Thursday, August 15, 2024
- Negotiating for Lower Drug Prices Works, Saves Billions
- Resources & Flexibilities to Assist with the Public Health Emergency in Florida, Georgia, and South Carolina
- Hospitals: New EMTALA Poster for Use in Emergency Departments
- PrEP for HIV Transition of Coverage: Get Ready Now
- CMS Roundup (August 9, 2024)
- ESRD: Oral-Only Renal Dialysis Service Drugs & Biological Products — Revised Guidance
- Telehealth Services: Billing & Payment for Place of Service Code 10
- Medicare Physician Fee Schedule Database: October Update
- Hospice Payments: FY 2025 Update
- ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2025 Update
- Hospital Outpatient Prospective Payment System: July 2024 Update — Revised
News
Negotiating for Lower Drug Prices Works, Saves Billions
In a historic moment that will help lower prescription drug prices for millions of people across America, the Biden-Harris Administration announced that it has reached agreement for new, lower prices for all 10 drugs selected for negotiations. These negotiated drugs are some of the most expensive and most frequently dispensed drugs in the Medicare program and are used to treat conditions such as heart disease, diabetes, and cancer. The new prices will go into effect for people with Medicare Part D prescription drug coverage beginning January 1, 2026.
More information:
- Full press release
- Medicare Drug Price Negotiation Program: Negotiated Prices for Initial Price Applicability Year 2026 fact sheet
- CMS Negotiated Prices (PDF) fact sheet
- ASPE Historic Trends fact sheet
- Infographic (PDF)
Resources & Flexibilities to Assist with the Public Health Emergency in Florida, Georgia, and South Carolina
CMS announced additional resources and flexibilities available in response to Hurricane Debby, now Tropical Storm Debby, in the states of Florida, Georgia, and South Carolina. CMS is working closely with these states to ensure those affected by this natural disaster have access to the care they need — when they need it most.
On August 6, 2024, HHS Secretary Xavier Becerra determined that a public health emergency exists in Florida and has existed since August 1, 2024. On August 7, 2024, Secretary Becerra determined that a public health emergency exists in Georgia and South Carolina and has existed since August 4, 2024.
CMS stands ready to assist with resources and waivers to ensure hospitals and other facilities can continue to operate and provide access to care to those impacted by the consequences of the tropical storm.
More Information:
Hospitals: New EMTALA Poster for Use in Emergency Departments
CMS released a new poster for hospitals to display for patients to know their Emergency Medical Treatment & Labor Act (EMTALA) rights. The poster also includes information about how to file a complaint if they believe their rights are violated.
We encourage hospitals to use this poster in emergency room departments and other hospital settings. Visit EMTALA to download posters in several formats.
PrEP for HIV Transition of Coverage: Get Ready Now
In late September 2024, CMS expects to release the final National Coverage Determination to transition coverage of preexposure prophylaxis (PrEP) using antiretroviral drugs to prevent HIV from Medicare Part D to Medicare Part B.
We encourage pharmacies and other interested parties to prepare for this transition:
- Visit the PrEP for HIV & Related Preventive Services webpage
- Register for the Pharmacy Enrollment Office Hours on Thursday August 22 from 3:30-4:30 pm ET
CMS Roundup (August 9, 2024)
You may be interested in these topics from the CMS Roundup:
- Fact Sheet on Services Available Through GUIDE Model
- Extended Accountable Care Organization Primary Care Flex Model Application Submission Period
ESRD: Oral-Only Renal Dialysis Service Drugs & Biological Products — Revised Guidance
CMS revised Including Oral-Only Drugs in the ESRD Prospective Payment System (PPS) Bundled Payment (PDF) to clarify:
- Guidance for JW and JZ modifiers
- Process for incorporating XPHOZAHTM
More Information:
- ESRD PPS Consolidated Billing webpage
- ESRD & Acute Kidney Injury Dialysis: CY 2024 Updates (PDF) MLN Matters Article
Compliance
Patient Lifts: Prevent Claim Denials
In 2022, the improper payment rate for patient lifts was 44.5%, with a projected improper payment amount of $4.1 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 patient lifts provider compliance tip for more information, including:
- Codes
- Denial reasons and how to prevent them
- Documentation requirements and example
Claims, Pricers, & Codes
Telehealth Services: Billing & Payment for Place of Service Code 10
Starting January 1, 2024, use place of service (POS) code 10 for telehealth services provided in a patient’s home. Medicare pays for these services at the Medicare Physician Fee Schedule non-facility rate.
More Information:
- Telehealth Services (PDF) fact sheet
- Sections 20.4.2 and 190 Medicare Claims Processing Manual, Chapter 12 (PDF)
- Section 10.5 Medicare Claims Processing Manual, Chapter 26 (PDF)
- Instruction to your MAC (PDF)
Medicare Physician Fee Schedule Database: October Update
Learn about the October quarterly updates (ZIP) to the Medicare Physician Fee Schedule Database, including:
- New codes
- Procedure status changes
- Code short descriptor revisions
- Payment policy indicator changes
Your Medicare Administrative Contractor (MAC) will give you 30-days’ notice before they implement these changes. Then, they’ll adjust claims that you bring to their attention.
More Information:
MLN Matters® Articles
Hospice Payments: FY 2025 Update
Learn about updates effective October 1, 2024 (PDF):
- Payment rates
- Inpatient and aggregate caps
- Wage index
ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2025 Update
Learn about revisions effective January 1, 2025 (PDF):
- New codes
- Recent coding changes
Medicare Administrative Contractors will adjust claims processed in error that you bring to our attention.
Hospital Outpatient Prospective Payment System: July 2024 Update — Revised
CMS updated information (PDF) on certain drugs, biologicals, and radiopharmaceuticals.
Publications
Skilled Nursing Facility Place of Service Codes: Updated Resources
CMS updated Medicare Learning Network resources to clarify how to use place of service codes 21, 31, and 32:
- Skilled Nursing Facility 3-Day Rule Billing fact sheet
- Medicare Payment Systems: Skilled Nursing Facility Prospective Payment System educational tool
- Skilled Nursing Facility Billing Reference educational tool
From Our Federal Partners
Increase in Human Parvovirus B19 Activity in the U.S.
The CDC issued this Health Alert Network (HAN) Health Advisory to notify health care providers, public health authorities, and the public about current increases in human parvovirus B19 activity in the U.S. Parvovirus B19 is a seasonal respiratory virus that is transmitted through respiratory droplets by people with symptomatic or asymptomatic infection. In the first quarter of 2024, public health authorities in 14 European countries observed unusually high numbers of cases of parvovirus B19. Recently, CDC has received reports indicating increased parvovirus B19 activity in the U.S. Data include increased test positivity for parvovirus B19 in clinical specimens and pooled plasma from a large commercial laboratory, and reports of clusters of parvovirus B19-associated complications among pregnant people and people with sickle cell disease.
See the full Health Advisory for more information, including recommendations for health care providers.
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