Knowledge Base Article

Medicare Transmittals & MLN Articles

June 6, 2025: MLN MM14101: Ambulatory Surgical Center Payment System: July 2025 Update

This article provides payment system updates effective July 1, 2025 for your billing staff.

https://www.cms.gov/files/document/mm14101-ambulatory-surgical-center-payment-system-july-2025-update.pdf

 

June 9, 2025: MLN MM14089: ESRD Prospective Payment System: July 2025 Update

Make sure your billing staff are aware of changes to the outlier services listed under the ESRD PPS starting July 1, 2025.

https://www.cms.gov/files/document/mm14089-esrd-prospective-payment-system-july-2025-update.pdf

 

June 9, 2025: MLN 14041: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2025 Update

Make sure your billing staff knows about new codes and recent coding changes effective October 1, 2025 for the following NCDs:

 

20.9.1 Ventricular Assist Devices (VADs)

110.24 CAR T-cell Therapy

190.11 Home prothrombin time/international normalized ratio for monitoring for anticoagulation management

210.41 Counseling to Prevent Tobacco Use

210.13 Screening for Hepatitis C virus (HCV) in adults

 

https://www.cms.gov/files/document/mm14041-icd-10-other-coding-revisions-national-coverage-determinations-october-2025-update.pdf

 

June 10, 2025: MLN MM14031: Updates to Colorectal Cancer Screening & Hepatitis B Vaccine Policies

Make sure your billing staff knows about coverage changes for colorectal cancer (CRC) screening tests, policy clarification that applies to complete CRC screening, and expanded coverage and changes to billing policies for the hepatitis B vaccine. https://www.cms.gov/files/document/mm14031-updates-colorectal-cancer-screening-hepatitis-b-vaccine-policies.pdf

 

June 24, 2025: MLN Matters MM14132: Inpatient Rehabilitation Facility Prospective Payment System: FY 2026 Pricer Update

Per CMS actions needed that are listed in this MLN article includes FY 2026 IRF PPS rates, the rural transition policy, and the wage index cap. https://www.cms.gov/files/document/mm14132-inpatient-rehabilitation-facility-prospective-payment-system-fy-2026-pricer-update.pdf

 

June 30, 2025: MLN MM14091: Hospital Outpatient Prospective Payment System: July 2025 Update

This article highlights coding and billing changes effective July 1, 2025. For example, guidance is provided on how to bill for the split dose administration of AUCATZYL® (HCPCS code Q2058). https://www.cms.gov/files/document/mm14091-hospital-outpatient-prospective-payment-system-july-2025-update.pdf

 

Coverage Updates

June 9, 2025: Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to COPD Final National Coverage Determination

CMS posted this final NCD and decision memo establishing national Medicare coverage of respiratory assist devices and home mechanical ventilators. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=315

 

Compliance Education Updates

April 2025: MLN Booklet: MLN1986542: Medicare & Mental Health Coverage

CMS made several revisions to this MLN booklet, for example they added information on provider caregiver training, depression screening, and tobacco use cessation counseling services through telehealth, and information about adding coverage information for opioid treatment programs, including Brixadi® and Opvee®. https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf

 

May 2025: MLN Booklet: MLN9560465: Substance Use Screenings & Treatment

CMS made four changes to this MLN booklet, for example CMS has added safety planning intervention for patients in crisis and post-discharge phone follow-up contacts intervention. https://www.cms.gov/files/document/mln9560465-substance-use-screenings-treatment.pdf

 

May 2025: MLN Booklet: Screening, Brief Intervention & Referral to Treatment (SBIRT) Services

CMS made several changes to this MLN Booklet (MLN904084). For example, is the reminder that “you can prescribe controlled medications like buprenorphine using telehealth through December 31, 2025.” https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/sbirt_factsheet_icn904084.pdf

 

Other Updates

June 2, 2025: OIG Spring 2025 Semi-annual Report to Congress

In this report, the OIG has summarized their activities and accomplishments from October 1, 2024, through March 31, 2025. The OIG noted work during this period led to $16.61 billion total monetary impact, demonstrating the agency’s role in protecting taxpayer funds and improving program performance. https://oig.hhs.gov/documents/sar/10324/Spring_2025_SAR_508.pdf

 

June 5, 2025: MA Compliance Audit Results of Specific Diagnosis Codes

OIG completed this audit to examine diagnosis codes submitted by Coventry Health and Life Insurance Company. The OIG has identified the following 10 high-risk groups that include diagnoses at higher risk for being miscoded:

 

Acute stroke,

Acute myocardial infarction,

Embolism,

Sepsis,

Pressure Ulcer,

Lung cancer,

Breast cancer,

Colon cancer,

Prostate cancer, and

Ovarian Cancer.

 

Ultimately, OIG made three recommendations to Coventry, refund the Federal Government the $6.9 million in estimated net overpayments, identified similar instances of noncompliance after the audit period and refund any resulting overpayments, and continue to examine their existing compliance procedures to identify areas for improving compliance with Federal requirements. Coventry disagreed with some of the OIG findings and three of their recommendations. https://oig.hhs.gov/documents/audit/10329/A-02-22-01020.pdf

 

June 10, 2025: 2026 ICD-10-CM & PCS Files

CMS announced the October 1, 2025 procedure code and diagnosis code update files are now available. These codes are to be used for discharges occurring from October 1, 2025 to September 30, 2026, and for patient encounters for the same period.

 

The ICD-10-PCS Official Guidelines for Coding and Reporting for 2026 are available. As of June 26, 2025, CMS has not released the ICD-10-CM 2026 guidelines. https://www.cms.gov/medicare/coding-billing/icd-10-codes

 

June 23, 2025: Save the Date: July 30, 2025 CMS Teleconference on Transition of Short-Stay Reviews to the MACs

Effective September 1, 2025, MACs will assume responsibility for conducting short stay inpatient hospital medical reviews to determine appropriateness of the inpatient admission. This “save the date” announcement is to let providers know they will be holding a session on Wednesday, July 30, 2025 from 2-3PM ET to provide an overview about the transition of short stay reviews from the BFCC-QIOs to the MACs and address questions from beneficiary and industry stakeholders.

 

Prior to this session, you can find information about this transition on the CMS Inpatient Hospital Reviews webpage at https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/hospital-patient-status-reviews.

 

June 26, 2025: Medicare Fraud Alert: Phishing Fax Requests

CMS noted in the Thursday, June 26, 2025 edition of the MLN Connects Newsletter that they have “identified a fraud scheme targeting Medicare providers and suppliers. Scammers are impersonating CMS and sending phishing fax requests for medical records and documentation, falsely claiming to be part of a Medicare audit.

 

Important: CMS doesn’t initiate audits by requesting medical records via fax. Protect your information. If you receive a suspicious request, don’t respond. If you think you got a fraudulent or questionable request, work with your Medical Review Contractor to confirm if it’s real.” https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-06-26-mlnc