CMS issues final rule on catheter billing

WASHINGTON – CMS has issued a final rule that addresses suspicious billing activity within the Medicare Shared Savings Program that resulted in an increase in DMEPOS billing for certain intermittent urinary catheter supplies. The 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” (CMS-1799-F) is part of a larger strategy to address significant, anomalous and highly suspect (SAHS) billing activity within Accountable Care Organizations (ACOs) reconciliation. This rule finalizes changes in policies for assessing performance year (PY) 2023 financial performance of Shared Savings Program ACOs; establishes benchmarks for ACOs starting agreement periods in 2024, 2025, and 2026; and calculates factors used in the application cycle for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025, and continuing their participation in the program for PY 2025, as a result of SAHS billing activity for the two intermittent urinary catheter codes. A proposal in the calendar year (CY) 2025 Physician Fee Schedule (PFS) proposed rule addresses SAHS billing activity for CY 2024 onward. In early 2023, CMS identified a concerning rise in urinary catheter billings attributed to a small group of DME companies. The agency determined that the beneficiaries did not receive catheters and were not billed directly, physicians did not order these supplies and supplies were not needed. The observed billing was for A4352 and A4353. CMS issued the proposed rule June 28. 

• Go here for more information on the final rule.