After 11 healthcare organizations urged CMS to remove catheter expenditures from accountable care organization calculations, the agency proposed excluding payment amounts for two catheter codes.
During 2023, there was an unexplainable increase in claims for codes A4352 [Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each] and A4353 (Intermittent urinary catheter, with insertion supplies), CMS said.
In 2021, spending for the two codes was $153 million, and in 2023, that figure increased to $3.1 billion, according to Premier, the American Hospital Association and other healthcare groups.
The organizations told CMS about the issue in late April, and two months later, the agency issued a proposed rule to mitigate the unusual billing activity.
"Recently, CMS observed an increase in Durable Medical Equipment, Prosthetics, Orthotics & Supplies billing to Medicare for selected intermittent urinary catheter supplies in 2023, which could, if unaddressed, adversely impact the accuracy, fairness, and integrity of Shared Savings Program financial calculations," the agency said in a June 28 statement.
CMS categorized the billing volume as "significant, anomalous and highly suspect." The FBI and CMS are investigating an alleged fraud scheme related to catheter spend.
The proposal recommends cutting payment amounts for the two codes on claims from expenditure and revenue calculations used for assessing 2023 financial performance of accountable care organizations.
The agency will accept comments on the proposed rule through July 29.