Knowledge Base Article

Medicare Transmittals & MLN Articles

July 23, 2025: MLN MM14153: Laboratory National Coverage Determination Edit Software Updates: October 2025

Make sure your billing staff is aware of the ICD-10-CM codes that have been added to the National Coverage Determinations (NCDs). https://www.cms.gov/files/document/mm14153-laboratory-national-coverage-determination-edit-software-updates-october-2025.pdf

 

July 24, 2025: MLN MM14159: Acute Kidney Injury Renal Dialysis Billing: Additional Revenue Codes

Affected providers for this article includes ESRD facilities and other providers billing MACs for renal dialysis services. CMS advises that you make sure your billing staff is aware of changes to home dialysis billing for patients with acute kidney injury (AKI) starting January 1, 2025.  

https://www.cms.gov/files/document/mm14159-acute-kidney-injury-renal-dialysis-billing-additional-revenue-codes.pdf

 

July 31, 2025: MLN MM14130: Billing the Laboratory Specimen Collection Travel Allowance to the 10^th of a Mile

Effective January 1, 2026 providers will be allowed to bill HCPCS code P9603 calculated to the 10^th of a mile. This MLN article provides information on how to bill to the 10^th of a mile properly and when to bill using a whole number of miles. https://www.cms.gov/files/document/mm14130-billing-laboratory-specimen-collection-travel-allowance-10th-mile.pdf

 

August 4, 2025: MLN MM14101: Ambulatory Surgical Center Payment System: July 2025 Update

Initially released on June 6, 2025, this article was updated on Augusth 4, 2025 to update the number of new HCPCS code and coding information in the drugs, biologicals, and radiopharmaceuticals section. https://www.cms.gov/files/document/mm14101-ambulatory-surgical-center-payment-system-july-2025-update.pdf

 

August 5, 2025: MLN MM14185: Bypassing Common Working File Edits on Inpatient Medicare Part B Ancillary 12X Claims: Effective Date Change

CMS advises you to make sure your billing staff knows about the updates to the effective date for the bypass of Common Working File editing on inpatient Medicare Part B ancillary 12X claims previously added to Change Request 13810. https://www.cms.gov/files/document/mm14185-bypassing-common-working-file-edits-inpatient-medicare-part-b-ancillary-12x-claims-effective.pdf

 

August 22, 2025: MLN MM14197: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2026 Update (1 of 2)

Make sure your billing staff knows about updates to NCDs with new or deleted ICD-10-CM diagnosis codes effective January 1, 2026.

https://www.cms.gov/files/document/mm14197-icd-10-other-coding-revisions-national-coverage-determinations-january-2026-update-1-2.pdf-0

 

August 25, 2025: MLN MM14177: Home-Based Noninvasive Positive Pressure Ventilation to Treat Chronic Respiratory Failure Due to Chronic Obstructive Pulmonary Disease

Make sure your billing staff knows about updates effective June 9, 2025, including updated Medicare coverage guidance for respiratory assistance devices (RADs) and home mechanical ventilators (HMVs). https://www.cms.gov/files/document/mm14177-home-based-noninvasive-positive-pressure-ventilation-treat-chronic-respiratory-failure-due.pdf

 

August 26, 2025: MLN MM14194: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2026 Update (2 of 2)

Make sure your billing staff knows about updates to NCDs with new or deleted ICD-10-CM diagnosis codes effective January 1, 2026. https://www.cms.gov/files/document/mm14194-icd-10-other-coding-revisions-national-coverage-determinations-january-2026-update-2-2.pdf

 

Coverage Updates

June 2, 2025: Final Decision Memo (CAG-00468N) and NCD 20.38: Transcatheter Edge-to Edge Repair for Tricuspid Valve Regurgitation (T-TEER)

CMS has posted the final NCD and decision memo. This procedure is covered when furnished according to an FDA market-authorized indication and patient, physician and CED study criteria are met.

 

1. Patient Criteria: Despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve repair being considered as appropriate by a heart team.
   1. CMS noted in the Decision Memo that “we are finalizing the coverage indications without specifying TR severity. We note the final NCD criteria are consistent with the current FDA-approved label and will continue to align with FDA labeling for symptomatic TR if indication language on severity is updated.”

    

2. Physician Criteria: The patient (preoperatively and postoperatively) is under the care of a heart team, which includes, at minimum, a Cardiac Surgeon, Interventional Cardiologist, Cardiologist with training and experience in heart failure management, and an Interventional echocardiographer. Per the Decision Memo, all specialists must have experience in the care and treatment of tricuspid regurgitation.

    

3. Coverage with Evidence Development (CED) Study Criteria: The T-TEER items and services are furnished in the context of a CMS-approved CED study. CMS-approved CED study protocols must: include only those patients who meet the patient and physician criteria, and the study includes all the criteria listed in the NCD.

 

https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=316

 

Note: CMS published related MLN Matters Article MM14200 on August 20, 2025 and advises that you make sure your billing staff knows about the NCD criteria, coverage with evidence development (CED) study criteria, and claims processing requirements. https://www.cms.gov/files/document/mm14200-national-coverage-determination-2038-transcatheter-edge-edge-repair-tricuspid-valve.pdf

 

August 1, 2025: MLN Matters MM14149: National Coverage Determination 20.37: Transcatheter Tricuspid Valve Replacement (TTVR)

The Final Decision Memo for TTVR (CAG-00467N) was issued on March 19, 2025. This related MLN article provides detail about the coverage with evidence development (CED) study criteria and claims processing requirements. They also note that MACs will not search for files for TTVR claims processed with dates of service from March 19, 2025 to January 5, 2026; however, they’ll adjust any claims you bring to their attention. https://www.cms.gov/files/document/mm14149-national-coverage-determination-2037-transcatheter-tricuspid-valve-replacement.pdf

 

Note: CMS published related MLN Matters Article MM14149 on August 1^st and advises that you make sure your billing staff knows about the NCD criteria, coverage with evidence development (CED) study criteria, and claims processing requirements. https://www.cms.gov/files/document/mm14149-national-coverage-determination-2037-transcatheter-tricuspid-valve-replacement.pdf

 

Compliance Education Updates

June 2025: MLN Booklet: MLN909188: Chronic Care Services

CMS updated this booklet with information about Advanced Primary Care Management (APCM). https://www.cms.gov/files/document/chroniccaremanagement.pdf

 

July 2025: MLN Educational Tool: MLN006559: Medicare Preventive Services Updated

In the Thursday, August 14^th edition of MLN Connects, CMS included information about information added to several sections of the Medicare Preventive Services tool including:

• Alcohol misuse screening and counseling,
• Counseling to prevent tobacco use,
• Depression screening,
• Hepatitis C screening,
• PrEP using antiretroviral therapy to prevent HIV infection, and
• FAQ: billing the office and outpatient evaluation and management visit complexity add-on HCPCS code G2211 with Medicare Part B preventive services.

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

 

Other Updates

 

July 14, 2025: Livanta Provider Bulletin #24: Short Stay Reviews returning to the MACs

Livanta sent a bulletin to let providers know their contract as the National Claims Review Contractor concludes on August 11, 2025 that included the following about the transition of short stay reviews (SSR):

• September 1, 2025: Medicare Administrative Contractors will assume responsibility for conducting SSR.
• Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIO) will continue to conduct Higher Weighted Diagnosis-Related Group (HWDRG) reviews.

 

CMS noted during their July 30, 2025, webinar Inpatient Hospital Short Stay Review Transition, the short stay review policy has not changed, this shift in who will be reviewing records is an administrative change.

 

What is changing is the timing of the audit. Livanta reviewed claims post-payment, and the MACs will review claims pre-payment as part of the Targeted Probe and Education (TPE) program.

 

You will find a list of Inpatient Hospital FAQs re: Short Stays on the CMS website at https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/inpatient-hospital-reviews-faqs#FAQs-7/3/2025. As of August 1, 2025, the FAQs were last updated on July 3, 2025.

 

July 14, 2025: CMS Published CY 2026 Physician Fee Schedule Proposed Rule

CMS Fact Sheet: https://www.cms.gov/newsroom/press-releases/cms-proposes-physician-payment-rule-significantly-cut-spending-waste-enhance-quality-measures-and

 

July 15, 2025: CMS Publishes CY 2026 OPPS Proposed Rule

Like the 2020 Proposed Rule, CMS has proposed to eliminate the current IPO List (approximately 1,731 services), through a 3-year transition. For CY 2026 they have proposed to eliminate 285 mostly musculoskeletal-related services.

CMS notes “Given the significant number of services on the list and that we would establish new reimbursement rates for those services under the OPPS, we recognize that interested parties may need time to adjust to the removal of procedures from the list. Providers may need time to prepare to furnish newly removed procedures on an outpatient basis, update their billing systems, and gain experience with newly removed procedures eligible to be paid under either the IPPS or OPPS.

 

They go on to note that “there is already a set of C-APCs for musculoskeletal services for patients in the outpatient setting, which facilitates the removal of these types of services from the IPO list for CY 2026.” To further facilitate this process, CMS is proposing “to establish a 7 level Musculoskeletal Procedures APC series, which will allow for the assignment of musculoskeletal procedures removed from the IPO to an APC with an applicable range of estimated costs.”

 

https://public-inspection.federalregister.gov/2025-13360.pdf?utm_campaign=pi+subscription+mailing+list&utm_medium=email&utm_source=federalregister.gov

 

July 2025: CMS.Gov/Fraud: Hospice Fast Facts

CMS noted in the July 24^th edition of MLN Connects that they have posted a new Hospice Fast Facts document to inform the public about significant enhancements to address hospice fraud, including:

• What hospital fraud is,
• How CMS has enhanced oversight, and
• What CMS is doing to stop fraud.

https://www.cms.gov/files/document/cpi-hospice-fast-facts.pdf

 

July 31, 2025: CMS MLN Matters Special Edition Announcing Final Rules

 

FY 2026 IPPS  and Long-Term Care Hospital PPS Final Rule (CMS-1833-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0

 

FY 2026 Inpatient Rehabilitation Facilities PPS Final Rule (CMS-1829-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-inpatient-rehabilitation-facilities-prospective-payment-system-final-rule-cms-1829-f

 

FY 2026 Medicare Inpatient Psychiatric Facility PPS and Quality Reporting Final Rule (CMS-1831-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-medicare-inpatient-psychiatric-facility-prospective-payment-system-ipf-pps-and-quality

 

FY 2026 Skilled Nursing Facility (SNF) PPS Final Rule (CMS-1827-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-skilled-nursing-facility-snf-prospective-payment-system-final-rule-cms-1827-f

 

FY 2026 Hospice Wage Index and Payment Rate Update and Hospital Quality Reporting Program Requirements Final Rule (CMS-1835-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting-program