Knowledge Base Article

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.

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