Insights

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 ...

CPT Code For The Third Dose Of Pfizer’s Pediatric COVID-19 Vaccine Announced

The American Medical Association (AMA) announced an update to the Current Procedural Terminology (CPT) code set that includes a new vaccine administration code for a third dose of the pediatric COVID-19 vaccine developed by Pfizer. ...

CMS Announces New ICD-10 Codes For COVID-19 Monoclonal Antibodies

The Centers for Medicare & Medicaid Services (CMS) is implementing 2 new procedure codes, in addition to the 7 new procedure codes announced in November 2021, bringing the total to 9 new procedure codes, to describe the introduction or infusion ...

CMS Announces New HCPCS Code For Remdesivir Antiviral Medication

The Centers for Medicare & Medicaid Services (CMS) issued a new Healthcare Common Procedure Coding System (HCPCS) code for the antiviral medication VEKLURYTM (remdesivir) when administered in the outpatient setting. The new code is in response to the recent statement from ...

AHA Updates Guidance On Using Z-Codes For Social Needs

The American Hospital Association (AHA) has posted updated guidance to help hospitals and clinicians use ICD-10-CM “Z codes” to capture data on the social needs of patient populations, including non-medical factors that may influence a patient’s health status. ...

CMS Issues The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Final Rule

The Centers for Medicare & Medicaid Services (CMS) issued the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) final rule (CMS-1738-F, CMS-1687-F, and CMS-5531-F) that updates payment and benefit category policies and other provisions for DMEPOS items. ...

New ICD-10 Codes Announced For Reporting COVID-19 Therapeutics, Vaccination Status

Effective April 1, 2022, the Centers for Disease Control and Prevention (CDC) will implement three new ICD-10 diagnosis codes for reporting COVID-19 vaccination status and the Centers for Medicare & Medicaid Services (CMS) will implement seven new ICD-10 procedure codes ...

Medicare Premiums, Deductibles & Coinsurance Increase For 2022

The Centers for Medicare & Medicaid Services (CMS) released the 2022 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2022 Medicare Part D income-related monthly adjustment amounts. ...

CMS Announces Extreme and Uncontrollable Circumstances Policy To Individual MIPS Eligible Clinicians

Due to the 2019 coronavirus pandemic public health emergency, the Centers for Medicare & Medicaid Services (CMS) is applying the automatic extreme and uncontrollable circumstances (EUC) policy to all individual MIPS eligible clinicians for the 2021 MIPS performance year. The ...

Home Health Payment System Final Rule For Calendar Year 2022

The Centers for Medicare & Medicaid Services (CMS) issued a rule that finalizes a nationwide expansion of the successful Home Health Value-Based Purchasing (HHVBP) Model and makes updates to the Medicare Home Health Prospective Payment System (PPS) and the home ...

Medicare Physician Fee Schedule Final Rule For Calendar Year 2022

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates on policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, on or after January 1, 2022. ...

CMS Releases Billing Codes for J&J and Moderna Boosters

The Centers for Medicare & Medicaid Services (CMS) released Medicare Part B billing codes and payment allowances for reporting and administering single booster doses of Johnson & Johnson and Moderna COVID-19 vaccines to eligible adults as authorized by the Food and Drug Administration ...

CMS Issues Guidance On Required Medicaid & CHIP COVID-19 Coverage

The Centers for Medicare & Medicaid Services (CMS) issued guidance on Medicaid and Children’s Health Insurance Program (CHIP) coverage of COVID-19-related treatment under the American Rescue Plan Act of 2021 (ARP). ...

AMA Announces CPT Codes for Pfizer’s Pediatric COVID-19 Doses

The American Medical Association (AMA) issued new Current Procedural Terminology (CPT) vaccine and administration codes for pediatric doses of the COVID-19 vaccine developed by Pfizer. The provisional codes will be effective for use if Pfizer’s two-dose COVID-19 vaccine for children ...

GAO Reports On Provider Performance And Experiences Under MIPS

The Centers for Medicare & Medicaid Services (CMS) administers the Merit-based Incentive Payment System (MIPS), under which MIPS-eligible providers receive a “final score” based on their performance on four measures (quality, cost, promoting interoperability and improvement activities). Their score is ...

CMS Releases Surprise Billing Interim Final Rule Part II Regulations

On September 30, 2021, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury (collectively, the Departments), along with the Office of Personnel Management (OPM), released an interim final rule with comment ...

CMS Releases 2022 Medicare Advantage and Prescription Drug Plans Information

The Centers for Medicare & Medicaid Services (CMS) released the 2022 premiums, deductibles and other key information for Medicare Advantage and Part D prescription drug plans in advance of the annual Medicare Open Enrollment to help Medicare enrollees decide on ...

CMS Will Pay For Beneficiaries’ COVID-19 Booster Shots

Following the Food and Drug Administration’s (FDA) recent action that authorized a booster shot of the Pfizer COVID-19 vaccine for certain high-risk populations and a recommendation from the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & ...

CMS Issues Additional Instructions For Submitting Home Health Notices Of Admission (NOAs)

The Centers for Medicare & Medicaid Services (CMS) has issued Change Request 12424, which updates chapter 10 of the Medicare Claims Processing Manual to include additional instructions for submitting home health Notices of Admission (NOAs). ...

Influenza Vaccine Payment Allowances For 2021-2022 Season

The Medicare Part B payment allowance limits for seasonal influenza (flu) vaccines are 95% of the Average Wholesale Price (AWP), except when the vaccine is given in a hospital outpatient department, rural health clinic (RHC) or federally qualified health center ...

CMS To Reprocess Certain Claims For Outpatient Clinic Visit Services

By November 1, 2021, the U.S. Centers for Medicare & Medicaid Services (CMS) will begin reprocessing claims for outpatient clinic visit services provided at excepted off-campus Provider-Based Departments (PBDs) so they’re paid at the same rate as non-excepted off-campus PBDs ...

AMA Releases 2022 CPT Code Set

The American Medical Association (AMA) released updates to the Current Procedural Terminology (CPT) code set for 2022. The new code set aims to streamline reporting and tracking of COVID-19 reporting, among other updates. ...

CMS Expands Medicare Payments for At-Home COVID-19 Vaccinations

In an effort to increase access to COVID-19 vaccinations, the Centers for Medicare & Medicaid Services (CMS) is expanding opportunities for people to receive vaccinations at home. Healthcare providers can now receive additional payments for administering vaccines to multiple residents ...

Medicare Reimbursement Announced For Third Dose Of COVID-19 Vaccine For Immunocompromised Individuals

The U.S. Food and Drug Administration (FDA) amended the emergency use authorizations for both the Pfizer-BioNTech and the Moderna COVID-19 vaccines to allow for the use of an additional dose in certain immunocompromised individuals, especially solid organ transplant recipients or ...

Hospital Inpatient Prospective Payment System & Long-Term Care Hospital Prospective Payment System For Fiscal Year 2022

The Centers for Medicare & Medicaid Services (CMS) has issued the final rule for fiscal year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). The rule revises the Medicare IPPS ...

Inpatient Psychiatric Facility Prospective Payment System Final Rule For Fiscal Year 2022

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule that updates Medicare payment policies and rates for the Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS) for Fiscal Year (FY) 2022 and finalizes changes to the ...

Inpatient Rehabilitation Facility Prospective Payment System Final Rule For Fiscal Year 2022

The Centers for Medicare & Medicaid Services (CMS) has issued a fiscal year (FY) 2022 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) final rule, which updates Medicare payment policies and rates for IRFs, finalizes policies under the IRF Quality ...

Hospice Payment Rate Update Final Rule For Fiscal Year 2022

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare hospice payments and the aggregate cap amount for fiscal year (FY) 2022, in accordance with existing statutory and regulatory requirements. This rule rebases the hospice ...

Skilled Nursing Facility Prospective Payment System Final Rule For Fiscal Year 2022

According to the Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility (SNFs) Prospective Payment System (PPS) final rule for Fiscal Year (FY) 2022, SNFs will see an increase in Medicare Part A payments of approximately $410 million in ...
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