This week in Medicare updates—2/10/2021

February 10, 2021

Medicare Insider

Medicare Mid-Build Off-Campus Outpatient Departments Exception Audit Results

On February 2, CMS published a Fact Sheet, dated January 19, 2021, regarding results from an audit of off-campus provider-based departments (PBD) claiming the mid-build exception under the 21st Century Cures Act. This exception allowed off-campus PBDs that met certain requirements to continue to be paid under the OPPS rather than under the Physician Fee Schedule, which would pay at 40% of the OPPS rate. The audit determined that only 132 of the 334 organizations subject to the audit qualified for the exception, meaning 60% of the off-campus PBDs subject to the audit likely received overpayments if they have been billing under the OPPS. The fact sheet notes that organizations have 240 days to address overpayments identified by the audit and may be eligible for an Extended Repayment Schedule. CMS stated that it issued audit determination letters to all affected providers on January 19.

Final Rule Delay: Secure Electronic Prior Authorization for Medicare Part D

On February 2, CMS published a Delay Notice in the Federal Register regarding the “Secure Electronic Prior Authorization for Medicare Part D” final rule, which had been published in the Federal Register on December 31, 2020. The notice announces a 60-day delay in the effective date for that rule as a result of the Biden administration’s temporary pause on regulatory changes.

The rule will now be effective on March 30, 2021. It was originally effective February 1, 2021. The rule amends Part D e-prescribing regulations to require Part D plan sponsors’ support of version 2017071 of the NCPDP SCRIPT standard for use in certain electronic prior authorization (ePA) transactions.

Final Rule Delay: Organ Procurement Organizations (OPO) Conditions for Coverage (CFC): Revisions to the Outcome Measure Requirements for Organ Procurement Organizations

On February 2, CMS published a Delay Notice in the Federal Register regarding the delay in effective date of the “OPO CFC: Revisions to Outcome Measure Requirements for Organ Procurement Organizations” final rule, which had been published in the Federal Register on December 2, 2020. The notice announces a 60-day delay in the effective date for that rule and an additional 30-day comment period as a result of the Biden administration’s temporary pause on regulatory changes.

The rule will now be effective March 30, 2021. It was originally effective February 1, 2021. The comment period has been extended until March 4, 2021. The rule revised the OPO CFCs to increase donation rates and organ transplantation rates by revising outcome measures and increasing competition for open donation service areas.

Acute Hospital Care At Home Approved List

On February 3, CMS updated a List of approved hospitals participating in the Acute Care Hospital at Home program as of January 29, 2021. The program has expanded to add four additional hospitals across two more states. That increases the number of total hospitals participating in the program to 96 hospitals across 26 states.

Updated Provider-Specific Fact Sheets on New Waivers and Flexibilities

On February 3, CMS updated multiple Fact Sheets distinguished by provider type on waivers and flexibilities during the COVID-19 PHE. The fact sheets include updates about coverage of and billing for monoclonal antibodies. Some fact sheets also include additional information on price transparency for COVID-19 testing, access to COVID-19 vaccines, or cost reporting delays. Updated fact sheets include:

HCPCS Code G2211 is a Bundled Service & Not Separately Paid

On February 4, CMS published a Note in MLN Connects stating that MACs will deny separate payment for HCPCS code G2211, an add-on E/M code for which implementation has been delayed until January 1, 2024. MACs will be automatically reprocessing any claims that were paid.