Recent Medicare Transmittals

on Wednesday, 09 December 2015. All News Items | Outpatient Services | Miscellaneous | Billing

Keep On Keeping Up

One of the challenges for healthcare providers and workers is keeping current on all the latest information. There are always new technologies, new best practices and protocols, and new regulations and requirements from various payers. Since our mission at Medical Management Plus is Making Healthcare Make Sense, we strive to provide the latest news concerning Medicare to assist our acute-care hospital readers and clients in keeping up with at least one aspect of their work world.

In January we will be starting a new feature in our Wednesday@One newsletter. As part of our Making Healthcare Make Sense Compliance Spotlight on the 4th week of the month, we will add a list of the CMS transmittals that are relevant to our clients and readers. But the New Year isn’t here yet and there are several recent transmittals that contain information worth sharing. Here is a summary of those transmittals.

Payment Reduction for CT Services

MLN Matters Article MM9250 discusses the payment reduction for Computed Tomography (CT) diagnostic services that will result when the CT scanner does not meet the NEMA Standard XR-29-2013. This payment reduction is mandated by the Protecting Access to Medicare Act of 2014 (PAMA) which also requires providers and suppliers to attest when a CT scan is provided on equipment that does not meet the standard. CMS has created modifier “CT” to be appended to the following CPT codes for CT services performed on equipment that does not meet the standards. The “CT” modifier will result in a 5% reduction of payment in 2016 and a 15% reduction in payment for 2017 and subsequent years.

  • CPT codes:70450-70498; 71250-71275; 72125-72133; 72191-72194; 73200-73206; 73700-73706; 74150-74178; 74261-74263; and 75571-75574.

New Influenza Virus Vaccine Code

Medicare will begin paying for new influenza virus vaccine CPT code 90630 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use) for dates of services on and after August 1, 2015 as described in MLN Matters Article MM9357. Medicare will not begin processing these claims until April 4, 2016 (implementation date). MACs will hold any institutional claims received prior to that date and will process and pay them after the implementation date. Medicare will accept hospital claim types of bills 12x and 13x for this vaccine. Part B deductible and co-insurance do not apply.

Therapy Cap Values for Calendar Year (CY) 2016

The Balanced Budget Act of 1997 applies annual financial limitations per patient on outpatient therapy services commonly referred to as “therapy caps.” Therapy caps are updated each year.  Therapy caps apply to all therapy providers providing Part B therapy services including therapy provided in an outpatient hospital setting. Therapy caps for 2016 listed in MLN Matters Article MM9448 are:

  • $1,960 for physical therapy and speech-language pathology combined
  • $1,960 for occupational therapy

The exceptions process to the therapy caps for reasonable and medically necessary services has currently been extended through December 31, 2017. Providers report therapy services beyond the therapy cap limit with modifier “KX” to attest the services are reasonable and necessary to exceed the limit.

Update to Medicare Deductible, Coinsurance and Premium Rates for 2016

CMS annually updates the deductibles, coinsurance, and premium rates for Medicare Part A and Part B services. Some of the updates include:

  • Part A Hospital Deductible: $1,288.00
  • Part B Premium: $121.80 per month
  • Part B Deductible: $166.00 a year
  • Part B Coinsurance: 20%

Please refer to the MLN Matters Article MM9410 link above for complete information.

Hopefully this information helps you “keep up” with some of the new issues facing you in 2016. Review our weekly newsletter and search our website at for more updates. Also watch for our educational live and on-demand webinars that address certain topics in a more in-depth manner. And as always, e-mail the authors of our newsletter articles if you have any questions or need more information.

Hope your holiday season is going well!

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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