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September 2023 Medicare Coverage, COVID-19 and Other Updates
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Coverage Updates


September 6, 2023: National Coverage Determination (NCD) Dashboard

CMS released an NCD dashboard that was last updated on August 23, 2023. This document details the seven accepted NCD requests that are on the CMS Wait List, the four open NCD topics currently undergoing a National Coverage Analysis (NCA) with opportunities for public comment, and the two NCDs finalized in the past twelve months. Links to all thirteen topics are included in this document.

COVID-19 Update

September 11, 2023: FDA Approves and Authorizes Updated COVID-19 Vaccines

The FDA has approved an update COVID-19 vaccine that was developed to target current circulating variants. The updated mRNA vaccines for 2023-2024 were manufactured by ModernaTX Inc. and Pfizer Inc. and have been updated to include a monovalent (single) component that corresponds to the Omicron variant ZBB.1.5.


September 14, 2023: Special MLN Connects: COVID-19 Updated mRNA Vaccines for Patients 6 Months or Older

CMS issues a special MLN Connects announcing the FDA’s approval of updated vaccines noting that the CDC recommends everyone 6 months and older get an updated COVID-19 vaccine. Also includes in this announcement are six new CPT codes effective September 11, 2023 for the vaccine and administration of the vaccine.

Other Updates

September 14, 2023: MLN Connects: Social Determinants of Health Resources

In this edition of MLN Connects, CMS let providers know about a new CMS infographic to help you understand and use Z codes. They also included links to additional resources.


As a reminder, effective October 1, 2023, CMS finalized their proposal to change the severity level designation for diagnosis codes Z59.00 (Homelessness, unspecified), Z59.01 (Sheltered homelessness), and Z59.02 (Unsheltered homelessness) from NonCC to CC.


September 19, 2023: CMS Requires States to Pause Disenrollments and Reinstate Coverage for Impacted Individuals

CMS indicated in a Press Release that they issued a call to action on August 30 about a potential issue where systems were inappropriately disenrolling children and other enrollees, even when the state had information indicating the person was still eligible for Medicaid coverage. As of September 19, 30 states report having system issues and “as a result, to avoid CMS taking further action, all 30 states were required to pause procedural disenrollments for impacted people unless they could ensure all eligible people are not improperly disenrolled due to this issue.”

Beth Cobb

New Place of Service Code 27 - "Outreach Site/Street"
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Did You Know?

Effective October 1, 2023, there is a new Place of Service (POS) Code 27 – “Outreach Site/Street.” This POS is defined as “a non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals.”


In the August 10th Transmittal 12202, CMS indicated that “Medicare has not identified a need for this new code. However, in order to comply with HIPAA and its goals of promoting administrative simplification, contractors are to accept claims containing this new code in accordance with its effective date. Medicare contractors shall therefore implement the systems and/or local-contractor-level changes needed for Medicare to return as unprocessable claims with the new code should it appear on a Medicare claim.”


Why it Matters?

On September 20, 2023, CMS rescinded Transmittal 12202 and replaced it with Transmittal 12254 indicating that the transmittal has been revised to “align with broader CMS efforts to address economic, social, and other obstacles impacting Medicare beneficiary healthcare access by revising the IOM as well as the policy section and business requirements 13313.2.”


The policy note has changed to indicate that “Contractors are to accept claims containing this new code in accordance with its effective date. Medicare contractors shall therefore implement the systems and/or local-contractor-level changes needed for processing claims with the new code should it appear on a Medicare claim.”


What Can I Do?

Make sure key stakeholders at your facility are aware of this change to the new POS Code 27.




August 10, 2023 Transmittal 12202: New Place of Service (POS) Code 27 – “Outreach Site/Street”


September 20, 2023 Transmittal 12254: New Place of Service (POS) Code 27 – “Outreach Site/Street”

Beth Cobb

September 2023 Medicare Transmittals and MLN Articles
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 | Billing 
 | Coding 

Medicare Transmittals & MLN Articles


August 28, 2023: MLN MM13350: Changes to the Laboratory National Coverage Determination Edit Software: January 2024 Update

Billing staff need to know about newly available codes, recent coding changes, and how to find NCD coding information. CMS noted that there are no policy changes in this ICD-10 quarterly update. Instead, they follow the current, longstanding NCD process to implement policy changes.


August 28, 2023: MLN MM13335: Inpatient Psychiatric Facilities Prospective Payment System: FY 2025 Updates

This article discusses changes for FY 2024 that are effective October 1, 2023. Make sure your billing staff knows about FY 2024 market basket update, wage index update, and changes to the Inpatient Psychiatric Facility (IPF) Quality Reporting Program (IPFQRP).


August 31, 2023: MLN MM13353: Ambulatory Surgical Payment System: October 2023 Update

CMS advises in this MLN article that you make sure your billing staff knows about the new HCPCS code for renal/kidney histotripsy, the new drugs and biological codes, and the new skin substitute HCPCS codes.


September 6, 2023: MLN MM13340: Hospital Outpatient Prospective Payment System: October 2023 Update

This article highlights new COVID-19 CPT vaccines and administration codes, proprietary laboratory analyses (PLA) coding changes, multianalyte assays with algorithmic analyses (MAAA) CPT coding change, advanced diagnostics tests (ADLTs) under the clinical lab fee schedule (CLFS) and HCPCS code changes.


September 6, 2023: MLN MM13343: DMEPOS Fee Schedule: October 2023 Quarterly Update

Make sure your billing staff knows about fee schedule adjustment relief for rural and non-contiguous areas, new HCPCS codes added, and new fee schedule amounts.


September 12, 2023: MLN MM11262: Limitation on Recoupment of Overpayments

This article reviews how Medicare recoups overpayments and how appeals and reconsiderations affect the recoupment process.


September 14, 2023: MLN MM13306: Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2024 Changes

Highlights of policy changes for FY 2024 are included in this MLN article. Of note, CMS indicates that for FY 2024, hospitals have until late-September to notify them of any errors in the calculation of their Total Hospital Acquired Conditions (HAC) Reduction Program score. For this reason, the list of hospitals subject to the HAC Reduction Program will not be available by October 1, 2023. They note that “until we issue a final list of hospitals that are subject to the HAC Reduction Program for FY 2024, MACs will hold hospital claims. We anticipate issuing the list on or about October 3, 2023.”


September 19, 2023: MLN MM13166: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2023 Update

Relevant NCD coding changes in related Change Request 13166 include:

  • NCD 20.20: External Counterpulsation Therapy (ECP) for Severe Angina, effective August 7, 2023,
  • NCD 90.2: Next Generation Sequencing (NGS), effective August 7, 2023, and
  • NCD 210.1: Prostate Screening Tests, effective October 1, 2023.

Beth Cobb

Happy Clinical Documentation Integrity Week 2023
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 | Coding 

We are mid-way through a week of celebrating Clinical Documentation Integrity Specialists. This year marks the 13th annual Clinical Documentation Integrity (CDI) Week. The Association of Clinical Documentation Integrity Specialists (ACDIS) theme for 2023 is CDI Success Stories: Writing your next chapter!

Like the detective in a good who done it book, CDI specialists review records to make sure all the key elements are in a patient’s “story.” They look for clues (clinical indicators) without a documented diagnosis and documentation without supporting clues and then work with physicians to make sure the record reflects the patient’s complete story.

MMP would like to wish all the hard-working CDI Professionals that we have the privilege to work with a happy CDI week. To help you prepare for the new CMS fiscal year, while celebrating this week, here are links to key documentation needed for a successful October 1st start of the 2024 CMS fiscal year.   


FY 2024 IPPS Final Rule Home Page

On this webpage you will find links to:

  • The FY 2024 IPPS Final Rule,
  • FY 2024 Final Rule Tables
    • Table 5: MS-DRGs, Relative Weighting Factors, Geometric and Arithmetic Mean Lengths of Stay, and Post-Acute Transfer designated MS-DRGs
    • Table 6: New Diagnosis Codes,
    • Table 6B: New Procedure Codes
    • Table 6I: Complete MCC List,
    • Table 6I.1: Additions to the MCC List,
    • Table 6I.2: Deletions to the MCC List,
    • Table 6J: Complete CC list,
    • Table 6J.1: Additions to the CC list,
    • Table 6J.2: Deletions to the CC list
  • FY 2024 MAC Implementation Files
    • MAC Implementation File 7: FY 2024 MS-DRGs Subject to the Replaced Devices Policy,
    • MAC Implementation File 8: FY 2024 New Technology Add-on Payment


2024 ICD-10-CM Files.)

Downloads available on this webpage includes:

  • 2024 POA Exempt Codes,
  • 2024 Conversion Table,
  • 2024 Addendum – UPDATED 6/29/2023,
  • 2024 Code Description in Tabular Order – UPDATE 6/29/2023,
  • 2024 Code Tables, Tabular and Index UPDATED 6/29/2023,
  • FY 2024 ICD-10-CM Coding Guidelines, and
  • 2024 Errata – July 26, 2023.



The ICD-10-Files are also available on the CDC’s Comprehensive Listing ICD-10-CM Files webpage (

2023 ICD-10-PCS Files

Downloads available on this webpage includes:

  • 2024 ICD-10-PCS Order File,
  • 2024 Official ICD-10-PCS Coding Guidelines,
  • 2024 Version Update Summary,
  • 2024 ICD-10-PCS Codes File,
  • 2024 ICD-10-PCS Conversion table,
  • 2024 ICD-10-PCS Code Tables and Index, and
  • 2023 ICD-10-PCS Addendum.


Again, happy CDI week from our team to yours.


Beth Cobb

PSMA PET Imaging for Prostate Cancer
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September is Prostate Cancer Awareness Month. Prostate cancer is the second leading cause of male cancer-related death in the U.S.[1] According to the American Cancer Society, it is estimated that in 2023 there will be 288,300 new cases of prostate cancer and 34,700 prostate-cancer related deaths in the U.S.[2]

Historically, there have been limited options in managing patients with advanced prostate cancer. However, in the last several years, we have seen remarkable progress in the development of new diagnostic and therapeutic tools. One of these, PSMA PET imaging for prostate cancer, is a particularly exciting development and is the focus of this article. Medical oncologist Michael Morris from Memorial Sloan Kettering Cancer Center calls this new imaging technology “the biggest advance in prostate cancer detection since the PSA test was developed in the 1980s.”[3]

PSMA PET Imaging: A New Diagnostic Tool

Prostate-Specific Membrane Antigen, or PSMA, is a protein that is present at a higher level in prostate cancer cells, and in addition, is often found on the surface of prostate cells.[4] These characteristics of PSMA make it a good target for imaging prostate cancer that might have escaped from the prostate and traveled to other parts of the body. PSMA should not be confused with Prostate-Specific Antigen, or PSA, which is a protein produced by the prostate.[5] The PSA test measures the level of PSA in the blood. An elevated PSA in the blood can be an indication of prostate cancer, although it can be due to other factors.

Imaging for advanced prostate cancer has been problematic for many years, with men often having to undergo a conventional CT scan and a bone scan to see if there is evidence of metastatic disease. However, according to the National Cancer Institute, both of these conventional imaging technologies have limitations since “neither is particularly good at finding individual prostate cancer cells, and thus can miss very small tumors.”[6] PSMA PET imaging promises to improve the sensitivity of detecting prostate cancer metastases compared to conventional imaging approaches, and thereby better inform the treatment and management of patients with advanced disease.[7]

Clinical trials have shown some promising results for this new imaging technology. For example:

  • In the CONDOR trial, a total of 208 men were enrolled in the study. The men had a rising PSA after surgery or radiotherapy. The study evaluated the radiotracer 18F-DCFPyL and its ability to detect prostate cancer in these men when performing a PET/CT. The trial demonstrated that the radiotracer correctly localized disease in approximately 85% of men with prostate cancer biochemical recurrence, all of whom had uninformative conventional imaging.[8]
  • In another trial, 276 prostate cancer patients were enrolled to evaluate the clinical impact of 68Ga-prostate-specific membrane antigen positron emission tomography/computed tomography on the planned management of prostate cancer patients with biochemical recurrence after surgery.[9] It was found that the use of this imaging technology allowed clinicians to radically change the intended treatment approach before imaging evaluation, in roughly two out three individuals.

FDA Approvals

During the last several years, the FDA has approved several radioactive tracers for use in PSMA PET imaging. For example:

  • On December 1, 2020, the FDA approved the radioactive tracer Gallium (Ga) 68 PSMA-11 for use in PET imaging of patients with suspected prostate cancer metastasis who are potentially curable by surgery or radiation therapy.[10] The tracer can also be used for patients with suspected prostate cancer recurrence based on elevated serum PSA levels.
  • On May 26, 2021, the FDA approved a second PSMA-targeted PET imaging drug, Pylarify (piflufolastat F 18), for the same prostate cancer imaging indications as Ga 68 PSMA-11.[11] The FDA noted that with this approval, certain men with prostate cancer will have greater access to PSMA-targeted PET imaging that can aid health care providers in assessing prostate cancer.

Additional FDA approvals have followed for Illuccix (gallium Ga 68 gozetotide) (12/17/2021)[12], Locametz (gallium Ga 68 gozetotide) (3/23/2022)[13], and Posluma (flotufolastat F 18) (5/25/2023)[14].

Once a PSMA-targeted radioactive tracer is injected into the patient, the tracer travels throughout the body and attaches to PSMA; the cells thus flagged will then “light up” when a PET scan is performed.[15]

PSMA Tracers by the Numbers

To measure the growth in utilization of this new imaging technology, RealTime Medicare Data constructed a Tableau visualization using its nationwide Medicare Fee-for-Service (FFS) paid claims database. Here is some key trending information from that visualization:

PSMA Tracer Procedure Volume by Place of Service

Data Source: RealTime Medicare Data, LLC. Time period: 12/1/2020-3/31/2023. Geography: all 50 states and D.C. CMS 1500 Office POS and Outpatient Hospital Medicare Fee-for-Service. The following HCPCS Codes were included in the data queries: A9593-GALLIUM GA-68 PSMA-11 DIAGNOSTIC UCSF 1 MCI, A9594-GALLIUM GA-68 PSMA-11 DIAGNOSTIC UCLA 1 MCI, A9595-PIFLUFOLASTAT F-18 DIAGNOSTIC 1 MCI, A9596-GALLIUM GA-68 GOZETOTIDE DIAG ILLUCCIX 1 MCI, A9597-POSITRON EMISSION TOMOGRAPHY RP DX TUMOR ID NOC, and A9800-GALLIUM GA-68 GOZETOTIDE DIAGNOSTIC 1 MCI. PDx's not related to prostate cancer, and CPT Modifier 26 (relating to professional fees), were filtered from the data.

As the above chart indicates, PSMA tracer utilization among the Medicare FFS population has increased substantially over the study period, especially during CY 2022. In addition, there has been a shift in the place of service where these procedures are being performed; indeed, by 2022 procedure volume in the Office setting was fast approaching that in the Outpatient Hospital setting.

From Imaging to Targeted Therapy

In addition to being a target for prostate cancer imaging, can PSMA be a target for prostate cancer therapy? In 2022, the FDA weighed into this question with these exciting developments:

  • On March 23, 2022, the FDA approved Pluvicto (lutetium Lu 177 vipivotide tetraxetan) for the treatment of adult patients with PSMA-positive metastatic castration-resistant prostate cancer who have been treated with androgen receptor pathway inhibition and taxane-based chemotherapy.[16]
  • On the same day, the FDA approved the radioactive tracer Locametz (gallium Ga 68 gozetotide) for positron emission tomography (PET) of PSMA-positive lesions, including the selection of patients with metastatic prostate cancer for whom lutetium Lu 177 vipivotide tetraxetan PSMA-directed therapy is indicated.[17] The FDA noted that Locametz is the first radioactive tracer approved for patient selection in the use of a radioligand therapeutic agent.

Pluvicto acts by binding to PSMA; a radioactive particle then kills the cancer cells.[18] In a clinical trial leading to the FDA approval, the trial demonstrated a statistically significant improvement in the primary endpoints of overall survival and radiographic progression-free survival.[19]

Questions remain as to who might be able to receive the new therapy drug beyond those who have already been treated with chemotherapy, whether it will benefit patients during earlier stages of prostate cancer, and whether its effectiveness will be improved if combined with other therapies.[20]

Disclaimer: This article does not provide medical advice. It is intended for general informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article.

Curtis Spraitzar

IPPS FY 2024 New Technologies
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“The primary objective of the IPPS and the LTCH PPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs, while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs in delivering necessary care to Medicare beneficiaries.”

  • Source: Appendix A: Economic Analysis of FY 2024 IPPS Final Rule


There are eighteen days until the October 1st start to the 2024 CMS Fiscal Year. As you continue to prepare, this article focuses on New Technologies Add-On Payments (NTAPs). Section E. Add-On Payments for New Services and Technologies for FY 2024 begins on page 58,793 of the FY 2024 IPPS Final Rule.


New Technologies Eligible for Add-On Payment (NTAPs) Background

Section 1886(d)(5)(K)(i) of the Act requires the Secretary to establish a mechanism to recognize the costs of new medical services and technologies under the payment system under the subsection which establishes the system for paying for the operating costs of inpatient hospital services.


The system of payment for capital costs is established in section 1886(g) of the Act. For this reason, capital costs are not included in the add-on payments for a new medical service or technology.  


NTAPs are not budget neutral and the “newness” for payment is limited to the 2-to-3-year period after the date a technology becomes available.


In response to the COVID-19 public health emergency (PHE) and as new therapies received approval to treat COVID-19, CMS established the New COVID-19 Treatments Add-on Payment (NCTAP). With the PHE ending in May of this year, the add-on payments for NCTAPs will end September 30, 2023.


There are three pathways for a new service or technology to be approved for the add-on payment (Traditional pathway, Certain Antimicrobial Products Alternative Pathway, and Certain Transformative New Devices Alternative Pathway).


For the alternative pathways, a technology is not required to have a specified FDA designation at the time the application for NTAP is made. Instead, “CMS reviews the application based on the information provided by the applicant only under the alternative pathway specified by the applicant at the time of new technology add-on payment application submission. However, to receive approval for the new technology add-on payment under that alternative pathway, the technology must have the applicable FDA designation and meet all other requirements in the regulations in § 412.87(c) and (d), as applicable.”


Coding NTAPs

Section X New Technology was added to ICD-10-PCS effective October 1, 2015. CMS has indicated ( that “Section X was created in response to public comments received regarding New Technology proposals presented at ICD-10 Coordination and Maintenance Committee Meetings, and general issues facing classification of new technology procedures.”  To receive payment for an eligible NTAP, the applicable section X New Technology ICD-10-PCS code must be on the claim submitted for adjudication.


NTAPs by the Numbers

Before looking ahead to FY 2024, I wanted to see what new technologies have been coded in FY 2023 claims with dates of service from October 1, 2022 through March 31, 2023. The following claims volume was provided by our sister company RealTime Medicare Data (RTMD), represents claims volume for the entire nation, and is specific to the Medicare Fee-for-Service population.   

FY 2023

25: The number of technologies eligible for add-on payment.


94,210: The number of claims with dates of service from October 1, 2022 through March 2023 that included an ICD-10-PCS code eligible for add-on payment.


7,551: The number of claims with an ICD-10-PCS new technology code when the technologies eligible for the COVID-19 Treatments Add-On Payment (NCTAP) (convalescent plasma, Olumiant, and Veklury® (remdesivir)) were excluded from the claims volume. 


FY 2024

33: The number of technologies eligible for add-on payment.


58,524.5: The number of Medicare beneficiaries that CMS expects will receive one of the new technologies. Note, the .5 is not an error. CMS’ estimated cases for the NTAP Livtencity™ is 129.5 cases.


$495,497,861.97: CMS’ estimated Medicare spending on NTAPs in FY 2024.


Moving Forward

Identifying and coding new technologies is an opportunity not to be missed for those hospitals providing these services. That said, some questions come to mind for you to think about:

  • Is your hospital providing any of these services or technologies?
  • Who needs to be aware of what the new technologies are? (i.e., Physicians, Pharmacy, Coding Professionals, Clinical Documentation Integrity Specialists, Case Managers)
  • What process do you have in place to alert your Coding Staff of the need to code the new technology ICD-10-PCS codes?



FY 2024 IPPS CMS webpage:

Beth Cobb

FAQ: Mixed Hyperlipidemia with Hypercholesterolemia (Pure)
Published on 


 | Coding 

We have a couple of questions regarding the coding of hyperlipidemia with hypercholesterolemia.



If a provider has documented mixed hyperlipidemia and hypercholesterolemia in the record, do you code both conditions?


Only assign code E78.2 for mixed hyperlipidemia.  Pure hypercholesterolemia, unspecified (E78.00) is included with code E78.2 so it is not coded separately. 

Effective date:  June 9, 2023



How do you code unspecified hyperlipidemia and hypercholesterolemia?


In this case, only the code for pure hypercholesterolemia, unspecified (E78.00) is assigned.  Hyperlipidemia, unspecified (E78.5) is not coded separately since hypercholesterolemia identifies the specific blood lipid elevated.

Effective date:  June 3, 2022


Hypercholesterolemia is defined as a high blood cholesterol level.

Hyperlipidemia is defined as high lipid or fat levels in the blood. 



ICD-10-CM Official Coding Book

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2023, Page 9

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2022, Pages 5 and 6

Susie James

A New Place of Service Code, Review Choice Demonstration for IRF Services FAQs, and Draft Guidance for Out-Of-Pocket Drug Costs
Published on 


 | Coding 
 | Billing 

August 10, 2023: New Place of Service Code 27 – Outreach Site/Street

CMS published Change Request (CR) 13314 to inform providers about the new Place of Service (POS) code 27 for “Outreach Site/Street” – a non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals. This code becomes effective on October 1, 2023.


In the August 25th MLN connects e-newsletter, CMS noted “at this time, Medicare won’t use this code in claims processing. If you submit a claim with this code, we’ll return it to you.”


August 10, 2023: Review Choice Demonstration for Inpatient Rehabilitation Facility Services FAQs

On May 15, 2023, CMS announced the new initiative, The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services. This demonstration started in Alabama with the first cycle of review dates being August 21, 2023 through February 29, 2024.


Palmetto GBA Jurisdiction J is the Medicare Administrative Contractor for Alabama, and they have a dedicated webpage specific to this demonstration ( On August 28th, they posted a link to FAQs. Topics covered in this document include general questions, choice selection questions, submission questions, pre-claim review (PCR) questions, and medical necessity questions.


For IRF Providers outside of Alabama, I encourage you to pay close attention to the general question 4 asking what states does this demonstration impact.


CMS notes the demonstration initially for providers physically located in the state of Alabama and bill to MAC Jurisdiction J. The demonstration will then expand to Pennsylvania, Texas, and California, “as well as any state that bill to the MAC jurisdictions JJ, JL, JH, and JE, regardless of where they are physically located.”


Here is one example included in the answer to question 4:

I am an IRF located in a demonstration state but bill to a different MAC than the one for that state.

“You are included in the demonstration if the MAC that you bill to is JJ, JE, JL, or JH. If you bill to another MAC, then you are not included in the demonstration.”

You can find additional information about this demonstration on the CMS website at


August 21, 2023: CMS Issues Draft Guidance on New Program to Allow People with Traditional Medicare Fee-for-Service to Pay Out-of-Pocket Prescription Drug Costs in Monthly Payments

The Inflation Reduction Act of 2022 was signed into law on August 16, 2022. This law caps annual out-of-pocket prescription drug costs at $2,000 for 2025.


In addition to capping the out-of-pocket amount, the law gives people with Medicare prescription drug coverage (Medicare Part D) the option to make monthly payments spread over the year, also starting in 2025. On August 21st, CMS published draft guidance for comment outlining the requirements and procedures for spreading out the cost sharing over the year.


Due to the size of the new program, CMS indicated they would release the guidance in two parts. Part one was released August 21st and focuses on “helping Medicare Part D plan sponsors and pharmacies prepare for the new programs and build necessary infrastructure for successful implementation.” CMS is soliciting comments on topics and strategies included in the guidance to ensure eligible Part D enrollees benefit from the programs.


You can submit comments to CMS on the first draft guidance through September 30, 2023.


The planned release date for part two of the guidance will be in early 2024. This second release will focus on Medicare Part D enrollee outreach and education, Medicare Part D plan bid information, monitoring and compliance. “CMS also intends to develop tools, such as calculators, to help people with Medicare Part D and their caregivers learn what monthly payments may look like under the new program.”


Links to a Fact Sheet about the Medicare Prescription Payment Plan, an implementation timeline, and the August 21st draft guidance are included in an August 21st CMS Press Release.

Beth Cobb

SMRC Error Rate for No Response to ADRs
Published on 



Did You Know?

Noridian Healthcare Solutions, LLC (Noridian) is the current Supplemental Medical Review Contractor (SMRC). “With CMS directed topic selections and timeframes, Noridian conducts nationwide medical reviews (Part A, Part B, and DME), in accordance with all applicable statutes, laws, regulations, national and local coverage determination policies, and coding guidance, to determine whether Medicare claims have been billed in compliance with coverage, coding, payment, and billing practices.”


Reviews are assigned to the SMRC based on analysis of national claims data issues identified by other Federal agencies (i.e., OIG, Government Accountability Office (GAO), the Comprehensive Error Rate Testing Program (CERT), and Program for Evaluating Payment Patterns Electronic Report (PEPPER)).


Why It Matters?

As of August 15, 2023, the SMRC has thirteen current projects. Examples of current projects includes hyperbaric oxygen of lower extremities diabetic wounds, hospice general inpatient (GIP) level of care, cryosurgery of the prostate, and Mohs surgery.


Also, as of August 15, 2023, Noridian has completed sixty projects since being awarded the $227 million SMRC contract by CMS in 2018. Error rates for their completed projects range from 1% to 98%.


The 1% error rate was for a sample of claims reviewed related to the 20% add-on payment for COVID-19 that was in place during the COVID-19 Public Health Emergency. The 98% error rate was for a review of claims for Medicare Part B emergency ambulance services.


In July of this year, in addition to reporting an error rate for the reviewed claims, Noridian began reporting an error rate for the number of claims denied due to no response to an Additional Documentation Request (ADR). To date, SMRC medical review findings that include the no response error rate, includes:


Project 01-080: Vitamin B12 with Modifier 25 Findings of Medical Review

Error Rate for Reviewed Claims: 43%

No Response to ADR Denials: 39%

Results Published July 18, 2023


Project 01-081: Outpatient Dental Services CPT 41899 Findings of Medical Review

Error Rate for Reviewed Claims: 95%

No Response to ADR: 20%

Results Published July 18, 2023


Project 01-093: Overlapping Claims – Hospital Transfers During the PHE Findings of Medical Review

Error Rate for Reviewed Claims: 12%

No Response to ADR: 8%

Results Published July 18, 2023


Project 01-050: Podiatry Findings of Medical Review

Error Rate for Reviewed Claims: 45%

No Response to ADR Denials: 29%

Published August 8, 2023


Project 01-072: Neurostimulator Implantation Findings of Medical Review

Error Rate for Reviewed Claims: 39%

No Response to ADR Denials: 23%

Results Published August 15, 2023


Noridian notes they must notify CMS of identified improper payments and noncompliance with documentation requests. They will initiate claims adjustments and/or overpayment recoupment by the standard overpayment recovery process.


What Can I Do?

First and foremost, make sure you have a process to receive and respond to ADR requests from the SMRC and other review contractors (i.e., CERT).


If a claim is denied for no receipt of documentation, you can complete the following steps posted to the Noridian Jurisdiction E (JE) MAC website:


SMRC Reviews Denied for No Documentation

“When a claim is denied for no receipt of documentation requested by the SMRC, the next step is to submit the documentation to the MAC that issued the demand letter for the overpayment. This must occur within 120 calendar days of the demand letter.


This situation is considered a reopening and the MAC will send the submitted documentation to the SMRC for a re-review decision. The SMRC has up to 60 calendar days to make this decision. The SMRC will then mail a letter to the supplier with their findings, either to pay the claim or they will outline the reasons for denial.


The SMRC will next notify the MAC of the payment or denial decision. The MAC will adjust the claim and a remittance advice with the adjustment results will be generated. The provider has the right to appeal the SMRC decision, if the claim remains denied.


Based on the timeframes and steps listed above, please call the MAC about the status of the SMRC re-review only after at least 140 days have passed from when documentation was sent.”


Last, become familiar with information available on the SMRC website ( 

Beth Cobb

August 2023 Medicare Transmittals and MLN Articles
Published on 


 | Billing 
 | Coding 

July 21, 2023: MLN MM13240: Patient Driven Payment Model Claim Edits

CMS advises that Skilled Nursing Facilities (SNFs) and Hospitals need to make sure your billing staff knows about edits for SNFs billing on Type of Bill (TOB) 21X and Swing Bed TOB 18X, and hospitals billing during an interrupted stay.


July 21, 2023: MLN MM13248: Processing Services During Disenrollment from the Program of All-Inclusive Care for the Elderly (PACE)

Hospitals, SNFs and other providers billing Medicare Administrative Contractors (MACs) for inpatient services they provide to PACE-eligible Medicare patients need to make sure your billing staff knows how CMS handles payment for Medicare patients disenrolling from PACE and condition codes and value code (VC) CMS requires to prevent claims denials.


July 27, 2023: MLN MM13275: ESRD Prospective Payment System: October 2023 Update

Make sure your billing staff knows about billing J0889 for daprodustat and new ICD-10-CM codes for comorbidity payment adjustment and acute kidney injury.


Augst 3, 2032: MLN MM13299: HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement: October 2023 Update

Make sure billing staff knows about updates to the lists of HCPCS codes that are subject to the CB provision of the SNF prospective payment system (PPS), and additions and deletions of certain chemotherapy, blood clotting factors, and therapies inclusion codes from the Medicare Part A SNF files.


August 10, 2023: MLN MM13289: Hospice Payments: FY 2024 Update

This article provides information about payment rates, inpatient and aggregate caps and wage index update effective October 1, 2023 for hospices and providers billing for hospice services.


August 16, 2023: SE19007 Revised: Activation of Validation Edits for Providers with Multiple Service Locations

This special edition MLN article was originally published on March 26, 2019 and recently updated for the fifth time on August 16th. CMS has added information about the practice location address screen for round 3 testing Substantive changes are in dark red on pages 3 and 4.


Effective August 1, 2023, CMS started deploying the systematic validation edits requirements in Section 170 of the Medicare Claims Processing Manual, Chapter 1. MACs have been told to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t exactly match.


CMS notes in the MLN article that they “expect that the almost 7-year time frame that the edits haven’t been active gave you ample time to validate your claims submission system and the PECOS information for your off-campus provider departments are exact matches.”


August 17, 2023: MLN MM13321: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

Make sure your billing staff know about private payor data reporting (you must report data between January – March 2024), general specimen collection fee increase, and new and deleted HCPCS codes.


August 24, 2023: Transmittal 12222: Inpatient Psychiatric Facilities Prospective Payment System Updates for Fiscal Year 2024

This Change Request (CR) 13335 identifies changes that are required as part of the annual IPF PPS update and applicable to discharges occurring from October 1, 2023 through September 30, 2024.

Beth Cobb

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