{"description":"Documents matching 'hipaa-compliant validation including original billing'","count":62,"total_pages":4,"next_page_url":"https://www.federalregister.gov/api/v1/documents?conditions%5Bterm%5D=hipaa-compliant+validation+including+original+billing&format=json&page=2","results":[{"title":"Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges","type":"Proposed Rule","abstract":"These proposals are intended to improve the electronic exchange of health care data and streamline processes related to prior authorization by increasing the interoperability of systems used across the health care industry. We are proposing new requirements for Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children's Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs), including issuers that offer small group market QHPs on the Federally-facilitated Small Business Health Options Program (FF- SHOP) Exchanges (hereinafter referred to as \"small group market QHP issuers on the FF-SHOPs\") (collectively \"impacted payers\"), to make available electronic prior authorization for drugs. We are also proposing to extend many existing interoperability requirements for the prior authorization of non-drug items and services to include prior authorizations for drugs to further reduce patient and provider burden. We are also proposing to require impacted payers to report their application programming interfaces (API) endpoints and related information for the Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization APIs to CMS. To help assess the impact of our policies, we are proposing to collect API usage metrics. In addition, we are proposing to apply the existing interoperability requirements to small group market QHP issuers on the FF-SHOPs as impacted payers. To improve impacted payers' ability to exchange health information while continuing CMS's drive toward interoperability, we are proposing to require certain Health Level Seven (HL7[supreg]) Fast Healthcare Interoperability Resources (FHIR[supreg]) implementation guides (IGs) that are currently recommended. In addition, HHS is proposing to adopt the HL7 FHIR base standard and certain associated specifications and IGs as the Health Insurance Portability and Accountability Act of 1996 (hereinafter referred to as \"HIPAA\") (Pub. L. 104-191, enacted Aug. 21, 1996) standards for dental, professional, and institutional \"referral certification and authorization\" transactions and \"eligibility for a health plan\" transactions associated with prior authorization. We are proposing to add a definition for \"failure to report,\" which would allow CMS to impose a civil monetary penalty (CMP) on applicable manufacturers or applicable group purchasing organizations (GPOs) if those entities fail to grant CMS timely access to documents for the purposes of an audit. Finally, ONC is using this rulemaking to propose to adopt updated versions of certain health information technology (health IT) standards and specifications for HHS use, such as CMS's interoperability requirements, to support a more robust health IT infrastructure.","document_number":"2026-07205","html_url":"https://www.federalregister.gov/documents/2026/04/14/2026-07205/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-interoperability-standards","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2026-04-14/pdf/2026-07205.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2026-07205.pdf?1775852111","publication_date":"2026-04-14","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"},{"raw_name":"Office of the Secretary"}],"excerpts":"maintaining standards for the exchange of information between providers, pharmacies, and payers. NCPDP is an SDO for pharmacy standards, <span class=\"match\">including</span> <span class=\"match\">billing</span>, subrogation, formulary and benefits, electronic prior authorization, electronic prescribing, and real-time benefit checks. The NCPDP SCRIPT standard can be used for multiple transactions between entities during the prescribing and dispensing processes <span class=\"match\">including</span> between providers, pharmacies, and payers for electronic prescribing; electronic prior authorization; and medication history exchange."},{"title":"Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program","type":"Rule","abstract":"This final rule will improve the electronic exchange of health care data and streamline processes related to prior authorization through new requirements for Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children's Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs). This final rule will also add new measures for eligible hospitals and critical access hospitals (CAHs) to report under the Medicare Promoting Interoperability Program and for MIPS eligible clinicians to report under the Promoting Interoperability performance category of the Merit-based Incentive Payment System (MIPS). These policies, taken together, will reduce overall payer and provider burden and improve patient access to health information while continuing CMS's drive toward interoperability in the health care market.","document_number":"2024-00895","html_url":"https://www.federalregister.gov/documents/2024/02/08/2024-00895/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2024-02-08/pdf/2024-00895.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2024-00895.pdf?1705612517","publication_date":"2024-02-08","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"},{"raw_name":"Office of the Secretary"}],"excerpts":"records in cases, like those cited by the commenter, when clinical data are derived from claims. The provenance profile contains contextual information about the data, <span class=\"match\">including</span> the data's <span class=\"match\">original</span> author(s), transmitters, and formats (<span class=\"match\">including</span> whether they are derived from a claim-related transaction). Thus, using the PDex IG can help mitigate the problem of duplicating data by <span class=\"match\">including</span> provenance information. We also strongly recommend that the data source be included at the point of record creation, so that users can appropriately understand the"},{"title":"Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program","type":"Proposed Rule","abstract":"This proposed rule would place new requirements on Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children's Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of healthcare data and streamline processes related to prior authorization, while continuing CMS' drive toward interoperability in the healthcare market. This proposed rule would also add a new measure for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS. These policies taken together would play a key role in reducing overall payer and provider burden and improving patient access to health information.","document_number":"2022-26479","html_url":"https://www.federalregister.gov/documents/2022/12/13/2022-26479/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2022-12-13/pdf/2022-26479.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2022-26479.pdf?1670361325","publication_date":"2022-12-13","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"},{"raw_name":"Office of the Secretary"}],"excerpts":"(that is, benefits not covered under <span class=\"match\">Original</span> Medicare) and/or lower beneficiary Part B or Part D premiums. Some examples of these supplemental benefits include vision, dental, hearing, fitness, and worldwide coverage of emergency and urgently needed services. \n To the extent that the Government's payments to plans for the bid plus the rebate exceeds costs in <span class=\"match\">Original</span> Medicare, those additional payments put upward pressure on the Part B premium, which is paid by all Medicare beneficiaries, <span class=\"match\">including</span> those in <span class=\"match\">Original</span> Medicare who do not have the supplemental"},{"title":"Procedures for Transportation Workplace Drug and Alcohol Testing Programs: Addition of Oral Fluid Specimen Testing for Drugs","type":"Rule","abstract":"This final rule amends the U.S. Department of Transportation's regulated industry drug testing program to include oral fluid testing. This additional methodology for drug testing will give employers a choice that will help combat employee cheating on urine drug tests and provide a less intrusive means of achieving the safety goals of the program. In order for an employer to implement oral fluid testing under the Department's regulation, the U.S. Department of Health and Human Services will need to certify at least two laboratories for oral fluid testing, which has not yet been done. The final rule includes other provisions to update the Department's regulation and to harmonize, as needed, with the Mandatory Guidelines for Federal Workplace Drug Testing Programs using Oral Fluid established by the U.S. Department of Health and Human Services. In addition, this rule amends the FAA, FMCSA, FRA and FTA regulations to ensure consistency within the Department of Transportation and by removing or adjusting references to the word \"urine\" and/or add references to oral fluid, as well as removing or amending some definitions for conformity and to make other miscellaneous technical changes or corrections.","document_number":"2023-08041","html_url":"https://www.federalregister.gov/documents/2023/05/02/2023-08041/procedures-for-transportation-workplace-drug-and-alcohol-testing-programs-addition-of-oral-fluid","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2023-05-02/pdf/2023-08041.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2023-08041.pdf?1682945116","publication_date":"2023-05-02","agencies":[{"raw_name":"DEPARTMENT OF TRANSPORTATION","name":"Transportation Department","id":492,"url":"https://www.federalregister.gov/agencies/transportation-department","json_url":"https://www.federalregister.gov/api/v1/agencies/492","parent_id":null,"slug":"transportation-department"},{"raw_name":"Federal Aviation Administration","name":"Federal Aviation Administration","id":159,"url":"https://www.federalregister.gov/agencies/federal-aviation-administration","json_url":"https://www.federalregister.gov/api/v1/agencies/159","parent_id":492,"slug":"federal-aviation-administration"},{"raw_name":"Office of the Secretary"},{"raw_name":"Federal Railroad Administration","name":"Federal Railroad Administration","id":185,"url":"https://www.federalregister.gov/agencies/federal-railroad-administration","json_url":"https://www.federalregister.gov/api/v1/agencies/185","parent_id":492,"slug":"federal-railroad-administration"},{"raw_name":"Federal Motor Carrier Safety Administration","name":"Federal Motor Carrier Safety Administration","id":181,"url":"https://www.federalregister.gov/agencies/federal-motor-carrier-safety-administration","json_url":"https://www.federalregister.gov/api/v1/agencies/181","parent_id":492,"slug":"federal-motor-carrier-safety-administration"},{"raw_name":"Federal Transit Administration","name":"Federal Transit Administration","id":193,"url":"https://www.federalregister.gov/agencies/federal-transit-administration","json_url":"https://www.federalregister.gov/api/v1/agencies/193","parent_id":492,"slug":"federal-transit-administration"}],"excerpts":"for the devices and recovery of drug from the same. These are assessed two times: first, by the manufacturer and second, during laboratory <span class=\"match\">validation</span> of the collection device. While HHS does not certify or <span class=\"match\">validate</span> the collection devices or the buffer, the NLCP laboratory inspection process does ensure accuracy of the results obtained by the laboratories as evidenced by each laboratory's method of <span class=\"match\">validation</span> documentation which must specify the collection device(s) used. HHS will approve each specific HHS-certified oral fluid laboratory to use only"},{"title":"Request for Information: Electronic Prior Authorization Standards, Implementation Specifications, and Certification Criteria","type":"Proposed Rule","abstract":"This request for information seeks input from the public regarding electronic prior authorization standards, implementation specifications, and certification criteria that could be adopted within the ONC Health IT Certification Program. Responses to this Request for Information will be used to inform potential future rulemaking.","document_number":"2022-01309","html_url":"https://www.federalregister.gov/documents/2022/01/24/2022-01309/request-for-information-electronic-prior-authorization-standards-implementation-specifications-and","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2022-01-24/pdf/2022-01309.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2022-01309.pdf?1642772741","publication_date":"2022-01-24","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Office of the Secretary"}],"excerpts":"information, we believe this functionality can support a wide range of use cases <span class=\"match\">including</span> research, public health, quality measurement, and healthcare operations, <span class=\"match\">including</span> prior authorization processes. \n b. Requirements Under HIPAA for Electronic Prior Authorization Transaction Standards \n \n Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Secretary must adopt electronic standards for use by “covered entities,” which is defined as <span class=\"match\">including</span> health plans, healthcare clearinghouses, and certain healthcare providers"},{"title":"Medicare and Medicaid Programs; CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Implementing Requirements for Manufacturers of Certain Single-dose Container or Single-use Package Drugs To Provide Refunds With Respect to Discarded Amounts; and COVID-19 Interim Final Rules","type":"Rule","abstract":"This major final rule addresses: changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute; Medicare Shared Savings Program requirements; updates to the Quality Payment Program; Medicare coverage of opioid use disorder services furnished by opioid treatment programs; updates to certain Medicare and Medicaid provider enrollment policies, including for skilled nursing facilities; updates to conditions of payment for DMEPOS suppliers; HCPCS Level II coding and payment for wound care management products; electronic prescribing for controlled substances for a covered Part D drug under a prescription drug plan or an MA-PD plan under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (SUPPORT Act); updates to the Medicare Ground Ambulance Data Collection System; provisions under the Infrastructure Investment and Jobs Act; and finalizes the CY 2022 Methadone Payment Exception for Opioid Treatment Programs IFC. We are also finalizing, as implemented, a few provisions included in the COVID-19 interim final rules with comment period.","document_number":"2022-23873","html_url":"https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2022-11-18/pdf/2022-23873.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2022-23873.pdf?1667420129","publication_date":"2022-11-18","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"May 2021, the CPT Editorial Panel revised the descriptors and <span class=\"match\">billing</span> instructions for CPT codes 64415 (\n Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, <span class=\"match\">including</span> imaging guidance, when performed \n ), 64416 (\n Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter (<span class=\"match\">including</span> catheter placement), <span class=\"match\">including</span> imaging guidance, when performed \n ), 64417 (\n Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, <span class=\"match\">including</span> imaging guidance, when performed \n ), 64445 (\n Injection(s)"},{"title":"Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2023 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Costs Incurred for Qualified and Non-Qualified DeferredCompensation Plans; and Changes to Hospital and Critical Access Hospital Conditions of Participation","type":"Rule","abstract":"This final rule will: revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals; make changes relating to Medicare graduate medical education (GME) for teaching hospitals; update the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). In addition it will establish new requirements and revise existing requirements for eligible hospitals and critical access hospitals (CAHs) participating in the Medicare Promoting Interoperability Program; and update policies for the Hospital Readmissions Reduction Program, Hospital Inpatient Quality Reporting (IQR) Program, Hospital VBP Program, Hospital- Acquired Condition (HAC) Reduction Program, PPS-Exempt Cancer Hospital Reporting (PCHQR) Program, and the Long-Term Care Hospital Quality Reporting Program (LTCH QRP). It will also revise the hospital and critical access hospital (CAH) conditions of participation (CoPs) for infection prevention and control and antibiotic stewardship programs; and codify and clarify policies related to the costs incurred for qualified and non-qualified deferred compensation plans. Lastly, this final rule will provide updates on the Rural Community Hospital Demonstration Program and the Frontier Community Health Integration Project.","document_number":"2022-16472","html_url":"https://www.federalregister.gov/documents/2022/08/10/2022-16472/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2022-08-10/pdf/2022-16472.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2022-16472.pdf?1659384921","publication_date":"2022-08-10","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"of MS-DRG 018, we have provided a description of the calculation of the relative weight for MS-DRG 018, <span class=\"match\">including</span> a step-by-step calculation of the CAR T-cell clinical trial adjustment factor, as set forth earlier in this section.\n \n We also note that some commenters requested additional clarifications regarding <span class=\"match\">billing</span> instructions for CAR T-cell therapies, such as appropriate CAR T-cell <span class=\"match\">billing</span> and charges. We do not believe changes to <span class=\"match\">billing</span> guidance are needed at this time but will take these comments into consideration when developing policies"},{"title":"Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2023 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Costs Incurred for Qualified and Non-Qualified Deferred Compensation Plans; and Changes to Hospital and Critical Access Hospital Conditions of Participation","type":"Proposed Rule","abstract":"This proposed rule would: Revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital- related costs of acute care hospitals; make changes relating to Medicare graduate medical education (GME) for teaching hospitals; update the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). In additon it would establish new requirements and revise existing requirements for eligible hospitals and critical access hospitals (CAHs) participating in the Medicare Promoting Interoperability Program; provide estimated and newly established performance standards for the Hospital Value- Based Purchasing (VBP) Program; and propose updated policies for the Hospital Readmissions Reduction Program, Hospital Inpatient Quality Reporting (IQR) Program, Hospital VBP Program, Hospital-Acquired Condition (HAC) Reduction Program, PPS-Exempt Cancer Hospital Reporting (PCHQR) Program, and the Long-Term Care Hospital Quality Reporting Program (LTCH QRP). It would also revise the hospital and critical access hospital (CAH) conditions of participation (CoPs) for infection prevention and control and antibiotic stewardship programs; and codify and clarify policies related to the costs incurred for qualified and non-qualified deferred compensation plans. Lastly, this proposed rule would provide updates on the Rural Community Hospital Demonstration Program and the Frontier Community Health Integration Project.","document_number":"2022-08268","html_url":"https://www.federalregister.gov/documents/2022/05/10/2022-08268/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2022-05-10/pdf/2022-08268.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2022-08268.pdf?1650312919","publication_date":"2022-05-10","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"table for a complete discussion of the new technology add-on payment application, coding and payment amount for these technologies, <span class=\"match\">including</span> the applicable indications and discussion of the newness start date. \n We are inviting public comments on our proposals to discontinue new technology add-on payments for FY 2023 for the technologies listed in the Table BBBB-A1. \n <span class=\"match\">BILLING</span> CODE 4120-01-P \n \n \n EP10MY22.076 \n \n <span class=\"match\">BILLING</span> CODE 4120-01-C \n \n Table II.F.-02 lists the technologies for which we are proposing to continue making new technology add-on payments"},{"title":"Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug; Payment for Office/Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Coding and Payment for Virtual Check-in Services Interim Final Rule Policy; Coding and Payment for Personal Protective Equipment (PPE) Interim Final Rule Policy; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID-19; and Finalization of Certain Provisions from the March 31st, May 8th and September 2nd Interim Final Rules in Response to the PHE for COVID-19","type":"Rule","abstract":"This major final rule addresses: Changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute; Medicare Shared Savings Program requirements; Medicaid Promoting Interoperability Program requirements for Eligible Professionals; updates to the Quality Payment Program; Medicare coverage of opioid use disorder services furnished by opioid treatment programs; Medicare enrollment of Opioid Treatment Programs; payment for office/outpatient evaluation and management services; Requirement for Electronic Prescribing for Controlled Substances for a Covered Part D drug under a prescription drug plan or an MA-PD plan and Medicare Diabetes Prevention Program (MDPP) expanded model Emergency Policy. This final rule also finalizes certain provisions of the interim final rules with comment period that CMS issued on March 31, 2020, May 8, 2020\\,\\ and September 2, 2020 in response to the Public Health Emergency (PHE) for the Coronavirus Disease 2019 (COVID-19). This rule also establishes coding and payment for virtual check-in services and for personal protective equipment (PPE) on an interim final basis.","document_number":"2020-26815","html_url":"https://www.federalregister.gov/documents/2020/12/28/2020-26815/medicare-program-cy-2021-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2020-26815.pdf?1606943727","publication_date":"2020-12-28","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"(SA103) supply was no longer typical in CPT codes 37238 (\n Transcatheter placement of an intravascular stent(s), open or percutaneous, <span class=\"match\">including</span> radiological supervision and interpretation and <span class=\"match\">including</span> angioplasty within the same vessel, when performed; initial vein \n ) and 37239 (\n Transcatheter placement of an intravascular stent(s), open or percutaneous, <span class=\"match\">including</span> radiological supervision and interpretation and <span class=\"match\">including</span> angioplasty within the same vessel, when performed; each additional vein \n ). The stakeholders stated that a new venous stent system"},{"title":"Medicaid Program; Patient Protection and Affordable Care Act; Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients' Electronic Access to Health Information for Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges; Health Information Technology Standards and Implementation Specifications","type":"Proposed Rule","abstract":"This proposed rule would place new requirements on state Medicaid and CHIP fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of health care data, and streamline processes related to prior authorization, while continuing CMS' drive toward interoperability, and reducing burden in the health care market. In addition, on behalf of the Department of Health and Human Service (HHS), the Office of the National Coordinator for Health Information Technology (ONC) is proposing the adoption of certain specified implementation guides (IGs) needed to support the proposed Application Programming Interface (API) policies included in this rule. Each of these elements plays a key role in reducing overall payer and provider burden and improving patient access to health information.","document_number":"2020-27593","html_url":"https://www.federalregister.gov/documents/2020/12/18/2020-27593/medicaid-program-patient-protection-and-affordable-care-act-reducing-provider-and-patient-burden-by","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2020-12-18/pdf/2020-27593.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2020-27593.pdf?1607962517","publication_date":"2020-12-18","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"},{"raw_name":"Office of the Secretary"}],"excerpts":"services, not <span class=\"match\">including</span> prescription drugs, that require prior authorization; \n (ii) The percentage of standard prior authorization requests that were approved, reported separately for items and services, not <span class=\"match\">including</span> prescription drugs; \n (iii) The percentage of standard prior authorization requests that were denied, reported separately for items and services, not <span class=\"match\">including</span> prescription drugs; \n (iv) The percentage of standard prior authorization requests that were approved after appeal, reported separately for items and services, not <span class=\"match\">including</span> prescription"},{"title":"Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, and End-Stage Renal Disease Quality Incentive Program","type":"Rule","abstract":"This final rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year (CY) 2021. This rule also updates the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). In addition, this rule updates requirements for the ESRD Quality Incentive Program (QIP).","document_number":"2020-24485","html_url":"https://www.federalregister.gov/documents/2020/11/09/2020-24485/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2020-11-09/pdf/2020-24485.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2020-24485.pdf?1604351725","publication_date":"2020-11-09","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"separately <span class=\"match\">billable</span> under Medicare Part B; (2) Renal dialysis laboratory tests that were or would have been, prior to January 1, 2011, separately <span class=\"match\">billable</span> under Medicare Part B; (3) Renal dialysis medical/surgical supplies, <span class=\"match\">including</span> syringes, used to administer renal dialysis drugs and biological products that were or would have been, prior to January 1, 2011, separately <span class=\"match\">billable</span> under Medicare Part B; (4) Renal dialysis drugs and biological products that were or would have been, prior to January 1, 2011, covered under Medicare Part D, <span class=\"match\">including</span> renal"},{"title":"Transparency in Coverage","type":"Rule","abstract":"The final rules set forth requirements for group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information upon request to a participant, beneficiary, or enrollee (or his or her authorized representative), including an estimate of the individual's cost-sharing liability for covered items or services furnished by a particular provider. Under the final rules, plans and issuers are required to make this information available on an internet website and, if requested, in paper form, thereby allowing a participant, beneficiary, or enrollee (or his or her authorized representative) to obtain an estimate and understanding of the individual's out-of-pocket expenses and effectively shop for items and services. The final rules also require plans and issuers to disclose in-network provider negotiated rates, historical out-of- network allowed amounts, and drug pricing information through three machine-readable files posted on an internet website, thereby allowing the public to have access to health coverage information that can be used to understand health care pricing and potentially dampen the rise in health care spending. The Department of Health and Human Services (HHS) also finalizes amendments to its medical loss ratio (MLR) program rules to allow issuers offering group or individual health insurance coverage to receive credit in their MLR calculations for savings they share with enrollees that result from the enrollees shopping for, and receiving care from, lower-cost, higher-value providers.","document_number":"2020-24591","html_url":"https://www.federalregister.gov/documents/2020/11/12/2020-24591/transparency-in-coverage","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2020-11-12/pdf/2020-24591.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2020-24591.pdf?1604438120","publication_date":"2020-11-12","agencies":[{"raw_name":"DEPARTMENT OF THE TREASURY","name":"Treasury Department","id":497,"url":"https://www.federalregister.gov/agencies/treasury-department","json_url":"https://www.federalregister.gov/api/v1/agencies/497","parent_id":null,"slug":"treasury-department"},{"raw_name":"Internal Revenue Service","name":"Internal Revenue Service","id":254,"url":"https://www.federalregister.gov/agencies/internal-revenue-service","json_url":"https://www.federalregister.gov/api/v1/agencies/254","parent_id":497,"slug":"internal-revenue-service"},{"raw_name":"DEPARTMENT OF LABOR","name":"Labor Department","id":271,"url":"https://www.federalregister.gov/agencies/labor-department","json_url":"https://www.federalregister.gov/api/v1/agencies/271","parent_id":null,"slug":"labor-department"},{"raw_name":"Employee Benefits Security Administration","name":"Employee Benefits Security Administration","id":131,"url":"https://www.federalregister.gov/agencies/employee-benefits-security-administration","json_url":"https://www.federalregister.gov/api/v1/agencies/131","parent_id":271,"slug":"employee-benefits-security-administration"},{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"}],"excerpts":"should include the following: Number of procedures performed by the provider in the reported period, number of bed days, total <span class=\"match\">billed</span> charges in the reporting period, total amount received/paid for services in the reporting period, mean <span class=\"match\">billed</span> charged amount, mean accepted amount, median <span class=\"match\">billed</span> charged amount, mean accepted amount, median <span class=\"match\">billed</span> charged amount, median accepted payment, minimum <span class=\"match\">billed</span> charged amount, maximum <span class=\"match\">billed</span> charged amount, minimum accepted payment, and maximum accepted payment. \n A goal of the final rules is to provide transparency"},{"title":"Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, and End-Stage Renal Disease Quality Incentive Program","type":"Proposed Rule","abstract":"This proposed rule would update and make revisions to the End- Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year (CY) 2021. This rule also proposes to update the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). In addition, this rule proposes to update requirements for the ESRD Quality Incentive Program (QIP).","document_number":"2020-14671","html_url":"https://www.federalregister.gov/documents/2020/07/13/2020-14671/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2020-07-13/pdf/2020-14671.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2020-14671.pdf?1594066514","publication_date":"2020-07-13","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"separately <span class=\"match\">billable</span> under Medicare Part B; (2) Renal dialysis laboratory tests that were or would have been, prior to January 1, 2011, separately <span class=\"match\">billable</span> under Medicare Part B; (3) Renal dialysis medical/surgical supplies, <span class=\"match\">including</span> syringes, used to administer renal dialysis drugs and biological products that were or would have been, prior to January 1, 2011, separately <span class=\"match\">billable</span> under Medicare Part B; (4) Renal dialysis drugs and biological products that were or would have been, prior to January 1, 2011, covered under Medicare Part D, <span class=\"match\">including</span> renal"},{"title":"Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule","type":"Rule","abstract":"This major final rule addresses: Changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute; Medicare Shared Savings Program quality reporting requirements; Medicaid Promoting Interoperability Program requirements for eligible professionals; the establishment of an ambulance data collection system; updates to the Quality Payment Program; Medicare enrollment of Opioid Treatment Programs and enhancements to provider enrollment regulations concerning improper prescribing and patient harm; and amendments to Physician Self-Referral Law advisory opinion regulations. In addition, we are issuing an interim final rule with comment period (IFC) to establish coding and payment for evaluation and management, observation and the provision of self-administered Esketamine to facilitate beneficiary access to care for treatment-resistant depression as efficiently as possible.","document_number":"2019-24086","html_url":"https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2019-11-15/pdf/2019-24086.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2019-24086.pdf?1572639331","publication_date":"2019-11-15","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"bundled payment that includes the cost of the drug would be <span class=\"match\">billed</span> during the week that the drug is administered, and if at least once service is furnished in a subsequent week, the non-drug bundle would be <span class=\"match\">billed</span>. For example, in the case of a patient receiving injectable buprenorphine, we would expect that HCPCS code G2069 would be <span class=\"match\">billed</span> for the week during which the injection was administered and that HCPCS code G2074, which describes a bundle not <span class=\"match\">including</span> the drug, would be <span class=\"match\">billed</span> during any subsequent weeks that at least one non-drug service"},{"title":"Medicare Program; Inpatient Rehabilitation Facility (IRF) Prospective Payment System for Federal Fiscal Year 2020 and Updates to the IRF Quality Reporting Program","type":"Rule","abstract":"This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2020. As required by the statute, this final rule includes the classification and weighting factors for the IRF prospective payment system's (PPS) case-mix groups (CMGs) and a description of the methodologies and data used in computing the prospective payment rates for FY 2020. This final rule rebases and revises the IRF market basket to reflect a 2016 base year rather than the current 2012 base year. Additionally, this final rule revises the CMGs and updates the CMG relative weights and average length of stay (LOS) values beginning with FY 2020, based on analysis of 2 years of data (FYs 2017 and 2018). Although we proposed to use a weighted motor score to assign patients to CMGs, we are finalizing based on public comments the use of an unweighted motor score to assign patients to CMGs beginning with FY 2020. Additionally, we are finalizing the removal of one item from the motor score. We are updating the IRF wage index to use the concurrent fiscal year inpatient prospective payment system (IPPS) wage index beginning with FY 2020. We are amending the regulations to clarify that the determination as to whether a physician qualifies as a rehabilitation physician (that is, a licensed physician with specialized training and experience in inpatient rehabilitation) is made by the IRF. For the IRF Quality Reporting Program (QRP), we are adopting two new measures, modifying an existing measure, and adopting new standardized patient assessment data elements. We are also making updates to reflect our migration to a new data submission system.","document_number":"2019-16603","html_url":"https://www.federalregister.gov/documents/2019/08/08/2019-16603/medicare-program-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal-fiscal","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2019-08-08/pdf/2019-16603.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2019-16603.pdf?1564604124","publication_date":"2019-08-08","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"distinct CMG number. Free downloads of the Inpatient Rehabilitation <span class=\"match\">Validation</span> and Entry (IRVEN) software product, <span class=\"match\">including</span> the Grouper software, are available on the CMS website at \n http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html \n .\n \n Once a Medicare Part A FFS patient is discharged, the IRF submits a Medicare claim as a Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191, enacted August 21, 1996) (<span class=\"match\">HIPAA) compliant</span> electronic claim or, if the Administrative Simplification Compliance"},{"title":"Medicare Program; Inpatient Rehabilitation Facility (IRF) Prospective Payment System for Federal Fiscal Year 2020 and Updates to the IRF Quality Reporting Program","type":"Proposed Rule","abstract":"This proposed rule would update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2020. As required by the Social Security Act (the Act), this proposed rule includes the classification and weighting factors for the IRF prospective payment system's (PPS) case-mix groups (CMGs) and a description of the methodologies and data used in computing the prospective payment rates for FY 2020. We are proposing to rebase and revise the IRF market basket to reflect a 2016 base year rather than the current 2012 base year. Additionally, we are proposing to replace the previously finalized unweighted motor score with a weighted motor score to assign patients to CMGs and remove one item from the score beginning with FY 2020 and to revise the CMGs and update the CMG relative weights and average length of stay values beginning with FY 2020, based on analysis of 2 years of data (FY 2017 and FY 2018). We are proposing to update the IRF wage index to use the concurrent FY inpatient prospective payment system (IPPS) wage index beginning with FY 2020. We are soliciting comments on stakeholder concerns regarding the appropriateness of the wage index used to adjust IRF payments. We are proposing to amend the regulations to clarify that the determination as to whether a physician qualifies as a rehabilitation physician (that is, a licensed physician with specialized training and experience in inpatient rehabilitation) is made by the IRF. For the IRF Quality Reporting Program (QRP), we are proposing to adopt two new measures, modify an existing measure, and adopt new standardized patient assessment data elements. We also propose to expand data collection to all patients, regardless of payer, as well as proposing updates related to the system used for the submission of data and related regulation text.","document_number":"2019-07885","html_url":"https://www.federalregister.gov/documents/2019/04/24/2019-07885/medicare-program-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal-fiscal","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2019-04-24/pdf/2019-07885.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2019-07885.pdf?1555591523","publication_date":"2019-04-24","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"distinct CMG number. Free downloads of the Inpatient Rehabilitation <span class=\"match\">Validation</span> and Entry (IRVEN) software product, <span class=\"match\">including</span> the Grouper software, are available on the CMS website at \n http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html. \n \n Once a Medicare Part A FFS patient is discharged, the IRF submits a Medicare claim as a Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191, enacted on August 21, 1996) (<span class=\"match\">HIPAA) compliant</span> electronic claim or, if the Administrative Simplification Compliance"},{"title":"Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; Quality Payment Program-Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year; Provisions From the Medicare Shared Savings Program-Accountable Care Organizations-Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder Under the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act","type":"Rule","abstract":"This major final rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This final rule also finalizes policies included in the interim final rule with comment period in \"Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year\" that address the extreme and uncontrollable circumstances MIPS eligible clinicians faced as a result of widespread catastrophic events affecting a region or locale in CY 2017, such as Hurricanes Irma, Harvey and Maria. In addition, this final rule addresses a subset of the changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) proposed in the August 2018 proposed rule \"Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Pathways to Success\". This final rule also addresses certain other revisions designed to update program policies under the Shared Savings Program. The interim final rule implements amendments made by the SUPPORT for Patients and Communities Act to the Medicare telehealth provisions in the Social Security Act and regarding permissible telehealth originating sites for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for telehealth services furnished on or after July 1, 2019 to an individual with a substance use disorder diagnosis.","document_number":"2018-24170","html_url":"https://www.federalregister.gov/documents/2018/11/23/2018-24170/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2018-24170.pdf?1541438783","publication_date":"2018-11-23","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"services that would be <span class=\"match\">billed</span> using the “PN” modifier. Instead, we analyzed hospital outpatient claims data from January 1 through August 25, 2016, that contained the “PO” modifier, which was a new mandatory reporting requirement for CY 2016 for claims that were <span class=\"match\">billed</span> by an off-campus department of a hospital. We limited our analysis to those claims <span class=\"match\">billed</span> on the 13X Type of <span class=\"match\">Bill</span> because those claims were used for Medicare Part B <span class=\"match\">billing</span> under the OPPS. We then identified the 25 most frequently <span class=\"match\">billed</span> major codes that were <span class=\"match\">billed</span> by claim line; that"},{"title":"Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019","type":"Rule","abstract":"This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2019. As required by the Social Security Act (the Act), this final rule includes the classification and weighting factors for the IRF prospective payment system's (PPS) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2019. This final rule also alleviates administrative burden for IRFs by removing the Functional Independence Measure (FIM\\TM\\) instrument and associated Function Modifiers from the IRF Patient Assessment Instrument (IRF-PAI) beginning in FY 2020 and revises certain IRF coverage requirements to reduce the amount of required paperwork in the IRF setting beginning in FY 2019. Additionally, this final rule incorporates certain data items located in the Quality Indicators section of the IRF-PAI into the IRF case-mix classification system using analysis of 2 years of data beginning in FY 2020. For the IRF Quality Reporting Program (QRP), this final rule adopts a new measure removal factor, removes two measures from the IRF QRP measure set, and codifies a number of program requirements in our regulations.","document_number":"2018-16517","html_url":"https://www.federalregister.gov/documents/2018/08/06/2018-16517/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2018-08-06/pdf/2018-16517.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2018-16517.pdf?1533068120","publication_date":"2018-08-06","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"distinct CMG number. Free downloads of the Inpatient Rehabilitation <span class=\"match\">Validation</span> and Entry (IRVEN) software product, <span class=\"match\">including</span> the Grouper software, are available on the CMS website at \n http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html. \n \n Once a Medicare Part A FFS patient is discharged, the IRF submits a Medicare claim as a Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191, enacted on August 21, 1996) (<span class=\"match\">HIPAA) compliant</span> electronic claim or, if the Administrative Simplification Compliance"},{"title":"Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019","type":"Proposed Rule","abstract":"This proposed rule would update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2019. As required by the Social Security Act (the Act), this proposed rule includes the classification and weighting factors for the IRF prospective payment system's (PPS) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2019. We are also proposing to alleviate administrative burden for IRFs by removing the Functional Independence Measure (FIM<SUP>TM</SUP>) instrument and associated Function Modifiers from the IRF Patient Assessment Instrument (IRF-PAI) and revising certain IRF coverage requirements to reduce the amount of required paperwork in the IRF setting. In addition, we are soliciting comments on removing the face-to-face requirement for rehabilitation physician visits and expanding the use of non-physician practitioners (that is, nurse practitioners and physician assistants) in meeting the IRF coverage requirements. For the IRF Quality Reporting Program (QRP), we are proposing to adopt a new measure removal factor, remove two measures from the IRF QRP measure set, and codify in our regulations a number of requirements.","document_number":"2018-08961","html_url":"https://www.federalregister.gov/documents/2018/05/08/2018-08961/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2018-05-08/pdf/2018-08961.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2018-08961.pdf?1524860118","publication_date":"2018-05-08","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"distinct CMG number. Free downloads of the Inpatient Rehabilitation <span class=\"match\">Validation</span> and Entry (IRVEN) software product, <span class=\"match\">including</span> the Grouper software, are available on the CMS website at \n http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html. \n \n Once a Medicare Part A FFS patient is discharged, the IRF submits a Medicare claim as a Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191, enacted on August 21, 1996) (<span class=\"match\">HIPAA) compliant</span> electronic claim or, if the Administrative Simplification Compliance"},{"title":"Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program","type":"Rule","abstract":"This major final rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies such as changes to the Medicare Shared Savings Program, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.","document_number":"2017-23953","html_url":"https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions","pdf_url":"https://www.govinfo.gov/content/pkg/FR-2017-11-15/pdf/2017-23953.pdf","public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2017-23953.pdf?1509653729","publication_date":"2017-11-15","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"excerpts":"modifier signifying that they were <span class=\"match\">billed</span> by an off-campus department of a hospital paid under the OPPS other than a remote location, a satellite facility, or a dedicated emergency department (ED). We noted that the use of the “PO” modifier was a new mandatory reporting requirement for CY 2016. We limited our analysis to those claims <span class=\"match\">billed</span> on the 13X Type of <span class=\"match\">Bill</span> because those claims were used for Medicare Part B <span class=\"match\">billing</span> under the OPPS. We then identified the top (most frequently <span class=\"match\">billed</span>) 25 major codes that were <span class=\"match\">billed</span> by claim line; that is, items"}]}