POE Advisory Group Details

12/5/2024 J6/JK Part A and FQHC POE Advisory Group Meeting

Meeting Minutes

Meeting Time: 10:30-12:30 p.m. ET

Member Attendees: Megan Appello, Mary Altieri, Carol Baron, Louise Bertrand, Kate Brewer, Mollie Brooks, Cindy Case, Kafi Cook, Dolores Dire, Amy Fanelli, Matthew Felton, Sam Hollis, Sara Luther, Annamaria Mastrofine, Amy Moore, Mara Nieves, Larisa Orlando, Joseph Rega, Theodora Revelas, Nancy Richman, Anna Santoro, Liz Saulnier, Joanne Schade-Boyce, and Beth Zavattero

National Government Services Associates: Mary Armstrong, Connie Arszman, Stephanie Boucher, Laura Brown, Michael Dorris, Alicia Forbes, Emily Fox-Squairs, Andrea Freibauer, Jeanine Gombos, Lisa Gross, Alison Hamilton, Phillip Harpenau, Christine Janiszcak, Casey Jones, Nathan Kennedy, Crystal Lewis (CGS DME), Kathy Mersch, Jean Roberts, Sydney Sabo, Susan Stafford, Auburn Sutton-Puckett, Maryrose Tomassi, Michelle Vannatter-Johnson, Mary Vier, Christine Warshel, and Denise Winsock (CGS DME)

Agenda

  1. Welcome, Introductions and Approval of Minutes from Previous Meeting
  2. Updates
  3. Review of Educational Material
  4. POE AG Member Suggestions for Education and Open Forum
  5. Upcoming Events and Additional Education
  6. 2024 Part A and FQHC POE AG Meeting Schedule

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I. Welcome, Introductions and Approval of Minutes from Previous Meeting

Jean Roberts and Christine Janiszcak, POE Consultant, NGS

Jean opened the meeting and greeted everyone. She explained this is the first-time using Teams, the PowerPoint agenda is on the screen, the original agenda and handouts are posted to the link previously provided and she emailed an updated agenda a few days ago due to last minute updates. She explained providers do not need to pre-register for meetings in Teams and if the member’s name is showing in Teams, we have the information we need. If the member’s phone number only is showing, then Jean asked the members to type their names into the chat for attendance purposes. Christine added that there is no need for anyone to print the material since it will be on the screen. She also asked for approval of the meeting minutes from our last meeting on 8/8/2024. One member verbally approved the minutes. Christine reminded everyone that we post the meeting minutes within 30 business days of the meeting date to our website under Education, POE Advisory Group, Meeting Minutes.

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II. Updates

Emily Fox-Squairs, POE Manager,NGS

Emily provided opening remarks. She welcomed everyone to the first POE AG meeting using Teams. She stated she hopes everyone finds using Teams is a simple way for us to have a conversation. Emily reminded the members the POE AG meetings are not meant to provide education; they are meant to be a time when we can have a conversation about our education. She explained members will not need to register for the meetings and members will not need to raise their hands to talk.

Emily then discussed our podcasts. She provided links to the podcasts on Apple and Spotify in the Teams chat. She asked those who listen to the podcast to continue listening and those who have not listened to start. She added that if our POE AG members followed us, it would be helpful because it will give us more visibility. She explained our followers are slowly going up over time and asked for members who have suggestions for topics or who want to be a guest, to let us know. She reminded members they can send us ideas and suggestions any time for our podcasts as well as for our other education methods since we want to provide a diverse portfolio.

Emily asked for questions and one member asked for the name of the podcast. Emily replied it is Navigating Medicare Part A Insights for Providers and explained it is one of three that we do including one for Home Health and Hospice providers and another for Part B providers. She confirmed the QR codes are in the Teams chat. One member tried the links and was successful.

Denise Winsock, Provider Relations Senior Analyst, CGS – DME MAC JB POE Manager, NGS

Denise reviewed the DME handout and provided the following DME updates:

  • On slide 3 about oxygen coverage criteria is the documentation that is required of the treating practitioner’s office. The initial coverage of home oxygen therapy and oxygen equipment is R&N for Groups I and II if the:
    • treating practitioner ordered and evaluated the results of a qualifying blood gas study performed at the time of need; and,
    • beneficiary's blood gas study meets the coverage criteria; and,
    • qualifying blood gas study was performed by a treating practitioner or a qualified provider or supplier of laboratory services; and,
    • provision of oxygen and oxygen equipment in the home setting will improve the beneficiary’s condition.
    • Time of need means during the patient’s illness when the presumption is the provision of oxygen in the home setting will improve the patient’s condition.
    • The top reason for oxygen denials was missing documentation supporting that the physician evaluated those test results. This was a new change because in 2021 the LCD was changed. Also, last year, we removed the requirement for CMN. Suppliers were having issues with this evaluation and the physician offices weren't aware of what was required.
  • On slide 4 about meeting oxygen coverage criterion 1, are links to “Treating Practitioner Evaluation of the Blood Gas Study for Oxygen”, published 7/3/2024, for Jurisdiction B and for Jurisdiction C. If the blood gas study was not conducted directly by the treating practitioner, documentation to support the evaluation of the blood gas study may include:
    • Copy of blood gas study (ABG or SAT) results in treating practitioner’s chart notes
    • Treating practitioner’s documentation referencing evaluation of blood gas study performed on a specific date
    • Treating practitioner’s signature on a copy of blood gas study results
    • Inclusion of blood gas study results on treating practitioner’s standard written order
    • Note: Blood gas study results must be corroborated in medical records
  • On slide 5 about pneumatic compression devices, the LCD was retired effective for DOS on/after 11/14/2024 because it was repetitive of the NCD. To be reimbursed, the R&N requirements in the Medicare NCD must be met. See the Pneumatic Compression Devices - Correct Coding and Billing article.
  • On slide 6 about the CERT Program common causes of medical necessity denials, remember all services provided to Medicare patients must be medically necessary. A lack of medical necessity denial occurs when the CERT contractor reviewers get enough medical records to decide billed services weren't medically necessary. These decisions are based on Medicare's coverage and payment policies. To ensure coverage requirements are met, there must be documentation that supports the medical necessity. This includes but is not limited to:
    • Standard written order
    • Written order prior to delivery
    • Treating or ordering practitioner notes
    • Face-to-face encounter records
    • Medical history
    • Physical exam
    • Diagnostic tests
    • Summary of findings
    • Progress notes
    • Treatment plan
    • Documentation of continued medical necessity
    • Documentation of continued use
  • On slide 7 about treating practitioners and prescribers DMEPOS education resources, is information about the Physician's Corner on our website designed to benefit physicians and practitioners who prescribe DMEPOS items for Medicare beneficiaries. In this section is information pertinent to the physician and the supplier that provides the items and services. On this page are “Dear Physician Letters” which provide information and resources for physicians and practitioners to assist with obtaining required documentation from physicians, “Documentation Checklists” which assist suppliers with confirming applicable documentation is available upon request, the “Medicare Minute MD™” which is a series of videos on a variety of topics provided by Dr. Sunil Lalla, the JB Medical Director, as well as LCDs.
  • On slide 8 regarding DME MAC & A/B MAC collaborative education, there will be education on 12/17/2024 to review the lower limb orthotics coverage criteria and common errors. Check with your local A/B MAC as this webinar is for the physician community not for suppliers.

Denise asked for questions and received none. She advised the members to send questions to Jean.

Stephanie Boucher, BSN, RN, Clinical Review Nurse Senior, Clinical Operations-PA NGS

Stephanie mentioned that she is now the lead of PA and that she will cover Exemptions and Sydney Sabo will cover PA. She then reviewed the PA handout and provided the following updates:

  • On slide 2 about exemptions, we provided the number of post-payment review providers in 2024 for J6 and JK, the number that have withdrawn, and that have continued. Until 12/18/2024, withdrawn providers may submit PARs. Requests received prior to this date will be rejected. Requests from continuing providers will be rejected.
  • On slide 3 about withdrawn providers through 2024, we issued withdrawal letters 11/2/2024. For non-response claims, providers may submit claims to PA for payment. For currently exempt providers, we sent pre-ADR withdrawal letters in 7/2024. The exemption remains in effect for the full calendar year. Our self-service exemption tool will be updated by 12/10/204. Withdrawn providers will be able to submit PARs on 12/18/2024.
  • On slide 4 about 2025 exemptions, we provided the number of providers for JK and J6. These numbers are off by one. Since we submitted these, we received opt-out requests. We have 29 J6 providers and 24 JK providers for 2025. There is a 1/1/2025 start date. NGSConnex providers will be asked to reference the exemption notice and will be unable to initiate requests. Regarding faxed requests, if the DOS is before 1/1/2025, we will review it but if the DOS is after 1/1/2025, we will reject it.
  • On slide 5 about 2025 exemptions, concerning what to expect, exempt notifications are issued by 11/2. For 1/1/2025, start PARS submitted on/after this date will be rejected. The opt-out cut off was 11/30/2024. Please attend our educational webinars. Follow submission instructions on the ADR regarding documentation to submit and to submit to PA.
  • On side 6 about 2025 exemptions, we provided a chart with the cycle overview dates, actions/information for non-exempt providers as well as actions/information for exempt providers. Refer to the information about UTNs.
  • On slide 7 about successful ADR submissions, follow the three steps. For step 1 (PA), follow the OPD guide, local policies, and national policies for PA submission requirements. For step 2 (exemption), if exempt, follow the exempt from PA requirements. For step 3 (post-payment reviews), follow the PA requirements, include the operative note so we can ensure you are billing accurately.

Stephanie then turned the review over to Sydney Sabo to review the PA updates.

Sydney Sabo, Sr. Clinical Review Nurse, PA NGS

Sydney continued the review of the PA handout:

  • On slide 8 about a PA timeliness change, be aware there is a timeliness change for PA effective 1/2/2025. Currently our standard timeframe for review is ten business days to communicate a decision to providers for all initial and resubmitted requests. That is going to change to seven calendar days from the date of receipt. As far as expedited requests, if they are substantiated, that will remain at two business days from the date of receipt. If not substantiated, the request will be subject to the standard review time frame, which would then be seven calendar days. The day the request is received is considered calendar day one. The validation period begins on the date the review nurse renders their decision. So that is remaining the same at 120 days.
  • On slide 9 about successful submissions, we provided information regarding submissions via NGSConnex, esMD, fax and mail. We recommend using NGSConnex as it reduces the risk of transmission errors, duplicate sending legibility issues related to faxing, and B providers can now access and request PA requests using their Part B credentials. If you still fax your request, be sure you are sending it to the initial fax line for the jurisdiction listed. Occasionally an additional fax line is given by a data tech or review nurse when an extra document is being requested, but that is not for initial submissions.
  • On slide 10 about successful submissions, we still see cases with missing or invalid required elements. We must have the Part A information to create each authorization. If you are Part B, consult with hospital billing, we need the TOB, the correct Part A PTAN and NPI combination. It is important that you understand the HOPD PA program. For an unsubstantiated expedited request, there is no need to resubmit if the expedited review was denied. Be aware of HCPCS codes that do not require PA. You may use our tool: Prior Authorization HCPCS Code Inquiry Tool. Also, we still receive Botox requests that include only one code. We require paired Botox codes to the administration code and the serum.
  • On slide 11 about successful submissions, we discuss resubmissions. For resubmissions, follow the review nurse instructions carefully which can be communicated by email, telephone, or via your non-affirmation letter you received on your initial request. Each resubmitted case must include all elements. So, when you are resubmitting a case, ensure it includes the cover sheet, the initial documentation submitted on the initial request, and the additional documentation needed to support an affirmation. Oftentimes, we have providers that resubmit with the missing information needed for the initial request, but each PA must stand alone. Every documentation requirement and medical necessity requirement must be met with each one. If any of that information is missing, it will result in subsequent rejections or non-affirmations. Also, the nurse, if outreaching for additional documentation, will typically provide a deadline for when that information will need to be submitted. If that deadline is not met, it will end up in a non-affirmation and will require another resubmission. Knowing this timeliness change is coming up, it's important to include all requirements with the initial submission since the timeframe for outreach for additional documentation is going to decrease.
  • On slide 12 about the most common non-affirmation reasons, note that we pulled the most common non affirmation reasons thus far, and the top reasons are related to facet intervention review. Most commonly, the facet request is not applicable due to missing information. It's not that it's not medically necessary, it's just that all the documentation requirements were not submitted in the request. For example, we were missing baseline pain assessments or post procedure pain assessments for all procedures we review related to facets. For percentage and duration of relief, we also need to see documentation that contains a limitation or contraindication that's listed in the LCD. Examples are requesting a subsequent radiofrequency ablation (RFA) when it's been greater than two years since the last one or requesting therapeutic injections with no medical contraindication as to why, and an RFA cannot be performed.
  • On slide 13 about POE webinars, PA will host quarterly webinars in 2025 like we did this year. Our first quarter webinar will focus on facet joint interventions, and we are looking to implement a webinar where you can ask the PA team questions.

Sydney asked for questions and received none.

Alison Hamilton, Clinical Review Nurse Senior, Clinical Operations

Alison reviewed the MR and CM handout and provided the following updates:

  • On slide 1, we provide information on resources often underutilized
  • On slide 2, we provide more information on underutilized resources including:
    • NGSConnex - a free, secure, web-based application developed by NGS
    • See our video on YouTube: Navigating NGSConnex
    • NGSConnex User Guide
    • NGSConnex Contact Info: 866-837-0241. Select Option 2 for NGSConnex Portal access, administration, or site performance assistance.
  • The next four slides provide hints for success:
    • Ensure we have an accurate point of contact for your facility for outreach.
    • Email contact information to JKACaseManagement@elevancehealth.com or J6ACaseManagement@elevancehealth.com
    • Prepare ahead for staff turnover and unexpected absences. Have a back-up plan by having more than one person involved in the TPE process.
    • Ensure the correct people have access to NGSConnex (we recommend LSO monitor Connex users for their PTAN and that contacts remain up to date)
    • Ensure the correct people attend education sessions offered by CM
    • Identify internal POCs for different functions (i.e., who has access to NGSConnex and the DDE or FISS
    • Monitor for incoming ADRs, which are delivered via mail in bright pink envelopes and electronically in NGSConnex (avoiding unnecessary 56900 denials)
    • Communicate with individuals who receive your mail. Explain what it is you are looking for and where NGS mail needs to go.
    • Research your own denial rationales. Full rationales are available to be reviewed in NGSConnex and the DDE system
    • Review the ADR carefully to make sure all components requested are submitted. We often see avoidable claim denials related to not sending accurate information.
    • Coordinate with a clinical staff member to ensure all clinical components are included in the documentation for submission. ADRs must be responded to prior to the 45-day deadline.
    • Respond to the ADR by sending all applicable medical records prior to day 45.
    • Talk to your peers and partners to help learn best practices that may be implemented.
    • Ensure your PECOS information is current. Verify your address is correct in PECOS to ensure mailed communication about TPE goes to the correct location. We provided instructions for Address Corrections and on how to Report Enrollment Changes.

Alison asked for questions. One member commented that the links in the material do not work (she is referring to the PDF documents). Christine tried the links and they do not seem to work from the PDF nor does the hover over feature. Post-meeting, Jean sent new agenda with working links.

Laura Brown, POE Consultant, NGS

Laura reviewed the CERT handout and provided the following updates:

  • On slide 2 is the 11/2024 JK data as of 10/31/2024. These are the final internal unofficial error rates which include claims received 7/1/2022-6/30/2023.
  • On slide 3 are the numbers of claims in each error category. The JK three top CERT errors remained the same during the 11/2024 reporting period (insufficient documentation, not medically necessary and incorrect coding).
  • On slide 4 is the 11/2024 J6 data as of 10/31/2024. These are the final internal unofficial error rates which include claims received 7/1/2022-6/30/2023.
  • On slide 5 are the numbers of claims in each error category. The J6 three top CERT errors remained the same during the 11/2024 reporting period (insufficient documentation, not medically necessary and incorrect coding). Since the 11/2024 report has ended, we are now working on the claims from the 11/2025 reporting period.
  • On slide 6, the agency financial report (AFR) was posted 11/25/2024. This report provides the national data from this reporting period, which includes high-level performance results with graphs. Use the link on this slide to view the CERT data which begins on page 190 under the Payment Integrity Report section. Although the Medicare FFS supplemental improper payment Data Report has not been posted, we provided a link to where all the CERT reports are posted so you can view the 11/2024 data once it is posted. Using these reports, you can review the CERT data from the 11/2024 reporting period including the Medicare FFS calculations and findings.
  • On Slide 7 is CERT contact information including a link to the CERT C3HUB website, which has a variety of topics including where to mail documentation, what information is being requested, copies of notifications and how to contact the CERT. This slide has the mailing address and fax number for submitting documentation, the CERT’s telephone number and email address for asking general questions and email address for submitting medical records by email. (CERT Documentation Center, 8701 Park Central Drive, Suite 400-A, Richmond, Virginia 23227. Fax: 804-261-8100, Telephone: 443-663-2699, Toll Free: 888-779-7477, Email: certprovider@empower.ai (general questions) and certmail@empower.ai (medical records and passwords)). Add the barcode coversheet with the CID number on all records submitted regardless of the submission method you use to send documents.

Laura said she'll provide new data at the next meeting. She asked for questions and received none.

Laura Brown, POE Consultant, NGS

Laura reviewed the Provider Enrollment handout and provided the following updates:

Laura asked for questions and received none.

Michael Dorris, POE Lead, NGS

Michael reviewed the Rural Health handout and provided the following updates:

  • During our Fall VC, on 11/19/2024, we held a day for our rural providers. We began with overall conversation about what CMS and NGS are doing for rural providers.
  • On slide 2 about CMS and rural health, we explained to our rural providers that CMS recognizes the growth of Americans living in rural areas and their unique health care challenges. Rural residents tend to be older and in poorer health than their urban counterparts. CMS and NGS are working toward finding solutions in various priorities and by listening to concerns. So, this is the foundation from which we are basing our next steps.
  • On slide 3 about CMS’ rural health framework is a link to a document CMS Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities which provides information on CMS’ rural health priorities:
    • Priority 1: Community-Informed Programs
    • Priority 2: Use of Standardized Data Collection
    • Priority 3: Strengthen/Support Health Care Professionals
    • Priority 4: Optimize Medicare and Communication Technologies
    • Priority 5: Expand Access to Health Care Coverage
    • Priority 6: Drive Innovation and Value-based Care
  • CMS is engaged in different ways; with individuals, organizations, and government entities across the nation to learn, over the last several years, about how to approach rural providers and patients in the rural community. One example of that is to listen to rural providers.
  • On slide 4 about CMS’ Rural Health Council, is a link to CMS’ Rural Health web page Rural Health Council which is focused on organizing and promoting work across CMS in three strategic areas:
    • Ensuring access to high-quality health care for all Americans in rural settings
    • Addressing unique economics of providing health care in rural America
    • Bringing rural health care focus to CMS’ health care delivery and payment reform initiatives
  • This is new, and more information will be coming out on this council in 2025.
  • On slide 5 about CMS’ health equity framework is a link to CMS web page CMS Framework for Health Equity 2022-2023 which discusses their priorities:
    • Priority 1: Expand Data Analysis
    • Priority 2: Assess Cause of Disparities
    • Priority 3: Build Capacities to Reduce Health Care Disparities
    • Priority 4: Advance Language Assess and Literacy
    • Priority 5: Increase Accessibility to Health Care Services/Coverage
  • CMS created these priorities but of the five, health literacy is still a challenge as well as increasing accessibility to health care services for people with disabilities.
  • On slide 6 about CMS’ Office of Minority Health is a link to information about the Office of Minority Health which works with local and federal partners to eliminate health disparities while improving the health of people from all minority populations, including:
    • People from racial and ethnic minorities
    • People with disabilities
    • Members of the LGBTQ+ community
    • Individuals with limited English proficiency
    • Rural communities
  • This slide also provides additional links to valuable resources
  • Note: CMS has a subdivision of the Office of Minority Health that's working with local and federal partners, as well as with MACS in trying to create and improve minority health access. CMS has spent a lot of time this year building more national immunization awareness.
  • On slide 7 about health literacy, be aware that nearly 90% of adults struggle with health literacy. We provided ways to help your patients with limited health literacy including using Plain Language, sharing resources in different languages and taking time to review information. There are additional resources available:
  • On slide 8 about NGS’ Ruralserv mission, we are focusing on Medicare providers serving beneficiaries located in rural areas focusing on CAH, rural hospitals, FQHCs, RHCs, home health & hospice agencies, rural physicians, ambulance suppliers and support staff.
  • On slide 9 about our Ruralserv program, we give you specific efforts we have tackled including providing our providers with tailored billing guides and materials, self-service options, access to POE experts to speak at events, topic-driven education based on provider input and needs as well as partnering to improve processes and reduce burden. We educate on self-service options to ensure our rural providers are aware of available tools and do not need to contact our PCC. We held a “voice of the customer” event this year to obtain feedback from our providers on our education and the services we provide. This POE AG meeting is just one avenue for providers including rural providers to be able to suggest or request specific education.
  • On slide 10, are links to our Ruralserv web banners:

Michael added that we want to be able to help the provider community in rural America, which translates into better access for patients to your health care settings. He asked that anyone who has an idea for education to contact Jean and Christine. Michael asked for questions and received none.

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III. Review of Education Materials

Christine Janiszcak, POE Consultant, NGS 

Christine reviewed the Education Material handout and provided the following information:

  • We conducted our Fall Virtual Conference on 11/12, 11/14 and 11/19 (Rural Day) of 2024. We themed the conference “Keeping Compliant with Medicare Starts with You.” On day one, we covered basic topics: Introduction to Medicare Contractors, Understanding Fraud & Abuse, Using Medicare Resources and How to Prevent Claim Errors that Could be Seen as Abusive or Fraudulent. On day two, we covered topics: Complying with the CERT program, the “How To” in Avoiding Documentation Related Claim Denials, Understanding Your MSP Responsibilities and Let’s Get Familiar with National Correct Coding Initiatives. On day three, we provided education for our rural providers and focused on FQHCs, RHCs and CAHs. We are seeking feedback from anyone who attended or had your staff attend. One member shared that she found the conference very informative, really liked it and thought it was great! She said it was not the case for this VC, but in the past, the issue their facility sometimes has is when we schedule Part A and Part B sessions on the same day at the same time because they want to attend both. Christine thanked the member for their feedback and explained we try not to conduct overlapping sessions for events like the VC. Sometimes there may be another LOB such as HH+H conducting education or sessions conducted routinely such as those related to provider enrollment on the same day/same time as a VC. But if that occurs, providers should be able to skip the routine webinar and attend it the following month.
  • We issued an article Hospital Billing for Beneficiaries Enrolled in Option Code C Medicare Advantage Organization Plans. One of our top rejection reason codes, U5233, occurs because hospitals are billing us for MAO plan enrollees when they should not be, such as in the case of outpatient services or billing us incorrectly for inpatient services. Also, we receive questions from inpatient hospitals about billing us for MAO plan enrollees. In this article, we’ve provided direction to specific hospital types as to how to submit inpatient claims for MAO plan enrollees who have such coverage for part of or for the entire inpatient stay. We included a chart which helps to identify the instructions and claim coding. We hope you find this article helpful. Please share it within your facilities and let us know if you have questions or comments. Note we placed the article on our website under Education > Specialties > Hospital so you can find hospital related articles quickly. One member asked to see where on our website the hospital tab is located so Jean provided a website demonstration. The member commented that she feels it will be extremely helpful to have hospital-related articles here. Christine said she has had a few articles moved from other locations to this location.
  • We’ve been updating the MSP articles on our website so providers understand the steps they need to take to have the BCRC add or update a beneficiary’s MSP record in the CWF since providers can no longer contact the BCRC for these purposes. CMS wants providers to send the new/updated information via their claims to us. Note the following articles were updated recently:

Christine asked for questions/comments and received none.

Kathy Mersch, POE Consultant, NGS 

Kathy advised the members we created an additional platform for our education; a new learning opportunity named Part A Teatime – Bite Size Learning for Busy Days. She explained these educational videos will provide a wealth of information on a variety of topics but in small portions providers can view at their convenience. She stated we are using YouTube and currently have a playlist that includes a series regarding NGSConnex. This includes a video on eligibility look up since CMS instructed us to remove eligibility from our Interactive Voice Response (IVR) unit effective on 11/18/2024. She mentioned we will be adding more videos as well. Kathy posted a playlist into the chat box of the Teams meeting. She asked members to let Jean and Christine know if they have topic suggestions for us to work on. Kathy asked for questions and received none.

Jean Roberts, POE Consultant, NGS 

Jean reviewed the Telehealth handout and provided the following updates:

  • Jean explained there have been many updates to telehealth for 2025 and she is providing just a brief overview of some of the known telehealth changes in references listed on the agenda:
  • Jean explained the important part of these updates is that, under current law, the temporary extension of flexibilities related to payment for many telehealth services is scheduled to expire at the end of 2024. Beginning 1/1/2025, absent congressional action, the statutory limitations in place for Medicare telehealth services prior to the COVID-19 PHE, will take effect for most telehealth services. That includes the geographic and location restrictions on where the services are provided, as well as limitations on the scope of practitioners who can provide Medicare telehealth services. After that date, people with Medicare will need to be in a medical facility in a rural area to receive most Medicare telehealth services (with the notable exception for behavioral health telehealth services which can continue to be provided in the patient's home). The NGS Telehealth Guide provides pre COVID-19 public health epidemic (PHE) information on telehealth. It will be updated in 2025 based on any additional changes and any congressional action so it will then reflect the permanent changes. Note there is an originating site section, and this includes a link to the HRSA website so you can determine your originating sites potential eligibility for Medicare telehealth payment. Once 2025 comes around, absent any congressional action, that link will help you to decide whether you can provide telehealth services. Now the calendar year 2025 MPFS final rule does reflect CMS’ goal to preserve some important but limited flexibility. CMS has authority to expand the scope of and access to telehealth services where appropriate. Certain practitioners will continue to be able to provide direct supervision via the virtual presence of auxiliary personnel when required, virtually through immediate availability via real time audio video technology. Also, there are temporary extensions to allow teaching physicians to present virtually when they are furnishing telehealth services involving residents and teaching settings now in 2025. CMS will also be adding several services to the Medicare telehealth list, and these include things such as pre-exposure prophylaxis for preventing HIV infections. Some of the frequency limitations will be suspended for a period of time for subsequent inpatient visits. In the 2025 OPPS final rule, CMS is maintaining the coding and billing policies for the PHP and in the IOP and this includes that neither PHP nor IOP services can be furnished remotely to beneficiaries in their homes. Even though that patient may be under a PHP or an IOP POC, they can receive other medically R&N services from a hospital, including remote mental health services provided outside of that POC by the same or another hospital. However, such services must not be counted as PHP. IOP services do not count toward the number of required IOP or PHP services per week. Absent subsequent language, OPPS providers will no longer be able to bill for Medicare telehealth services beginning 1/1/2025. Also beginning on 1/1/2025, physical, occupational and speech language practitioners will no longer be able to bill Medicare for telehealth services. Also, beginning in 2025, Medicare will no longer convert outpatient therapy DSMT and MNT services when furnished remotely by hospital staff to beneficiaries in their homes. There are several additional changes, but the CPT editorial panel created 17 new codes describing audio, video, and audio only. Telemedicine E&M services and those codes are in the range of 98000-98016. However, CMS is not recognizing these new telemedicine E&M codes under the OPPS. Instead, OPPS providers will continue to use the HCPCS code G0463 for such services. There are also changes for RHCs and FQHCs. I've given enough of an overview that you're going to want to look at this information to get on top of what you're going to need to do in 2025, absent changes that may come later.

One member asked if there is any indication there may be congressional action on this. Jean responded there have been hints about congressional action taking place before the end of this year but there are no guarantees at this time.  Also, a member asked if MAO plans that currently include telehealth office visits are permitted to continue them. Jean responded she suspects the answer is no but thinks the same rules that apply to Medicare apply to the MAO plans. She added that since we are not a MAO plan contractor, the member will need to discuss this with the MAO plan contractor.

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IV. POE AG Member Suggestions for Education and Open Forum

Jean Roberts, POE Consultant, NGS

Jean discussed the Education Tracker handout. Regarding the pending list, we recently received clarification on the request for cost outlier education, so we will plan on conducting education on this in 2025. We have several requests we have completed/closed. We had a request for education on the LCD retirement process which we completed on 10/10/2024 by posting an article to our website: Education > Medicare Topics > New Provider Center > Local Coverage Determination Retirement. We had a request for CAH Method II billing which was completed as part of our Fall VC on 11/19/2024. We had a request for a provider self-service tool, a SNF PDPM calculator, from a member saw one on another website which breaks down components and brings up per day calculations. We discussed this internally and felt it wasn't something we could keep on our website. Since CMS has one, we asked them to update it with the information. In September, we received notice CMS decided they're not going to make these updates. For what we can do, this Is closed. Jean asked the members to review the rest of the Educational Tracker.

Jean asked the members for topics/suggestions for 2025 education. One member commented she had a PHP related inquiry. Jean suggested she check the CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 4 but if she cannot find the information she needs, to contact our PCC. A member then asked if we have recordings of this meeting. Jean advised her we record the meetings only to create the minutes which we post to our website within 30 business days. She added the minutes include a lot of detail. When no further responses were received, Jean reminded the members the purpose of the meetings is to obtain this feedback and asked members to send us an email with topics as soon as possible.

Jean asked how the members liked using Teams for the meeting. One member replied she likes it, that it is easy and all the computers at their facility has Teams downloaded onto them.

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V. Upcoming Events and Additional Education

Jean Roberts, POE Consultant, NGS 

Jean advised the members to continue to check our NGS Events Page for educational events, explaining there are calendars for Part A and B for those providers who are looking for both.

She provided the following links to helpful articles:

She advised the members she would send an updated agenda with links to additional references. The updated agenda with hyperlinks was sent to all members several days after the meeting.

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VI. 2024 Part A and FQHC POE AG Meeting Schedule 

Jean Roberts, POE Consultant, NGS

Jean provided the following dates/times for the 2025 POE AG meetings, which will be held in Teams, all are held on Thursdays, 10:30a.m.-12:30p.m. ET:

  • 4/3/2025
  • 8/7/2025
  • 12/4/2025

Jean and Christine wished everyone happy holidays and new year.

Meeting adjourned

Posted 1/6/2025