2023-12-14-MLNC

On December 14, CMS released revised guidance detailing key requirements and procedures for calculating rebates and invoicing manufacturers that owe rebates to Medicare under the Medicare Prescription Drug Inflation Rebate Program for certain drugs covered under Medicare Part B and Part D. CMS also released the list of 48 prescription drugs for which Part B beneficiary coinsurances may be lower between January 1, 2024 – March 31, 2024. More information about these 48 Part B drugs and biological products can be found in the quarterly Average Sales Price (ASP) public files, available here (PDF). A fact sheet is available here (PDF).

This coinsurance adjustment applies to certain drugs and biologicals paid under Medicare Part B. The Part B drugs impacted by this coinsurance adjustment may change quarterly.

More Information:

Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier — Revised

Learn about the revised requirement to include a modifier (PDF) on claims for separately payable Part B drugs and biologicals acquired under the 340B Program.

Billing for Flu, Pneumococcal, & COVID-19 Vaccines

For flu, pneumococcal, and COVID-19 vaccines furnished on or after July 1, 2023, to patients in a Medicare Part A-covered skilled nursing facility (SNF) stay, immunizers can no longer bill Medicare directly.

Typical SNF consolidated billing regulations are in place, which require SNFs to bill for all services furnished to patients in a Medicare-covered SNF stay, including vaccines.

If you give the COVID-19, flu, and pneumococcal shot to groups of individuals (like people who live in a retirement community) you’re considered a mass immunizer and you may use a roster bill, traditional claim form, or 837P.

More Information:

SNF: Enforcement Discretion Relating to Certain Pharmacy Billing webpage
SNF Consolidated Billing webpage
Flu Shot webpage
Pneumococcal Shot & Administration
Section 20.4 Medicare Claims processing Manual, Chapter 6 (PDF)
Medicare Part D Vaccines (PDF) fact sheet

Expanded Home Health Value-Based Purchasing Model: October 2023 Interim Performance Reports

Download your final October 2023 Interim Performance Report (IPR) from iQIES. See instructions for accessing reports.

For the CY 2023 performance year, you’ll get a report if you:

Were Medicare-certified prior to January 1, 2022
Have enough data for at least 1 quality measure

More Information:

QIES/iQIES Service Center at 800-339-9313 or iqies@cms.hhs.gov: Register a user, or get help locating or downloading reports
Help Desk at HHVBPquestions@lewin.com: Questions about the Model

Claims, Pricers, & Codes

New Place of Service Code 27 for Outreach Site/Street

CMS created a new place of service (POS) code 27 (Outreach Site/Street) effective October 1, 2023. This is a non-permanent location on the street or found environment, not described by any other POS code, where you provide preventive, screening, diagnostic, or treatment services to unsheltered, homeless patients. We’ll process claims with POS 27 the same as POS 12 (Home).

See the instruction to your Medicare Administrative Contractor (PDF) (PDF) for more information.

National Correct Coding Initiative: January Update

Get the National Correct Coding Initiative (NCCI) first quarter edit files, effective January 1, 2024, on these Medicare NCCI webpages:

MLN Matters® Articles

Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting & Reporting Data for the Private Payor Rate-Based Payment System — Revised

Learn what’s changed (PDF):

For clinical diagnostic laboratory tests that aren’t advanced diagnostic laboratory tests, the data reporting period is delayed and resumes starting January 1, 2025 – March 31, 2025
CMS extended the 0% limit on laboratory payment reductions to the end of CY 2024 and the 15% limit on payment reductions per year to CY 2025 – 2027

Clinical Laboratory Fee Schedule: 2024 Annual Update

Learn about changes and instructions effective January 1, 2024 (PDF):

Delay in data reporting period and the phase-in of payment reductions
Mapping for new test codes
Updates for costs subject to the reasonable charge payment

Medicare Program Integrity Manual: CY 2024 Home Health Prospective Payment System Updates

Learn about changes to Chapter 10 (PDF), including:

Expanding the home health agency 36-month rule
Moving hospices into the high level of categorical risk-screening

Activation of Validation Edits for Providers with Multiple Service Locations — Revised

Learn how to verify and update your service locations (PDF) for Medicare enrollment, and what claim modifier to use if a service was provided at an off-campus, outpatient, provider-based hospital department.

Publications

Medicare Diabetes Prevention Program Expanded Model — Revised

Learn about updates to the Medicare Diabetes Prevention Program (MDPP) Expanded Model (PDF):

Set of services period
Flexibilities for virtual sessions
New coverage for A1c blood test during diabetes screening
Full-plus CDC recognition
No Medicare enrollment application fee for MDPP suppliers
CY 2024 HCPCS codes and payment rates
Payment structure
Flexibilities for weight measurements

CMS also updated the language, order, and formatting of content.

We changed this link. If you previously bookmarked it, update your link.

Rural Emergency Hospitals — Revised

Learn what’s changed (PDF). CMS added information about:

Subsection (d) and Indian Health Service hospitals
CY 2023 and CY 2024 payment amounts and cost reporting
Technical Assistance Center

Multimedia

Expanded Home Health Value-Based Purchasing Model: Agency Perspectives Video Series

This series features discussions with volunteer panelists reviewing strategic approaches to managing and improving agency performance:

Home Health Agency Perspectives on Quality Management (47:14) and panel summary (PDF): approaches to data-driven Quality Assurance and Performance Improvement and concurrent quality management strategies used to identify and correct problems before they become negative outcomes
Home Health Agency Perspectives on Innovation (57:22) and panel summary (PDF): approaches to care delivery and fostering an organizational culture where staff can thrive under value-based care

More Information:

Expanded Home Health Value-Based Purchasing (HHVBP) Model webpage: See the Quality Improvement Section
Expanded HHVBP YouTube Playlist

From Our Federal Partners

Severe & Fatal Confirmed Rocky Mountain Spotted Fever among People with Recent Travel to Tecate, Mexico

The CDC issued a Health Alert Network Health Advisory to notify health care providers about an outbreak of Rocky Mountain spotted fever (RMSF) among people in the U.S. with recent travel to or residence in the city of Tecate, state of Baja California, Mexico. Consider RMSF in your differential diagnosis of patients who:

Reported recent travel to Tecate, Mexico or other areas of northern Mexico
Develop signs or symptoms of an unexplained severe febrile illness.

Consider initiating doxycycline based on presumptive clinical and epidemiologic findings, and don’t delay treatment pending the result of a confirmatory laboratory test. Early treatment with doxycycline saves lives.

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