Insights

As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency (PHE), effective February 11, 2023, for another 90 days. Source: U.S. Department ...

On December 8, 2022, the U.S. Food and Drug Administration (FDA) amended the emergency use authorizations of the updated (bivalent) Pfizer-BioNTech and Moderna COVID-19 vaccines to include use in children down to 6 months old. Your patients may know these as “updated COVID-19 vaccines”: ...

Starting with claims for services on January 1, 2023, the 2 E/M visit families titled “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” and “Home Services” are now 1 E/M code family. The new family is titled “Home ...

Clinical Laboratory Improvement Amendments (CLIA) regulations require a facility to be appropriately certified for each test they do. CMS edits laboratory claims at the CLIA certificate level to make sure that Medicare and Medicaid only pay for laboratory tests in ...

Data on telecommunications technology use during a 30-day period of care at the patient level isn’t currently collected on the Home Health (HH) claim. While the provision of services provided via a telecommunications system must be in the patient’s plan ...

Effective, January 3, 2023, CMS will add the following codes to the home health consolidated billing non-routine supply code list: ...

On October 19, the U.S. Food and Drug Administration (FDA) amended the Novavax COVID-19 Vaccine, Adjuvanted emergency use authorization to authorize the use of a first booster dose for patients 18 years and older: ...

The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2023 hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system final rule (CMS 1772-FC). ...

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates and policy changes for Medicare payments under the calendar year (CY) 2023 Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or ...

The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2023 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule (CMS-1768-F) for renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2023. ...

The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2023 Home Health Prospective Payment System (HH PPS) Rate Update final rule (CMS-1766-F), which updates Medicare payment policies and rates for home health agencies (HHAs). This rule ...

The Centers for Disease Control and Prevention (CDC) recently expanded the use of updated (bivalent) COVID-19 vaccines to children ages 5 through 11 years. This followed the Food and Drug Administration’s (FDA) authorization of updated COVID-19 vaccines from Pfizer-BioNTech for ...

An Office of Inspector General (OIG) report found that Medicare improperly paid claims for implanted spinal neurostimulators when providers didn’t give sufficient documentation supporting medical necessity. For dates of service on or after July 1, 2021, you must ask your ...

The Centers for Medicare & Medicaid Services (CMS) has released numerous guidance documents and tools designed to help states prepare for the eventual end of the COVID-19 public health emergency (PHE), including a State Health Official Letter, Promoting Continuity of ...

Patients using covered Part A and Part B services may be subject to deductible and coinsurance requirements. Medicare subtracts an inpatient hospital deductible amount from the amount payable to the hospital for inpatient hospital services it provides in a spell ...

As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency (PHE), effective October 13, 2022, for another 90 days. ...

On September 28, 2022, the United States District Court for the District of Columbia vacated the differential payment rates for 340B-acquired drugs in the Calendar Year 2022 Outpatient Prospective Payment System (OPPS) final rule with respect to their prospective application. ...

The Home Health (HH) Grouper program has various data validity edits that make sure it uses consistent and accurate data when calculating payment groups on HH claims. Of these edits, currently only a principal diagnosis not assigned to a clinical ...

Building on its efforts to reduce administrative tasks in medicine, the American Medical Association (AMA) has released the 2023 Current Procedural Terminology (CPT) code set. Modifications to the E/M codes are among 393 editorial changes in the 2023 CPT code ...

The U.S. Centers for Medicare & Medicaid Services (CMS) had announced in August 2022 to only bill for monkeypox & smallpox vaccine administration when you got the vaccine at no cost from the government. CMS has now clarified that the ...

The American Medical Association (AMA) today announced an editorial update to Current Procedural Terminology (CPT), that includes eight new codes for the bivalent COVID-19 vaccine booster doses from Moderna and Pfizer-BioNTech. The updated boosters are adapted for the BA.4 and ...

he Centers for Medicare & Medicaid Services (CMS) issued the fiscal year (FY) 2023 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) final rule (CMS-1771-F). ...

The Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS 1765-F) that updates Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment System (SNF PPS) for fiscal year (FY) 2023. ...

The Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1767-F) to update Medicare payment policies and rates under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program (QRP) for fiscal year ...

The Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1769-F) to update Medicare payment policies and rates for the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) for fiscal year (FY) 2023. Here’s a summary of the ...

The Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1773-F) that updates Medicare hospice payments wage index, quality reporting programs, and policies for Fiscal Year (FY) 2023 in accordance with existing statutory and regulatory requirements. Here’s a ...

The American Medical Association (AMA) announced an editorial update to Current Procedural Terminology (CPT), that includes a new laboratory test code for the orthopoxvirus and two codes for the vaccines being utilized to prevent monkeypox infection. ...

The U.S. Food and Drug Administration (FDA) authorized emergency use of the Novavax COVID-19 vaccine, Adjuvanted for the prevention of COVID-19 disease in patients 18 years and older. The U.S. Centers for Medicare & Medicaid Services (CMS) issued 3 new ...

The U.S. Food and Drug Administration (FDA) amended the Moderna COVID-19 vaccine emergency use authorization to authorize use for all patients 6 months through 17 years of age. The U.S. Centers for Medicare & Medicaid Services (CMS) issued 7 new ...

For a post COVID-19 condition, unspecified, like Long COVID, use code DX U09.9. Add other codes for conditions related to the COVID-19 infection, like R50.9 for fever. ...

After implementing the 2020 Medicare Physician Fee Schedule Final Rule provision, which included revisions to the Evaluation and Management (E/M) office visit Current Procedural Terminology (CPT) (99201-99215) code descriptors and documentation standards that directly addressed the continuing problem of administrative ...

On June 17, 2022, the U.S. Food and Drug Administration (FDA) amended the Pfizer-BioNTech COVID-19 vaccine emergency use authorization to authorize use for all patients 6 months through 4 years of age. CMS issued new CPT codes effective June 17, ...

The fiscal year 2023 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis code files and guidelines are now available. ...

The Centers for Medicare & Medicaid Services (CMS) has published the 2023 ICD-10 Procedure Coding System (ICD-10-PCS) codes and guidelines for the 2023 fiscal year. ...

The American Medical Association (AMA) announced an editorial update to Current Procedural Terminology (CPT), that includes new product and administration codes assigned to the Moderna COVID-19 vaccine for children 6 months through 5 years old. The provisional CPT codes are ...

On May 17, 2022, the U.S. Food and Drug Administration (FDA) amended the Pfizer-BioNTech COVID-19 vaccine emergency use authorization (PDF) to authorize the use of a single booster pediatric dose (orange cap) for all patients 5 – 11 years old. ...

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 12657, removing the requirement to submit a Notice of Admission (NOA) before billing for home health denials. CMS will process home health claims without an election period on ...

The Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) released the 2023 Notice of Benefits and Payment Parameters Final Rule, finalizing many of the proposed changes. Overall, the final rule seeks to ...

The American Medical Association (AMA) announced an editorial update to Current Procedural Terminology (CPT), that includes newly assigned provisional CPT codes for COVID-19 booster candidates from Pfizer and Sanofi-GlaxoSmithKline. ...

On March 29, the Food and Drug Administration (FDA) authorized a second Moderna COVID-19 vaccine booster dose for adults aged 50 and older and certain immunocompromised adults. Following this, the Centers for Medicare & Medicaid Services (CMS) released Current Procedural ...

As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency (PHE), just ahead of its April 16 expiration date, providing an extension ...

The Centers for Medicare & Medicaid Services (CMS) announced it will pay for a second COVID-19 booster shot of either the Pfizer-BioNTech or Moderna COVID-19 vaccines without cost sharing, as it continues to provide coverage for this critical protection from ...

The Centers for Medicare & Medicaid Services (CMS) announced Calendar Year (CY) 2023 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (the Rate Announcement). ...

On February 24, 2022, the U.S. Food and Drug Administration (FDA) revised the emergency use authorization for tixagevimab co-packaged with cilgavimab (EVUSHELD™) to change the initial dose for the authorized use as pre-exposure prophylaxis of COVID-19 in certain adults and ...

The Centers for Medicare & Medicaid Services (CMS) announced that beginning April 1, 2022, home health agencies in Florida (FL) and North Carolina (NC) will be subject to a 25% reduction in payment if they choose not to participate in ...

Effective July 1 2022, a claims processing edit to prevent gap billing between hospice transfers will be implemented. Per Change Request (CR) 12619 Gap Billing Between Hospice Transfers, a patient can change hospices only once per benefit period (60-day or ...

On February 11, the US Food and Drug Administration (FDA) authorized the emergency use of the monoclonal antibody bebtelovimab for the treatment of mild-to-moderate COVID-19 in adult and pediatric patients when all of these apply: ...

The Centers for Medicare & Medicaid Services (CMS) announced that it will delay updating the Overall Hospital Quality Star Ratings on the Care Compare website from April until July 2022 so it can correct a calculation error in the calendar ...