Knowledge Base - Recent Articles
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
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