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CMS seeks to exclude cath codes from program 

CMS seeks to exclude cath codes from program 

WASHINGTON – CMS has published a proposed rule to address significant, anomalous and highly suspect (SAHS) billing activity within the Medicare Shared Savings Program in response to an observed increase in DMEPOS billing for selected intermittent urinary catheter supplies in calendar year 2023. 

The agency says SAHS billing activity for codes A4352 and A4353, if not addressed, could adversely impact the accuracy, fairness and integrity of the program’s financial calculations. 

In the proposed rule, CMS proposes to exclude payment amounts for the two codes on DMEPOS claims submitted by any supplier from expenditure and revenue calculations used for:

  • assessing performance year (PY) 2023 financial performance of Shared Savings Program ACOs
  • establishing benchmarks for ACOs starting agreement periods in 2024, 2025 and 2026, and
  • calculating factors used to determine revenue status and repayment mechanism amounts in the application and change request cycles for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025, or continue their participation in the program in PY 2025, respectively. 

CMS will accept comments on the proposed rule, “Medicare Program: Mitigating the Impact of Significant, Anomalous and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023,” until July 29, 2024.

Comments can be submitted at: Refer to file code CMS-1799-P). 


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