Insights

CMS Issues New G-Codes For Telehealth Home Health Services

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 ...

CY 2023 HCPCS Codes For Home Health Consolidated Billing

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

Novavax COVID-19 Vaccine Booster Authorized

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: ...

CY 2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule

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). ...

CY 2023 Medicare Physician Fee Schedule Final Rule

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 ...

CY 2023 End-Stage Renal Disease Prospective Payment System Final Rule

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. ...

CY 2023 Home Health Prospective Payment System Rate Update Final Rule

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 ...

CMS Announces No Cost Sharing For Bivalent COVID-19 To Children Ages 5 To 11

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 ...

Medicare Overpaid For Neurostimulator Implantation Surgeries

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 ...

CMS Releases COVID-19 PHE Unwinding FAQs

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 ...

CY 2023 Medicare Deductible, Coinsurance & Premium Rates Update

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 ...

HHS Renews COVID-19 Public Health Emergency For 90 Days

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. ...

340B Hospital Reimbursement Rate To Increase After Court Ruling

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. ...

New Grouper Edits For Home Health Claims

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 ...

AMA Releases 2023 CPT Code Set

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 ...

Monkeypox & Smallpox Vaccines: Include Product Code on Claims

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 ...

AMA Announces 8 New CPT Codes For Bivalent COVID-19 Booster Doses

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 ...

Hospital Inpatient Prospective Payment System & Long-Term Care Hospital Prospective Payment System Final Rule For Fiscal Year 2023

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). ...

Skilled Nursing Facility Prospective Payment System Final Rule For Fiscal Year 2023

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. ...

Inpatient Rehabilitation Facility Prospective Payment System Final Rule For Fiscal Year 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 ...

Inpatient Psychiatric Facility Prospective Payment System Final Rule For Fiscal Year 2023

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 ...

Hospice Payment Rate Update Final Rule For Fiscal Year 2023

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 ...

AMA Announces CPT Code Update For Monkeypox Vaccination & Testing

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. ...

New Codes For COVID-19 Novavax Vaccine, Adjuvanted

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 ...

New Codes For Moderna Vaccines For Children 6 Months Through 17 Years

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 ...

Use ICD-10 Code U09.9 For Long COVID

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. ...

2023 E/M Code Descriptors & Guidelines Summary Of Revisions

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 ...

New Codes For Pfizer-Biontech Vaccines For Children 6 Months Through 4 Years

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, ...

New ICD-10-CM Diagnosis Codes: Fiscal Year 2023

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

New ICD-10-PCS Procedure Codes: Fiscal Year 2023

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. ...

AMA Announces CPT Update For Moderna Pediatric COVID-19 vaccine

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 ...

New Administration Code for Pfizer Pediatric COVID-19 Vaccine Booster Dose

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. ...

Corrections To Home Health Billing For Denial Notices And Calculation Of 60-Day Gaps In Services

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 ...

CMS Finalizes 2023 Notice Of Benefit And Payment Parameters

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 ...

AMA Announces CPT Update For COVID-19 Booster Candidates

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. ...

CMS Releases New Codes for Moderna Vaccine Booster Doses

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 ...

HHS Extends COVID-19 Public Health Emergency

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 ...

CMS To Cover Second COVID-19 Booster Shot at No Cost

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 ...

CMS Finalizes 2023 Payment Changes For Medicare Advantage and Part D Plans

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). ...

CMS Releases Billing Code For Preventive COVID-19 Antibody Treatment

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 ...

North Carolina & Florida Home Health Agencies to See Review Choice Demonstration Changes

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 ...

CMS to Implement Claim Edit for Hospice Transfers

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 ...

CMS Releases Billing Code For New COVID-19 Omicron Variant Treatment

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: ...

CMS Delays Hospital Star Ratings Update Until July 2022

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 ...

CMS Expands Medicare Coverage For Lung Cancer Screening

The Centers for Medicare & Medicaid Services (CMS) announced a national coverage determination (NCD) that expands coverage for lung cancer screening with low dose computed tomography (LDCT) to improve health outcomes for people with lung cancer. ...

New HCPCS Code For Convalescent Plasma In Outpatient Setting

On December 28, the US Food and Drug Administration (FDA) revised the emergency use authorization for COVID-19 convalescent plasma with high titers of anti-SARS-CoV-2 antibodies. ...

CPT Update For Pediatric COVID-19 Vaccine Announced

The American Medical Association (AMA) announced an editorial update to the Current Procedural Terminology (CPT) code set to include new product and administration codes assigned to the Pfizer-BioNTech COVID-19 vaccine for children 6 months to under 5 years of age. ...

CMS Updates DMEPOS Requirements

The Centers for Medicare & Medicaid Services (CMS) has added 31 items and deleted 5 items on the Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Master List. Additionally, effective April 13, 2022, CMS is selecting items beyond Power Mobility ...
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