Monday Morning Rounds with CMS

ICYMI, here is recent communication from CMS.


Emergency Regulation Requiring COVID-19 Vaccination for Health Care Workers
The Biden-Harris Administration is requiring COVID-19 vaccination of eligible staff at health care facilities that participate in the Medicare and Medicaid programs. The emergency regulation issued by CMS protects those fighting this virus on the front lines while also delivering assurances to individuals and their families that they will be protected when seeking care.

Coverage is Available for COVID-19 Vaccinations for Eligible Children Ages 5 through 11
Following the FDA’s recent action authorizing the Pfizer-BioNTech COVID-19 Vaccine for the prevention of COVID-19 in children 5 through 11 years of age and a recommendation from the CDC, CMS is reminding eligible consumers that coverage is available without cost-sharing under Medicare, Medicaid, the Children’s Health Insurance Program, and in the commercial market for this critical protection from the virus. As with all vaccines, the Pfizer-BioNTech COVID-19 Vaccine was tested thoroughly in this age group prior to its authorization for emergency use.

Final Policies for the MDPP Expanded Model for the Calendar Year 2022 Medicare Physician Fee Schedule
CMS issued the Calendar Year 2022 Physician Fee Schedule final rule, which finalizes changes to the Medicare Diabetes Prevention Program expanded model. These policies are intended to boost supplier enrollment, with the goal of increasing beneficiary participation and access to services that can help them develop and maintain healthy behaviors to prevent onset of type 2 diabetes. They anticipate that these final changes will make it easier for local suppliers to participate and reach their communities. If the anticipated increased participation occurs, this will allow CMS to perform a more robust evaluation of the expanded model.

CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule
CMS finalized Medicare payment rates for hospital outpatient and Ambulatory Surgical Center services. In addition to updating the payment rates, the Calendar Year 2022 Hospital Outpatient Prospective Payment System and ASC Payment System Final Rule includes policies that align with several key goals of the Administration, including addressing the health equity gap, fighting the COVID-19 Public Health Emergency, encouraging transparency in the health system, and promoting safe, effective, and patient-centered care.

CMS OPPS/ASC Final Rule Increases Price Transparency, Patient Safety and Access to Quality Care
CMS released a final rule that will further advance its commitment to increasing price transparency, holding hospitals accountable and ensuring consumers have the information they need to make fully informed decisions regarding their health care. The Calendar Year 2022 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule with Comment Period will strengthen enforcement of price transparency requirements for hospitals, and increase Medicare beneficiary quality and safety by halting the phased elimination of the Inpatient Only list for surgical procedures.

CY 2022 End Stage Renal Disease Prospective Payment System Final Rule
CMS issued a final rule that updates payment rates under the End-Stage Renal Disease Prospective Payment System for renal dialysis services furnished to beneficiaries on or after January 1, 2022. This rule also finalizes updates to the Acute Kidney Injury dialysis payment rate for renal dialysis services furnished by ESRD facilities. Additionally, the rule finalizes modifications to the ESRD Treatment Choices Model policies to encourage certain health care providers to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status. This makes the model one of the agency’s first CMS Innovation Center models to directly address health equity.

Now Open: Virtual Group Election Period for the MIPS 2022 Performance Year
If you’re interested in forming a virtual group for the 2022 Merit-based Incentive Payment System (MIPS) performance year, the election period starts today. To form a virtual group, an election must be submitted to CMS via e-mail between October 1, 2021 and December 31, 2021 (11:59 p.m. ET).

NOTE: A virtual group must submit an election to CMS for each performance year that it intends to participate in MIPS as a virtual group (as required by statute). If your virtual group was approved for the 2021 MIPS performance year and intends to participate in MIPS as a virtual group for the 2022 MIPS performance year, your virtual group is still required to submit an election to CMS for the 2022 MIPS performance year between October 1, 2021 and December 31, 2021 (11:59 p.m. ET).

Quality Payment Program

Quality Payment Program: 2021 Performance Period Merit-based Incentive Payment System (MIPS) Quality Measures Impacted by the Annual ICD-10 Coding Update
In the Calendar Year (CY) 2021 Quality Payment Program Final Rule (85 FR 84898 through 84900), CMS finalized the policy allowing for the review of quality measures for significant impacts due to International Classification of Diseases, Tenth Revision (ICD-10) coding changes during the performance period. Performance for these quality measures will be assessed based only on the first 9 months of the 12-month performance period. Additional information regarding this policy can be found in the 2021 MIPS Quality Measures Impacted by ICD-10 Updates located on the QPP Resource Library.

Reminder: 2021 APM Incentive Payment Details Available; Learn if Action Needed
CMS previously published 2021 Alternative Payment Model (APM) Incentive Payment details on the Quality Payment Program (QPP) website. To access this information, clinicians and surrogates can now log in to the QPP website using their HARP credentials. Eligible clinicians who were Qualifying APM Participants (QPs) based on their 2019 performance should have begun receiving their 2021 5% APM Incentive Payments earlier this summer. CMS has posted the 2021 Learning Resources for QP Status and APM Incentive Payment (ZIP) with more details.

Update: 2020 MIPS Performance Feedback, Final Score, and 2022 MIPS Payment Adjustment Information
CMS will be updating the Merit-based Incentive Payment System (MIPS) performance feedback and final scores for some clinicians for performance year 2020 and the associated MIPS payment adjustment information for payment year 2022. You can view your current MIPS performance feedback, final score, and payment adjustment on the Quality Payment Program website. Please note the information you see now may be changing.

Upcoming MIPS Important Dates and Deadlines

CMS would like to remind clinicians of important upcoming Merit-based Incentive Payment System (MIPS) dates and deadlines:

  • December 31 – 2021 Promoting Interoperability Hardship Exception and Extreme and Uncontrollable Circumstances (EUC) Applications close. Clinicians, groups, and virtual groups who believe they’re eligible for these exceptions may apply, and if approved, will qualify for a re-weighting of one or more MIPS performance categories. Alternative Payment Model (APM) Entities can also request reweighting of all performance categories through the EUC application. CMS will notify applicants via email whether their requests are approved or denied. If approved, the exception will also be added to the QPP Participation Status Tool but may not appear in the tool until the data submission period begins in 2022.
  • December 31 – 2022 virtual group election period closes.
  • January 3, 2022 – 2021 MIPS performance year data submission period begins.
  • March 31, 2022 – 2021 MIPS performance year data submission period closes.

Claims, Pricers & Codes

  • HCPCS Application Summaries & Coding Decisions: 510(k)-Cleared Wound Care Products
    CMS published the 2021 HCPCS Application Summary for Supplemental Coding Cycle (PDF). Visit the HCPCS Level II Coding Decisions webpage for more information.
  • LTCH: New Web Pricer Released
    CMS released the fiscal years 2020 and 2021 Long-Term Care Hospital (LTCH) Web Pricer. For the best experience, access the Web Pricer through Google Chrome. You may also use Microsoft Edge or Mozilla Firefox, but not Microsoft Internet Explorer. Email your feedback on the LTCH Web Pricer to using the subject line “LTCH Web Pricer.”
  • Health Care Code Sets: ICD-10 — Revised
    Read new information (PDF) in this Medicare Learning Network fact sheet:

    • Simple code explanations
    • HIPAA requirement
    • Resources to advance health equity and help eliminate health disparities
  • HCPCS Level II Application Submission: Launch of MEARISTM
    The Medicare Electronic Application Request Information System (MEARIS) is available for HCPCS Level II fourth quarter 2021 and first biannual 2022 application submissions. For more information, visit the HCPCS – General Information webpage.
  • HCPCS Level II Application Submission Deadlines
    CMS announced HCPCS Level II application submission deadlines:

    • First quarter and first biannual 2022 coding cycles — January 4, 2022
    • Second quarter 2022 coding cycle — April 1, 2022
  • Non-Drug & Non-Biological Items and Services: HCPCS Application Summaries & Coding Decisions
    Visit the HCPCS Level II Coding Decisions webpage for more information.
  • ICD-10-CM Diagnosis Code Files for FY 2022
    Visit the 2022 ICD-10-CM webpage for Fiscal Year (FY) 2022 diagnosis code information
  • ICD-10-CM Codes: FY 2022
    Fiscal year (FY) 2022 ICD-10-CM codes are available on the 2022 ICD-10-CM webpage. Use these codes for discharges and patient encounters on or after October 1, 2021, through September 30, 2022.
  • ICD-10-PCS Procedure Codes: FY 2022
    Fiscal year 2022 ICD-10-PCS procedure codes are available on the 2022 ICD-10 PCS webpage. Use these codes for discharges on or after October 1, 2021, through September 30, 2022.


Additional Resources Now Available in 2021 Quality Benchmarks Zip File – When you submit measures for the Merit-based Incentive Payment System (MIPS) quality performance category, each measure is assessed against its benchmark to determine how many points the measure earns. The 2021 MIPS Quality Benchmarks (ZIP) lists and explains the 2021 benchmarks used to assess performance in the quality performance category of MIPS. This file is available on the QPP Resource Library.

CMS COVID Provider ToolkitCMS released a set of toolkits for providers, states and insurers to help the health care system prepare to swiftly administer the vaccine. These resources are designed to increase the number of providers that can administer the vaccine and ensure adequate reimbursement for administering the vaccine in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover the vaccine at no charge to beneficiaries. In addition, CMS is taking action to increase reimbursement for any new COVID treatments that are approved by the FDA.

CDC COVID-19 Vaccination Communication Toolkit – Medical centers, clinics, and clinicians can use or adapt these ready-made materials to build confidence about COVID-19 vaccination among your healthcare teams and other staff.

MLN Matters Articles

From CMS Innovation Center

The Centers for Medicare & Medicaid Services Innovation Center, (@CMSinnovates) also known as “the Innovation Center,” develops and tests new healthcare payment and service delivery models.

Announced: Radiation Oncology Model
The Radiation Oncology (RO) Model aims to improve the quality of care for cancer patients receiving radiotherapy (RT) and move toward a simplified and predictable payment system. The RO Model tests whether prospective, site neutral, modality agnostic, episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for RT episodes of care reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. The Consolidated Appropriations Act, 2021 (H.R. 133) enacted on December 27, 2020 includes a provision that prohibits implementation of the RO Model prior to January 1, 2022. CMS has addressed this delay through notice and comment rulemaking in the CY 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule (CMS-1753-F).

Announced: Medicare Diabetes Prevention Program (MDPP) Expanded Model
The Medicare Diabetes Prevention Program expanded model is a structured intervention with the goal of preventing type 2 diabetes in individuals with an indication of prediabetes. The clinical intervention consists of a minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After the completing the core sessions, less intensive follow-up meetings furnished monthly help ensure that the participants maintain healthy behaviors. The primary goal of the expanded model is at least 5 percent weight loss by participants. The National DPP is based on the results of the Diabetes Prevention Program (DPP) study funded by the National Institutes of Health (NIH). The study found that lifestyle changes resulting in modest weight loss sharply reduced the development of type 2 diabetes in people at high risk for the disease.