On Sept. 24, CMS issued a final ruling to address "significant, anomalous and highly suspect" billing activity on the Medicare Shared Savings program to mitigate financial impacts for Accountable Care Organizations.
Here are six things to know:
1. The 2025 Physician Fee Schedule includes a methodology to address suspicious billing activity from 2024 onward.
2. The bill addressed two CPT codes identified as suspect:
- A4352, intermittent urinary catheter; Coude (curved) tip, with or without coding
- A4353, intermittent urinary catheter, with insertion supplies
3. Payments for these codes are excluded. Codes are considered suspect when there is an unexplained spike in claims either in volume or dollar amounts, at the regional or national level.
4. CMS noticed a spike in urinary catheter billings in 2023. The spike was connected to a small group of durable medical equipment supplies. CMS found that the beneficiaries did not receive catheters, physicians did not order them and the supplies were not needed.
5. CMS uses payment and claims data from Medicare Parts A and B to calculate several factors used in MSSP financial calculations. This includes expenditures for people assigned to an ACO, expenditures for the national assignable fee-for-service population, the assignable population in an ACO's service area and calculations used to determine ACO revenue status.
6. This rule finalizes changes in assessment for performance year 2023, financial performance of MSSP, policies for establishing benchmarks for ACOs in 2024, 2025 and 2026, and calculating factors used in the application cycle for new ACO agreement periods starting Jan. 1, 2025.