--- kind: "section" citation: "42 C.F.R. § 425.670" title: "42" number: "425.670" heading: "Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2023." url: "https://uscodex.org/cfr/42/425.670" --- # §425.670. Adjustments to mitigate the impact of significant, anomalous, and highly suspect billing activity on Shared Savings Program financial calculations involving calendar year 2023. - (a) **General.** This section describes adjustments CMS makes to Shared Savings Program calculations to mitigate the impact of significant, anomalous, and highly suspect billing activity occurring in calendar year 2023. - (b) **Significant, anomalous, and highly suspect billing activity for a HCPCS or CPT code impacting Shared Savings Program calculations.** CMS has determined that the billing of the following HCPCS codes represents significant, anomalous, and highly suspect billing activity for calendar year 2023 that warrants adjustment— - (1) A4352 (Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each); and - (2) **A4353 (Intermittent urinary catheter, with insertion supplies).** - (c) **Applicability of adjustments to performance year and benchmark year calculations.** Notwithstanding any other provision in this part, CMS adjusts the following Shared Savings Program calculations, as applicable, to exclude all Medicare Parts A and B fee-for-service payment amounts on DMEPOS claims (claim types 72 and 82) associated with a HCPCS code specified in [paragraph (b)](#b) of this section for the period specified in [paragraph (d)](#d) of this section: - (1) Calculation of Medicare Parts A and B fee-for-service expenditures for an ACO's assigned beneficiaries for all purposes including the following: Establishing, adjusting, updating, and resetting the ACO's historical benchmark and determining performance year expenditures. - (2) Calculation of fee-for-service expenditures for assignable beneficiaries as used in determining county-level fee-for-service expenditures and national Medicare fee-for-service expenditures, including the following calculations: - (i) Determining average county fee-for-service expenditures based on expenditures for the assignable population of beneficiaries in each county in the ACO's regional service area according to §§ [425.601(c)](/cfr/42/425.601.md?p=c) and [425.654(a)](/cfr/42/425.654.md?p=a) for purposes of calculating the ACO's regional fee-for-service expenditures. - (ii) Determining the 99th percentile of national Medicare fee-for-service expenditures for assignable beneficiaries for purposes of the following: - (A) Truncating assigned beneficiary expenditures used in calculating benchmark expenditures under [§ 425.652(a)(4)](/cfr/42/425.652.md?p=a-4), and performance year expenditures under §§ [425.605(a)(3)](/cfr/42/425.605.md?p=a-3) and [425.610(a)(4)](/cfr/42/425.610.md?p=a-4). - (B) Truncating expenditures for assignable beneficiaries in each county for purposes of determining county fee-for-service expenditures according to §§ [425.601(c)(3)](/cfr/42/425.601.md?p=c-3) and [425.654(a)(3)](/cfr/42/425.654.md?p=a-3). - (C) Truncating expenditures for assignable beneficiaries for purposes of determining truncated national per capita fee-for service expenditures for purposes of calculating the ACPT according to [§ 425.660(b)(3)](/cfr/42/425.660.md?p=b-3). - (iii) Determining truncated national per capita fee-for-service Medicare expenditures for assignable beneficiaries for purposes of calculating the ACPT according to [§ 425.660(b)(3)](/cfr/42/425.660.md?p=b-3). - (iv) Determining national per capita expenditures for Parts A and B services under the original Medicare fee-for-service program for assignable beneficiaries for purposes of capping the regional adjustment to the ACO's historical benchmark according to [§ 425.656(c)(3)](/cfr/42/425.656.md?p=c-3) and capping the prior savings adjustment according to [§ 425.658(c)(1)(ii)](/cfr/42/425.658.md?p=c-1-ii). - (v) Determining national growth rates that are used as part of the blended growth rates used to trend forward BY1 and BY2 expenditures to BY3 according to [§ 425.652(a)(5)(ii)](/cfr/42/425.652.md?p=a-5-ii) and as part of the blended growth rates used to update the benchmark according to §§ [425.601(b)(2)](/cfr/42/425.601.md?p=b-2) and [425.652(b)(2)(i)](/cfr/42/425.652.md?p=b-2-i). - (3) Calculation of Medicare Parts A and B fee-for-service revenue of ACO participants for purposes of calculating the ACO's loss recoupment limit under the BASIC track as specified in [§ 425.605(d)](/cfr/42/425.605.md?p=d). - (4) Calculation of total Medicare Parts A and B fee-for-service revenue of ACO participants and total Medicare Parts A and B fee-for-service expenditures for the ACO's assigned beneficiaries for purposes of identifying whether an ACO is a high revenue ACO or low revenue ACO, as defined under [§ 425.20](/cfr/42/425.20.md), and determining an ACO's eligibility to receive advance investment payments according to [§ 425.630](/cfr/42/425.630.md). - (5) Calculation or recalculation of the amount of the ACO's repayment mechanism arrangement according to [§ 425.204(f)(4)](/cfr/42/425.204.md?p=f-4). - (d) **Period of adjustment.** CMS adjusts the Shared Savings Program calculations specified in [paragraph (c)](#c) of this section for significant, anomalous, and highly suspect billing activity identified pursuant to [paragraph (b)](#b) of this section for calendar year 2023, when calendar year 2023 is either a performance year or a benchmark year. - (e) **Adjustments for growth rates used in calculating the ACPT.** In addition to adjustments described in [paragraph (c)](#c) of this section, CMS makes adjustments for payments associated with a HCPCS code specified in [paragraph (b)](#b) of this section for BY3 in projecting per capita growth in Parts A and B fee-for-service expenditures, according to [§ 425.660(b)(1)](/cfr/42/425.660.md?p=b-1), for purposes of calculating the ACPT for agreement periods beginning on January 1, 2024. ## Notes ### Amendments [89 FR 79171, Sept. 27, 2024] ### Authority Authority: 42 U.S.C. 1302, 1306, 1395hh, and 1395jjj. ### Source Source: 76 FR 67973, Nov. 2, 2011, unless otherwise noted. ### Amendments [89 FR 79171, Sept. 27, 2024]