2024-07-11-MLNC

On June 28, 2024, CMS issued a proposed rule that proposes an approach for mitigating the impact of significant, anomalous, and highly suspect (SAHS) billing activity in CY 2023 for selected intermittent urinary catheter supplies on Medicare DMEPOS claims on Medicare Shared Savings Program financial calculations. The CY 2025 Physician Fee Schedule proposed rule includes proposals to mitigate the impact of SAHS billing activity on Medicare Shared Savings Program financial calculations in CY 2024 or subsequent calendar years.

Submit comments; refer to file code CMS-1799-P. The comment period closes on July 29, 2024.

See the full fact sheet for more information.

News

Guiding an Improved Dementia Experience by Clearing the Path for Comprehensive, High-Quality Dementia Care

On July 1, 2024, CMS launched the Guiding an Improved Dementia Experience (GUIDE) Model with 390 participating organizations building Dementia Care Programs that will serve hundreds of thousands of people with Medicare nationwide. The GUIDE Model aims to increase access to much-needed support for people living with dementia and their caregivers.

Read the full blog.

New Alzheimer’s Drugs: Updates to CMS National Patient Registry

On July 2, 2024, CMS announced that Medicare coverage is now available for Kisunla™ (donanemab-azbt) following the FDA’s move to grant traditional approval to the drug that treats people with Alzheimer’s disease. Kisunla joins Leqembi® (the brand name for lecanemab-irmb) as the second monoclonal amyloid beta antibody treatment granted traditional FDA approval for Alzheimer’s disease.

Medicare Part B covers these 2 drugs with traditional FDA approval in this class when a prescribing clinician or their staff decides the Medicare coverage criteria are met and submits information to help answer treatment questions in a qualifying study.

More Information:

CMS National Patient Registry for Alzheimer’s Drugs fact sheet
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease webpage
National Coverage Determination 200.3: Monoclonal Antibodies for the Treatment of Alzheimer’s Disease (PDF) MLN Matters Article
Medicare Coverage for Alzheimer’s Drugs fact sheet: information for your patients

Epileptologists: New Physician Specialty Code

CMS established a new physician specialty code for epileptologists (F6) effective July 1, 2024.

You must enroll in Medicare to submit claims, and get paid for covered items or services. Enroll now. Find out how to become a Medicare provider, and take these steps to enroll:

Review the application: electronic version in PECOS or paper CMS-855I (PDF)
Gather your supporting documents
Find your Medicare Administrative Contractor's website
Sign up to get our weekly MLN Connects newsletter

More information:

Medicare Diabetes Prevention Program Supplier Enrollment: Updated CDC Organization Codes

Effective June 1, 2024, use CDC organization codes from the 2024 Diabetes Prevention Recognition Program (DPRP) Standards to enroll in Medicare as a Medicare Diabetes Prevention Program (MDPP) supplier.

The updated DPRP Standards include 5 types of modes:

In-person
Distance learning
In-person with a distance learning component
Online
Combination with an online component

Organizations receive a separate CDC DPRP organization code for each mode they deliver. If your organization is enrolling as an MDPP supplier, it must demonstrate an “in-person” or “in-person with a distance learning component” CDC DPRP code starting June 1, 2024.

These CDC organization codes aren’t required on your MDPP claims.

CMS Health Information Handler Helps You Submit Medical Review Documentation Electronically

Learn about the CMS Health Information Handler (CMS HIH), a free service to help you upload and submit your medical documentation electronically to your Medicare Administrative Contractor using the following formats:

Portable document format (PDF)
Extensible markup language (XML)
JavaScript object notation (JSON)

Respond electronically to prior authorization and additional document requests:

Unlimited number of transactions
Fast, safe, and secure environment
Easily accessible

The benefits of the CMS HIH include:

Hosted on CMS Amazon Web Services cloud
Adheres to all CMS security and privacy standards
Accommodates small or large users

Contact cmshih@cms.hhs.gov to learn more, and get started.

Help People Living with Disabilities Get the Care They Need

People living with disabilities face unique barriers and health care challenges, like not having access to a regular health care provider and routine check-ups. As a result, they have poorer overall health outcomes including increased likelihood of obesity (41.6%), diabetes (15.9%), and heart disease (9.6%) (see CDC). During Disability Pride Month and the Americans with Disabilities Act anniversary month, find out how you can help address these challenges.

More Information:

Modernizing Health Care to Improve Physical Accessibility web-based training
Getting the Care You Need: Guide for People with Disabilities (PDF) publication
Improving Access to Care for People with Disabilities webpage
How to Improve Physical Accessibility at Your Health Care Facility (PDF) booklet

Compliance

Negative Pressure Wound Therapy: Prevent Claim Denials

In 2022, the improper payment rate for negative pressure wound therapy was 39.1%, with a projected improper payment amount of $31.9 million (see 2022 Medicare Fee-for-Service Supplemental Improper Payment Data (PDF), Appendices E and G). Learn how to bill correctly for these services. Review the negative pressure wound therapy provider compliance tip for more information, including:

Denial reasons and how to prevent them
Documentation requirements

See Medicare Advisory Panel on Clinical Diagnostic Laboratory Tests to learn more. You don’t need to register to view or listen to the meeting virtually.

Publications

Post-Acute Care Quality Reporting Programs: Technical Expert Panel Measurement Sets Report

CMS released the Standing Technical Expert Panel (TEP) for the Development, Evaluation, and Maintenance of Post-Acute Care (PAC) and Hospice Quality Reporting Program (QRP) Measurement Sets (PDF) summary report. This report includes input provided by a TEP in December 2023 on:

Developing additional cross-setting measures for the PAC and Hospice QRPs
Filling measurement gaps with the CMS Universal Foundation measures

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