tips: Major Hip & Knee Replacement or Reattachment of Lower Extremity (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/medicare-provider-compliance-tips/medicare-provider-compliance-tips.html#Hip), and
  • MLN Matters article SE19002: Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19002.pdf), and
• Annually, take the time to review the new Supplemental Improper Payment Data report. Historically, a new FY report is released in late November.

Resource

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.

https://www.cms.gov/files/document/mln2886155-prescribers-guide-medicare-prescription-drug-part-d-opioid-policies.pdf

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).

HHS Press Release: https://www.hhs.gov/about/news/2024/08/15/historic-first-biden-harris-administration-successfully-negotiates-medicare-drug-prices-delivers-promise-lower-prescription-drug-costs-american-seniors.html

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 published details about this five-year mandatory model as part of the FY 2025 IPPS and LTCH PPS Final Rule. CMS indicates that it will incentivize coordination between care providers during a surgery as well as the services provided during the 30 days after surgery with the aim of:

• Improving the quality of care of people with Medicare undergoing certain surgical procedures;
• reducing hospitalization and recovery time;
• lowering Medicare spending; and
• driving equitable outcomes.

The model is set to start in January 2026 and end in December 2030.

TEAM Participation

All acute care hospitals, with limited exceptions, located within the mandatory Core-Based Statistical Areas (CBSAs) that CMS selected will be required to participate in TEAM.

CMS will allow a one-time opportunity for hospitals that participate until the last performance period in the BPCI Advanced model or CJR model, that are not located in a mandatory CBSA to voluntarily opt into TEAM.

A final list of the selected mandatory CBSAs is available in the FY 2025 IPPS Final Rule Table X.Z.-05: Final List of CBSAs for Selection into TEAM

TEAM Episode

An Episode will include non-excluded Medicare Parts A and B items and services and would begin with an anchor hospitalization or anchor procedure and will end 30 days after hospital discharge.

The following table is available in the final rule and provides the specific TEAM episode categories and related billing codes.

Billing Medicare

TEAM participants will continue to bill Medicare FFS for services furnished to Medicare FFS beneficiaries. However, the TEAM participant may also receive a reconciliation payment amount from CMS depending on their Composite Quality Score (CQS) and if their performance year spending is less than their reconciliation target price.

Participants may also owe CMS a repayment amount, subject to their quality performance adjustment, if their spending is above the reconciliation target price.

Target Prices will be based on 3 years of baseline data, prospectively trended forward to the relevant performance year, and calculated at the level of MS-DRG/HCPCS episode type and region.

The Target Prices will include a discount factor, a normalization factor, a retrospective trend adjustment factor, and a beneficiary and provider level risk-adjustment.

Moving Forward

Determine if your hospital is in one of the selected mandatory CBSA. If your hospital will be part of this model, you can find additional information and resources available on the CMS Innovation Center’s TEAM webpage at:https://www.cms.gov/priorities/innovation/innovation-models/team-model

Resource

CMS FY 2025 IPPS Final Rule webpage: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2025-ipps-final-rule-home-page

Medicare Transmittals & MLN Articles

June 24, 2024: Changes to the Laboratory National Coverage Determination Edit Software: October 2024 Update

CMS advises providers to make sure your billing staff know about newly available codes, recent coding changes, and how to find NCD coding information.

https://www.cms.gov/files/document/mm13672-changes-laboratory-national-coverage-determination-edit-software-october-2024-update.pdf

June 25, 2024: MLN MM13656: Ambulatory Surgical Center Payment Update – July 2024

Initially released on June 13, 2024, this article was updated to remove HCPCS codes J3393, J3394, J9172, J9322, and J9324 from table of the change request, which now has 12 codes. https://www.cms.gov/files/document/mm13656-ambulatory-surgical-center-payment-update-july-2024.pdf

June 25, 2024: MLN MM13487: Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule

Initially released May 3, 2024, this article was updated to clarify claims processing requirements for ICD-10-CM diagnosis code Z13.1 and previously processed claims. https://www.cms.gov/files/document/mm13487-diabetes-screening-definitions-update-cy-2024-physician-fee-schedule-final-rule.pdf

June 27, 2024: Change Request (CR) 13649: Utilization of KX Modifier Medicare Physician Fee Schedule Payment for Dental Services Inextricably Linked to Covered Medical Services

This CR provides instructions to A/B MACs regarding usage of the KX modifier for dental services inextricably linked to covered medical services under the Medicare Physician Fee Schedule. CMS includes four examples of types of evidence that providers must submit to demonstrate the inextricable link between the dental service and covered medical service. https://www.cms.gov/files/document/r12702otn.pdf

July 18, 2024: MLN MM13717: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: October Update

Make sure your billing staff knows about the next private payor data reporting period of January 1, 2025 – March 31, 2025, and new and deleted HCPCS codes.

https://www.cms.gov/files/document/mm13717-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-october.pdf

July 18, 2024: MLN MM13286: Lymphedema Compression Treatment Items: Implementation

Now in it’s fourth iteration, this MLN article was updated on July 18^th to add information on how to prevent claims denial due to duplicate payments for compression bandaging systems. https://www.cms.gov/files/document/mm13286-lymphedema-compression-treatment-items-implementation.pdf

Compliance Education Updates

July: CMS’ Oral Health Cross-Cutting Initiative Fact Sheet

In the July 25, 2024, edition of MLN Connects, CMS released this Fact Sheet noting that overall health and well-being are impacted by oral health, affecting individuals, families, and communities. CMS is committed to eliminating barriers to oral health as part of our broader goal of improving quality, equity, and outcomes in the health care system. The CMS Oral Health Cross-Cutting Initiative aligns our programs and policies to better address oral health needs, and the fact sheet highlights this important work and accomplishments to date.

• Link to MLN Connects: https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-07-25-mlnc#_Toc172639983
• Link to Fact Sheet: https://www.cms.gov/files/document/oral-health-cci-fact-sheet.pdf

   

  July: CMS Request for Inpatient for Improving the PEPPER

  Also, in the July 25, 2024 edition of MLN Connects, CMS noted they are taking steps to improve the effectiveness, accessibility, and design of the Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) and Comparative Billing Reports (CBRs). They note you can help by responding to their Request for Information (RFI) by August 19, 2024. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-07-25-mlnc#_Toc172639983

   

  Other Updates

  CMS Publishes CY 2025 Final Rules for Home Health and End-Stage Renal Disease

  Links to related Final Rule Fact Sheets: 

• June 26, 2024: CY 2025 Home Health Prospective Payment System Proposed Rule Fact Sheet (CMS-1803-P)
• https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-home-health-prospective-payment-system-proposed-rule-fact-sheet-cms-1803-p

   

• June 27, 2024: CY 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule Fact Sheet (CMS-1805-P)
• CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-2025-end-stage-renal-disease-esrd-prospective-payment-system-pps-proposed-rule-cms

June 27, 2024: CDC Recommendations Updated 2024-2025 COVID-19 and Flu Vaccines for Fall/Winter Virus Season

The CDC encourages providers to begin their influenza vaccination planning efforts now and to vaccinate patients as indicated once 2024-2025 influenza vaccines become available.

Kepro

Kepro’s service areas include CMS Regions 1,4, 6, 8, and 10. In December 2022, Kepro merged with CNSI. Six months later, they announced the organization had been rebranded as Acentra Health indicating that “the name Acentra Health derives from the root words “accelerate” and “central,” reflecting the company’s uncompromising resolve to be a vital partner to public sector health agencies in the delivery of comprehensive healthcare solutions and services, with “Health” being its central business focus.”

On April 30, 2024, Kepro published a special bulletin letting providers know about their name change. They encouraged providers to update their beneficiary notices, the Important Message from Medicare (IM) and the Notice of Medicare Non-Coverage (NOMNC), by replacing “Kepro” with “Acentra Health.” However, they did note that notices that still have the name “Kepro” listed will be accepted and validated and posted a list of FAQs on their website about this change. Key things to be aware of include:

• Phone numbers and fax numbers will not be changing,
• Their “go live” target date for rebranding to “Acentra Health” is August 1^st and plan to have all their items changed by fall 2024,
• Kepro has been contracted to perform Medicare’s mandatory reviews through 2029 and its CMS Regions will not be changing,
• There will be a new website with a new web address, and will be available when the name change occurs by fall 2024, and
• They encourage you to sign up to their newsletter, Case Review Connections, which includes updates and news from Kepro.

   

  A day after the special bulletin was published, on May 1, 2024, Kepro began a new process for hospital discharge appeals. Specifically, when a Medicare Fee-for-Service beneficiary calls Kepro to file a discharge appeal due to concerns with their discharge planning will be transferred to the Immediate Advocacy (IA) team. This team will review the concerns, identify any gaps or misunderstandings, and determine if additional guidance is needed. You can read more about this new process on Kepro’s Hospital Discharge Appeals webpage.

   

  Livanta

  Livanta’s service areas include CMS Regions 2, 3, 5, 7, and 9. On May 17, 2024 they distributed Provider Bulletin # 21 announcing that they had been awarded the BFCC-QIO contract for case reviews from May 1, 2024, through April 30, 2029. Livanta will also continue to serve as the national Medicare Claim Review contractor.

   

  Livanta’s announcement includes the following four sections:

• Section 1: Beneficiary Case Review versus Claim Review,
• Section 2: What is changing, and what is staying the same?
• Section 3: Updating Contact Information and Memoranda of Agreement, and
• Section 4: Stay in Touch with Livanta.

If you are unsure who your BFCC-QIO is, you can use the QIO “Locate Your BFCC-QIO” tool at https://qioprogram.org/locate-your-bfcc-qio.

Resource

March 1, 2024: CDC Updates Respiratory Virus Guidance

The CDC notes that respiratory viruses are responsible for millions of illnesses and thousands of hospitalizations and deaths in the United States every year. This new guidance “provides practical recommendations and information to help people lower risk from a range of common respiratory illnesses, including COVID-19, flu, and RSV. A downloadable infographic highlights five core prevention strategies (immunizations, hygiene, steps for cleaner air, treatment, and stay home and prevent spread).

March 5, 2024: HHS Statement Regarding the Cyberattack on Change Healthcare

HHS announced immediate steps being taken by CMS to assist providers. You can read their full statement at https://www.hhs.gov/about/news/2024/03/05/hhs-statement-regarding-the-cyberattack-on-change-healthcare.html.

March 11, 2024: OIG’s FY 2024 Justification of Estimates for Congress

The OIG published their FY 2025 budget requests to provide oversight of HHS programs. The OIG “is responsible for overseeing more than $2 trillion in HHS spending and more than 100 different programs that provide critical services for hundreds of millions of individuals. With just 2 cents to oversee every $100 spent by HHS, HHS OIG must target its resources to maximize the impact of oversight and enforcement work.” They are requesting a total of $499.7 million to provide oversight of HHS programs. This is a $67.2 million increase from FY 2023. https://oig.hhs.gov/documents/budget/9814/FY%202025%20OIG%20Budget.pdf

March 14, 2024: Health Related Social Needs FAQ Document

In the Thursday, March 21, 2024, edition of MLN Connects, CMS announced that they have published a Health-Related Social Needs FAQ document about four services in the CY 2024 Physician Fee Schedule (Caregiver Training, Social Determinants of Health Risk Assessment, Community Health Integration, and Principal Illness Navigation).

For example, “are there limits on how often I can bill for SDOH risk assessment? Yes, in the CY 2024 PFS Final Rule, we established a limitation on payment for the SDOH risk assessment service of once every 6 months per practitioner per beneficiary.” https://www.cms.gov/medicare/payment/fee-schedules/physician/care-management

March 21, 2024: New Video: HHS-OIG’s Perspective on Managed Care

In this just over four-minute video, the OIG advised notes that “Managed care is health care delivery model and an alternative way for Medicare and Medicaid patients to receive their health care benefits,” details potential risks and concerns with managed care and provide information on how patients can protect themselves. https://www.youtube.com/watch?v=CQEPszbprwY

In addition to this new video, on March 18^th, the OIG published their first Impact Brief highlighting the impact the OIG’s work has on HHS programs. This first impact brief addresses Medicare Advantage Prior Authorization issues, outlines specific concerns, and demonstrates the agency’s progress to address those concerns. https://oig.hhs.gov/documents/impact-briefs/9820/Medicare%20Advantage%20Prior%20Authorization%20Impact%20Brief.pdf

March 22, 2024: March ICD-10 Coordination and Maintenance Committee Meeting Update

CMS sent a notice letting providers know that the meeting materials for the March 19^th and 20^th meeting are now available at https://www.cms.gov/medicare/coding-billing/icd-10-codes/icd-10-coordination-maintenance-committee-materials.

March 2024: CMS Fast Facts Updated

CMS Fast Facts provides summary information on total program enrollment, utilization, expenditures, and the total number of Medicare providers including physicians by specialty area. This information is refreshed twice a year and was most recently refreshed this month. https://data.cms.gov/fact-sheet/cms-fast-facts

What is a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)?

“A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare…BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality health care. They manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. They also handle cases in which beneficiaries want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services. Two designated BFCC-QIOs serve all 50 states and three territories, which are grouped into ten regions.”¹

Who are the BFCC-QIOs?

Kepro and Livanta are the two contractors that serve as the BFCC-QIOs for all fifty states and three territories, which are grouped into ten regions.

Kepro

Region 1: Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont

Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Region 10: Alaska, Idaho, Oregon, Washington

Livanta

Region 2: New Jersey, New York, Puerto Rico, U.S. Virgin Islands

Region 3: Delaware, Maryland, Pennsylvania, Virginia, West Virginia, Washington D.C.

Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Region 7: Iowa, Kansas, Missouri, Nebraska

Region 9: Arizona, California, Hawaii, Nevada, Pacific Territories

BFCC-QIO 2023 Annual Reports

In late February, Kepro and Livanta released their Annual Medical Services Review Reports for 2023 which includes data for claims with dates of service from January 1, 2023 through October 31, 2023.

Livanta noted in their March 5^th edition of The Livanta Compass, that they prepare “a report for each of the five regions it serves, highlighting data points and the accomplishments of each specific region. Although each report is tailored to a particular region, the processes and individuals who safeguard the rights of Medicare beneficiaries remain consistent across all the regions that Livanta serves.”

Each report includes data at the region and state level.

The data in Table 6 (Beneficiary Appeals of Provider Discharge/Service Termination and Denials of Hospital Admission Outcomes by Notification Type) in the annual reports includes the number of appeal reviews and percentage of reviews for each outcome in which the peer reviewer either agreed or disagreed with the hospital discharge or discontinuation of skilled services. The following Appeals Notification Types are included in table 6:  

• Notice of Non-coverage Fee-for-Service (FFS) Preadmission/Admission – Admission and Preadmission/HINN 1,
• Notice of Non-coverage Request for BFCC-QIO Concurrence - HINN 10,
• Medicare Advantage Appeal Review for Comprehensive Outpatient Rehabilitation Facilities (CORFs), Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Value-Based Insurance Design (VBID) Model Hospice Benefit Component – Grijalva,
• FFS Expedited Appeal (CORF, HHA, Hospice, SNF) – BIPA,
• Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (FFS hospital discharge), and
• MA Notice of Non-coverage Hospital Discharge Notice – Attending Physician Concurs (MA hospital discharge).

Did You Know?

In the February 2024 edition of The Livanta Claims Review Advisor, Livanta reported findings from their second year of higher-weighted diagnosis related groups (HWDRG) validation reviews completed from November 1, 2022 through October 31, 2023. They note in the newsletter that these types of reviews “involve validation of codes on the claim by credentialed coding auditors and clinical review by board-certified practicing physicians as appropriate.”

Coding auditors utilize official coding guidelines, the American Hospital Association (AHA) Coding Clinics, and other authoritative coding references to complete their DRG validation reviews.  

Why It Matters?

When a hospital submits a record for a HWDRG, the review may also include a review to determine if the documentation also supported the medical necessity of an inpatient admission. The following table highlights a compare of Livanta’s Year One and Year Two review results.

In a November 16^th Press Release HHS announced three new key resources to “build on the Administration’s work to advance health equity by acknowledging that peoples’ social and economic conditions play an important role in their health and wellbeing.”

White House Resource: U.S. Playbook to Address Social Determinants of Health (SDOH)

HHS defines SDOH as “the conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

The White House’s vision is for every American to lead full and healthy lives within their community. “This Playbook lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.” The playbook groups actions into the following three pillars:

• Pillar 1: Expanding Data Gathering and Sharing,
• Pillar 2: Support Flexible Funding to Address Social Needs,
• Pillar 3: Support Backbone Organization.

   

  HHS Resource: Medicaid and Children’s Health Insurance Program (CHIP) Health-Related Social Needs (HRSN) Framework

  In a related Press Release HHS notes “the Playbook highlights ongoing and new actions that federal agencies are taking to support health by improving the social circumstances of individuals…The second resource provides guidance “to structure programs that address housing and nutritional insecurity for enrollees in high need populations.”

   

  HHS Resource: HHS’s Call to Action to Address Health Related Social Needs

  The third document is meant to “encourage cross-sector partnerships among those working in health care, social services, public and environmental health, government, and health information technology to create a stronger, more integrated health and social care system through shared decision making and by leveraging community resources, to address unmet health related social needs.”

   

  Z-Codes: Identifying and Coding Social Determinates of Health

  Identifying and coding SDOH supports quality measurement, planning, and implementation of social needs, and identifying community population needs. This data can be used to advocate for updating and creating new policies. For example, effective October 1, 2023, the severity designation for three Z codes was changed to a CC (comorbidity or complication) for purposes of MS-DRG assignment:

• Z59.00: Homelessness, unspecified,
• Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
• Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).

CMS noted in a FY 2024 IPPS Final Rule Fact Sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.” 

To help with understanding and coding Z Codes, CMS has published an infographic titled Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. This document defines Z codes, explains the importance of collecting them and includes recent SDOH Z Code Categories and new codes effective October 1, 2023.

A related Journey Map walks you through five steps to using Z codes and how using these codes can enhance your quality improvement initiatives.