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FY 2025 ICD-10-PCS Official Guidelines for Coding & Reporting
Published on 

6/12/2024

20240612
 | Coding 

Did You Know?

CMS published the FY 2025 ICD-10-PCS files on June 5, 2024. There were no changes made to the Official ICD-10-PCS Coding Guidelines for October 1, 2024.

 

For FY 2025 there are 371 new codes, no revised codes, and sixty-one deleted codes bringing the total number of ICD-10-PCS codes to 78,948.

 

Section X New Technology Codes

In FY 2016, a new section X New Technology was created to classify new technology procedures. In FY 2016 there were fourteen section X codes. For FY 2025 there are now 378 section X codes.

 

Beginning with FY 2024, CMS began posting the new technology applications publicly to increase transparency and enable increased stakeholder engagement. The NTAP Public Application Summaries are available on the Medicare Electronic Application Requests Information System (MEARIS).

 

Changes to the codes will be in effect for discharges occurring from October 1, 2024, through September 30, 2025.

 

Why it matters?

CMS notes, on the opening page of the 2025 ICD-10-PCS Official Guidelines for Coding and Reporting, “These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

 

What can I do?

Share this information with coding and clinical documentation professionals at your facility as you begin to prepare for the October 1, 2024, start of the CMS FY 2025. Even though there were no changes made to the Official ICD-10-PCS Coding Guidelines, I consider an annual review a worthwhile part of your summer reading.

Resource

CMS.gov: 2025 ICD-10-PCS webpage: https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-pcs

Beth Cobb

Underdosing for PRN Medications
Published on 

6/12/2024

20240612
 | Coding 

Question:

Do we assign a code for underdosing of medication when the patient takes it on an “as needed” basis only?

 

Answer:

Per Coding Clinic, First Quarter, 2021, pages 12-13, PRN medications are not classified as long-term drug therapy; therefore, a code for underdosing of a PRN medication should not be assigned when it is not being taken.  However, the ICD-10-CM Z code for Patient’s noncompliance with other medical treatment and regimen for other reason (Z91.198) can be assigned. This ICD-10-CM diagnosis code became effective October 1, 2023.

 

References:

Coding Clinic for ICD-10-CM/PCS, First Quarter 2021:  Pages 12-13

Susie James

New Cervical Fusion Local Coverage Determinations
Published on 

6/5/2024

20240605

Did You Know?

In 2023, the Medicare Administrative Contractors (MACs) came together for a multi-MAC collaboration to provide an evidence-based Local Coverage Determination (LCD) for cervical fusion.

 

Why it Matters?

Historically, there have been LCDs for back procedures for Cervical Disk Replacement (i.e., Palmetto GBA LCD L38033), Lumbar Artificial Disc Replacement (i.e., Palmetto GBA LCD L37826), and Lumbar Spinal Fusion (i.e., Palmetto GBA LCD L37826).

 

Cervical Fusion is new to this group of back procedure LCDs, and the original effective date for this new LCD is July 7, 2024.

 

Per Palmetto’s LCD, cervical fusion surgery is considered medically reasonable and necessary when one of three covered indications:

  1. For decompression of symptomatic cervical nerve root impingement,
  2. For decompression of symptomatic cervical canal stenosis, or
  3. For decompression or stabilization of the cervical spine for one of four indications (traumatic injuries, spinal tumors, infection, deformities that include the cervical spine.)

 

In addition to meeting one of the above three indications, there are specific requirements for each that also must be met.  

 

What Can You Do?

Find your MAC specific LCD and related Billing and Coding Article on the Medicare Coverage Database (MCD) and share this information with key stakeholders at your facility. Below are the MAC specific policies and related articles listed on the MCD as of June 3rd.   

 

MAC Specific Cervical Fusion LCD and related Billing and Coding Article

CGS J14: L39741 / A59608 (A59738 – Response to Comments Article)

First Coast JN: DL39799

NGS J6/JK: DL39770 / DA59632

Noridian JE: L39758 / A59624 (A59796 – Response to Comments Article)

Noridian JF: L39762 / A59645 (A59797 – Response to Comments Article)

Novitas JH/JL: DL39793

Palmetto JJ/JM: L39773 / A59634 (A59736 – Response to Comments Article)

WPS J5/J8: L39788 / A59664 (A59800 – Response to Comments Article)

Beth Cobb

Cataract Awareness Month June 2024
Published on 

6/5/2024

20240605

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.

 

In addition to age, you may be at a higher risk of developing cataracts if you:

  • Have certain health problems like diabetes
  • Smoke
  • Drink too much alcohol
  • Have a family history of cataracts
  • Have had an eye injury, eye surgery, or radiation treatment on your upper body
  • Have spent a lot of time in the sun
  • Take steroids

 

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 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 2023 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table G1: Improper Payment Rates by Service Type: Part B. The improper payment rate was 8.2% with the projected improper payment of $149,241,566.

 

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 published on April 15, 2024 for claims with dates of service from January 1, 2024 through March 31, 2024:  

  • Noridian JE error rate was 22% down from 48.67% in April 2023.
  • Noridian JF was 43.6% down from error rate 45.88% in April 2023.

 

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

 

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.

Beth Cobb

May 2024 Medicare Transmittals and MLN Articles
Published on 

5/29/2024

20240529

Medicare Transmittals & MLN Articles

April 25, 2024: MLN MM13449: Stay of Enrollment – Revised

This article provides information about a new provider enrollment status called a stay of enrollment and related updates to the Medicare Program Integrity Manual, Chapter 10. On April 25th, CMS reissued this article to revise the effective and implementation dates to May 30, 2024 and the web address of Change Request (CR) 13449. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf

 

May 3, 2024: MLN MM13487: Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule

CMS advises providers to make sure your billing staff knows about the revised regulatory definition of diabetes, the revised diabetes screening frequency limitations, and coverage of the Hemoglobin A1C (HbA1c) test for diabetes screening.

 

Prior to January 1, 2024 the HbA1C test (HCPCS code 83036) was covered for the purpose of diabetes management but not for diabetes screening. As of January 1, 2024, CMS now covers the HbA1c test for diabetes screening. https://www.cms.gov/files/document/mm13487-diabetes-screening-definitions-update-cy-2024-physician-fee-schedule-final-rule.pdf

 

May 3, 2024: MLN MM13486: Annual Wellness Visit: Social Determinants of Health Risk Assessment

Make sure your billing staff knows that the social determinants of health (SDOH) risk assessment is now an optional annual wellness visit (AWV) element and what the eligibility and billing requirements are for completing the SDOH risk assessment as part of the AWV. https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf

 

May 3, 2024: MLN MM13592: Updates for Split or Shared Evaluation & Management Visits

Information in this article for your billing staff include the definition of split or shared visit and substantive portion, and how to bill appropriately for split or shared evaluation and management (E/M) visits. https://www.cms.gov/files/document/mm13592-updates-split-or-shared-evaluation-management-visits.pdf

 

May 9, 2024: MLN MM13608: ESRD Prospective Payment System Quarterly Update

Make sure your billing staff knows about the Transitional Drug Add-On Payment Adjustment (TDAPA) for HCPCS code J0911 and the updated list of outlier services under the ESRD PPS. https://www.cms.gov/files/document/mm13608-esrd-prospective-payment-system-quarterly-update.pdf

 

May 16, 2024: MLN MM13617: Medicare Claims Processing Manual Update: Gap-Filling DMEPOS Fees

Make sure your billing staff knows about the revised Section 60.3 in the Medicare Claims Processing Manual, Chapter 23 and updated factors for gap-filling purposes.

https://www.cms.gov/files/document/mm13617-medicare-claims-processing-manual-update-gap-filling-dmepos-fees.pdf

 

May 23, 2024: MLN MM13598: NCD 200.3 – Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD)

This article includes information about FDA-approved monoclonal antibodies, the criteria for coverage, coding information, and claims processing instructions. https://www.cms.gov/files/document/mm13598-national-coverage-determination-2003-monoclonal-antibodies-treatment-alzheimers-disease.pdf

 

May 24, 2024: MLN MM13613: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article was initially released on May 3rd, 2024 with guidance from CMS to make sure your billing staff know that the next private payor data reporting period of January 1, 2025 – March 31, 2025 and new and deleted HCPCS codes. No substantive changes were made in the May 24th revision other than to update the web address of the CR transmittal. https://www.cms.gov/files/document/mm13613-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

Beth Cobb

May 2024 Medicare Coverage, Compliance, and Other Updates
Published on 

5/29/2024

20240529

Coverage Updates

April 30, 2024: New National Coverage Analysis (NCA)Tracking Sheet for Implanted Pulmonary Artery Pressure Sensor for Heart Failure Management (CAG-00466N)

CMS posted a National Coverage Analysis (NCA) Tracking Sheet regarding a request from Abbott to provide coverage for the CardioMEMS™ HF System. This device measures Pulmonary artery (PA) pressures by using a combination of an implantable PA pressure sensor and a remote hemodynamic monitoring system that is accessible by the physician. CMS is soliciting public comment until May 30, 2024 and has indicated a proposed Decision Memo due date of October 30, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=313

 

May 2, 2024: CMS Statement on Proposed LCD for Skin Substitute Grafts/Cellular and Tissue-Based Products for Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

CMS notes in the May 2, 2024 edition of MLN Connects that they are aware of the MACs having issued a collaborative proposed Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Local Coverage Determination (LCD). CMS strongly encourages interested parties to provide comments during the public comment period that is open until June 8, 2024.  

 

May 10, 2024: MLN MM13596: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2024 Update

This article highlights new codes and recent coding changes related to the Next Generation Sequencing (NGS) (NCD 90.2), Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (NCD 100.1), and the Aprepitant for Chemotherapy-Induced Emesis (NCD 110.18). https://www.cms.gov/files/document/mm13596-icd-10-other-coding-revisions-national-coverage-determinations-october-2024-update.pdf

 

May 13, 2024: MLN MM13604: National Coverage Determination 110.23: Allogeneic Hematopoietic Stem Cell Transplantation

Make sure your billing staff knows about coverage for HSCT using bone marrow, peripheral blood or umbilical cord blood stem cell products for Medicare patients and all other indications for stem cell transplantation not otherwise specified. https://www.cms.gov/files/document/mm13604-national-coverage-determination-11023-allogeneic-hematopoietic-stem-cell-transplantation.pdf

 

Compliance Education Updates

May 2024: MLN Fact Sheet: Swing Bed Services

CMS has updated this fact sheet to include information about covered Critical Access Hospital (CAH) swing bed services.  https://www.cms.gov/files/document/mln006951-swing-bed-services.pdf

 

Other Updates

May 9, 2024: CMS Publication – Part B Drug Payment Limits Overview

In the Thursday, May 9th edition of MLN Connects, CMS noted they have published a Part B Drug Payment Limits Overview document to explain the Average Sales Price (ASP) payment limit calculation and other Medicare Part B drug payment methodologies including Wholesale Acquisition Cost (WAC), Average Wholesale Price (AWP), Average Manufacturer Price (AMP), Widely Available Market Price (WAMP), and Contractor Pricing.  

 

May 9, 2024: Mental Health: It’s Important at Every Stage of Life

Also in the Thursday, May 9th edition of MLN Connects, CMS noted that mental and physical health are equally important components of overall health, and they provide links to information about appropriate preventive services and preventive services (i.e. Medicare & Mental Health Coverage) covered by Medicare.

 

May 21, 2024: CMS Launches New Option for Individuals to Report Potential Violations of the Emergency Medical Treatment and Labor Act (EMTALA)

CMS announced the launch of a new web resource to educate the public and promote patients’ access to emergency medical care to which they are entitled under federal law. https://www.cms.gov/newsroom/press-releases/biden-harris-administration-launches-new-option-report-potential-violations-federal-law-and-continue

 

Beth Cobb

Older Americans Month 2024
Published on 

5/22/2024

20240522

Meaningful connections are not just about having someone to chat with, they’re about the transformative potential of community engagement in enhancing mental, physical, and emotional well-being. By recognizing and nurturing the role that connectedness plays, we can mitigate issues like loneliness, ultimately promoting healthy aging for more Americans.

According to the U.S. Surgeon General's Advisory on the Healing Effects of Social Connection and Community:

  • Social isolation among older adults alone accounts for an estimated $6.7 billion in excess Medicare spending annually, largely due to increase hospital and nursing facility spending,
  • Loneliness and social isolation increase the risk for premature death by 26% to 29% respectively,
  • Poor or insufficient social connection is associated with increased risk of disease, including a 29% increased risk of heart disease and a 32% increased risk of stroke,
  • Loneliness is also associated with an increased risk for anxiety, depression, and dementia, and
  • The lack of social connection may increase susceptibility to viruses and respiratory illness.

How can community groups, businesses, and organizations mark OAM?

  • Spread the word about the mental, physical, and emotional health benefits of social connection through professional and personal networks.
  • Encourage social media followers to share their thoughts and stories of connection using hashtag #PoweredByConnection to inspire and uplift.
  • Promote opportunities to engage, like cultural activities, recreational programs, and interactive virtual events.
  • Connect older adults with local services, such as counseling, that can help them overcome obstacles to meaningful relationships and access to support systems.
  • Host connection-centric events or programs where older adults can serve as mentors to peers, younger adults, or youths.

What can individuals do to connect?

  • Invite more connection into your life by finding a new passion, joining a social club, taking a class, or trying new activities in your community. 
  • Stay engaged in your community by giving back through volunteering, working, teaching, or mentoring.
  • Invest time with people to build new relationships and discover deeper connections with your family, friends, colleagues, or neighbors.

For more information, visit the official OAM website and follow ACL on X, Facebook, and LinkedIn. Join the conversation on social media using the hashtag #OlderAmericansMonth.

Beth Cobb

What's New with the BFCC-QIOs
Published on 

5/22/2024

20240522

Kepro

Kepro’s service areas include CMS Regions 1,4, 6, 8, and 10. In December 2022, Kepro merged with CNSI. Six months later, they announced the organization had been rebranded as Acentra Health indicating that “the name Acentra Health derives from the root words “accelerate” and “central,” reflecting the company’s uncompromising resolve to be a vital partner to public sector health agencies in the delivery of comprehensive healthcare solutions and services, with “Health” being its central business focus.”

 

On April 30, 2024, Kepro published a special bulletin letting providers know about their name change. They encouraged providers to update their beneficiary notices, the Important Message from Medicare (IM) and the Notice of Medicare Non-Coverage (NOMNC), by replacing “Kepro” with “Acentra Health.” However, they did note that notices that still have the name “Kepro” listed will be accepted and validated and posted a list of FAQs on their website about this change. Key things to be aware of include:

 

  • Phone numbers and fax numbers will not be changing,
  • Their “go live” target date for rebranding to “Acentra Health” is August 1st and plan to have all their items changed by fall 2024,
  • Kepro has been contracted to perform Medicare’s mandatory reviews through 2029 and its CMS Regions will not be changing,
  • There will be a new website with a new web address, and will be available when the name change occurs by fall 2024, and
  • They encourage you to sign up to their newsletter, Case Review Connections, which includes updates and news from Kepro.

     

    A day after the special bulletin was published, on May 1, 2024, Kepro began a new process for hospital discharge appeals. Specifically, when a Medicare Fee-for-Service beneficiary calls Kepro to file a discharge appeal due to concerns with their discharge planning will be transferred to the Immediate Advocacy (IA) team. This team will review the concerns, identify any gaps or misunderstandings, and determine if additional guidance is needed. You can read more about this new process on Kepro’s Hospital Discharge Appeals webpage.

     

    Livanta

    Livanta’s service areas include CMS Regions 2, 3, 5, 7, and 9. On May 17, 2024 they distributed Provider Bulletin # 21 announcing that they had been awarded the BFCC-QIO contract for case reviews from May 1, 2024, through April 30, 2029. Livanta will also continue to serve as the national Medicare Claim Review contractor.

     

    Livanta’s announcement includes the following four sections:

  • Section 1: Beneficiary Case Review versus Claim Review,
  • Section 2: What is changing, and what is staying the same?
  • Section 3: Updating Contact Information and Memoranda of Agreement, and
  • Section 4: Stay in Touch with Livanta.

 

If you are unsure who your BFCC-QIO is, you can use the QIO “Locate Your BFCC-QIO” tool at https://qioprogram.org/locate-your-bfcc-qio.

 

Resource

Livanta Provider Bulletin #21: https://www.livantaqio.cms.gov/assets/files/13-SOW-MD2024-QIOBFCC-PROV-1.pdf

Beth Cobb

Osteoporosis Awareness and Prevention Month
Published on 

5/15/2024

20240515

May is National Osteoporosis Awareness and Prevention Month.

 

Did You Know?

Osteoporosis is a “silent” disease because you typically do not have symptoms and may not even know you have the disease until you break a bone.

 

Despite this being a “silent” disease there are risk factors for developing osteoporosis, including:  

  • A family history of broken bones or osteoporosis,
  • History of broken bone after age 50,
  • Previous surgery to remove the ovaries before menopause,
  • Poor dietary habits, including insufficient amounts of calcium and or vitamin D or protein.
  • Physical inactivity or prolonged periods of bedrest,
  • Smoking cigarettes,
  • Heavy use of alcohol,
  • Long-term use of certain medications, such as corticosteroids, proton pump inhibitors, and antiepileptic medications,
  • Altered level of hormones, such as too much thyroid hormone, too little estrogen in women, or too little testosterone in men, and
  • Low body mass index or underweight.

 

Why it Matters?

According to the National Osteoporosis Foundation (NOF):

  • Approximately 54 million Americans have low bone density or osteoporosis.
  • Women can lose up to 20% of bone mass in the first 5-7 years post-menopause.
  • Men aged 50 years and older are more likely to break a bone due to osteoporosis than they are to get prostate cancer.
  • Studies suggest that approximately 1 in 2 women and up to 1 in 4 men 50 and older will break a bone due to osteoporosis in their lifetime.

 

What Can You Do?

As we celebrate Osteoporosis Awareness and Prevention Month, here are some steps you can take to improve your bone health:

  • Eat foods that support bone health. Get enough calcium, vitamin D, and protein each day. Low-fat dairy; leafy green vegetables; fish; and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.
  • Get active. Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.
  • Don’t smoke. Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.
  • Limit alcohol consumption. Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.

 

Resources

National Institute of Health: National Institute on Aging: Osteoporosis: https://www.nia.nih.gov/health/osteoporosis/osteoporosis

 

National Osteoporosis Foundation (NOF) May 2024 Social Media Toolkit: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2024-OAPM-Social-Media-Toolkit.pdf

 

National Institute of Health: National Institute of Arthritis and Musculoskeletal and Skin Diseases: Osteoporosis: https://www.niams.nih.gov/health-topics/osteoporosis

Beth Cobb

New Technologies Eligible for Add-On Payment FY 2025 IPPS Proposals
Published on 

5/15/2024

20240515
 | Coding 
 | Billing 

“The primary objective of the IPPS and the LTCH PPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs, while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs in delivering necessary care to Medicare beneficiaries.”

  • Source: Appendix A: Economic Analysis of FY 2025 IPPS Proposed Rule

 

New Technologies Eligible for Add-On Payment (NTAPs) Background

Effective for discharges beginning on or after October 1, 2002, Section 1886(d)(5)(K)(i) of the Act requires the Secretary to establish a mechanism to recognize the costs of new medical services and technologies under the payment system under the subsection which establishes the system for paying for the operating costs of inpatient hospital services.

 

The system of payment for capital costs is established in section 1886(g) of the Act. For this reason, capital costs are not included in the add-on payments for a new medical service or technology.

 

NTAPs are not budget neutral and the “newness” for payment is limited to the 2-to-3-year period after the point at which data begin to become available reflecting the inpatient hospital code assigned to the new service or technology.

 

There are three pathways for a new service or technology to be approved for the add-on payment (Traditional pathway, Certain Antimicrobial Products Alternative Pathway, and Certain Transformative New Devices Alternative Pathway).

 

For the alternative pathways, a technology is not required to have a specified FDA designation at the time the application for NTAP is made. Instead, “CMS reviews the application based on the information provided by the applicant only under the alternative pathway specified by the applicant at the time of new technology add-on payment application submission. However, to receive approval for the new technology add-on payment under that alternative pathway, the technology must have the applicable FDA designation and meet all other requirements in the regulations in § 412.87(c) and (d), as applicable.”

 

Coding NTAPs

Section X New Technology was added to ICD-10-PCS effective October 1, 2015. CMS has indicated (https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Section-X-New-Technology-.pdf) that “Section X was created in response to public comments received regarding New Technology proposals presented at ICD-10 Coordination and Maintenance Committee Meetings, and general issues facing classification of new technology procedures.”  To receive payment for an eligible NTAP, the applicable section X New Technology ICD-10-PCS code must be on the claim submitted for adjudication.

 

NTAPs by the Numbers

For FY 2025, CMS has proposed to:

  • Discontinue 7 technologies no longer considered to be “new,”
  • Continue coverage for 24 technologies they consider to still be “new,” and
  • Have assessed 26 applications.

 

For the 24 technologies that CMS considers to still be “new,” CMS estimates that collectively there will be 50,910 cases with an estimated total financial impact of just over $416 million.

 

Based on preliminary information from the FY 2025 applicants for new technology approval, CMS estimates the collective impact to be $345.3 million.

 

FY 2025 NTAP Program Proposals

Consistent with CMS’ Sickle Cell Disease Action Plan, CMS is proposing to increase the NTAP percentage from 65% to 75% for a gene therapy that is indicated specifically for the treatment of sickle cell disease (SCD) (subject to CMS’ determination in the FY 2025 IPPS final rule that any applicable gene therapy(ies) indicated and used specifically for treatment of SCD meets the criteria for approval for NTAP).

 

CMS has also proposed to use the October 1st start of a new fiscal year, instead of April 1st, to determine whether a technology is within its 2- to 3- year newness period. This change would be effective in FY 2026 for new applicants and extending the NTP an additional year for technologies initially approved in FY 2025.

 

CMS is accepting comments on the proposed rule through June 10, 2024.

 

Resource

FY 2025 IPPS Proposed Rule CMS webpage:

https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2025-ipps-proposed-rule-home-page

Beth Cobb

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