2025-01-16-MLNC

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2025-01-16
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Weekly Edition
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Thursday, January 16, 2025

News

Compliance

Claims, Pricers & Codes

Publications

 

News 

Resources & Flexibilities to Assist with the Public Health Emergency in California

On January 10, 2025, HHS Secretary Xavier Becerra determined that a public health emergency exists in California and has existed since January 7, 2025. CMS announced additional resources and flexibilities in response to the 2025 Southern California Wildfires. CMS is working closely with the State of California and federal partners to put these 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 multiple wildfires causing major damage in several areas, including the Palisades fire, which has impacted about 20,000 acres, the Eaton Fire that has impacted 13,000+ acres, and the Hurst fire that has impacted 770+ acres.

More Information:

CMS Moves Closer to Accountable Care Goals with 2025 Accountable Care Organization Initiatives

CMS has made substantial progress on its goal for all people with Traditional Medicare to be in a care relationship with accountability for quality and total cost of care by 2030. As of January 2025, 53.4% of people with Traditional (fee-for-service) Medicare are in an accountable care relationship with a provider. This represents more than 14.8 million people and marks a 4.3 percentage point increase from January 2024, the largest annual increase since CMS began tracking accountable care relationships. This includes patients whose providers are in Accountable Care Organizations (ACOs), including the Medicare Shared Savings Program ACOs and entities participating in Center for Medicare and Medicaid Innovation (Innovation Center) accountable care models, as well as other Innovation Center models focused on total cost of care, advanced primary care, and specialty care.

ACOs are groups of doctors, hospitals, and other health care professionals that work together to give patients high-quality, coordinated service and health care, improve health outcomes, and manage costs.

Steadily increased participation in accountable care arrangements demonstrates that changes CMS has made over the last few years through rulemaking and Innovation Center models are connecting people to longitudinal care relationships with providers.

Read the full fact sheet for more information.
 

Telehealth Flexibilities Extended until March 31

Recent legislation extended the waiver of the geographic, site of service, and practitioner type restrictions.  Medicare patients in non-rural areas and in their homes can continue to get telehealth services from this extended range of practitioners until March 31, 2025.
 

CMS Roundup (January 10, 2025)

You may be interested in these topics from the CMS Roundup:

  • Campaign to Increase Nursing Home Staffing by Nursing Professionals
  • Early Lessons Learned from Acute Hospital Care at Home Initiative
  • National Health Expenditures Report Showing Growth in Health Care Spending and Strong Growth in Health Insurance Coverage
  • Four States Selected to Participate in the Innovation in Behavioral Health Model
  • Proposed National Coverage Determination for Transcatheter Tricuspid Valve Replacement
  • Seeking Input on MBI Lookup Tools and Preventing MBI Theft and Misuse
  • Data on the Experiences & Health of Women in the Medicare Program
  • Request for Application for Rural Community Hospital Demonstration
  • Explanations for Negotiated Drug Prices
  • List of Hospices Selected to Participate in the Hospice Special Focus Program
  • Report on Use of Waivers & Flexibilities in Response to COVID-19 Public Health Emergency Information on Hospital Price Transparency Compliance Requirements
  • Funding Opportunity to Recruit RNs to Work in Nursing Homes, State Survey Agencies
     

Health Professional Shortage Areas: Learn about Physician Bonuses 

Health Professional Shortage Areas (HPSAs) are geographic areas of populations that lack enough health care providers to meet the health care needs of that population. CMS pays a 10% quarterly bonus when you deliver Medicare-covered services to Medicare patients in a geographic HPSA. Visit Physician Bonuses in Health Professional Shortage Areas to learn more, including:

  • What are HPSAs?
  • Who can get an HPSA bonus?
  • Do I need to use a claims modifier?
  • How do I find HPSA ZIP Codes?
     

Hympavzi Covered Under Part B with a Furnishing Fee 

The FDA recently approved Hympavzi, an anti-tissue factor pathway inhibitor, indicated for routine prophylaxis in patients with hemophilia A or B treatment. The treatment is self-administered using a pre-filled auto-injector pen once-weekly and can decrease the intensity of bleeding in patients. Medicare Part B will pay for Hympavzi as a clotting factor and add the clotting factor furnishing fee. Affected providers include:

  • Hematologists
  • Orthopedists
  • Physical therapists
  • Nurses

Medicare Part B pays for clotting factor under section 1847A of the Social Security Act. Since Hympavzi doesn't have a HCPCS code yet, billing providers should use a Not Otherwise Classified code and Medicare Administrative Contractors (MACs) will determine the furnishing fee.

More Information:

Change of Ownership:  Both Parties Must Submit Enrollment Applications Within 30 Days 

Providers and suppliers must report a change of ownership (CHOW) within 30 days of the change. For certified providers undergoing a CHOW, 42 CFR 424.550 states:

  • Both the seller and the buyer must submit enrollment applications to report the CHOW
  • If the seller fails to submit an enrollment application to report the CHOW, the seller may be sanctioned or penalized (even after the date of the ownership change)  
  • If the buyer fails to submit an enrollment application containing information about the buyer within 30 days of the CHOW, the provider’s billing privileges may be deactivated

See Medicare Provider Enrollment for more information. 
 

Cervical Health: Encourage Screening

All women are at risk for cervical cancer, but it occurs most often in women over age 30 (see CDC). During Cervical Health Awareness Month, talk with your patients about cervical and vaginal cancer screenings.

Medicare covers:

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

More Information:

Compliance

Continuous Positive Airway Pressure Devices & Accessories: Prevent Claim Denials

In 2023, the improper payment rate for Continuous Positive Airway Pressure Devices & Accessories is 15%, with a projected improper payment amount of $157.5 million (see 2023 Medicare Fee-for-Service Supplemental Improper Payment Data (PDF), Appendices F, G, H, K, L and N). 

Learn how to bill correctly for these services. Review the Continuous Positive Airway Pressure Devices & Accessories provider compliance tip for more information, including:

  • Billing codes
  • Denial reasons and how to prevent them
  • Refill and documentation requirements

 

Claims, Pricers & Codes

HCPCS Application Summaries & Coding Decisions

CMS published HCPCS Level II application summaries:

See HCPCS Level II Coding Decisions for more information.
 

Therapy Code List: 2025 Annual Update 

CMS updated the list of codes that sometimes or always describe therapy services.

More Information:

Therapy Services: CY 2025 KX Modifier Threshold Amounts

The CY 2025 KX modifier threshold amount is $2,410 for:

  • Physical therapy and speech-language pathology services combined
  • Occupational therapy services

More Information:

 

Publications

Guidelines for Teaching Physicians, Interns & Residents — Revised

Learn about guideline updates:

  • Teaching providers can submit IRIS data for the Direct Graduate Medical Education and Indirect Medical Education reimbursement programs
  • Teaching physicians can use two-way, interactive, audio-video telehealth when residents provide telehealth services, in all residency training locations through the end of CY 2025
     

Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model — Revised

Learn what’s changed (PDF):

  • Removed the option to request an expedited prior authorization (PA) review
  • Updated the standard PA review timeframe from 10 business days to 7 calendar days

     

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