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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.

https://www.cms.gov/files/document/mm13993-hospital-outpatient-prospective-payment-system-april-2025-update.pdf

 

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. 

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.

 

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.

 

 

 

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.

 

 

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-sheet

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.

  https://www.cms.gov/files/document/mm13887-medicare-physician-fee-schedule-final-rule-summary-cy-2025.pdf

   

  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