Knowledge Base Category -
Question:
Are there any updates for rehabilitative therapy services’ threshold amounts for the coming year?
Answer:
Yes. Change Request (CR) 13371 issued September 14, 2023 and re-communicated November 6, 2023 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2024. These thresholds were previously known as “therapy caps.”
CY 2024 KX Modifier Threshold Amounts
- $2,330 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
- $2,330 for Occupational Therapy (OT) services.
Providers can track a patient’s year-to-date therapy amounts on Medicare eligibility screens. The KX modifier must be appended to therapy services’ line-items on the claim for medically necessary therapy services above the threshold amounts. The medical necessity of services beyond the threshold amount must be justified by appropriate documentation in the medical record. Services provided beyond the threshold that are not billed with the KX modifier will be denied with Claim Adjustment Reason Code 119 - Benefit maximum for this time period or occurrence has been reached.
There is also a therapy threshold related to the targeted medical review process, now known as the Medical Record (MR) threshold amount. This threshold remains at $3,000 for PT and SLP combined and a separate $3,000 for OT until CY 2028.
Resource
Beth Cobb
Medicare Transmittals & MLN Articles
November 22, 2023: MLN MM13452: Medicare Physician Fee Schedule Final Rule Summary: CY 2024
This article highlights changes in the CY 2024 Physician Fee Schedule final rule. For example, starting in CY 2024, telehealth services provided to people in their homes will be paid at the non-facility PFS rate. https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf
November 30, 2023: Change Request (CR) 13312: Indian Health Services (IHS) Rural Emergency Hospital (REH) Provider Enrollment
Beginning January 1, 2024, a tribal or IHS operated hospital that converts to an REH (IHS-REH) that provides hospital outpatient services to a Medicare beneficiary may be paid under the outpatient hospital All-Inclusive rate that is established and published annually by the IHS, rather than the rate for REH services. This CR updates Chapter 10 of the CMS Publication 100-08 (Medicare Program Integrity Manual) to include provider enrollment guidance regarding IHS-REHs. https://www.cms.gov/files/document/r12217pi.pdf
December 7, 2023: MLN MM13333: Medicare Program Integrity Manual: CY 2024 Home Health Prospective Payment System Updates
This article includes information about expanding the HHS 36-month rule, moving hospices into the high level of categorical risk-screening, and other updates to Chapter 10 of the Medicare Program Integrity Manual. https://www.cms.gov/files/document/mm13333-medicare-program-integrity-manual-cy-2024-home-health-prospective-payment-system-updates.pdf
December 7, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised
The December 7th revision of this special edition MLN article adds information on how to verify and update service locations for Medicare enrollment and what claim modifier to use. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
December 12, 2023: MLN MM13463: DMEPOS Fee Schedule: CY 2024 Update
Make sure your billing staff knows about CY 2024 fee schedule amounts for new and existing codes and payment policy changes. For example, the CY 2024 HH PPS final rule established a new benefit category for standard and custom fitted compression garments and additional lymphedema compression treatment items under Medicare Part B. https://www.cms.gov/files/document/mm13463-dmepos-fee-schedule-cy-2024-update.pdf
December 20, 2023: Change Request (CR) 13222: Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92
Effective January 1, 2024, Section 4124 of the Consolidated Appropriations Act of 2023 establishes Medicare coverage and payment for IOP services for individuals with mental health needs when furnished by hospital outpatient departments, Critical Access Hospital outpatient departments, and Community Mental Health Centers. The original Transmittal 12125 has been rescinded and replaced by Transmittal 12423 (CR 13222) dated December 20, 2023. The purpose of this CR is to implement the new condition code 92 for IOP services and enforce billing requirements (https://www.cms.gov/files/document/r12423cp.pdf). Additional information about condition code 92 is available in a related MLN article 13496. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf
December 21, 2023: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update
Make sure your billing staff knows about system updates for January, including new codes for covered devices for pass-through payments, biology-guided radiation therapy, dental services, surgical procedures, drugs and biologicals, and skin substitutes. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf
December 26, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – REVISED
This article was originally published March 26, 2019. In this most recent revision CMS clarified that these instructions do not apply to separately enrolled provider-based rural health clinics and add information on the 09/23 version of the paper-based enrollment form. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdfBeth Cobb
Coverage Updates
October 30, 2023: MLN MM13017: Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening – Revised
The initial release of this MLN article was February 2, 2023. Now in it’s third iteration, CMS has added clarifying information about the -KX modifier for screening colonoscopy claims in the context of a complete colorectal cancer screening. https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf
November 20, 2023: MLN MM13429: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease
On October 13, 2023 CMS published a Final Decision Memo announcing a final decision to remove this NCD and now permitting Medicare coverage determinations to be made by the MACs. Removing the NCD also removes the current limitation of one PET beta-amyloid scan per lifetime from the coverage requirements.
CMS notes in MLN article MM13429 that “your MAC will adjust any PET beta amyloid claims processed incorrectly that you bring to their attention, effective for claims with DOS on or after October 13, 2023. https://www.cms.gov/files/document/mm13429-beta-amyloid-positron-emission-tomography-dementia-and-neurodegenerative-disease.pdf
Compliance Education Updates
MLN Educational Tool: Medicare Payment Systems
CMS has updated this tool to include FY 2024 updates to the:
- Acute Care Hospital Inpatient Prospective Payment System,
- Hospice Payment System & Coverage,
- Inpatient Psychiatric Facility Prospective Payment System,
- Inpatient Rehabilitation Facility Prospective Payment System,
- Long-Term Care Hospital Prospective Payment System, and
- Skilled Nursing Facility Prospective Payment System.
Substantive changes to this tool are in dark red. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html
October 2023: MLN Booklet: Independent Diagnostic Testing Facility
CMS has updated this booklet to include more information on several topics, including supervising physicians, interpreting physicians, and technicians. https://www.cms.gov/files/document/mln909060-independent-diagnostic-testing-facility.pdf
New and Updated CMS National Training Program (NTP) Products
You can order CMS products in bulk by visiting our product ordering website.
Beth Cobb
October 30, 2023: MLN MM13390: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 1 of 2)
CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information. https://www.cms.gov/files/document/mm13390-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-1-2.pdf
October 30, 2023: MLN MM13391: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 2 of 2)
CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information. https://www.cms.gov/files/document/mm13391-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-2-2.pdf
November 3, 2023: MLN MM13244: Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Claims
Effective January 1, 2024, Medicare will make separate payment for HCPCS code A9272 on type of bill (TOB) 032x, instead of 034x. Also, Medicare Administrative Contractors (MACs) will apply deductible and coinsurance.
November 6, 2023: MLN MM13055: Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order – Revised
Initially published June 1, 2023, this article was revised on November 6, 2023 to add two new CPT codes effective January 1, 2024, based on Change Request (CR) 13279.
https://www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdfBeth Cobb
CMS issued the CY 2024 OPPS/ASC Final Rule on November 2, 2023. You can read about changes to the Inpatient Only (IPO) Procedure List and ASC Coverage Procedure List (CPL) in a related article in this week’s newsletter. This article highlights additional topics that historically our clients have reached out to us to learn about.
OPPS Remedy for 340B-Acquired Drug Payment Policy
On July 7, 2023, CMS published a proposed rule, referred to as “remedy proposed rule” to address reduced payment amounts to 340B hospitals for CYs 2018 through 2022 and to comply with the statutory requirement to maintain budget neutrality. The “remedy proposed rule” proposed changes to the calculation of the OPPS conversion factor beginning in CY 2025.
The 340B final remedy was also issued on November 2nd. In this final rule, CMS finalized their proposed methodology of estimating the reduction in drug payments to affected 340B covered entity hospitals in CY 2018 through September 27, 2022, and will make total lump sum payments in the amount of $9.004 billion.
CMS will be issuing instructions to the MACs to issue a one-time lump sum payment to the affected hospitals within 60 calendar days of the MAC’s receipt of the instructions.
Based on updated analyses, the final rule Addendum AAA was updated with new hospital-specific payment amounts and accounts for all payment activity that has happened since the proposed rule was issued. Updated claims data reflects that affected hospitals received approximately $10.6 billion less in 340B drug payments (including money that would have been paid by Medicare and money that would have come from the beneficiaries as copayments) than they would have for drugs provided in CY 2018 through September 27, 2022, had the 340B policy not been implemented.
“The amounts included in Addendum AAA are the amounts that hospitals will receive, except that payment amounts may be affected by MACs continuing to follow normal accounting processes for collecting repayment amounts stemming from provider-specific overpayment obligations, adjustments resulting from errors identified through the lump-sum technical correction process described below, as well as other unique situations such as provider bankruptcy or payment suspension, any of which may impact the provider’s net payment amount.”
Unfortunately, the lump sum payments do not include interest and CMS is following budget neutrality requirements to make these payments. This means that “beginning in CY 2026, we will reduce all payments for non-drug items and services to all OPPS providers, except new providers (hospitals with a CMS CCN effective date of January 2, 2018, or later), by 0.5 percent each year until the total estimated offset of $7.8 billion is reached. We currently estimate that the payment decrease will be completed after approximately 16 years. To implement this reduction and exception for new providers, we are finalizing the proposed regulation text changes at § 419.32(b)(1)(iv)(B) as proposed, except for changing the implementation date of the 0.5 percent reduction from CY 2025 to CY 2026.”
CMS notes in the 340B remedy final rule that “generally the impact of that annual 0.5 percent reduction to the OPPS conversion factor on individual providers, as well as categories of providers, will depend on the percentage of their OPPS payments that are conversion factor-based, and in most cases will be a decrease of slightly less than 0.5 percent of overall OPPS payments.”
Beneficiary Cost Sharing
CMS noted in the final rule that commenters overwhelmingly supported their proposed approach and rationale for accounting for beneficiary cost sharing. They finalized their “policy to account for beneficiary cost sharing as proposed. We will exercise our authority under section 1833(t)(2)(E) of the Act (42 U.S.C. 1395l(t)(2)(E)) to make adjustments “as necessary to ensure equitable payments,” to pay the full $9.0 billion difference, including $1.8 billion, an amount that is approximately equivalent to what affected 340B covered entity hospitals would have collected from beneficiaries for these 340B-acquired drugs if the 340B Payment Policy had not been in effect from CY 2018 through September 27, 2022, so that affected 340B covered entity hospitals are paid the approximate amount they would have been paid in full without application of the 340B Payment Policy.”
340B Modifiers “JG” and “TB”
The Inflation Reduction Act of 2022 expanded the provider types that must report one of these modifiers no later than January 1, 2024, to now include critical access hospitals, Maryland All-Payer or Total Cost of Care Model Hospitals, and Non-excepted off-campus provider-based departments (PBD).
In the CY 2023 OPPS/ASC final rule, CMS maintained the requirements that 340B hospitals report one of two modifiers, “JG” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes, or “TB” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes for select entities.
In the CY 2024 OPPS/ASC proposed rule, CMS notes they “now believe utilizing a single modifier will allow for greater simplicity, especially because both modifiers are used for the same purpose: to identify separately payable drugs and biologicals acquired under the 340B program.”
CMS is proposing that all 340B covered entity hospitals would report the “TB” modifier effective January 1, 2025, even if the hospital previously reported the “JG” modifier. The “JG” modifier will remain effective through December 31, 2024. Beginning January 1, 2025, the “JG” modifier would be deleted.
CMS notes hospitals currently using the “JG” modifier could choose to continue to use it in CY 2024 or choose to transition to the “TB” modifier during that year.
Beth Cobb
It has been thirteen years since CMS published the first Medicare Quarterly Compliance Newsletter in 2010. At that time, this Medicare Learning Network® (MLN) educational product was meant “to help providers understand the major findings identified by Medicare Claims Processing Contractors, Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, and other governmental organizations such as the Office of Inspector General.”
In the second edition of this newsletter CMS indicated that it was “designed to help FFS providers, suppliers, and their billing staffs understand their claims submission problems and how to avoid certain billing errors and other improper activities, such as failure to submit timely medical record documentation, when dealing with the Medicare FFS program.”
Thirteen years later, the newsletter is published twice a year instead of quarterly, and there have been additions to who is reviewing records (i.e., Noridian as the current Supplemental Medical Review Contractor (SMRC) and Livanta as the National Medicare Claim Review Contractor for short stay reviews (SSRs) and higher-weighted DRG (HWDRG) reviews nationally).
CMS announced the release of the September 2023 newsletter in the October 5, 2023 edition of MLN Connects. This edition of the newsletter includes guidance from the Comprehensive Error Rate Testing (CERT) and the Recovery Auditor program.
CERT: Hospital Outpatient Services
The CERT guidance affects physicians, non-physician practitioners (NPPs), and providers who bill 12x-19x. For 2022, the CERT reported an improper payment rate of 5.4% for hospital outpatient services. While the error rate is relatively low, it equates to a projected improper payment of $4.4 billion.
Ninety-one percent of the improper payments were attributed to insufficient documentation. CMS notes that “hospital outpatient claims with insufficient documentation errors most commonly were due to a missing order, missing provider’s intent to order, or inadequacies (that is, required elements are missing) with an order.” An example of a missing order or provider’s intent to order is in the newsletter as well as links to resources to help avoid errors when billing hospital outpatient services.
Recovery Auditor Review 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements
The Recovery Auditor guidance affects outpatient hospitals, ambulatory surgical centers (ASCs), and professional services. The problem cited related to this RAC topic is that providers should know the documentation and medical necessity requirements when billing for this service.
The CPT code for this procedure 64582 (Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array) became effective January 1, 2022 and CMS approved this RAC topic for review on June 7, 2022.
There are very specific indications that must be met for this procedure to be covered (i.e., beneficiary must be 22 years of age or older with a body mass index less than 35, and Shared Decision-Making (SDM) must occur between the beneficiary, sleep physician, and qualified otolaryngologist (if they are not the same).
CMS recommends that providers review coverage indications, limitations, and medical necessity requirements in Local Coverage Determinations (LCDs) and related Local Coverage Articles (LCAs) for billing and coding guidance.
The September Medicare Provider Compliance Newsletter includes links to a National Government Services, Inc. (NGS) LCA and a Palmetto GBA LCD. If neither one of these Medicare Administrative Contractors (MACs) is your MAC, you can find a listing of all MACs that have published an LCD and related LCA on the RAC approved topic description for recovery auditor review 0210 on the CMS webpage.
CPT Code 64582 by the Numbers
With this being a relatively new CPT code and RAC approved topic, I turned to our sister company, RealTime Medicare Data (RTMD), to quantify actual claims volume and payment for this service. The following data represents Medicare Fee-for-Service paid claims data available in RTMD’s database for all U.S. States and D.C. for calendar year 2022.
Hospital Outpatient Setting
- Claims volume: 5,632
- Sum of CPT Paid: $113,462,444.15
- Average Payment: $20,146.03
- Top five states performing this procedure in the hospital outpatient setting: Florida, Texas, Arizona, South Carolina, and Indiana
ASC Setting
- Claims Volume: 1,052
- Sum of CPT Paid: $5,207,088.00
- Average Payment: $4,949.70
- Top five states performing this procedure in an ASC: Texas, Illinois, New Jersey, New Mexico, and Washington
In addition to ensuring that documentation in the medical record supports indications, documentation requirements, and coding and billing guidance, CMS recommends that you respond to RAC review requests promptly and completely. While this seems obvious, no/insufficient documentation continues to be cited as a cause for claim denials. For this reason, make sure you have processes in place to ensure record requests from contractors make it to the right person and/or department in your hospital, you send all documentation needed to support the service provided, and the review contractor receives the record in a timely manner.
Beth Cobb
Medicare Transmittals & MLN Articles
August 28, 2023: MLN MM13350: Changes to the Laboratory National Coverage Determination Edit Software: January 2024 Update
Billing staff need to know about newly available codes, recent coding changes, and how to find NCD coding information. CMS noted that there are no policy changes in this ICD-10 quarterly update. Instead, they follow the current, longstanding NCD process to implement policy changes. https://www.cms.gov/files/document/mm13350-changes-laboratory-national-coverage-determination-edit-software-january-2024-update.pdf
August 28, 2023: MLN MM13335: Inpatient Psychiatric Facilities Prospective Payment System: FY 2025 Updates
This article discusses changes for FY 2024 that are effective October 1, 2023. Make sure your billing staff knows about FY 2024 market basket update, wage index update, and changes to the Inpatient Psychiatric Facility (IPF) Quality Reporting Program (IPFQRP). https://www.cms.gov/files/document/mm13335-inpatient-psychiatric-facilities-prospective-payment-system-fy-2024-updates.pdf
August 31, 2023: MLN MM13353: Ambulatory Surgical Payment System: October 2023 Update
CMS advises in this MLN article that you make sure your billing staff knows about the new HCPCS code for renal/kidney histotripsy, the new drugs and biological codes, and the new skin substitute HCPCS codes. https://www.cms.gov/files/document/mm13353-ambulatory-surgical-center-payment-system-october-2023-update.pdf
September 6, 2023: MLN MM13340: Hospital Outpatient Prospective Payment System: October 2023 Update
This article highlights new COVID-19 CPT vaccines and administration codes, proprietary laboratory analyses (PLA) coding changes, multianalyte assays with algorithmic analyses (MAAA) CPT coding change, advanced diagnostics tests (ADLTs) under the clinical lab fee schedule (CLFS) and HCPCS code changes. https://www.cms.gov/files/document/mm13340-hospital-outpatient-prospective-payment-system-october-2023-update.pdf
September 6, 2023: MLN MM13343: DMEPOS Fee Schedule: October 2023 Quarterly Update
Make sure your billing staff knows about fee schedule adjustment relief for rural and non-contiguous areas, new HCPCS codes added, and new fee schedule amounts. https://www.cms.gov/files/document/mm13343-dmepos-fee-schedule-october-2023-quarterly-update.pdf
September 12, 2023: MLN MM11262: Limitation on Recoupment of Overpayments
This article reviews how Medicare recoups overpayments and how appeals and reconsiderations affect the recoupment process. https://www.cms.gov/files/document/mm11262-limitation-recoupment-overpayments.pdf
September 14, 2023: MLN MM13306: Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2024 Changes
Highlights of policy changes for FY 2024 are included in this MLN article. Of note, CMS indicates that for FY 2024, hospitals have until late-September to notify them of any errors in the calculation of their Total Hospital Acquired Conditions (HAC) Reduction Program score. For this reason, the list of hospitals subject to the HAC Reduction Program will not be available by October 1, 2023. They note that “until we issue a final list of hospitals that are subject to the HAC Reduction Program for FY 2024, MACs will hold hospital claims. We anticipate issuing the list on or about October 3, 2023.” https://www.cms.gov/files/document/mm13306-inpatient-long-term-care-hospital-prospective-payment-system-fy-2024-changes.pdf
September 19, 2023: MLN MM13166: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2023 Update
Relevant NCD coding changes in related Change Request 13166 include:
- NCD 20.20: External Counterpulsation Therapy (ECP) for Severe Angina, effective August 7, 2023,
- NCD 90.2: Next Generation Sequencing (NGS), effective August 7, 2023, and
- NCD 210.1: Prostate Screening Tests, effective October 1, 2023.
Beth Cobb
August 10, 2023: New Place of Service Code 27 – Outreach Site/Street
CMS published Change Request (CR) 13314 to inform providers about the new Place of Service (POS) code 27 for “Outreach Site/Street” – a non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals. This code becomes effective on October 1, 2023.
In the August 25th MLN connects e-newsletter, CMS noted “at this time, Medicare won’t use this code in claims processing. If you submit a claim with this code, we’ll return it to you.”
August 10, 2023: Review Choice Demonstration for Inpatient Rehabilitation Facility Services FAQs
On May 15, 2023, CMS announced the new initiative, The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services. This demonstration started in Alabama with the first cycle of review dates being August 21, 2023 through February 29, 2024.
Palmetto GBA Jurisdiction J is the Medicare Administrative Contractor for Alabama, and they have a dedicated webpage specific to this demonstration (https://palmettogba.com/palmetto/jja.nsf/DID/FHT2JV6UCF). On August 28th, they posted a link to FAQs. Topics covered in this document include general questions, choice selection questions, submission questions, pre-claim review (PCR) questions, and medical necessity questions.
For IRF Providers outside of Alabama, I encourage you to pay close attention to the general question 4 asking what states does this demonstration impact.
CMS notes the demonstration initially for providers physically located in the state of Alabama and bill to MAC Jurisdiction J. The demonstration will then expand to Pennsylvania, Texas, and California, “as well as any state that bill to the MAC jurisdictions JJ, JL, JH, and JE, regardless of where they are physically located.”
Here is one example included in the answer to question 4:
I am an IRF located in a demonstration state but bill to a different MAC than the one for that state.
“You are included in the demonstration if the MAC that you bill to is JJ, JE, JL, or JH. If you bill to another MAC, then you are not included in the demonstration.”
You can find additional information about this demonstration on the CMS website at 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#timeline.
August 21, 2023: CMS Issues Draft Guidance on New Program to Allow People with Traditional Medicare Fee-for-Service to Pay Out-of-Pocket Prescription Drug Costs in Monthly Payments
The Inflation Reduction Act of 2022 was signed into law on August 16, 2022. This law caps annual out-of-pocket prescription drug costs at $2,000 for 2025.
In addition to capping the out-of-pocket amount, the law gives people with Medicare prescription drug coverage (Medicare Part D) the option to make monthly payments spread over the year, also starting in 2025. On August 21st, CMS published draft guidance for comment outlining the requirements and procedures for spreading out the cost sharing over the year.
Due to the size of the new program, CMS indicated they would release the guidance in two parts. Part one was released August 21st and focuses on “helping Medicare Part D plan sponsors and pharmacies prepare for the new programs and build necessary infrastructure for successful implementation.” CMS is soliciting comments on topics and strategies included in the guidance to ensure eligible Part D enrollees benefit from the programs.
You can submit comments to CMS on the first draft guidance through September 30, 2023.
The planned release date for part two of the guidance will be in early 2024. This second release will focus on Medicare Part D enrollee outreach and education, Medicare Part D plan bid information, monitoring and compliance. “CMS also intends to develop tools, such as calculators, to help people with Medicare Part D and their caregivers learn what monthly payments may look like under the new program.”
Links to a Fact Sheet about the Medicare Prescription Payment Plan, an implementation timeline, and the August 21st draft guidance are included in an August 21st CMS Press Release. https://www.cms.gov/newsroom/press-releases/cms-issues-draft-guidance-new-program-allow-people-medicare-pay-out-pocket-prescription-drug-costs
Beth Cobb
Did You Know?
Noridian Healthcare Solutions, LLC (Noridian) is the current Supplemental Medical Review Contractor (SMRC). “With CMS directed topic selections and timeframes, Noridian conducts nationwide medical reviews (Part A, Part B, and DME), in accordance with all applicable statutes, laws, regulations, national and local coverage determination policies, and coding guidance, to determine whether Medicare claims have been billed in compliance with coverage, coding, payment, and billing practices.”
Reviews are assigned to the SMRC based on analysis of national claims data issues identified by other Federal agencies (i.e., OIG, Government Accountability Office (GAO), the Comprehensive Error Rate Testing Program (CERT), and Program for Evaluating Payment Patterns Electronic Report (PEPPER)).
Why It Matters?
As of August 15, 2023, the SMRC has thirteen current projects. Examples of current projects includes hyperbaric oxygen of lower extremities diabetic wounds, hospice general inpatient (GIP) level of care, cryosurgery of the prostate, and Mohs surgery.
Also, as of August 15, 2023, Noridian has completed sixty projects since being awarded the $227 million SMRC contract by CMS in 2018. Error rates for their completed projects range from 1% to 98%.
The 1% error rate was for a sample of claims reviewed related to the 20% add-on payment for COVID-19 that was in place during the COVID-19 Public Health Emergency. The 98% error rate was for a review of claims for Medicare Part B emergency ambulance services.
In July of this year, in addition to reporting an error rate for the reviewed claims, Noridian began reporting an error rate for the number of claims denied due to no response to an Additional Documentation Request (ADR). To date, SMRC medical review findings that include the no response error rate, includes:
Project 01-080: Vitamin B12 with Modifier 25 Findings of Medical Review
Error Rate for Reviewed Claims: 43%
No Response to ADR Denials: 39%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-080/
Project 01-081: Outpatient Dental Services CPT 41899 Findings of Medical Review
Error Rate for Reviewed Claims: 95%
No Response to ADR: 20%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-081/
Project 01-093: Overlapping Claims – Hospital Transfers During the PHE Findings of Medical Review
Error Rate for Reviewed Claims: 12%
No Response to ADR: 8%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-093/
Project 01-050: Podiatry Findings of Medical Review
Error Rate for Reviewed Claims: 45%
No Response to ADR Denials: 29%
Published August 8, 2023
https://noridiansmrc.com/completed-projects/01-050/
Project 01-072: Neurostimulator Implantation Findings of Medical Review
Error Rate for Reviewed Claims: 39%
No Response to ADR Denials: 23%
Results Published August 15, 2023
https://noridiansmrc.com/completed-projects/01-072/
Noridian notes they must notify CMS of identified improper payments and noncompliance with documentation requests. They will initiate claims adjustments and/or overpayment recoupment by the standard overpayment recovery process.
What Can I Do?
First and foremost, make sure you have a process to receive and respond to ADR requests from the SMRC and other review contractors (i.e., CERT).
If a claim is denied for no receipt of documentation, you can complete the following steps posted to the Noridian Jurisdiction E (JE) MAC website:
SMRC Reviews Denied for No Documentation
“When a claim is denied for no receipt of documentation requested by the SMRC, the next step is to submit the documentation to the MAC that issued the demand letter for the overpayment. This must occur within 120 calendar days of the demand letter.
This situation is considered a reopening and the MAC will send the submitted documentation to the SMRC for a re-review decision. The SMRC has up to 60 calendar days to make this decision. The SMRC will then mail a letter to the supplier with their findings, either to pay the claim or they will outline the reasons for denial.
The SMRC will next notify the MAC of the payment or denial decision. The MAC will adjust the claim and a remittance advice with the adjustment results will be generated. The provider has the right to appeal the SMRC decision, if the claim remains denied.
Based on the timeframes and steps listed above, please call the MAC about the status of the SMRC re-review only after at least 140 days have passed from when documentation was sent.”
Last, become familiar with information available on the SMRC website (https://noridiansmrc.com/).
Beth Cobb
July 21, 2023: MLN MM13240: Patient Driven Payment Model Claim Edits
CMS advises that Skilled Nursing Facilities (SNFs) and Hospitals need to make sure your billing staff knows about edits for SNFs billing on Type of Bill (TOB) 21X and Swing Bed TOB 18X, and hospitals billing during an interrupted stay. https://www.cms.gov/files/document/mm13240-patient-driven-payment-model-claim-edits.pdf
July 21, 2023: MLN MM13248: Processing Services During Disenrollment from the Program of All-Inclusive Care for the Elderly (PACE)
Hospitals, SNFs and other providers billing Medicare Administrative Contractors (MACs) for inpatient services they provide to PACE-eligible Medicare patients need to make sure your billing staff knows how CMS handles payment for Medicare patients disenrolling from PACE and condition codes and value code (VC) CMS requires to prevent claims denials. https://www.cms.gov/files/document/mm13248-processing-services-during-disenrollment-program-all-inclusive-care-elderly.pdf
July 27, 2023: MLN MM13275: ESRD Prospective Payment System: October 2023 Update
Make sure your billing staff knows about billing J0889 for daprodustat and new ICD-10-CM codes for comorbidity payment adjustment and acute kidney injury. https://www.cms.gov/files/document/mm13275-esrd-prospective-payment-system-october-2023-update.pdf
Augst 3, 2032: MLN MM13299: HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement: October 2023 Update
Make sure billing staff knows about updates to the lists of HCPCS codes that are subject to the CB provision of the SNF prospective payment system (PPS), and additions and deletions of certain chemotherapy, blood clotting factors, and therapies inclusion codes from the Medicare Part A SNF files. https://www.cms.gov/files/document/mm13299-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-october-2023.pdf
August 10, 2023: MLN MM13289: Hospice Payments: FY 2024 Update
This article provides information about payment rates, inpatient and aggregate caps and wage index update effective October 1, 2023 for hospices and providers billing for hospice services. https://www.cms.gov/files/document/mm13289-hospice-payments-fy-2024-update.pdf
August 16, 2023: SE19007 Revised: Activation of Validation Edits for Providers with Multiple Service Locations
This special edition MLN article was originally published on March 26, 2019 and recently updated for the fifth time on August 16th. CMS has added information about the practice location address screen for round 3 testing Substantive changes are in dark red on pages 3 and 4.
Effective August 1, 2023, CMS started deploying the systematic validation edits requirements in Section 170 of the Medicare Claims Processing Manual, Chapter 1. MACs have been told to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t exactly match.
CMS notes in the MLN article that they “expect that the almost 7-year time frame that the edits haven’t been active gave you ample time to validate your claims submission system and the PECOS information for your off-campus provider departments are exact matches.” https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
August 17, 2023: MLN MM13321: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
Make sure your billing staff know about private payor data reporting (you must report data between January – March 2024), general specimen collection fee increase, and new and deleted HCPCS codes. https://www.cms.gov/files/document/mm13321-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf
August 24, 2023: Transmittal 12222: Inpatient Psychiatric Facilities Prospective Payment System Updates for Fiscal Year 2024
This Change Request (CR) 13335 identifies changes that are required as part of the annual IPF PPS update and applicable to discharges occurring from October 1, 2023 through September 30, 2024. https://www.cms.gov/files/document/r12222cp.pdf
Beth Cobb
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