CMS PHE Fact Sheet
CMS published a Fact Sheet to explain what will change after the Public Health Emergency is officially over. It covers COVID-19 vaccines, testing, and treatments; Telehealth services; Continuing flexibilities; and Inpatient Hospital Care at Home.
Many Medicare telehealth flexibilities have been extended through December 31, 2024:
- People with Medicare can access telehealth services in any geographic area in the United States, rather than only those in rural areas.
- People with Medicare can stay in their homes for telehealth visits that Medicare pays for rather than traveling to a health care facility.
- Certain telehealth visits can be delivered audio-only (such as a telephone) if someone is unable to use both audio and video, such as a smartphone or computer.
Medicare Advantage plans may offer additional telehealth benefits and some Accountable Care Organizations (ACOs) may offer telehealth services after 2024.
Medicare Participation for 2023
A CMS announcement provides information to help clinicians determine whether to become a Medicare participating provider, or to continue Medicare participation.
Click here to access a Novitas lookup tool for the 2023 rates.
CMS announced updates to the Quality Payment Program effective in 2023, including MIPS.
eRx Required for CDS under Medicare Part D as of January 1
Beginning January 1, 2023, providers must transmit prescriptions for controlled dangerous substances (CDS) electronically for Medicare Part D beneficiaries. Any prescriber who issues 100 or fewer qualifying Part D CDS prescriptions in a calendar year is exempt. Section 2003 of the SUPPORT Act mandates that a health care practitioner transmit a prescription for a Part D drug under a prescription drug plan (or under an MA–PD plan) for a Schedule II, III, IV, or V controlled substance electronically in accordance with an electronic prescription drug program.
To promote compliance, apply penalties, and support a waiver process, CMS has established the Electronic Prescribing for Controlled Substances (EPCS) Program. This CMS program is separate from any state EPCS program. CMS will analyze Medicare Part D claims and use the prescriber’s National Provider Number (NPI) to measure compliance annually. After the EPCS compliance analysis is complete for 2023, CMS will send a notice of non-compliance via email to prescribers violating the EPCS mandate. (Be sure your email addresses in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and the National Plan and Provider Enumeration System (NPPES) are up to date.)
Check the EPCS website for resources and updates.
Mental Health Booklet Update
The CMS Mental Health Booklet outlines requirements effective 2022 including:
•Interactive telecommunications systems can include inter-active, real-time, 2-way audio-only diagnosis, evaluation, or mental health or substance use disorder telehealth services treatment technology when the patient is in their home (page 6).
•Revised regulations require an in-person visit within 6 months before furnishing telehealth mental health services, and every 12 months while the patient gets telehealth services, unless physician and patient agree risks and burdens outweigh an in-person visit benefits and it’s documented in the medical record (page 24).
Billing for Medicare Psychotherapy Services
A Novitas reminder on billing psychotherapy services is available here.
Please refer to the APA Coding and Reimbursement site for the most up-to-date information regarding coding and documentation changes, including a Quick Guide that is available with member credentials.
MIPS Performance Feedback and 2023 Payments
Performance in 2021 is reflected in MIPS payment adjustments applied to Medicare payments for services furnished in 2023. View your MIPS performance feedback, final score, and payment adjustment on the Quality Payment Program (QPP) website.
Check Your MIPS Status
Use the Quality Payment Program (QPP) Participation Status Tool to find your participation status for the Merit-based Incentive Payment System (MIPS). Your status may change from year to year. For more information, visit the MIPS Participation page or contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222).
Exemption from MIPS Reporting
Use the Quality Payment Program (QPP) Participation Status Tool to find your status for the Merit-based Incentive Payment System (MIPS) based on Medicare Part B claims and PECOS data for the prior period.
To be eligible, you must:
- Bill more than $90,000 a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS); AND
- Furnish covered professional services to more than 200 Medicare Part B beneficiaries; AND
- Provide more than 200 covered professional services under the PFS.
If you do not exceed all 3 of the above criteria, you are excluded from MIPS. However, you can opt-in to MIPS and receive a payment adjustment if you meet or exceed 1 or 2, but not all, of the low-volume threshold criteria.
Assistance with Medicare Appeals, Denials and Grievances
The State Health Insurance Assistance Program (SHIP) meets the most universal needs of Medicare beneficiaries, such as understanding their health insurance benefits, bills, and rights. Trained staff and volunteer counselors in all 23 counties and Baltimore City provide in-person and telephone assistance. Topics covered include:
- Medicare Part A: Hospital Insurance
- Medicare Part B: Medical Insurance
- Medicare Part C: Advantage Plans
- Medicare Part D: Prescription Drug Plans
- Financial Assistance for Low-Income Beneficiaries
- Billing Issues, Appeals, Denials, and Grievances
- Medicare Fraud and Abuse
Click here to contact the closest SHIP office.
Qualified Registries for MIPS Data Submission
Under the Medicare Quality Payment Program option, MIPS, there are several data submission methods, one of which is Qualified Registries. A qualified registry is a CMS-approved entity that collects clinical data from MIPS eligible clinicians (both individual and groups) and submits it to CMS on their behalf for purposes of MIPS. CMS has designated the qualified registries that can report data (measures and/or activities) for the Quality, Advancing Care Information, and Improvement Activities performance categories, on behalf of individual MIPS eligible clinicians and groups. The APA’s PsychPRO registry is approved by CMS.
Medicare Quality Payment Program
Resources on the Quality Payment Program (QPP) website help eligible clinicians prepare to participate:
- Quality Payment Program: Key Objectives
- Advancing Care Information Fact Sheet
- Alternative Payment Models (APMs) in the Quality Payment Program
- Improvement Activities in MIPS APMs
- APMs: Medicaid and All-Payer Models Fact Sheet
Download the APA’s fact sheet about the MIPS Quality Performance Category for help deciphering your MIPS composite score and its impact on Medicare Part B payments. It also includes a Mental/Behavioral Health specialty measure set as well as a list of measures pertinent to psychiatrists. Visit the APA website for more Medicare payment reform resources, including a MACRA toolkit.
CMS educational videos are available on YouTube at http://Go.cms.gov/QPPvideos.
Medicare Revalidation Reminder
The Affordable Care Act requires all currently and actively enrolled providers to revalidate their enrollment information every three or five years. Go to the revalidation dates page to search for your due date by name or browse the entire list. For more information, see the revalidation webpage and the FAQs.
If a provider does not revalidate the due date, the enrollment record will be deactivated. Deactivated providers must submit a full and complete application to reestablish their provider enrollment record and Medicare billing privileges. An interruption in billing will occur, resulting in a gap in coverage. Retroactive billing privileges back to the period of deactivation will not be granted. Services provided between deactivation and reactivation are the provider’s liability.
Please review the CMS revalidation document for more information. Any questions or concerns should be directed to Andrea King, Novitas Provider Outreach and Education, at: email@example.com or 717-526-6392.
Medicare Provider Data Published
A subset of PECOS data is available to providers, suppliers, state Medicaid programs, private payers, etc. Click here for more information. The Public Provider Enrollment files are published at https://data.cms.gov/public-provider-enrollment and updated on a quarterly basis. Opt-out providers will not be included. Elements include:
- Enrollment ID and PECOS Unique IDs
- Provider Enrollment Type and State
- Provider’s First and Last Name/ Legal Business Name
- Provider or Supplier Specialty
- Limited address information (City, State, ZIP code)
Small Practices and Health Professional Shortage Areas & Medically Underserved Populations
A section of the Medicare Quality Payment Program (QPP) is dedicated to clinicians working in small or rural practices and those treating patients in underserved areas. This page is a single point of reference especially for the QPP Merit-based Incentive Payment System (MIPS) track.
Health Professional Shortage Areas (HPSAs) are designated as having shortages of primary care, dental care, or mental health providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible) or facilities (e.g., federally qualified health centers, or state or federal prisons). Providers who serve these areas are eligible for bonus payments under Medicare. A search tool is available to check an address for bonus eligibility. Use another online tool to find HPSAs by state, country and discipline.
Changes to the Medicare Opt-Out Law
As a result of changes made by MACRA, valid opt-out affidavits signed on or after June 16, 2015 will automatically renew every 2 years. If physicians who file affidavits effective on or after June 16, 2015 do not want their opt-out to automatically renew, they may cancel the renewal by notifying all Medicare Administrative Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period. Check this CMS publication for more details.
Medicare Private Contracting Change
Physicians who opt-out of Medicare should be aware that CMS has changed its definition of emergency care services to encompass urgent care services, which are furnished within 12 hours to avoid the likely onset of an emergency medical condition. It has also specified that the enrollment appeals process should be used to appeal Medicare opt-out determinations, such as whether a physician or practitioner has failed to properly opt-out, failed to maintain opt-out, failed to timely renew opt-out, failed to privately contract, or failed to properly terminate opt-out. These changes are effective July 13, 2015. For details, click here.
Opting Out of Medicare
Since 1998, physicians have been permitted to opt out of Medicare and enter into private contracts with Medicare patients that allow them to set their own fees. A physician who opts out of Medicare agrees not to see any Medicare patients for two years (barring emergencies or urgent services), except for those with whom s/he has entered into private contracts. The opt-out applies for every Medicare patient a physician sees in clinics or elsewhere, not just those seen in private practice. If there is any possibility of having to see Medicare patients as part of a new contract or employment, a physician should not consider opting out of Medicare. The rules for opting out are very specific. Please continue reading at the APA website.
To search for providers who have opted out of the Medicare program, see the CMS Opt-Out Affidavit listing, which is updated on a quarterly basis. If you opted out of Medicare and cannot locate your information, please call 1-877-235-8073.
A new Behavioral Health Integration Services fact sheet explains psychiatric collaborative care services and how to bill for this model of care.
A new Care Management page is available with fact sheets, FAQs, etc. Those who provide patients with chronic care management, non-face-to-face services such as reviewing test results or coordinating with other providers, may not be aware of the separate payments under the Medicare Physician Fee Schedule and may not be receiving the full separate payments that are now available. The Chronic Care Management Services Changes for 2017 fact sheet has information about 2017 coding changes, included services and reduced requirements for initiating care. The existing Chronic Care Management Services fact sheet has been revised, and addresses separately payable services for patients with multiple chronic conditions, codes and billing requirements, etc.
Novitas Behavioral Health Page – up-to-date topics, resources, training and coverage information.
Medicare Physician Fee Schedule Fact Sheet — Revised
Health Professional Shortage Area Physician Bonus Program
Medicare Fraud & Abuse: Prevention, Detection, and Reporting Fact Sheet
Definition of Treatment-Resistant Depression in the Medicare Population
Substance Abuse Services – Describes the levels of services and authorized suppliers that are covered under Medicare, as well as Part D drugs for opioid dependence.
Guidance on dually eligible individuals enrolled in the Qualified Medicare Beneficiary (QMB) Program was updated February 1, 2016. QMB is a Medicaid program for Medicare beneficiaries that exempts them from liability for Medicare cost-sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary.
Transitional Care Management Services can be billed by one clinician for services during the 30 days after discharge from an inpatient setting that include three TCM components: an interactive contact, certain non-face-to-face services, and a face-to-face visit.
HIPAA Privacy and Security Basics for Providers – Information on covered entities, business associates, and resources.
HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules – HIPAA basics, such as privacy, security, breach notification rules, covered entities, business associates, and disposal of private health information.
Medical Privacy of Protected Health Information addresses how the privacy rule applies to customary health care practices, tips for securing health information on a mobile device, and HIPAA resources.
Telehealth Services describes services that can be furnished to Medicare beneficiaries via a telecommunications system, including information about originating sites, distant site practitioners, telehealth services, billing and payment for services and facility fees, etc.
PECOS Fact Sheet includes Medicare enrollment application submission options, how to complete an enrollment application using PECOS, and PECOS user ID and password helpful hints.
Medicare Appeals Process fact sheet explains the five levels of claim appeals in Original Medicare (Parts A and B).
Medicare Secondary Payer fact sheet explains situations when Medicare may pay first or second, coordination of benefits, etc.