Knowledge Base Article

Medicare Transmittals & MLN Articles

September 23, 2025: MLN MM14246: Ambulatory Surgical Center Payment System: October 2025 Update

CMS details payment system updates effective October 1, 2025 in the ASCs. For example, new hospital outpatient prospective payment system (OPPS) device pass-through category payable in ASCs. https://www.cms.gov/files/document/mm14246-ambulatory-surgical-center-payment-system-october-2025-update.pdf

 

September 25, 2025: MLN MM14223: Hospital Outpatient Prospective Payment System: October 2025 Update

This MLN article includes updates effective October 1, 2025. For example, new COVID-19 monoclonal antibody and pleural-peritoneal shunt HCPCS codes, and status indicator updates. https://www.cms.gov/files/document/mm14223-hospital-outpatient-prospective-payment-system-october-2025-update.pdf

 

September 29, 2025: MLN MM14098: Implementing the Transforming Episode Accountability Model: Skilled Nursing Facility 3-Day Rule Waiver

This Transforming Episode Accountability Model (TEAM) will run from January 1, 2026 to December 31, 2030. There were no substantive changes to this third iteration of this MLN article. As a reminder for participating hospitals in this model, “CMS will allow acute care hospitals who participate in the model to discharge patients without a 3-day hospital stay to a qualified SNF or swing bed provider, including a CAH.” https://www.cms.gov/files/document/mm14098-implementing-transforming-episode-accountability-model-skilled-nursing-facility-3-day-rule.pdf

 

You can visit the CMS.gov TEAM webpage to learn more about this mandatory model. https://www.cms.gov/priorities/innovation/innovation-models/team-model

 

November 21, 2025: MLN MM14215: Implementing the Transforming Episode Accountability Model: Telehealth Waiver

CMS provides details regarding telehealth services under the TEAM (Transforming Episode of Accountability Model) with dates of service on or after January 1, 2026. As a reminder, this is a mandatory model that will run for five performance years from January 1, 2026, to December 31, 2030, in selected Core-Based Statistical Areas nationwide.

Link to MLN Article: https://www.cms.gov/files/document/mm14215-implementing-transforming-episode-accountability-model-telehealth-waiver.pdf

Link to learn more about TEAM: https://www.cms.gov/priorities/innovation/innovation-models/team-model

 

November 21, 2025: MLN MM14219: Outpatient Services for Hospice Patients: New Edit

CMS has “created a new edit to automatically compare the outpatient claim’s primary diagnosis with the hospice claim’s primary diagnosis codes by doing an exact diagnosis match. This edit will deny hospital inpatient and outpatient claims when there’s a hospice claim for the same Medicare patient within the same covered period with condition code 07 or modifier GW with the same principal diagnosis.” Make sure your billing staff know about new systems’ edits that will compare primary diagnosis codes on hospital and hospice claims for Medicare hospice patients to prevent duplicate payments and how to use condition code 07. https://www.cms.gov/files/document/mm14219-outpatient-services-hospice-patients-new-edit.pdf

 

Coverage Updates

October 28, 2025: Final National Coverage Determination (NCD): Cardiac Contractility Modulation (CCM) for Heart Failure

CMS’ final decision is that CCM for heart failure (HF) management is covered under Coverage with Evidence Development (CED) according to sections (B) Coverage Criteria and (C) Other Uses of CCM. https://www.cms.gov/files/document/id317a.pdf-0

 

October 28, 2025: Final NCD: Renal Denervation for Uncontrolled Hypertension

CMS’ final decision is that radiofrequency renal denervation (rfRDN) and ultrasound renal denervation (uRDN) (collectively, RDN) for uncontrolled hypertension is covered under CED. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=318

 

Compliance Education Updates

September 2025: MLN Educational Tool (MLN6922507): Medicare Payment Systems

The Acute Care Hospital Inpatient Prospective Payment System section of this tool was updated to include FY 2026 changes.  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html#Acute

 

September 2025: MLN Fact Sheet (MLN900943): Health Care Code Sets

This MLN Fact Sheet was updated to include information about National Drug Codes (NDCs) in the code sets table. https://www.cms.gov/files/document/mln900943-health-care-code-sets.pdf

 

Other Updates

September 2025: Joint Commission Goals Starting in 2026: New – Nurse Staffing as Core Component of Quality

Effective January 1, 2026, National Performance Goals (NPGs) are replacing National Patient Safety Goals. The Joint Commission notes this is “a new chapter that organizes requirements that rise above regulation (excluding the “Medical Staff” (MS) chapter) into salient, measurable topics with clearly defined goals. NPGs are available for the Hospital and Critical Access Hospital accreditation programs.” For the first time, nurse staffing is a core component in Goal 12.02.01 – EP 5 which states “there must be an adequate number of licensed registered nurses, licensed practical (vocational) nurses, and other staff to provide nursing care to all patients, as needed.” https://www.jointcommission.org/en-us/standards/national-performance-goals

 

October 22, 2025: Acentra Health Special Bulletin: Higher-Weighted DRG (HWDRG) Reviews

Previously Livanta, the National Claim Review Contractor, completed short stay reviews (SSRs) and higher-weighted DRG (HWDRG) reviews nationwide. Livanta’s contract concluded August 11, 2025. As of September 1, 2025, the Medicare Administrative Contractors (MACs) assumed responsibility for pre-payment SSRs.

 

Acentra Health’s special bulletin provides information about HWDRG reviews now being completed by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) according to their regional assignments. Acentra noted they would soon begin requesting medical records for these reviews. You can read more about this on their HWDRG reviews webpage at https://www.acentraqio.com/providers/hwdrg.

 

October 31, 2025: CMS Releases CY 2026 Physician Fee Schedule (PFS) Final Rule

Specific to telehealth services, CMS finalized streamlining the process for adding services to the Medicare Telehealth Services List by simplifying the review process by removing the distinction between provision and permanent services and limited their review on whether the service can be furnished using an interactive, two-way audio-video telecommunication system. You can read more about the final rule in a CMS Fact Sheet at https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-final-rule-cms-1832-f.

 

November 14, 2025: 2026 Medicare Parts A & B Premium and Deductibles

CMS published a Fact Sheet releasing the 2026 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2026 Part D income-related monthly adjustment amounts. For example, the Inpatient Hospital Deductible: Is increasing $60 from $1,676 in 2025 to $1,736 in 2026. You can read about other changes in the CMS Fact Sheet at

https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles.

 

November 20, 2025: CMS Released CY 2026 ESRD Prospective Payment System (PPS) Final Rule

CMS notes for CY 2026 the ESRD PPS base rate will increase to $281.71 and total payments to all ESRD facilities, both freestanding and hospital-based, are expected to increase by approximately 2.2%. You can read more about the final rule in a related CMS Fact Sheet at https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-end-stage-renal-disease-esrd-prospective-payment-system-final-rule.

 

 

November 21, 2025: CMS Releases CY 2026 Outpatient Prospective Payment System (OPPS) / Ambulatory Surgical Center (ASC) Final Rule

In this final rule CMS finalized the elimination of the Inpatient Only List over three years with 285 mostly musculoskeletal procedures being removed for CY 2026. At the same time 271 of the 285 codes are being added to the ASC Covered Procedure List (CPL) as well as 289 additional procedures that were not on the IPO list.

 

CY 2026 OPPS/ASC Final Rule Resources

CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-empowers-patients-boosts-transparency-modernizing-hospital-payments

 

CY 2026 OPPS Final Rule CMS webpage: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notices/cms-1834-fc

 

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-2026-hospital-outpatient-prospective-payment-system-opps-ambulatory-surgical-center

 

Hospital Price Transparency Policy Changes Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cy-2026-opps-ambulatory-surgical-center-final-rule-hospital-price-transparency-policy-changes

 

Medicare and You 2026 Edition Now Available

Medicare and You is the official U.S. government Medicare handbook. The 2026 version is now available. CMS noted in the November 20, 2025 edition of MLN Connects new and important items this year includes:

• Capping yearly out-of-pocket Part D prescription drug costs,
• Meeting health care needs with Advanced Primary Care Management services,
• Detecting colon cancer early through a wide range of screenings, and
• Information to help fight fraud and cut waste.

 

You can download your copy today at: https://www.medicare.gov/publications/10050-medicare-and-you.pdf.