Knowledge Base Article

Medicare Transmittals & MLN Articles

May 9, 2025: MLN MM14025: New Waived Tests

FDA has approved six new waived tests under Clinical Laboratory Improvement Amendments (CLIA) that will be effective July 1, 2025.

https://www.cms.gov/files/document/mm14025-new-waived-tests.pdf

 

Coverage Updates

May 23, 2025: MLN MM14000: National Coverage Determination 20.36: Implantable Pulmonary Artery Pressure Sensors (IPAPS) for Heart Failure Management

For services performed on or after January 13, 2025, CMS determined the evidence is sufficient to cover IPAPS for heart failure (HF) management under Coverage with Evidence Development (CED) when provided according to an FDA market-authorized indication and indications in NCD 20.36 are met. CMS advises that your billing staff knows about the NCD, criteria for coverage, CED study criteria and claim processing requirements. https://www.cms.gov/files/document/mm14000-national-coverage-determination-2036-implantable-pulmonary-artery-pressure-sensors-heart.pdf

 

May 23, 2025: MLN MM13922: Qualifications for Speech-Language Pathologies Providing Outpatient Speech-Language Pathology Services

Make sure your billing staff knows about updates to the Medicare Benefit Policy Manual, Chapter 15, section 230.3 to match the regulatory provision for the qualifications of SLPs providing outpatient therapy services. The implementation and effective date for the updates was April 18, 2025. https://www.cms.gov/files/document/mm13922-qualifications-speech-language-pathologists-providing-outpatient-speech-language-pathology.pdf

 

Compliance Education Updates

May 2025: MLN Fact Sheet (MLN006951) Swing Bed Services Updates

This MLN Fact Sheet was updated to include the following:

• Billing Instructions for when a patient has a change of status review on their qualifying inpatient hospital stay,
• Swing bed services and the 96-hour certification requirement time exemption, and
• Home health and swing bed patients.

  https://www.cms.gov/files/document/mln006951-swing-bed-services.pdf

   

  Other Updates

  May 6, 2025: OIG Brief: $17 Billion in potential cost savings could be generated if Congress takes action based on these HHS-OIG reports

  This OIG notes in this brief that “some of the reports recommend legislative actions while others recommend program or process changes that Congress could address. The potential savings reflect the conditions and timeframes within the scope of each report. https://oig.hhs.gov/about-oig/hhs-oig-impact/potential-cost-savings-in-hhs-programs/potential-cost-savings-in-hhs-programs-legislative-actions/

   

  May 19, 2025: Palmetto GBA JM Adds Low Biller Targets to Active Medical Review List

  In the Medicare Fee-for-Service Payment Integrity Scorecard for the Q1 2025 reporting period, CMS noted that they are on track to begin the Low Biller program in May 2025. The Low Biller program is a modified version of Targeted Probe and Educate program which will allow the program to include more providers who may not bill enough claims of a particular service type to be included in the traditional program.

   

  On May 19, 2025, Palmetto GBA Jurisdiction M published an updated Medical Review List. Included in the list was a new Low Biller Probe and Educate Part A review of HCPCS J9271 (Pembrolizumab (Keytruda®).

   

  https://www.cfo.gov/wp-content/uploads/scorecards/FY25-Q1/Centers%20for%20Medicare%20&%20Medicaid%20(CMS)%20-%20Medicare%20Fee-for-Service%20(FFS).pdf

   

  https://palmettogba.com/jma/did/btpod0a22i

   

  May 21, 2025: CMS Strategy to Accelerate Medicare Advantage Audits

  In a press release, CMS notes “the last significant recovery of MA overpayments occurred following the audit of payment year (PY) 2007, despite federal estimates suggesting MA plans may overbill the government by approximately $17 billion annually.” To address the backlog a plan has been introduced to complete all remaining Risk Adjustment Data Validation (RADV) audits for PY 2018 to PY 2024 by early 2026. Two key elements of this plan include:

• Workforce expansion: CMS increasing its team of medical coders from 40 to approximately 2,000 by September 1, 2025. These coders will manually verify flagged diagnoses to ensure accuracy, and
• Increased audit volume: By leveraging technology, CMS will be able to increase audits to all eligible MA plans (approximately 550 MA plans) and increase auditing from 35 records per health plan to between 35 and 200 records based on the size of the health plan.

https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits

 

May 22, 2025: MACs to Resume Short Stay Inpatient Reviews

CMS announced that “beginning September 1, 2025, the MACs will assume responsibility for conducting patient status reviews to determine the appropriateness of Part A payment for short stay inpatient hospital claims, which previously were conducted by Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) (BFCC-QIO). While this change impacts where medical records will be sent and the contractor making claim review decisions, the policy for assessing short stay inpatient admissions remains unchanged.”

 

Short stay inpatient admissions have been closely scrutinized by contractors since the implementation of the 2 Midnight Rule on October 1, 2013. MACs are not new to this type of review as they conducted probe and educate reviews through September 30, 2015.

 

The CERT also focuses on inpatient denials by length of stay. In the 2024 report, 0- or 1-day stays continued to have the highest improper payment rate of all inpatient stays at 24.3% with project improper payments of $1.7 billion.

 

You can find more information about this notice on the CMS.gov 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.

 

For a look back at the history of short stay review and useful downloads can be found on the CMS Inpatient Hospital Reviews webpage at https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/inpatienthospitalreviews.

 

May 22, 2025: CMS Fast Facts: Annual Update

CMS noted in the Thursday, May 21, 2025, edition of MLN Connects that the CMS Fast Facts have been updated to include data for 2022-2025. This data can be used as a “quick reference statistical summary for information on Medicare and Medicaid enrollment, utilization, expenditures, and Medicare provider counts. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-05-22-mlnc#_Toc198712331

 

May 22, 2025: OIG Brief: Potential Cost Savings: HHS Actions

The OIG indicates in this brief that there is $50B in potential savings through recovery and payment program improvements based on their work. They cited 35 reports where they had identified this potential cost savings. The largest example of misspent funds was $783.6M that could be recovered from misspent COVID-19 Uninsured Program funds.

 

One example of “select reports with potential savings” is the report Medicare Could Save Millions if It Implements an Expanded Hospital Transfer Payment Policy for Discharges to Post-acute Care. Based on their sample results, the OIG “estimated that Medicare could have saved approximately $694 million, or an average of $6,470 per claim, from 2017 through 2019 if it had expanded its hospital transfer policy to include all MS-DRGs.”

https://oig.hhs.gov/about-oig/hhs-oig-impact/potential-cost-savings-in-hhs-programs/potential-cost-savings-50-billion/

 

May 30, 2025: HHS-OIG Fiscal Year 2026 Justification of Estimates for Congress

The OIG is requesting $454.4 million for FY 2026 with 81% of this money ($367.4 million) for oversight of Medicare and Medicaid. The OIG notes that for every $1 invested in OIG, there is an expected return of $11 in government recoveries and receivables. https://oig.hhs.gov/documents/budget/10322/FY%202026%20OIG%20CJ.pdf