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9/3/2025
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.
July 31, 2025: MLN MM14130: Billing the Laboratory Specimen Collection Travel Allowance to the 10th of a Mile
Effective January 1, 2026 providers will be allowed to bill HCPCS code P9603 calculated to the 10th of a mile. This MLN article provides information on how to bill to the 10th 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.
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.
- Patient Criteria: Despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve repair being considered as appropriate by a heart team.
- 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.”
- 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.
- 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 1st 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 14th 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.
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.”
July 2025: CMS.Gov/Fraud: Hospice Fast Facts
CMS noted in the July 24th 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
Beth Cobb
7/3/2025
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.
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
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
Beth Cobb
6/4/2025
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://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.
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.”
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.pdfBeth Cobb
6/2/2025
Medicare Transmittals & MLN Articles
March 28, 2025: Transmittal 13079: January 2025 Update of the Ambulatory Surgical Center (ASC) Payment System
Transmittal 13079 replaces Transmittal 13044 that was issued January 10, 2025. The original document has been updated to add an additional requirement and note for MACs for their work implementing the updates. All the other information remained the same. https://www.cms.gov/files/document/r13079cp.pdf
April 1, 2025: MLN MM13993: Hospital Outpatient Prospective Payment System: April 2025 Update
This article highlights coding and billing changes for certain lab tests, COVID-19 monoclonal antibody therapy products, and hospital OPPS device categories. It also highlights changes to APCs, surgical and imaging procedures, drugs, biologicals, and radiopharmaceuticals, and skin substitute products.
April 3, 2025: MLN MM13990: DMEPOS Fee Schedule: April 2025 Quarterly Update
CMS advises that your billing staff needs to know about new HCPCS codes, new fee schedule amounts, new HCPCS codes on the fee schedule file for DMEPOS repairs and servicing, complex rehabilitative power wheelchair accessories, and lymphedema compressions treatment items. https://www.cms.gov/files/document/mm13990-dmepos-fee-schedule-april-2025-quarterly-update.pdf
April 25, 2025: MLN MM14017: Ambulatory Surgical Center Payment System: April 2025 Update
CMS advised that your billing staff be aware of updates effective April 1, 2025 (i.e., a new HCPCS code for simulation angiogram for radioembolization of tumors). https://www.cms.gov/files/document/mm14017-ambulatory-surgical-center-payment-system-april-2025-update.pdf
Coverage Updates
March 19, 2025: Transcatheter Tricuspid Valve Replacement (TTVR) Final Decision Memo (CAG-00467N)
CMS now covers TTVR for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) when provisions in the Decision Memo are met for patient, physician, and CED study criteria. Specific to that patient, it is covered when “despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve replacement being considered as appropriate by a heart team.” The heart team, at a minimum, must include a cardiac surgeon, interventional cardiologist, cardiologist with training and experience in heart failure management, electrophysiologist, multi-modality imaging specialists, and an interventional cardiographer. “All of the specialists listed above must have experience in the care and treatment of tricuspid regurgitation.” CMS also notes that “all CMS-approved CED studies must meet the patient and physician criteria. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=314&fromTracking=Y&
March 20, 2025: Change Request (CR) 13939: ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2025
This change request provides a quarterly maintenance update of ICD-10 coding conversions and other coding updates specific to NCDs. No policy change is being made. NCDs with updates:
NCD 80.2, 80.2.1, 80.3.1: OPT Verteporfin,
NCD 90.2 Next Generation Sequencing,
NCD 100.1 Bariatric Surgery,
NCD 110.18 Aprepitant,
NCD 110.23 Stem Cell Transplants,
NCD 110.24 CAR T-cell Therapy,
NCD 160.18 Vagus Nerve Stimulation,
NCD 210.3 Colorectal Cancer Screening, and
NCD 250.3 IVIG for Treatment Autoimmune Mucocutaneous Blistering Disease.
https://www.cms.gov/files/document/r13097otn.pdf
April 3, 2025: Proposed Decision Memo (CAG-00468N) Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER)
Just under a month after the final decision memo for Transcatheter Tricuspid Valve Replacement (TTVR) was published, CMS released a proposed decision memo for T-TEER procedure. The Benefit Category for this procedure is inpatient hospital services and physicians’ services.
Abbott submitted the request for a National Coverage Analysis (NCA) to evaluate this procedure indicating that “The T-TEER procedure is intended to treat patients with symptomatic tricuspid regurgitation (TR). T-TEER procedures are performed percutaneously using a catheter-based technology to approximate the leaflets of the tricuspid valve with a clip device.
The T-TEER procedure using Abbott’s TriClip™ system was developed leveraging the experience of the MitraClip™ therapy, which is used to treat mitral valve regurgitation using transcatheter edge-to-edge repair of the mitral valve.”
The TripClip™ G4 System received FDA premarket approval on April 1, 2024 as a Breakthrough Device. This system was granted new technology eligible for add-on payment status effective October 1, 2024. The maximum add-on payment for FY 2025 is $26,000.
The ICD-10-PCS code used to describe this procedure is 02UJ3JZ (supplement tricuspid valve with synthetic substitute, percutaneous approach). This procedure groups to DRG pair 266/267 (endovascular cardiac valve replacement and supplement procedures with MCC and without MCC respectively).
The public comment period for this NCA ends May 3, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=316
Compliance Education Updates
April 2025: MLN Booklet (MLN901705) Telehealth & Remote Patient Monitoring
CMS has updated this MLN booklet including information about some telehealth flexibilities that have been extended through September 30, 2025. https://www.cms.gov/files/document/mln901705-telehealth-remote-patient-monitoring.pdf
April 2025: MLN Educational Tool Medicare Preventive Services (MLN006559)
CMS has made changes to preventive screening for colorectal cancer and ultrasound abdominal aortic aneurysm. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#COLO_CAN
Other Updates
March 6, 2025: Livanta Publishes Year 3 Review Findings for Higher-Weighted DRG Validation
In their February 2025 edition of “The Livanta Claims Review Advisor,” Livanta shares their higher-weighted diagnosis related groups (HWDRG) validation reviews for reviews completed from November 1, 2023 through October 31, 2024. Of the 6,447 claims found to be in error, 5,744 (10%) were a result of DRG changes and 703 (1%) were a result of failure to meet the guidelines of the Two-Midnight Rule. CMS Region 4 (AL, FL, GA, KY, MS, NC, SC, and TN) have the highest volume of claims reviewed and the highest regional error rate at 14%. For the third review cycle, sepsis DRGs (871 and 872) collectively continue to account for the highest percentage of DRGs found to be in error. Livanta posts their newsletters on their Provider Education and Toolkit webpage at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/provider_education.html.Beth Cobb
4/3/2025
Medicare Transmittals & MLN Articles
February 24, 2025: MLN MM13937: Roster Billing for Hepatitis B: July 2025 Release
For affected providers make sure your billing staff knows about the expanded coverage for more Medicare patients to receive the hepatitis B vaccine, that Medicare patients no longer need a doctor’s order for the administration of the vaccine, and that mass immunizers can use the roster billing process to submit Medicare Part B claims for hepatitis B vaccinations and their administration. https://www.cms.gov/files/document/mm13937-roster-billing-hepatitis-b-july-2025-release.pdf
March 14, 2025: MLN MM13959: HCPCS Codes & Clinical Laboratory Amendments Edits: April 2025
This article includes updates about discontinued and new HCPCS codes and HCPCS codes subject to and those that are excluded from Clinical Laboratory Improvement Amendments (CLIA) edits. https://www.cms.gov/files/document/mm13959-hcpcs-codes-clinical-laboratory-improvement-amendments-edits-april-2025.pdf
March 17, 2025: MLN MM13966: Clinical Laboratory Fee Schedule (CLFS) & Laboratory Services Subject to Reasonable Charge Payment: April 2025 Quarterly Update
Make sure your billing staff knows about when the next CLFS reporting period for Clinical Diagnostic Laboratory Tests (CDLTs) begins and new and deleted CPT codes effective April 1, 2025. https://www.cms.gov/files/document/mm13966-quarterly-update-clinical-laboratory-fee-schedule-clfs-and-laboratory-services-subject.pdf
March 21, 2025: MLN MM13946: Rural Health Clinic & Federally Qualified Health Center Medicare Benefit Policy Manual Update
CMS advises that your billing staff needs to know about the 2025 updates to the Medicare Benefit Policy Manual, Chapter 13, and all other revisions clarifying existing policy. https://www.cms.gov/files/document/mm13946-rural-health-clinic-federally-qualified-health-center-medicare-benefit-policy-manual-update.pdf
Coverage Updates
March 11, 205: Proposed Decision Memo (CAG-00465N) Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure consequent to COPD
CMS has published a proposed Decision Memo in response to a request for reconsideration of NCD 280.1, to establish coverage policies for the use of noninvasive home mechanical ventilators and respiratory assist devices for Medicare beneficiaries with various respiratory conditions. CMS accepted the request for the indication of COPD. The public comment period for this proposed Decision Memo is from March 11, 2025 through April 10, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=315
March 19, 2025: Transcatheter Tricuspid Valve Replacement (TTVR) Final Decision Memo (CAG-00467N)
CMS now covers TTVR for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) when provisions in the Decision Memo are met for patient, physician and CED study criteria. Specific to that patient, it is covered when “despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve replacement being considered as appropriate by a heart team.” The heart team, at a minimum, must include a cardiac surgeon, interventional cardiologist, cardiologist with training and experience in heart failure management, electrophysiologist, multi-modality imaging specialists, and an interventional cardiographer. “All of the specialists listed above must have experience in the care and treatment of tricuspid regurgitation.” CMS also notes that “all CMS-approved CED studies must meet the patient and physician criteria. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=314&fromTracking=Y&
Compliance Education Updates
December 2024: MLN Fact Sheet: Complying with Medical Record Documentation Requirements
CMS updated this MLN Fact Sheet (MLN909160) to add documentation guidelines for medical services and additional resources for Medicare documentation requirements. For example, “if providers don’t include sufficient documentation on claims we’ve already paid, we may consider the payment an overpayment, which we can partially or fully recover.” https://www.cms.gov/files/mln909160-complying-with-medical-record-documentation-requirements.pdf
February 2025: MLN Fact Sheet: Medicare Coverage of Diabetes Supplies
CMS updates this MLN Fact Sheet (MLN7674574) to add coverage information on continuous glucose monitors. https://www.cms.gov/files/document/mln7674574-medicare-coverage-diabetes-supplies.pdf
March 2025: MLN Fact Sheet: Hospital Price Transparency
This new fact sheet (MLN7215754) opens with the following: “On February 25, 2025, the White House issued an Executive Order to empower consumers with clear, accurate, and actionable health care pricing information. Read this White House fact sheet for more information.” https://www.cms.gov/files/document/mln7215754-hospital-price-transparency.pdf
Other Updates
February 26, 2025: ICD-10-CM/PCS What’s New Effective April 1, 2025
CMS has updated the ICD-10 webpage to announce 50 new ICD-10-PCS codes, effective April 1, 2025 and to let providers know there are no new ICD-10-CM codes. https://www.cms.gov/medicare/coding-billing/icd-10-codes
March 6, 2025: Livanta Published Year 3 Review Findings for Higher-Weighted DRG Validation
In their February 2025 edition of “The Livanta Claims Review Advisor,” Livanta shares their higher-weighted diagnosis related groups (HWDRG) validation reviews for reviews completed from November 1, 2023 through October 31, 2024. Of the 6,447 claims found to be in error, 5,744 (10%) were a result of DRG changes and 703 (1%) were a result of failure to meet the guidelines of the Two-Midnight Rule. CMS Region 4 (AL, FL, GA, KY, MS, NC, SC, and TN) have the highest volume of claims reviewed and the highest regional error rate at 14%. For the third review cycle, sepsis DRGs (871 and 872) collectively continue to account for the highest percentage of DRGs found to be in error. Livanta posts their newsletters on their Provider Education and Toolkit webpage at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/provider_education.html.
Beth Cobb
2/28/2025
Medicare Transmittals & MLN Articles
December 19, 2024: MLN MM13898: Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations Policy
Make sure your billing staff knows about updated Medicare coverage requirements for pneumococcal vaccinations and changes to align with the Advisory Committee on Immunization Practices (ACIP) recommendations for pneumococcal vaccination coverage. https://www.cms.gov/files/document/mm13898-revisions-medicare-part-b-coverage-pneumococcal-vaccinations-policy.pdf
December 26, 2024: MLN MM13473: How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211
This MLN article was released on January 1, 2024 and updated on December 26, 2024. CMS has added information on how to use G2211 with modifier 25 for certain Medicare Part B services starting January 1, 2025. Substantive content changes are in dark red. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf
Coverage Updates
December 12, 2024: MLN MM13843: National Coverage Determination 210.15: Pre-Exposure Prophylaxis (PrEP) for HIV Prevention
CMS advises that you make sure your billing staff knows about the national coverage of PrEP using FDA-approved antiretroviral drugs to prevent HIV, HCPCS and diagnosis codes, and billing and payment requirements. https://www.cms.gov/files/document/mm13843-national-coverage-determination-21015-pre-exposure-prophylaxis-prep-hiv-prevention.pdf
December 19, 2024: Proposed Decision Memo (CAG-00467N): Transcatheter Tricuspid Valve Replacement (TTVR)
CMS has proposed to cover TTVR under Coverage with Evidence Development (CED) for the treatment of symptomatic tricuspid regurgitation (TR) when furnished with an FDA-approved complete TTVR system, the TR is graded as at least severe and meets the coverage criteria listed in the proposed decision memo. The comment period for this proposed decision memo is from December 19, 2024 through January 18, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=314
Other Updates
December 2, 2024: Beneficiary Notices Initiative (BNI) Fee for Service Medicare Change of Status Notice (MCSN) Webpage Updated
CMS updated this webpage to provide information about this new notice and appeals process for Original Medicare beginning February 14, 2025. https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative-bni/ffs-mcsn
December 2024: New ICD-10-PCS Codes Effective April 1, 2025
CMS announced 50 new ICD-10-PCS codes, effective April 1, 2025. Of note, 35 of the new ICD-10-PCS codes are new technology, group 10 X-codes. CMS also noted that the April 1, 2025 code update files are now available. Use these codes for discharges occurring from April 1, 2025 – September 30, 2025, and for patient encounters occurring from April 1, 2025 – September 30, 2025. https://www.cms.gov/medicare/coding-billing/icd-10-codes
December 20, 2024: Review and Decision Timeframe Update Reminder from Palmetto GBA
Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M published an article reminding providers that effective January 1, 2025, CMS will reduce the timeframe requirements for MACs to provide a hospital outpatient department (OPD) prior authorization request (PAR) provisional affirmed or non-affirmed decision within seven calendar days of receipt of the request. https://www.palmettogba.com/palmetto/jja.nsf/DID/QIXFKBAMOI#ls
December 27, 2024: Proposed HIPAA Security Rule to Strengthen Cybersecurity for Electronic Protected Health Information
The Office for Civil Rights (OCR) at HHS issued a Notice of Proposed Rulemaking (NPRM) to modify the HIPAA Security Rule to strengthen cybersecurity protections for electronic protected health information (ePHI). Read about the NPRM in a related HHS Fact Sheet at https://www.hhs.gov/hipaa/for-professionals/security/hipaa-security-rule-nprm/factsheet/index.html.
Beth Cobb
2/28/2025
Medicare Transmittals & MLN Articles
January 2, 2025: MLN Matters MM13918: Billing Instructions: Expedited Determinations Based on Medicare Change of Status Notifications
The implementation date for this new process is February 15, 2025. CMS advised that you make sure your billing staff knows about when patients are eligible to appeal a hospital status discharge, the Beneficiary and Family Centered Care (BFCC-QIO) role in the appeals process, and about claims processing based on the BFCC-QIO appeal decision. https://www.cms.gov/files/document/mm13918-billing-instructions-expedited-determinations-based-medicare-change-status-notifications.pdf
January 13, 2025: MLN MM13947: Travel Allowance Fees for Specimen Collection – 2025 Updates
Change Request (CR) 13947) revised travel allowance payment for CY 2025 when billed on a per mileage basis using HCPCS code P9603 or billed on a flat rate basis using HCPCS code P9604. Make sure your billing staff knows about the update to the CY 2025 specimen collection fees and travel allowance mileage rate, how to determine eligibility for the specimen collection fee, and know the travel allowance policies. https://www.cms.gov/files/document/mm13947-travel-allowance-fees-specimen-collection-2025-updates.pdf
January 14, 2025: MLN MM13934: Ambulatory Surgical Center Payment Update – January 2025
Make sure your billing staff knows about January payment system updates for new device categories, CPT, and HCPCS codes, drugs and biologicals, skin substitutes, and non-opioid treatments for pain relief.
January 15, 2025: MLN MM13933: Hospital Outpatient Prospective Payment System: January 2025 Update
CMS advises that you make sure your billing staff knows about January 1, 2025 coding updates, device pass-through status updates, changes to the comprehensive ambulatory payment classification, updates related to drugs, biologicals, and pharmaceuticals, and changes to the Outpatient Prospective Payment System (OPPS) Pricer logic. https://www.cms.gov/files/document/mm13933-hospital-outpatient-prospective-payment-system-january-2025-update.pdf
January 16, 2025: MLN MM13923: Payment for Medicare Part B Preventive Vaccines & Their Administration for Rural Health Clinics & Federally Qualified Health Centers
Make sure your billing staff knows that Hepatitis B vaccines are paid like other Part B preventive vaccines starting January 1, 2025, and new claim-based payments for Part B preventive vaccines and their administration are starting July 1, 2025. https://www.cms.gov/files/document/mm13923-payment-medicare-part-b-preventive-vaccines-their-administration-rural-health-clinics.pdf
Coverage Updates
January 10, 2025: National Coverage Analysis: Cardiac Contractility Modulation (CCM) for Heart Failure
The NCA issue is that despite advancements in treatment options, mortality in heart failure (HF) patients is high. “CCM is designed to treat select HF patients who continue to have persistent symptoms despite guideline-directed medical therapy (GDMT) and are ineligible for cardiac resynchronization therapy (CRT). CCM devices deliver electrical stimulation to the heart muscle to increase the strength of the heart’s contractions. CMS notes, this technology may improve symptoms, quality of life, functional capacity, and exercise tolerance.
CMS has received a formal request to provide coverage for CCM for heart failure. This is a Transitional Coverage for Emerging Technologies (TECT) pilot that tested the processes and concepts of TECT. The scope of this NCA is limited to CCM for heart failure.
The public comment period is from January 1, 2025 to February 9, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=317
January 13, 2025: Final Decision Memo (CAG-00466N): Implantable Pulmonary Artery Pressure Sensors (IPAPS) for Heart Failure Management
In this final Decision Memo CMS indicates that they will cover IPAPA for heart failure management under coverage with evidence development when all listed patient criteria in this document are met. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=313
January 13, 2025: National Coverage Analysis (NCA CAG-0047ON) Renal Denervation for Uncontrolled Hypertension
In December 2024, Medtronic submitted a letter requesting a National Coverage Determination (NCD) for renal denervation (RDN). Medtronic’s Symplicity Spyral™ RDN System was granted premarket approval on November 17, 2023. This system is described as an option for hypertension treatment that is adjunctive to medications to help lower blood pressure.
The scope of this NCA is limited to radiofrequency and ultrasound-based denervation procedures. CMS is soliciting public comment. They are particularly interested in comments that include scientific evidence describing the role of RDN. They are also interested in health disparities and equity aspects that should be considered in this review. The public comment period ends February 12, 2025 with an expected proposed decision memo in mid- July 2025.
Of note, effective October 1, 2024, this system was approved for a new technology add-on payment in the hospital IPPS final rule. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=318
Other Updates
January 14, 2025: CY 2025 Therapy Services Updates
CMS updated this webpage to reflect the 2025 threshold amounts for rehabilitative services. The following is a compare of 2024 and 2025 threshold amounts.
|
Calendar Year |
Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined |
Occupational Therapy (OT) Services |
|
2024 |
$2,330 |
$2,330 |
|
2025 |
$2,410 |
$2,410 |
|
Source: CMS Therapy Caps webpage: https://www.cms.gov/medicare/coding-billing/therapy-services |
||
Links to more information is available in the Thursday January 16, 2025 edition of MLN Connects at https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-01-16-mlnc.
Beth Cobb
12/20/2024
In mid-November, the Comprehensive Error Rate Testing (CERT) published the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data (https://www.cms.gov/files/document/2024-medicare-fee-service-supplemental-improper-payment-data.pdf). This report supplements the FY 2024 HHS Agency Final Report for Fiscal Year 2024, highlights common causes of improper payments, and includes tables allowing you to drill down into the review findings.
Estimated Improper Payment Rates
Calculation for the FY 2024 Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2022 through June 30, 2023. As compared to FY 2020 and 2021, the improper payment rate is trending up.
Table 1
|
Fiscal Year |
Improper Payment Rate |
Estimated Improper Payment |
|
2020 |
6.37% |
$25.74 Billion |
|
2021 |
6.26% |
$25.03 Billion |
|
2022 |
7.46% |
$31.46 Billion |
|
2023 |
7.38% |
$31.23 Billion |
|
2024 |
7.66% |
$31.7 Billion |
“It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).
Unfortunately, like last year, “insufficient documentation” continues to be the main cause of improper payments. The CERT defines “insufficient documentation” as when the medical record documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that the billed services were provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.
While the CERT data reports on improper payments in various settings (i.e., skilled nursing facilities, hospital outpatient, hospice), this article focuses on Part A (Hospital IPPS) findings.
“0 or 1 day” Length of Stay Claims
A compare of improper payments rates for Part A hospital claims by length of stay (LOS) has been a part of this annual report since the October 1, 2013 implementation of the Two-Midnight Rule. Table 1 trends short stays findings from the initial year this information was included in the CERT report.
Table 2
|
Report FY |
Improper Payment Rate |
Projected Improper Payments |
Percent of Overall Improper Payments |
|
2014 |
37.18% |
$3.3B |
6.8% |
|
2020 |
19.9% |
$1.9B |
7.0% |
|
2021 |
16.8% |
$1.5B |
5.7% |
|
2022 |
20.1% |
$1.5B |
4.7% |
|
2023 |
21.7% |
$1.7B |
5.1% |
|
2024 |
24.3% |
$1.7B |
5.2% |
In addition, to the CERT’s focus on claims by length of stay, short stays (“0 of 1 Day” Stays) short stays are also actively being reviewed by the OIG as part of their Work Plan (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp) and Livanta, the National Medicare Claim Review Contractor (https://livantaqio.com/en/ClaimReview/index.html), who reviews short stay claims across the nation on a monthly bases.
Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS
Table D4 of the CERT report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories.
For fourteen of the top 20 DRG types, the type of error with the highest percentage was error type medical necessity. A claim is placed in this category when the CERT contractor reviewer receives adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. The following three DRG types had the highest percent of errors attributed to medical necessity:
- DRG Pair 551 and 552 (Medical Back Problems): 99.6% error attributed to medical necessity.
- DRG 884 (Organic Disturbances & Intellectual Disability): 93.1% error attributed to medical necessity.
- DRG Pair 469 and 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity): 92.8% error attributed to medical necessity.
Top Root Causes of Improper Payments
The 2024 CERT report includes the same top three service types with the highest improper payments in the Part A (Hospital IPPS) setting as in the 2023 report. Each of the three service types also have the same top root cause for improper payments in FY 2023 and FY 2024.
In the 2024 report, the CERT identified the following new root causes of improper payments not noted listed in the 2023 report.
New Root Causes for DRG 469 and 470
- Documentation to support conservative treatment for the billed surgical procedure(s) – missing,
- Preoperative surgeon’s office notes – missing,
- Documentation to support conservative treatment for the billed surgical procedure(s) – inadequate, and
- Radiographs to support medical necessity for the billed surgical procedure(s) – inadequate.
New Root Cause for DRGs 273 and 274
- Documentation to support medical necessity for the procedure – Missing.
New Root Causes for DRGs 266 and 267
- NCD requirements, other documentation required for payment – Missing, and
- Incorrect secondary diagnosis code – DRG change.
Moving Forward
Moving forward, here are ideas and resources to help in your efforts to prevent claims errors:
- Visit the CERT Provider Website (https://c3hub.certrc.cms.gov/) to find information about the CERT, how to submit records, view sample request letters and much more,
- Become familiar with National and Local Coverage Determinations and Local Coverage Articles that detail indications and limitations of coverage for applicable services. For example, CMS has published two resources related to Major Hip and Knee replacement:
- MLN Product: Medicare Compliance Tips: Major Hip & Knee Replacement or Reattachment of Lower Extremity (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/medicare-provider-compliance-tips/medicare-provider-compliance-tips.html#Hip), and
- MLN Matters article SE19002: Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19002.pdf), and
- Annually, take the time to review the new Supplemental Improper Payment Data report. Historically, a new FY report is released in late November.
Resource
CMS.gov Fact Sheet, November 15, 2024, Fiscal Year 2024 Improper Payments Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2024-improper-payments-fact-sheetBeth Cobb
12/20/2024
Medicare Transmittals & MLN Articles
November 5, 2024: MLN MM13818: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2025 Update (CR 1 of 2)
CMS advises making sure your billing staff knows about newly available codes, recent coding changes, and National Coverage Determination (NCD) coding information. https://www.cms.gov/files/document/mm13818-icd-10-other-coding-revisions-national-coverage-determinations-april-2025-update-cr-1-2.pdf
November 5, 2024: MLN MM13828: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2025 Update (CR 2 of 2)
CMS advises making sure your billing staff know about the same updates as in MLN article (MM13818). https://www.cms.gov/files/document/mm13828-icd-10-other-coding-revisions-national-coverage-determinations-april-2025-update-cr-2-2.pdf
November 6, 2024: MLN MM13858: New Waived Tests
This article provides information about the new waived test approved by the FDA that will be effective January 1, 2025. https://www.cms.gov/files/document/mm13858-new-waived-tests.pdf
November 8, 2024: MLN MM13796: Medicare Deductible, Coinsurance, & Premium Rates: CY 2025 Update
This article includes Medicare Part A and Part B deductible, Part A and Part B coinsurance rates, and Part A and Part B premiums effective January 1, 2025. https://www.cms.gov/files/document/mm13796-medicare-deductible-coinsurance-premium-rates-cy-2025-update.pdf
November 22, 2024: MLN MM13846: Medicare Change of Status Notice Instructions (Expedited Determinations When a Patient is Reclassified from an Inpatient to an Outpatient Receiving Observation Services)
Hospitals (including Critical Access Hospitals) need to make sure your staff knows about:
- Appeal rights for eligible Medicare patients reclassified from an inpatient to outpatient receiving observation services,
- Medicare Change of Status Notice (MCSN) delivery requirements, and
- New Section 450 to the Medicare Claims Processing Manual, Chapter 30.
https://www.cms.gov/files/document/mm13846-medicare-change-status-notice-instructions.pdf
November 25, 2024: MLN MM13887: Medicare Physician Fee Schedule Final Rule Summary: CY 2025
Make sure your billing staff knows about change to the following services:
- Telehealth,
- Caregiver training,
- Therapy,
- Cardiovascular risk assessment and management,
- Evaluation and management (E/M),
- Behavioral Health,
- Advanced Primary Care Management (APCM),
- Global Surgery Payment, and
- Dental and Oral Health.
Coverage Updates
November 15, 2024: CMS National Coverage Determination (NCD) Dashboard Updated
As of November 14, 2024, there are eight topics on the NCD wait list, four open NCDs, and two NCDs finalized in the past twelve months. https://www.cms.gov/files/document/ncddashboard2024.pdf
Compliance Education Updates
November 2024: MLN Booklet (MLN907166) Global Surgery Revised
This booklet has been reviewed to add information about modifiers and about new G-code, HCPCS code G0559, for post-operative care services provided by a practitioner other than the one who performed the surgical procedure (or another practitioner in the same group practice). https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf
Other Updates
November 1, 2024: Calendar Year (CY 2025 Medicare Physician Fee Schedule (PFS) Final Rule
CMS finalized their proposal to establish coding and payment under the PFS for a new set of Advanced Primary Care Management Services (APCM) described by three new HCPCS G-codes (G0556, G0557, G0558). The finalized APCM incorporates elements of several existing care management and communication technology-based services. However, unlike existing care management codes, there are no time-based thresholds included in the service elements, which is intended to reduce the administrative burden associated with coding and billing. Instead, the new APCM codes are stratified into three levels based on an individual’s number of chronic conditions and status as a Qualified Medicare Beneficiary, reflecting the patient’s medical and social complexity. You can read additional high level summary of this final rule in a related CMS Fact Sheet at https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-final-rule and CMS Press Release at https://www.cms.gov/newsroom/press-releases/hhs-finalizes-physician-payment-rule-strengthening-person-centered-care-and-health-quality-measures
November 1, 2024: CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (1809-FC)
CMS is finalizing an update to OPPS payment rates of 2.9% for hospitals that meet applicable quality reporting requirements. Policies in this final rule will affect approximately 3,500 hospitals and approximately 6,100 ASCs.
Following are the changes being made to the Medicare Inpatient Only (IPO) Procedure list effective January 1, 2025 as listed in Table 138 in the final rule:
CPT Codes to be Added to IPO List
- 0894T (Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device decannulation of the liver allograft following normothermic perfusion)
- 0895T (Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary)
- 0896T (Connection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour, including physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile PH, bile glucose, biliary bicarbonate, lactate levels, macroscopic
CPT Removed from the IPO List
- 22848 (Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)
You can read a high level summary of this final rule in a related CMS Press Release at https://www.cms.gov/newsroom/press-releases/cms-announces-new-policies-reduce-maternal-mortality-increase-access-care-and-advance-health-equity.
November 1, 2024: Calendar Year 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule (CMS-1805-F)
For CY 2025, CMS is increasing the ESRD PPS base rate to $273.82, which CMS expects will increase total payments to all ESRD facilities, both freestanding and hospital-based, by approximately 2.7%. This final rule also includes changes to the methodology for calculating the ESRD facility wage index, changes to the Low-Volume Payment Adjustment (LVPA) methodology, and several changes to the ESRD outlier policy. You can read more in a related CMS Fact Sheet at https://www.cms.gov/newsroom/fact-sheets/calendar-year-2025-end-stage-renal-disease-esrd-prospective-payment-system-pps-final-rule-cms-1805-f.
November 4, 2024: CMS Update to Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Initiative
CMS is changing the review timeframe for standard prior authorization decision from 10 business days to 7 calendar days for requests submitted on or after January 1, 2025. The timeframe for expedited requests remains 2 business days. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
Note, this change in the review timeframe will also go into effect for the Prior Authorization Process for Certain DMEPOS Items and Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport Initiative.
November 8, 2024: CMS Fact Sheet: 2025 Medicare Parts A & B Premiums and Deductibles
CMS published a Fact Sheet that includes the 2025 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2025 Medicare Part D income-related monthly adjustments. The standard Part B premium will be $185.00 for 2025, an increase of $10.30 from $174.70 in 2024. The following table provides a comparison of Part A deductible, and coinsurance amounts for CY 2024 and CY 2025 by type of cost sharing.
|
Part A Deductible and Coinsurance Amounts for Calendar Years 2024 and 2025 by Type of Cost Sharing |
||
|
|
2024 |
2025 |
|
Inpatient hospital deductible |
$1,632 |
$1,676 |
|
Daily hospital coinsurance for 61st-90th day |
$408 |
$419 |
|
Daily hospital coinsurance for lifetime reserve days |
$816 |
$838 |
https://www.cms.gov/newsroom/fact-sheets/2025-medicare-parts-b-premiums-and-deductibles
November 2024: Acentra Health Case Review Connections: Appeals Update – Safe Discharges
Acentra Health notes the following in their November edition of Case Review Connections for Acute Care:
“What are the key factors you are looking at for a safe discharge plan? What if a member needs a higher level of care, but there is no movement on finding a discharge plan?
Key considerations for a safe discharge plan:
- Secure a skilled nursing facility (SNF) bed, if applicable.
- If the beneficiary is going home, ensure they can safely return alone.
- Confirm that home health care is arranged.
- Ensure durable medical equipment (DME) is ordered and will arrive before discharge.
All arrangements needed for the discharge must be confirmed and not pending when the appeal is filed.” https://acentraqio.com/bene/newsletter/november2024acute
MLN Fact Sheet: Rural Emergency Hospitals (MLN2259384)
This MLN Fact Sheet was updated in November to add new information on Indian Health Services Hospitals and CY 2025 payment amount. https://www.cms.gov/files/document/mln2259384-rural-emergency-hospitals.pdf
Beth Cobb
11/14/2024
Medicare Transmittals & MLN Articles
October 3, 2024: Transmittal 12864 – Change Request (CR) 13800: October 2024 Update of the Ambulatory Surgical Center (ASC) Payment System
This CR replaced the September 5, 2024, Transmittal 12824. Updates included adding and removing HCPCS codes, adding new table 7 to add descriptor changes for HCPCS code A2024 and therefore, sub-section b. to policy section 5 has been added. https://www.cms.gov/files/document/r12864cp.pdf
October 8, 2024: MLN MM13734: Inpatient & Long-Term Care Hospital Prospective Payment Systems: FY 2025 Changes – Revised
CMS made changes to the FY 2025 policies that apply to the wage index section of this MLN article.
October 11, 2024: MLN MM13734: Inpatient & Long-Term Care Hospital Prospective Payment Systems: FY 2025 Changes – Revised
In this third iteration of this MLN article, CMS has added language to information on page 4 regarding the FY 2025 wage index computation. https://www.cms.gov/files/document/mm13734-inpatient-long-term-care-hospital-prospective-payment-system-fy-2025-changes.pdf
October 15, 2024: MLN MM13590: Separate Payment for Essential Medicines – New Biweekly Interim Payments for the Inpatient Prospective Payment System
CMS advises making sure your billing staff knows about the payment adjustments for establishing and maintaining access to essential medicines, how providers can be paid (biweekly or annually), and how future payment will be determined. https://www.cms.gov/files/document/mm13590-separate-payment-essential-medicines-new-biweekly-interim-payments-inpatient-prospective.pdf
Coverage Updates
October 3, 2024: National Coverage Analysis (CAG-00468N): Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER)
In March 2023, Abbot submitted a letter to CMS requesting a National Coverage Analysis (NCA) for T-TEER indicating “that a national coverage policy for T-TEER will ensure long-term, predictable, and consistent coverage for all Medicare beneficiaries.” The NCA focuses on the clinical indications for use of T-TEER among Medicare beneficiaries.
Abbott’s TriClip™ therapy received FDA approval on April 2, 2024. Effective October 1, 2024, this technology is eligible for a New Technology Add-On Payment in the hospital inpatient setting. CMS estimates there will be 150 cases using this device nationwide in FY 2025.
The public comment period ends November 2, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=316
October 30, 2024: Proposed Decision Memo (CAG-00466N): Implanted Pulmonary Artery Pressure Sensor (IPAPS) for Heart Failure Management
This proposed decision memo includes patient criteria, physician criteria, and that it be used under coverage with evidence development (CED). The public comment period ends November 29, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=313&=
Compliance Education Updates
September 2024: MLN006559: MLN Education Tool: Medicare Preventive Services
This tool was updated in September for the following Medicare Preventive Services:
- Alcohol misuse screening and counseling: clarified frequency policy,
- Flu Shot & Administration: Updates with the 2024-2025 flu season vaccine codes,
- Pneumococcal Shot & Administration: Added CPT code 90684, effective June 27, 2024, with an implementation date of November 25, 2024,
- Prolonged Preventive Services: Added information on the “substantive portion” and how it relates to prolonged preventive services, and
- Sexually Transmitted Infection (STI) Screening & High Intensity Behavioral Counseling (HIBC) to Prevent STIs: Removed CPT code 0353U, effective June 30, 2024, added CPT code 0455U, effective July 1, 2024, and clarified frequency policy
October 24, 2024: OIG Report (OEI-03-23-00380): Medicare Advantage: Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions
Per the OIG, in-home health risk assessments (HRAs) and HRA-linked chart reviews generated 63% of the estimated $7.5 billion in risk-adjusted payments. They also indicate that “diagnoses reported only on these types of records heighten concerns about the validity of the diagnoses or the coordination of care for MA enrollees.” https://oig.hhs.gov/documents/evaluation/10028/OEI-03-23-00380.pdf
Other Updates
September 30, 2024: Acute Hospital care at Home Initiative Fact Sheet
CMS released a report on the agency’s study of the Acute Hospital Care at Home (AHCAH) initiative, which allows certain Medicare-certified hospitals to treat patients with inpatient-level care at home.
October 2, 2024: BFCC-QIO Livanta has New Address
Effective October 7, 2024, Livanta’s mailing address for correspondence to its Beneficiary and Family Centered Care – Quality Improvement Organization (BFCC-QIO) Program changed. Their new address for U.S. postal mail is:
BFCC-QIO Program
Livanta LLC
PO Box 2687
Virginia Beach, VA 23450
You can learn more about Livanta LLC on their website at https://www.livantaqio.cms.gov/en.
CMS Case Study: Urinary Catheter Case: CMS’ Swift Action Saves Billions
CMS published this case study in response to identifying a concerning risk in urinary catheter billings attributed to a small group of 15 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supply companies that had recently changed ownership.
https://www.cms.gov/files/document/cpi-urinary-catheter-case-study.pdf
October 31, 2024: Sickle Cell Disease Provider Toolkit
CMS released a Sickle Cell Disease (SCD) Provider toolkit focused on strengthening the infrastructure across care settings to care for people with SCD, improve care management, and support the needs of people with SCD. The toolkit includes information on how CMS program coverage can assist people with SCD and educational materials for individuals with SCD and community partners who serve them. https://www.cms.gov/sites/default/files/2024-10/cms_2024_omh_scd_provider_toolkit.pdfBeth Cobb
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