Knowledge Base Category -

Did You Know?

June is cataract awareness month and according to the National Eye Institute (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts), most cataracts are age-related, there are no early symptoms of cataracts and later symptoms includes blurry vision, colors that seem faded, sensitivity to light, trouble seeing at night and double vision.

A cataract is diagnosed by a dilated eye exam and the treatment is surgery. Cataract surgery is one of the most common operations in the United States. In fact, more than half of all Americans aged eighty or older either have cataracts or have had surgery to get rid of cataracts.

Why it Matters?

Being a high-volume surgery, means scrutiny by CMS and Medicare Contractors to assure documentation in the medical record supports medical necessity of the procedure.

Recovery Audit Contractors

RAC Issue 0002 cataract removal (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0002-Cataract-Removal-Medical-Necessity-and-Documentation-Requirements) has been an approved complex review for procedures performed in the outpatient hospital setting and ambulatory surgery centers (ASCs) since February 1, 2017. RACs will review documentation to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) are included on this RAC issue webpage.

Comprehensive Error Rate Testing (CERT)

In the 2021 and 2022 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table D1: Top 20 Service Types with Highest Improper Payments: Part B (https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0).

2021 CERT Report

The improper payment rate for this surgery was 12.7%. The CERT cited two types of errors, insufficient documentation, and incorrect coding, as being the cause of improper payments. Specifically,

the insufficient documentation project improper payment was $190,495,888 and the incorrect coding improper payment was $27,844,602.

2022 CERT Report

The improper payment rate for this surgery was 8.3%. Unlike 2021, 100% of the errors were due to insufficient documentation. The project improper payment rate was $146,067,233.

Medicare Administrative Contractors (MACs)

JE and JF MAC: Noridian

Cataract surgery has been a review target for Noridian MAC jurisdictions for a few years. Their most recent review findings were for claims with dates of service from January 1, 2023 through March 31, 2023.

Review results for jurisdictions were published April 12, 2023:

• Noridian JE error rate of 48.67%. https://med.noridianmedicare.com/web/jea/cert-review/mr/review-results
• Noridian JF error rate 45.88%. https://med.noridianmedicare.com/web/jfa/cert-review/mr/review-results

Noridian’s review results articles include top denial reasons, educational resources, and education regarding the medical necessity for cataract surgery.

Supplemental Medical Review Contractor (SMRC)

On February 16, 2022, the SMRC published a notification of their intent to review cataract surgeries performed in the physician office, outpatient hospital and specialty facility clinical access hospitals. In the background section of the notification, they note that “this type of surgery has been a topic of interest for the Office of Inspector General (OIG) for a number of years. The OIG looked into surgery in both the outpatient facility and ambulatory service center settings. CMS data reflects a potential vulnerability.”

The SMRC published review results on September 27, 2022 (https://noridiansmrc.com/completed-projects/01-302/). The error rate was 51%.

What Can You Do?

With so many entities focused on reviewing cataract surgery claims, moving forward providers should:

• Respond to ADRs in a timely manner,
• Become familiar with medical necessity indications and documentation requirements detailed in Medicare coverage documents (NCDs, LCDs, LCAs),
• Be aware of who is performing cataract surgery reviews,
• Read published review results to understand reasons for denials and ways to prevent future denials, and
• Ensure physicians performing these procedures are also aware of Medicare coverage requirements.

Did You Know?
According to the American Lung, about 10 to 30% of adults in the U.S. may have sleep apnea and your risk increases with age and weight. One relatively new treatment for this condition is Hypoglossal Nerve Stimulation (HNS).

Effective January 1, 2022, there were three new CPT codes related to implantation, revision, or removal of the HNS system. A few months later, on June 7, 2022, the first RAC approved issue in 2022 was RAC Issue 0201 (Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements). You can read more about this in a related MMP article.

The affected CPT code for RAC Issue 0201 is 64582 (open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array). The following table highlights the place of service, volume and claims paid in CY 2022 for this CPT code.  

Why It Matters?

Medicare Administrative Contractors (MACs) have published Local Coverage Determinations (LCDs) and related coding and billing articles for this procedure. Currently, two of the indications are a body mass index (BMI) less than 35 kg/m2, and a polysomnography (PSG) demonstrating an apnea-hypopnea index (AHI) of 15 to 65 events per hour within 24 months of initial consultation for HNS implant.

In the U.S. Food & Drug Administration’s June 9, 2023 FDA Roundup, they announced they have approved an expanded indication for the Inspire Medical Systems’ Inspire Upper Airway Stimulation (UAS) System to include an updated AHI and BMI threshold.

“The safety and effectiveness data available now increased the AHI baseline to 100 and a BMI level of 40 for adults with moderate to severe Obstructive Sleep Apnea (OSA).”

What Can I Do?

With this device being on the RAC approved issue list you should:

• Be mindful of the timing of the FDA’s expanded indications in the event you receive a request for records for dates of service on or after June 9, 2023.
• Watch for updated indication information in your MACs related LCD.
• Share this information with key stakeholders.

Resources

American Lung Association article Learn About Sleep Apnea at https://www.lung.org/lung-health-diseases/lung-disease-lookup/sleep-apnea/learn-about-sleep-apnea

FDA Roundup: June 9, 2023: https://www.fda.gov/news-events/press-announcements/fda-roundup-june-9-2023

Coverage Updates

May 9, 2023: U.S. Preventive Services Task Forces (USPSTF) Posts Draft Recommendation Statement for Screening Breast Cancer

The USPSTF issued a draft recommendation indicating that science now shows all women should get screened for breast cancer every other year starting at age 40. This recommendation applies to women at average risk of breast cancer and includes people with a family history of breast cancer, and people who have other risk factors, such as dense breasts. https://uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/breast-cancer-screening-draft-rec-bulletin.pdf

Compliance Education Updates

MLN Fact Sheet: Clinical Laboratory Fee Schedule

This fact sheet has been updated to include the CY 2023 specimen collection amounts and flat-rate travel allowance. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/clinical-laboratory-fee-schedule-fact-sheet-icn006818.pdf

MLN Fact Sheet: Skilled Nursing Facility 3-Day Rule Billing

The end of the COVID-19 PHE brought an end to the 3-day prior hospitalization waiver. CMS has updated this MLN Fact Sheet to remove language related to this waiver. For Case Managers hired during the pandemic, this is a must read to help understand what is required for your Medicare Fee-for-Service beneficiary to qualify for admission to a Skilled Nursing Facility. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNF3DayRule-MLN9730256.pdf

COVID-19 Updates

May 19, 2023: End of COVID-19 PHE FAQs Updates

Learn about updates to the Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency (questions 21-23 on page 9). For example, CMS answers the question, can hospitals bill for outpatient physical therapy (PT), occupational therapy (OT), speech language therapy (SLF) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by hospital-employed staff?

May 25, 2023: FDA Approved Oral Antiviral Paxlovid for Treatment of Mild to Moderate COVID-19

This drug is for use in adults at high risk for progression to severe CODI-19, including hospitalization and death. Approved during the COVID-19 PHE, Patrizia Cavazzoni, M.D., director for the FDA’s Center for Drug Evaluation and Research notes that “Today’s approval demonstrates that Paxlovid has met the agency’s rigorous standards for safety and effectiveness, and that it remains an important treatment option for people at high risk for progression to severe COVID-19.” https://content.govdelivery.com/accounts/USFDA/bulletins/35c86d9

Other Updates

Comprehensive Error Rate Testing (CERT) Review Contractor: Same Company, New Name

The CERT review contractor, formerly known as NCI Information Systems, Inc. has changed their company name to Empower AI, Inc. Their email domain is @empower.ai.

You can learn more about changes to the CERT Contractors (Review Contractor and Statistical Contractor) in a related Palmetto GBA article at https://www.palmettogba.com/palmetto/jja.nsf/DID/M5PPHI24YK#ls

May 4, 2023 MLN Connects: May is National Mental Health Month

CMS notes in the May 4^th edition of MLN connects that 20% of Americans experience mental illness each year and disproportionately affects racial and ethnic minority groups. I encourage you to read this edition of MLN Connects to learn about appropriate preventive services covered by Medicare (i.e., Depression Screening) and additional mental health resources made available by CMS. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-05-04#_Toc134022248

May 24, 2023: Inpatient Rehabilitation Review Choice Demonstration and Targeted Probe and Educate

Medicare Transmittals & MLN Articles

April 27, 2023: MLN MM12889: New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

This MLN article issued October 6, 2022 has been revised to add information to explain how to verify attending physician information. https://www.cms.gov/files/document/mm12889-new-fiscal-intermediary-shared-system-edit-validate-attending-provider-npi.pdf

May 4, 2023: MLN MM13195: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article includes information the COVID-19 PHE expiration, the next Clinical Laboratory Fee Schedule data reporting period, the general specimen collection fee increase, and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13195-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

May 4, 2023: MLN MM13180: Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process

Billing staff for physicians and End Stage Renal Disease (ESRD) facilities assigned to the ESRD Treatment Choices (ETC) Model should know about adjustments to claim lines on type of bill 072X with condition codes 74 or 76. They also need to know about monthly capitation payment (MCP) claims on claim lines with CPT codes 90957-90962 and 90965-90966. https://www.cms.gov/files/document/mm13180-home-dialysis-payment-adjustment-performance-payment-adjustment-esrd-treatment-choices-model.pdf

May 16, 2023: MLN MM13071: Travel Allowance Fees for Specimen Collection: 2023 Updates

Initially released January 9, 2023, this article was revised May 16, 2023 to delete the phrase “including Medicare Advantage” from the Travel Allowance Policy section of this article. https://www.cms.gov/files/document/mm13071-travel-allowance-fees-specimen-collection-2023-updates.pdf

May 17, 2023: MLN MM13064: Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2023 Final Rules

Billing staff for physicians, hospitals, suppliers, and other providers billing MACs for services provided to Medicare patients need to be aware of the updated billing instructions for nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit. https://www.cms.gov/files/document/mm13064-updating-medicare-manual-policy-changes-cy-2020-cy-2021-final-rules.pdf

May 18, 2023: Transmittal 12047: Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule

The Change Request (CR 13190) provides further clarity to and directs the A/B MACs to develop educational materials to aid in the implementation of the Medicare payment policies for dental services as described in Section II.L of the CY 2023 PFS final rule. This guidance is intended to facilitate a consistent application of the payment policy nationally, with MACs providing payment for more types of dental services associated with a broader set of medical services than before CY 2023. https://www.cms.gov/files/document/r12047bp.pdf

May 19, 2023: MLN MM13192: HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update

Information in this MLN article includes updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS) as well as additions and deletions of certain chemotherapy and vaccine codes from the Medicare Part B SNF files. https://www.cms.gov/files/document/mm13192-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-july-2023.pdf

May 23, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

This article describes coding changes and policy effective July 1, 2023, for the hospital OPPS including payment system updates and new codes for COVID-19, drugs, biologicals, and radiopharmaceuticals, devices and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

May 23, 2023: MLN SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers

First released March 30, 2022, in this fourth iteration, CMS revised the article to show a legislative change about in-person visits and added modifier 93 for reporting audio-only mental health visits. For RHCs and FQHCs, CMS will not require in-person visits until January 1, 2025. https://www.cms.gov/files/document/se22001-mental-health-visits-telecommunications-rural-health-clinics-federally-qualified-health.pdf

May 25, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: 2023 Update

The CMS Review Choice Demonstration for Inpatient Rehabilitation Facility (IRF) Services is set to begin in Alabama in August 2023. You can read more about the program and choices that Alabama IRF providers will need to make in a related article in this week’s newsletter.

This article looks back at past IRF claims reviews and resources available to providers on Palmetto GBA’s website, the Medicare Administrative Contractor (MAC) for Alabama.

Prior IRF Claims Reviews

Office of Inspector General (OIG)

In September 2018, the OIG published the report “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements” (A-01-15-00500). The audit covered $6.75 billion in Medicare payments to 1,139 IRFs nationwide for 370,872 IRF stays. The objective was to determine if IRFs complied with Medicare coverage and documentation requirements for claims for services provided in 2013. Based on sample results, the OIG estimated that Medicare paid IRF’s $5.7 billion for care to beneficiaries that was not reasonable and necessary.

The OIG noted errors occurred because many IRFs did not have adequate internal controls to prevent inappropriate admissions; Medicare Part A FFS lacked a prepayment review for IRF admissions and CMS’ extensive educational efforts and post payment reviews were unable to control an increasing improper payment rate reported by CERT.

https://oig.hhs.gov/oas/reports/region1/11500500.asp

Supplemental Medical Review Contractor (SMRC)

Based on the 2018 OIG report findings, CMS tasked Noridian, the current SMRC, to complete a review of Medicare Part A IRF claims for CY 2018 claims. Noridian published their review results in October 2021 and reported a 33% error rate. I encourage you to read their review results as it includes common reasons for denial and references and resources.

https://noridiansmrc.com/completed-projects/01-025/

Comprehensive Error Rate Testing (CERT)

The OIG noted in the above 2018 report the CERT program found that the error rate for IRFs had increased, ranging from 9 percent in 2012 to a high of 62 percent in 2016. Although the error rate has decreased in subsequent years, the Improper Payment Rate remained high at 19.3 percent in 2022 with close to $7M projected improper payments.

https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

Active OIG Work Plan Item: Inpatient Rehabilitation Facility Nationwide Audit

In this active issue description, the OIG notes that in fiscal year 2021, Medicare paid approximately $8.7 billion for 373,000 IRF stays nationwide. The CERT has consistently found high error rates, and their Hospital Compliance audits also frequently include IRF claims and have similarly found high error rates.

“In response to these findings, IRF stakeholders have stated that Medicare audit contractors and OIG have misconstrued the IRF coverage regulations. To better understand which claims IRFs believe are properly payable by Medicare, OIG needs more information from the IRF stakeholders. We plan to determine whether there are areas in which CMS can clarify Medicare IRF claims payment criteria. In addition, we will follow up on recommendations from our prior IRF audit, A-01-15-00500. We believe data and input from IRF stakeholders are critical to identifying any specific areas that might require clarification and will result in more meaningful recommendations and a greater positive impact on the program.”

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000729.asp

Palmetto GBA IRF Education Resources

IRF Avoiding Common Billing Issues Module

Palmetto notes their goal with this module is to ensure providers are in compliance with Medicare coverage, coding, and billing rules so that payments will not be delayed.

https://www.palmettogba.com/palmetto/jja.nsf/DID/HBEIF25RPF#ls

Did You Miss It? Jurisdictions J, M Current Year 2023 IRF Webinar

Palmetto has made available a webinar on demand where Palmetto discusses IRF documentation requirements, Targeted Probe and Educate (TPE), CERT and the FY 2023 IRF Final Rule.

https://www.palmettogba.com/palmetto/jja.nsf/DID/000GWG3K8O#ls

Inpatient Rehabilitation Facility (IRF) Resources

This Palmetto GBA article provides links to the CMS IRF Prospective Payment System educational tool and a Medicare Learning Network web-based training course that includes information about IRF services, documentation requirements and the CERT program.

Moving Forward

Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments through medical reviews. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules. One such initiative is the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services.

On May 15, 2023, CMS announced a new initiative, The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services.  CMS notes “this program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay care to Medicare beneficiaries. This RCD protects our programs’ sustainability for future generations by serving as a responsible steward of public funds.”

About the Initiative

According to the CMS, this initiative provides flexibility and choice for IRFs, and a risk-based approach to reduce burden on providers that demonstrate compliance with the Medicare IRF rules.

Cycle 1 Choice Selection

The first milestone for IRF providers is to select between pre-claim or post-payment reviews. Following are the steps of each choice as outlined in a flow chart available on the RCD for IRF webpage.

Choice 1: 100% Pre-claim review

• IRF must request Pre-Claim review (PCR) for all stays.
• Claims submitted without PCR will undergo prepayment review.
• An affirmation rate to be calculated every 6 months.

   

  Choice 2: 100% Post-payment review (Initial Default)

• IRF submits claims for each stay.
• Each claim is processed and paid per CMS procedures.
• MAC sends Additional Documentation Requests (ADRs) and follows CMS’ post-payment review procedures.
• An approval rate is to be calculated every 6 months.

   

  The selection period will start on July 7, 2023 and end on August 6, 2023. Alabama IRF providers will need to go to the Palmetto GBA Provider Portal to make your selection.  If a choice is not selected, an IRF will automatically be assigned to participate in Choice 2: Post-payment Review.

   

  Cycle 1 Review Dates

  The first cycle of review dates for this demonstration is August 21, 2023 through February 29, 2024.

   

  IRFs with Full Affirmation Rate of Claim Approval

  Palmetto GBA notes in a related article that “IRFs will be evaluated for six months, if the full affirmation rate or claim approval meets the target rate or greater (based on a minimum of 10 submitted pre-claim review requests or claims) in the first cycle, the IRF may select one of three subsequent review choices:

• Choice 1: Pre-Claim Review;
• Choice 3: Selective Post-payment Review; or
• Choice 4: Spot Check Review.”

If an IRF does not actively choose one of the subsequent review options, it will automatically be assigned to participate in Choice 3: Selective Post-payment Review.

Note, IRFs with less than the target affirmation rate or who have not submitted at least 10 requests/claims must again choose from one of the initial two options.

What Can You Do?

Now is the time to make sure you are following the Medicare program rules for IRFs. You can read about prior Medicare IRF reviews and available education resources on Palmetto GBA’s website in a related article in this week’s newsletter.

Resources

CMS RCD for IRF Services webpage: https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services

CMS issued a display copy of the FY 2024 IPPS Proposed Rule on Monday, April 10, 2023. This article contains a high-level look at the proposed operating payment rate changes, Rural Emergency Hospitals change, social determinants of health codes severity designation changes, when the New COVID-19 Treatment Add-On Payments are proposed to end, and updates to the Affordable Care Act Quality Programs.

Proposed Payment Rate Changes

The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and meaningful electronic health record (EHR) use is projected to be 2.8%.

In a summary of costs and benefits in the proposed rule, CMS notes that “acute care hospitals are estimated to experience an increase of approximately $2.7 billion in FY 2024, primarily driven by: (1) a combined $3.2 billion increase in FY 2024 operating payments and capital payments, as well as changes in DSH and uncompensated care payments, and (2) a decrease in $466 million resulting from estimated changes in new technology add-on payments, as modeled for this proposed rule.”

Rural Emergency Hospitals (REHs) and Graduate Medical Education (GME)

REH’s became a new provider type effective January 1, 2023. You can read more about them in a related MLN Fact Sheet. CMS is proposing to change to GME payments for training in a REH “to address the growing concern over closures of rural hospitals.”

Social Determinants of Health

The U.S. Department of Health and Human Services (HHS) defines Social Determinants of Health (SDOH) as "the conditions in the environments 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." Effective February 18, 2018, the AHA Coding Clinic published advice allowing the reporting of SDOH codes Z55-Z65, based on information documented by all clinicians involved in the care of the patient.

For FY 2024, CMS is proposing to change the severity level designation for diagnosis codes Z59.00 (Homelessness, unspecified), Z59.01 (Sheltered homelessness), and Z59.02 (Unsheltered homelessness) from NonCC to CC for FY 2024. CMS also continues to be interested in receiving feedback on “how we might otherwise foster the documentation and reporting of the diagnosis codes describing social and economic circumstances to more accurately reflect each health care encounter and improve the reliability and validity of the coded data including in support of efforts to advance health equity.”

Changes to the New COVID-19 Treatment Add-On Payment (NCTAP)

In response to the Public Health Emergency (PHE), CMS established NCTAP for eligible discharges during the PHE. In the FY 2022 final rule, CMS finalized the extension of NCTAP through the end of the FY in which the PHE ends. In the FY 2024 proposed rule, CMS notes “if the PHE ends in May of 2023, as planned by the Department of Health and Human Services (HHS), discharges involving eligible products would continue to be eligible for the NCTAP through September 30, 2023 (that is, through the end of FY 2023).”

Affordable Care Act Quality Programs

Hospital Readmission Reduction Program (HRRP)

CMS is not proposing any changes to this value-based purchasing program that reduces payments to hospitals with excess readmissions.

Hospital-Acquired Condition (HAC) Reduction Program

This program creates an incentive for hospitals to reduce the incidence of hospital-acquired conditions by reducing payment by 1% for applicable hospitals ranking in the worst-performing quartile on select measures. For FY 2023, due to the ongoing COVID-19 PHE, no hospital was subject to the 1-percent payment reduction. You can read more about this program in a related FY 2023 CMS Fact Sheet.

In the FY 2024 proposed rule, CMS is requesting comments from stakeholders on potential future measures that would advance patient safety and reduce health disparities.

Hospital Value-Based Purchasing (VBP) Program

This is a budget-neutral program funded by reducing hospitals’ base operating DRG payments each fiscal year by 2% and redistributing the entire amount back to the hospitals as value-based incentive payments. Like the HAC Reduction Program, CMS finalized hospitals’ keeping the 2% payment due to the ongoing COVID-19 PHE. For FY 2024, CMS is proposing several changes to this program, for example:

• Adopting the Severe Sepsis and Septic Shock: Management Bundle measure in the Safety Domain beginning with the FY 2026 program year, and
• Adopting changes to the administration and submission requirements of the HCAHPS survey measure beginning with the FY 2027 program year.

CMS is also requesting feedback on potential additional future changes to the Hospital VBP Program scoring methodology that would address health equity.

I encourage you to submit comments to CMS. The deadline to submit comments is June 9, 2023.

Resources

CMS FY 2024 IPPS Proposed Rule CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2024-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective

Understanding the many parts of Medicare (i.e., Part A, Part B, Part C and Part D), can be confusing. As a case manager, too often, one of my patients with Medicare Part C coverage was surprised and dismayed to learn they would have a co-payment on day one if transferred from the hospital to a Skilled Nursing Facility (SNF). In other instances, a patient’s insurance would contact us to let us know our hospital was out of network and needed to be transferred to an in-network facility for their specific Medicare Advantage Plan.

On April 5, 2023, CMS issued the 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F). This article focuses on protecting beneficiaries and new marketing requirements for Medicare Advantage (MA) plans. A related CMS Fact Sheet reviews this and other major provisions of the final rule.

Per CMS, the final rule “takes critical steps to protect people with Medicare from confusing and potentially misleading marketing while also ensuring they have accurate and necessary information to make coverage choices that meet their needs.” CMS is “finalizing requirements to further protect Medicare beneficiaries by ensuring they receive accurate information about Medicare coverage and are aware of how to access accurate information from other available resources.”

The following excerpt from the final rule details finalized changes to combat misleading marketing practices:  

• Notifying enrollees annually, in writing, of the ability to opt out of phone calls regarding MA and Part D plan business.
• Requiring agents to explain the effect of an enrollee’s enrollment choice on their current coverage whenever the enrollee makes an enrollment decision.
• Simplifying plan comparisons by requiring medical benefits be in a specific order and listed at the top of a plan’s Summary of Benefits.
• Limiting the time that a sales agent can call a potential enrollee to no more than 12 months following the date that the enrollee first asked for information.
• Limiting the requirement to record calls between third-party marketing organizations (TPMOs) and beneficiaries to marketing (sales) and enrollment calls.
• Prohibiting a marketing event from occurring within 12 hours of an educational event at the same location.
• Clarifying that the prohibition on door-to-door contact without a prior appointment still applies after collection of a business reply card (BRC) or scope of appointment (SOA).
• Prohibiting marketing of benefits in a service area where those benefits are not available, unless unavoidable because of use of local or regional media that covers the service area(s).
• Prohibiting the marketing of information about savings available that are based on a comparison of typical expenses borne by uninsured individuals, unpaid costs of dually eligible beneficiaries, or other unrealized costs of a Medicare beneficiary.
• Requiring TPMOs to list or mention all of the MA organization or Part D sponsors that they represent on marketing materials.
• Requiring MA organizations and Part D sponsors to have an oversight plan that monitors agent/broker activities and reports agent/broker non-compliance to CMS.
• Modifying the TPMO disclaimer to add SHIPs as an option for beneficiaries to obtain additional help.
• Modifying the TPMO disclaimer to state the number of organizations represented by the TPMO as well as the number of plans.
• Prohibiting the collection of Scope of Appointment cards at educational events.
• Placing discrete limits around the use of the Medicare name, logo, and Medicare card.
• Prohibiting the use of superlatives (for example, words like “best” or “most”) in marketing unless the material provides documentation to support the statement, and the documentation is based on data from the current or prior year.
• Clarifying the requirement to record calls between TPMOs and beneficiaries, such that it is clear that the requirement includes virtual connections such as video conferencing and other virtual telepresence methods.
• Requiring 48 hours between a Scope of Appointment and an agent meeting with a beneficiary, with exceptions for beneficiary-initiated walk-ins and the end of a valid enrollment period.

CMS notes they did not address their “proposal to prohibit TPMOs from distributing beneficiary contact information in this final rule and may address it in a future final rule. These changes will become effective on September 30, 2023 for all activity related to CY 2024.

Medicare Transmittals & MLN Articles

February 27, 2023: MLN MM12103: Extension of Changes to the Low-Volume Hospital Payment Adjustment & the Medicare Dependent Hospital Program

Affected Providers includes Low-volume hospitals and Medicare-dependent hospitals (MDHs). This article includes information and criteria and payment adjustments for FY 2023 and the extension of the MDH program through September 30, 2023. https://www.cms.gov/files/document/mm13103-extension-changes-low-volume-hospital-payment-adjustment-medicare-dependent-hospital-program.pdf

March 16, 2023: Pub 100-20 One Time Notification: Instructions Relating to the Evaluation of Section 1115 Waiver Days in the Calculation of Disproportionate Share Hospital Reimbursement

The purpose of this Change Request (CR) 12669 is to provide updated direction related to the evaluation of Section 1115 Waiver days in the calculation of Disproportionate Share Hospital (DSH) reimbursement for open cost reports and cost reports currently under administrative appeal. https://www.cms.gov/files/document/r11912otn.pdf

March 16, 2023: MLN MM13143: Ambulatory Surgical Center Payment System: April 2023 Update

Make sure your billing staff know about the new HCPCS codes for drugs and biologicals, corrected 2023 ASC code pair file, and skin substitute product coding updates. This article was revised on March 24, 2023 to remove a code paid from Table 1 and corrected language associated with this code pair. https://www.cms.gov/files/document/mm13143-ambulatory-surgical-center-payment-system-april-2023-update.pdf

March 17, 2023: MLN MM13136: Hospital Outpatient Prospective Payment System: April 2023 Update

This article highlights payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. Of note, once the COVID-19 PHE ends, CMS instructs that they will package payment for COVID-19 treatments into the payment for a comprehensive APC (C-APC) when services are billed on the same outpatient claim, subject to standard exclusions under the C-APC policy. https://www.cms.gov/files/document/mm13136-hospital-outpatient-prospective-payment-system-april-2023-update.pdf

March 17, 2023: MLN MM13153: DMEPOS Fee Schedule: April 2023 Update

The DMEPOS fee schedule is updated on a quarterly basis, when necessary to implement fee schedule amounts for new and existing codes as applicable and apply changes to payment policies. In this update, pay close attention to guidance regarding payment policies as the COVID-19 PHE ends. https://www.cms.gov/files/document/mm13153-dmepos-fee-schedule-april-2023-update.pdf

March 17, 2023: MLN MM13118: Medicare Part B Coverage of Pneumococcal Vaccinations

Effective October 19, 2022, CMS updated the part B requirements to align with the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations. This MLN article details the updated recommendations. https://www.cms.gov/files/document/mm13118-medicare-part-b-coverage-pneumococcal-vaccinations.pdf

March 20, 2023: MLN MM13094: Supervision Requirements for Diagnostic Tests: Manual Update

This article provides information about the expanded list of provider types authorized to supervise diagnostic tests and updates to the Medicare Benefit Policy Manual. https://www.cms.gov/files/document/mm13094-supervision-requirements-diagnostic-tests-manual-update.pdf

Coverage Updates

March 1, 2023: MLN Matters MM13073: National Coverage Determination: Cochlear Implantation

This article provides information about the expanded coverage for cochlear implantation services that was effective September 26, 2022 and an implementation date of March 24, 2023. https://www.cms.gov/files/document/mm13073-national-coverage-determination-cochlear-implantation.pdf

March 22, 2023: OIG Report: Medicare Improperly Paid Physicians an Estimated $30 Million for Spinal Facet-Joint Interventions

The OIG performed this audit due to prior audits revealing that facet-joint interventions are at risk for overutilization and improper payments for these services. Of the 120 sampled sessions, 66 sessions did not comply with 1 or more of the requirements. Based on audit results, the OIG estimated that Medicare improperly paid physicians $29.6 million.

Compliance Education

March 9, 2023: Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier – Revised

In the March 9^th edition of MLN Connects CMS encouraged readers to learn about the requirement to include a modifier on claims for separately payable Part B drugs and biologicals acquired under the 340B Program. Along with the announcement, CMS provided links to an updated MLN Fact Sheet and Updated FAQs. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-09-mlnc

March 27, 2023: The Livanta Claims Review Advisor: Short Stay Review (SSR) – Review Findings from Year One

In Livanta’s March 2023 edition of their Claims Review Advisor newsletter, they report findings from the first year of reviews, noting that Medicare short stay reviews were paused in May 2019 and resumed in October 2021. Of the 18,672 claims reviewed, 2,663 (14%) were admission denials. The first common reason cited by Livanta for denials was insufficient documentation to support a two-midnight expectation at the time of the admission order. You can find past issues of the Livanta Claims Review Advisor as well as the full Review Findings from Year One report on Livanta’s website at https://www.livantaqio.com/en/ClaimReview/Provider/provider_education.html.

COVID-19 Updates

February 27, 2023: CMS PHE Fact Sheet: What Do I Need to Know? Waivers, Flexibilities, and the Transition Forward

CMS published a fact sheet covering COVID-19 vaccines, testing, and treatments; telehealth services; continuing flexibilities for health care professionals; and inpatient hospital care at home when the PHE expires at the end of the day on May 11, 2023. https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf

March 10, 2023: OIG’s COVID-19 PHE Flexibilities End May 11, 2023

The OIG published a notice to describe the flexibilities they had implemented in response to the COVID-19 PHE (i.e., their March 17, 2020 Telehealth Policy Statement), and to remind the health care community said flexibilities will end on May 11, 2023.  https://oig.hhs.gov/coronavirus/covid-flex-expiration.asp

 March 13, 2023: FDA’s Guidance Documents related to COVID-19

The FDA published this notice in the Federal Register “to provide clarity to stakeholders with respect to the guidance documents that will no longer be effective with the expiration of the PHE declaration and the guidance’s that FDA is revising to continue in effect after the expiration of the PHE declaration.” Specifically, there are 72 COVID-19 related guidance documents currently in effect addressed in this notice. Twenty-two will expire at the end of the COVID-19 PHE, another twenty-two will continued for 180 days after the PHE ends, twenty-four will remain in effect with plans to revise (i.e., guidance related to emergency use authorization for vaccines to prevent COVID-19), and the remaining four will also remain in effect. https://www.federalregister.gov/documents/2023/03/13/2023-05094/guidance-documents-related-to-coronavirus-disease-2019-covid-19

March 16, 2023: MLN Connects: Do not Report CR Modifier & DR Condition Code After Public Health Emergency

CMS included the following in the March 13^th edition of MLN Connects: “The end of the COVID-19 public health emergency (PHE) is expected to occur on May 11, 2023. Since the CR modifier and DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023.” https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-16-mlnc#_Toc129789600

Other Updates

February 28, 2023: New Region 2 Recovery Auditor

On February 28^th, Performant posted a general program update alerting providers that on February 7, 2023, CMS approved Performant to begin performing on their new Region 2 contract. Coming soon to their website will be Provider Outreach and education plans. https://performantrac.com/cms-rac/cms-rac-resources/cms-rac-provider-resources/default.aspx

March 9, 2023: MLN Connects: New Inflation Reduction Act Resources