2024-10-03-MLNC

Date
2024-10-03
Title
Weekly Edition
MLN Connects logo

Thursday, October 3, 2024 

News

Claims, Pricers, & Codes

Events

Publications

 

 

News

HHS Releases Final Guidance for Second Cycle of Historic Medicare Drug Price Negotiation Program

As part of the continued implementation of the Inflation Reduction Act, HHS, through CMS, released final guidance (PDF) outlining the process for the second cycle of negotiations under the Medicare Drug Price Negotiation Program. The guidance also explains how CMS will help ensure people with Medicare can access drugs at the negotiated prices from the first and second cycles when those prices become effective beginning in 2026 and 2027, respectively.

More Information:

 

Resources & Flexibilities to Assist with the Public Health Emergency in Florida, Georgia, North Carolina, Tennessee, & South Carolina

HHS Secretary Xavier Becerra determined that public health emergencies exist in Florida, Georgia, North Carolina, Tennessee, and South Carolina. CMS is working closely with these states to put flexibilities in place to ensure those affected by this natural disaster have access to the care they need – when they need it most.

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 hurricane.

More Information:

 

CMS to Provide Hurricane Helene Public Health Emergency Accelerated Payments to Medicare Fee-for-Service Providers and Suppliers

HHS, through CMS, is taking action to support providers and suppliers impacted by Hurricane Helene within the Federal Emergency Management Agency disaster zones, under the President’s major disaster declarations. These providers and suppliers may face significant cash flow issues from the unusual circumstances impacting facilities’ operations, preventing facilities from submitting claims and receiving Medicare claims payments. CMS made available accelerated payments to Medicare Part A providers and advance payments to Medicare Part B suppliers affected by Hurricane Helene beginning October 2, 2024.

More Information:

 

Changes to the Fiscal Year 2025 Hospital Inpatient Prospective Payment System (IPPS) Rates Due to Court Decision (CMS-1808-IFC) 

In the FY 2020 Inpatient Prospective Payment System/Long-Term Care Hospital (IPPS/LTCH) PPS final rule (84 FR 42325 through 42339), CMS finalized a policy to address increasing wage index disparities between low wage index hospitals and other hospitals. We explained that those growing disparities are likely caused, at least in part, by the use of historical wage data to prospectively set hospitals’ wage indexes. That lag between when hospitals increase wages and when those wage increases are reflected in the historical data creates barriers to hospitals with low wage index values being able to increase employee compensation, because those hospitals will not receive corresponding increases in their Medicare payment for several years (84 FR 42327).

Accordingly, CMS finalized a policy that provided certain low wage index hospitals with an opportunity to increase employee compensation without the usual lag in those increases being reflected in the calculation of the wage index (as they would expect to do if not for the lag). The agency accomplished this by temporarily increasing the wage index values for certain hospitals with low wage index values and doing so in a budget neutral manner through an adjustment applied to the standardized amounts for all hospitals. We increased the wage index for hospitals with a wage index value below the 25th percentile wage index value for a fiscal year by half the difference between the otherwise applicable final wage index value for a year for that hospital and the 25th percentile wage index value for that year across all hospitals (the low wage index hospital policy).

On July 23, 2024, the Court of Appeals for the D.C. Circuit held that Department of Health and Human Services lacked authority under section 1886(d)(3)(E) of the Act or under the “adjustments” language of section 1886(d)(5)(I)(i) of the Act to adopt the low wage index hospital policy for FY 2020, and that the policy and related budget neutrality adjustment must be vacated. (Bridgeport Hosp. v. Becerra, 108 F.4th 882, 887-91 & n.6 (D.C. Cir. 2024))

The Interim Final Action with Comment (IFC) implements revised Medicare IPPS wage index values for FY 2025, establishes a transition for low wage hospitals significantly impacted by those revisions, and makes conforming changes to the IPPS payment rates for FY 2025. These changes reflect the removal of the low wage index hospital policy following the D.C Circuit court decision in Bridgeport Hosp. v. Becerra. This IFC also makes conforming changes to IPPS rates and factors used to determine certain payments under the Long-Term Care Hospital Prospective Payment System (LTCH PPS).

 

CMS Covers PrEP to Prevent HIV

CMS issued a final National Coverage Determination for FDA-approved Pre-exposure Prophylaxis (PrEP) Using Antiretroviral Drugs to Prevent Human Immunodeficiency Virus (HIV) Infection. Starting September 30, 2024, we cover PrEP and other related services to prevent HIV in individuals at increased risk of getting HIV, without cost-sharing (for example, deductibles or co-pays for people with Medicare Part B). The physician or health care practitioner who assesses the patient’s history determines whether they’re at increased risk for HIV. We also cover furnishing PrEP to prevent HIV, including supplying or dispensing these drugs and the administration of injectable PrEP.

If you’re assessing your patients for PrEP to prevent HIV, or they’re using it, we cover the following as an additional preventive service:

  • Up to 8 individual counseling visits every 12 months
  • Up to 8 HIV screening tests every 12 months
  • Single screening for hepatitis B virus 

More information:

 

Clinical Laboratory Fee Schedule: Submit Comments & Reconsideration Requests by October 25

Get the latest payment information on the Clinical Laboratory Fee Schedule (CLFS), and find out how to comment and request a reconsideration by October 25, 2024:

Visit CLFS Annual Public Meetings for more information on the annual ratesetting processes.

 

DMEPOS: Adding New Product Categories to CMS-855S Enrollment Form on October 26

On October 26, 2024, CMS will include these new product categories on the electronic CMS-855S DMEPOS Enrollment Form:

  • Cognitive behavioral therapy devices
  • Rehabilitative therapy devices
  • Urinary suction pumps
  • External electrical stimulation devices (not otherwise classified)

You must be an enrolled DMEPOS supplier to get Medicare payment for furnishing these products.

Starting October 26, 2024, if you enroll in Medicare to supply these DMEPOS products or want to add them to your current enrollment:

  • Report the products in Section 2 if you submit an online application using PECOS.
  • Submit a letter with your paper application stating that you want to supply these products. We’re working on updating this application.

 

Improve Your Search Results for CMS Content

If you’re using a search engine to find information on CMS.gov, include “CMS” in your search term to get optimal results. If you recently visited a CMS webpage, you may need to refresh your browser to see the latest content.

 

Help Detect Breast Cancer Early

Almost 99% of women diagnosed with breast cancer at the earliest stage live for 5 years or more (see data snapshot). During National Breast Cancer Awareness Month, talk with your patients about the best screening options for them to help detect breast cancer early.

Medicare pays for:

Your patients pay nothing if you accept assignment. Find out when your patient is eligible for their next screening. If you need help, contact your eligibility service provider.

More Information:

 

 

Claims, Pricers, & Codes

Medicare Part B Drug Pricing Files & Revisions: October Update

Learn about quarterly updates to the following average sales price and not otherwise classified pricing files:

  • October 2024
  • July 2024 
  • April 2024 
  • January 2024
  • October 2023

More Information:

 

PrEP for HIV Billing: CMS Requires Diagnosis Codes

If you’re a physician or health care practitioner, you should include at least one valid ICD-10-CM diagnosis code on prescriptions you send to pharmacies to help them prepare their Medicare Part B claims.

There are multiple diagnosis codes that may be appropriate when you’re billing for PrEP, including codes for:

  • Encounter for HIV pre-exposure prophylaxis
  • Encounter for screening for human immunodeficiency virus
  • Increased risk factors

For Information:

 

RARCs, CARCs, Medicare Remit Easy Print, & PC Print: October Update

Get updated remittance advice remark codes (RARCs) and claim adjustment reason codes (CARCs), and watch for software updates if you use Medicare Remit Easy Print or PC Print.

More Information:

 

 

Events

Hospital Price Transparency: Encoding January 2025 Requirements in the Machine-Readable File Webinar — October 21

Monday, October 21, 2024, from 1–2:30 pm ET

Register for this webinar.

As of July 1, 2024, hospital machine-readable files (MRFs) must conform to a CMS template layout and data specifications. Starting January 1, 2025, you’re also required to encode additional data elements.​

Join CMS to review:

  • How to encode the data elements required by January 1, 2025
  • Tips to make sure your MRFs conform to the requirements effective July 1, 2024 

More Information:

  • Hospitals webpage
  • Data Dictionary GitHub Repository: 
    • Required CMS template layouts
    • Data dictionary
    • Examples of how to encode standard charges in the MRF
    • Q&A discussion board
  • Tools webpage:
    • Online validator
    • Command-line interface validator
    • TXT file generator
    • MRF naming convention tool
  • Resources webpage:
    • Final rules
    • FAQs
    • Guides
    • Webinar materials

 

 

Publications

Substance Use Screenings & Treatment

CMS expanded substance use disorder (SUD) coverage. Learn about screenings and treatment (PDF), including:

  • Alcohol misuse screenings
  • Counseling to prevent tobacco use and tobacco-related diseases
  • Opioid use disorder (OUD) screenings
  • OUD treatment: 
    • Evaluation and management services
    • Office-based SUD treatment
    • Opioid Treatment Programs
    • Drugs to treat opioid dependence
  • Behavioral health integration services
  • Principal illness navigation services
  • SBIRT services

 

 

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