This week in Medicare—10/16/2024
New Biweekly Interim Payments for IPPS Separate Payment for Additional Resource Costs of Establishing and Maintaining Access to Buffer Stocks of Essential Medicines
On October 7, CMS published Medicare Claims Processing Transmittal 12615 regarding updates to the claims processing system to prepare for a new, separate payment under the IPPS to small, independent hospitals for the cost of voluntarily establishing and maintaining access to buffer stocks of essential medicines via biweekly interim payments. This policy was finalized under the FY 2025 IPPS Final Rule. The transmittal is no longer sensitive and may now be published to the internet.
CMS published MLN Matters 13590 to accompany the transmittal.
Effective date: October 1, 2024 – For cost reporting periods beginning on or after October 1, 2024
Implementation date: October 7, 2024
Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) National Coverage Determination (NCD) 110.23
On October 7, CMS published Medicare National Coverage Determinations Transmittal 12868 and Medicare Claims Processing Transmittal 12868, which rescind and replace Transmittals 12813, dated August 28, to revise line 8 of the attached spreadsheet to align with billing guidance in the Claims Processing Manual and revise Pub 100-04 BR 04.3.3 and CPM to add Group Code PR to messaging.
The original transmittals were issued to announce expanded coverage for allogeneic HSCT using bone marrow, peripheral blood, or umbilical cord blood stem cell products for Medicare patients with MDS. CMS issued a final decision regarding this expanded coverage in March 2024 and has revised these transmittals numerous times.
CMS revised MLN Matters 13604 to accompany the revised transmittals.
Effective date: March 6, 2024
Implementation date: October 7, 2024
JYNNEOS Coverage Fact Sheet
On October 7, CMS published a Fact Sheet regarding coverage of the JYNNEOS vaccine series for monkeypox under Medicare, Medicaid, and private/commercial insurance. ACIP recommends vaccination with the 2-dose vaccine for people aged 18 and older who are at risk for monkeypox. Because of that recommendation, various types of coverage are available under Part D and Part B.
Fiscal Year (FY) 2025 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
On October 8, CMS published Medicare Claims Processing Transmittal 12869, which rescinds and replaces Transmittal 12843, dated September 12, to update language for the low wage index hospital policy section and to update BRs 13734.12 and 13734.12.1.
The original transmittal was issued to detail the implementation of policies and rate changes finalized through the FY 2025 IPPS and LTCH PPS final rule.
CMS revised MLN Matters 13734 on the same date to accompany the transmittal.
Effective date: October 1, 2024
Implementation date: October 7, 2024
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update Fiscal Year (FY) 2025
On October 8, CMS published Medicare Claims Processing Transmittal 12870, which rescinds and replaces Transmittal 12705, dated August 1, to correct an error regarding the reference to an incorrect OMB Bulletin by revising BR 13701.3. In addition, the responsibility for BR 13701.1 was changed from FISS to A/B MAC Part A, and FISS was removed from BR 13701.4.
The original transmittal was issued regarding updates to payment rates under the SNF PPS for FY 2025.
Effective date: October 1, 2024
Implementation date: October 7, 2024
Request for Information: Medicare $2 Drug List Model
On October 8, CMS published a Request for Information (RFI) regarding the development of the Medicare $2 Drug List Model, an initiative based on direction from a 2022 Executive Order on lowering prescription drug costs. The model would allow Part D sponsors to offer low cost, clinically important generic drugs to beneficiaries at no more than $2 per drug for a month’s supply. CMS is looking for feedback on the sample list of drugs, the development process for the list, how to maximize plan participation, and more.
CMS published a Press Release on the RFI on the same date. Comments are due by December 9.
Advance Copy: Revisions to State Operations Manual (SOM), Chapter 2 – The Certification Process; SOM Appendix X, Guidance to Surveyors: Organ Transplant Programs; and SOM Chapter 9 - Exhibits
On October 10, CMS published a Memorandum to state survey agency directors regarding updates to Chapters 2, 9, and Appendix X of the SOM as they pertain to transplant program compliance. CMS is enhancing and adding additional detail to survey guidance, providing clarity on frequently asked questions, and standardizing operational procedures related to transplant program certification. Because of these changes, certain previous memos are now obsolete and are identified as such in the memo.
Effective date: Immediately. Please Communicate to all appropriate staff within 30 days.
Outcome Requirements for Initial Transplant Program Approval
On October 10, CMS published a Memorandum to state survey agency directors regarding outcome requirements for initial transplant program approval. These outcome requirements must include one-year post transplant data, which may cause a delay in the availability of the outcomes data at the time of the program’s application for initial Medicare approval. The memo instructs the survey agencies that onsite surveys cannot be initiated until the outcomes data is available and discusses how to handle applications considering these data requirements.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the State of Florida
On October 10, CMS published a News Alert to announce additional resources and flexibilities available in response to Hurricane Milton in Florida. CMS detailed the waivers, special enrollment opportunities, dialysis care, DMEPOS replacements, and other resources available for those impacted by the hurricane. These are retroactive to October 5.
CMS also has a variety of resources posted on its Current Emergencies website.
Correction to Editing for Inpatient Part B Ancillary 12X Claims When Part A Benefits Exhaust and Manual Updates for Billing of Inpatient Pre-Entitlement Days
On October 10, CMS published Medicare Claims Processing Transmittal 12887 regarding a correction to editing for inpatient Part B ancillary 12X claims for non-physician outpatient services provided within an IPPS hospital admission when Part A benefits exhaust during the inlier portion of the inpatient stay that has exceeded a cost outlier threshold. The transmittal also includes updated instructions in the manual for billing pre-entitlement days.
CMS published MLN Matters 13810 on the same date to accompany the transmittal.
Effective date: April 1, 2025
Implementation date: April 7, 2025
Allowing Home Health (HH) Telehealth Services During an Inpatient Stay
On October 10, CMS published Medicare Claims Processing Transmittal 12888 regarding a revision to claims editing to allow non-paid telehealth visits to be reported while a beneficiary is hospitalized. The transmittal will allow claims to process when home health telehealth services reported by HCPCS codes G0320, G0321, and G0322 (all of which are non-payable) overlap with an inpatient stay, as these codes will not lead to duplicate payment.
CMS published MLN Matters 13812 on the same date to accompany the transmittal.
Effective date: April 1, 2025
Implementation date: April 7, 2025
TEFRA Reimbursement to IPPS-Excluded Hospitals for Excess Costs Related to Providing CAR T-Cell Therapy
On October 10, CMS published One-Time Notification Transmittal 12881, which rescinds and replaces Transmittal 12698, dated June 27, to revise the Summary of Changes section with updates that encompass the reporting on the subscripted Line 55.03 as well as some updates to the background section. The revisions also add language to BR 13367.1, and they add BRs 13667.4 and 13667.5. The transmittal is no longer sensitive and may now be posted to the internet.
The original transmittal was issued regarding cost reporting information for CAR T-Cell Therapy.
Effective date: July 29, 2024
Implementation date: July 29, 2024
The Recovery and Adjustment of Medicare Claims where the Department of Veteran Affairs (VA) also Made Payment Using the Medicare Duplicate Payment (DP) Process
On October 10, CMS published Medicare Secondary Payer Transmittal 12891, which rescinds and replaces Transmittal 12800, dated August 19, to delete BRs 13694.22 and 13694.23 as well as to revise a number of BRs, all of which are listed in the transmittal.
The original transmittal was issued to provide updates to the Medicare Secondary Payer DP process to handle the recovery of duplicate payments when both Medicare and the VA made payments for the same services.
Effective date: January 1, 2025 - For CWF (requirements/coding/preliminary unit testing); for FISS (design/coding); for MCS (analysis/design/coding); for VMS (analysis & coding); April 1, 2025 - For CWF (testing/implementation); FISS (continued development/testing/implementation); MCS (continued coding/testing/implementation); and VMS (testing & implementation)
Implementation date: January 6, 2025 - For CWF (requirements/coding/preliminary unit testing); for FISS (design/coding); for MCS (analysis/design/coding); for VMS (analysis & coding); April 7, 2025 - For CWF (testing/implementation); FISS (continued development/testing/implementation); MCS (continued coding/testing/implementation); and VMS (testing & implementation)
CMS Releases 2025 Medicare Advantage and Part D Star Ratings
On October 10, CMS published a Fact Sheet regarding the star ratings for 2025 Medicare Advantage and Part D Prescription Drug Plans. Approximately 40% of Medicare Advantage plans offering prescription drug coverage in 2025 will have at least a four-star rating, down from 42% in 2024. The average star rating for all Medicare Advantage plans with prescription drug coverage is 3.92% for 2025, a decrease from the 2024 average of 4.07%.
Annual Inflation Updates to the Annual Cap on Patient Engagement Tools and Supports Under 42 CFR §1001.952(hh)
On October 11, the OIG published a Notice to announce the annual monetary cap for the safe harbor for arrangements for patient engagement and support at 42 CFR 1001.952(hh). The 2025 cap is $605, a 2.4% increase from 2024.
Notice of New Interest Rate for Medicare Overpayments and Underpayments – 1st Quarter Notification for FY 2025
On October 11, CMS published Medicare Financial Management Transmittal 12893 regarding an update to the new interest rate for Medicare overpayments and underpayments. The private consumer rate has been changed to 12.375% for Q1 of FY 2025.
Effective date: October 18, 2024
Implementation date: October 18, 2024
Update to Medicare Claims Processing Manual, Chapter 18, Section 170.1 and Chapter 32, Section 340.2 for Coding Revisions to NCDs – January 2025 Change Request 13706
On October 11, CMS published Medicare Claims Processing Transmittal 12883 regarding updates to two sections of the manual to coincide with NCD updates for January 2025. These changes apply to coding for STI screening and for Mitral Valve TEER services on professional claims.
Effective date: January 1, 2025 – See business requirements 13804.1 and 13804.2 for dates
Implementation date: January 16, 2025
Reporting Identifiers for HIGLAS Payments Reported for Periodic Interim Payment (PIP) Claims
On October 11, CMS published One-Time Notification Transmittal 12878 regarding changes to ensure that PIP claims reimbursement types are accurately recorded on the Provider Statistical & Reimbursement (PS&R) report.
Effective date: April 1, 2025
Implementation date: April 7, 2025
Implementation of a New NUBC Condition Code and a New NUBC Value Code
On October 11, CMS published One-Time Notification Transmittal 12882 regarding the implementation of two new NUBC codes. One is condition code “KX” which allows providers to report when documentation is on file to support that requirements specified in the medical policy have been met. The other is value code “92” to allow providers to report invoice cost when required by federal regulation.
Effective date: April 1, 2025; July 1, 2025 – for claims received on or after the effective date
Implementation date: April 7, 2025; April 7, 2025
Guiding an Improved Dementia Experience (GUIDE) Model Implementation
On October 11, CMS published Demonstrations Transmittal 12892, which rescinds and replaces Transmittal 12708, dated July 3, to remove CWF from BR 13412.32.
The original transmittal was issued to implement the GUIDE Model, a demonstration testing alternative payment models and support for people with dementia and their caregivers.
Effective date: April 1, 2024 - Analysis, Design and Coding; July 1, 2024 - Testing and Implementation
Implementation date: April 1, 2024 - Analysis, Design and Coding; July 1, 2024 - Completion of Coding, Testing and Implementation