This week in Medicare—3/27/2024
Health-Related Social Needs FAQs
On March 14, CMS published an FAQ on services that address health-related social needs in the 2024 Physician Fee Schedule final rule. The FAQ clarifies billing practices for the following:
- Caregiver training services (CPT codes 96202, 96203, 97550, 97551, and 97552)
- Social determinants of health risk assessment (HCPCS code G0136)
- Community health integration services (HCPCS codes G0019 and G0022)
- Principal illness navigation services (HCPCS codes G0023, G0024, G0140, and G0146)
HHS-OIG Impact Brief: Medicare Advantage Prior Authorization
On March 18, the OIG published an Impact Brief to highlight the impact of its recent oversight of prior authorization under Medicare Advantage (MA). In a 2022 report, the OIG determined that MA organizations sometimes delayed or denied MA enrollee access to needed services through the use of prior authorization. The impact brief details recent actions taken by CMS, Congress, and payers after the OIG drew national attention to the issue.
Fiscal Intermediary Shared System (FISS) User Enhancement Change Request (UECR) - Expiration of a Unique Tracking Number (UTN) on the Prior Authorization (PA) Tracking File
On March 19, CMS published One-Time Notification Transmittal 12549, which rescinds and replaces Transmittal 12309, dated October 19, 2023, to add BR 13284.2.1. Contractors shall enter “999” in the in the MED REV CT field for specific outpatient services, as instructed by CMS.
The original transmittal was issued to modify the FISS to set the expiration date of a UTN on the Prior Authorization Detail Screen automatically in order to prevent providers inadvertently using an expired UTN.
Effective date: April 1, 2024
Implementation date: April 1, 2024
Biden-Harris Administration Announces New Initiative to Increase Investments in Person-Centered Primary Care
On March 19, CMS published a Press Release to announce a new voluntary model focused on improving funding to support primary care delivery in the Medicare Shared Savings Program. The Accountable Care Organization Primary Care Flex Model (ACO PC Flex Model) will test how prospective payments and increased funding for primary care in ACOs impact health outcomes, quality, and costs of care.
All participating ACOs will receive a one-time Advanced Shared Savings Payment of $250,000 to cover costs associated with forming an ACO (where relevant) and administrative costs for required model activities. Participating ACOs will also receive monthly Prospective Primary Care Payments (PPCP) that replace fee-for-service reimbursement. ACOs will distribute these PPCPs to their primary care providers, including federally qualified health centers and rural health clinics.
The five-year model will begin on January 1, 2025. CMS plans to select approximately 130 low revenue ACOs to participate in the new model. ACOs must apply to the Shared Savings Program before applying to the new model. The ACO PC Flex Model Request for Applications is expected to be released in the second quarter of 2024.
CMS also published a Fact Sheet and FAQ on the model on the same date. CMS also created a Web Page specifically for the model.
Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs)
On March 20, CMS published a Memorandum to state survey agency directors and long term care facilities regarding new guidance on the use of enhanced barrier precautions (EBP) in nursing homes to prevent the spread of MDROs.
The updated recommendations now include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities, regardless of their MDRO status. The new EBP guidance is being incorporated into F880 Infection Prevention and Control.
Effective date: April 1, 2024
April Quarterly Update for 2024 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
On March 21, CMS published Medicare Claims Processing Transmittal 12553 regarding the quarterly update to the DMEPOS fee schedule. The transmittal updates the DMEPOS fee schedule, PEN fee schedule, and Rural Zip Code files. The update includes 17 code additions, one code deletion, and ten fee schedule amount additions.
CMS published MLN Matters 13574 on the same date to accompany the transmittal.
Effective date: April 1, 2024
Implementation date: April 1, 2024
April 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On March 21, CMS published Medicare Claims Processing Transmittal 12552 regarding the April update to the OPPS. Updates include 11 proprietary laboratory analyses (PLA) coding changes, a slew of changes to HCPCS codes for drugs, biologicals, and radiopharmaceuticals, and more.
On March 25, CMS published MLN Matters 13568 to accompany the transmittal.
Effective date: April 1, 2024
Implementation date: April 1, 2024
April 2024 Integrated Outpatient Code Editor (I/OCE) Specifications Version 25.1
On March 21, CMS published Medicare Claims Processing Transmittal 12551 regarding the April updates to the I/OCE.
Effective date: April 1, 2024
Implementation date: April 1, 2024
Eleventh General Update to Provider Enrollment Instructions in Chapter 10 of CMS Publication (Pub.) 100-08
On March 21, CMS published Medicare Program Integrity Transmittal 12550 to clarify several provider enrollment topics, including revised model letters, in Chapter 10 of the Medicare Program Integrity Manual.
Effective date: April 21, 2024
Implementation date: April 21, 2024
HHS-OIG’s Perspective on Managed Care
On March 21, the OIG published a Video to its Managed Care featured topic page that details its perspective on managed care and identifies several risk areas associated with the model, including care stinting and risk adjustment payments.