Knowledge Base Article

Medicare Transmittals & MLN Articles

August 27, 2025: MLN MM14098: Implementing the Transforming Episode Accountability Model: Skilled Nursing Facility 3-Day Rule Waiver

Make sure your billing staff knows about updates the details, participation, and payments for the new Transforming Episode Accountability Model (TEAM) running from January 1, 2026 – December 31, 2030. For example, 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

 

September 2, 2025: MLN MM14195: National Fee Schedule for Vaccine Administration: October 2025 Update

Make sure your billing staff knows about coding updates for: AVTOZMA® for post-exposure prophylaxis or COVID-19 treatment, and newly FDA-approved products not yet assigned to a unique HCPCS Level II code. https://www.cms.gov/files/document/mm14195-national-fee-schedule-vaccine-administration-october-2025-update.pdf

 

September 18, 2025: MLN Matters MM14136: Medicare Severity Diagnosis-Related Groups Subject to Inpatient Prospective Payment System Replaced Devices Policy: FY 2026 Update

Key Updates for FY 2026 related to this policy includes the addition of 2 MS-DRGs to the list subject to the policy for reducing payment for replaced devices offered without cost or with credit (MS-DRGs 209 and 213), and conforming title changes for 2 MS-DRGs (MS-DRGs 023 and 024). https://www.cms.gov/files/document/mm14136-medicare-severity-diagnosis-related-groups-subject-inpatient-prospective-payment-system.pdf

 

September 19, 2925: MLN MM14190: Hospice Payments: FY 2026 Update

CMS advises that you make sure your billing staff knows about FY 2026 hospice updates effective October 1, 2025, including payment rates, inpatient and aggregate caps, and wage index. https://www.cms.gov/files/document/mm14190-hospice-payments-fy-2026-update.pdf

 

September 22, 2025: MLN MM14203: Inpatient and Long-Term Care Hospital Prospective Payment Systems: FY 2026 Changes

CMS advises that you make sure your billing staff knows about the FY 2026 updates in this article.

 

This article should also be shared with HIM, CDI, Case Management, and Quality professionals. Examples of key updates included in this MLN article:

• CMS has deleted 6 MS-DRGs and finalized 5 new MS-DRGs, decreasing the number of MS-DRGs by 1 for a total of 772 for FY 2026.
• No MS-DRGs were added to or removed from the list of those subject to the post-acute transfer or special payment policies. Table 5 of the final rule includes a list of all post-acute and special post-acute MS-DRGs.
• Related to the new technology add-on payment policy for FY 2026, MAC implementation file 8 provides information on new technologies either continuing to receive payments, or those starting to receive payments, and technologies no longer eligible for the new technology add-on payment.
• This MLN article also includes updates related to quality programs (i.e., the Hospital-Acquired Condition Reduction Program, Value-Based Purchasing Program, and Hospital Readmission Reduction Program). https://www.cms.gov/files/document/mm14203-inpatient-long-term-care-hospital-prospective-payment-systems-fy-2026-changes.pdf

 

Coverage Updates

September 10, 2025: Screening for Colorectal Cancer-Non-Invasive Biomarker Tests National Coverage Analysis (NCA) (CAG-0040R)

CMS received a formal request to provide coverage for ColoSense, an FDA-approved multi-target stool RNA (mt-sRNA) colorectal cancer (CRC) screening test. This NCA focuses on coverage of CRC non-invasive biomarker screening tests, including mt-sRNA tests only and does not intend to review the long-standing coverage for fecal occult blood tests (FOBT). CMS is accepting comments until October 10, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=319

 

September: CMS National Coverage Determination (NCD) Dashboard

At the time of the CMS NCD Dashboard September update, there are three open NCDs, five NCDs have been finalized in the past twelve months, there is one pending Transitional Coverage for Emerging Technologies (TCET) pathway topic and nine accepted requests on the NCD wait list.  https://www.cms.gov/files/document/ncddashboard2025.pdf

 

Compliance Education Updates

July 2025: MLN Fact Sheet: MLN905364: Complying with Medicare Signature Requirements

CMS updated this fact sheet in July by adding information about stamped signatures, artificial intelligence, and attestations and signature logs. https://www.cms.gov/files/document/mln905364-complying-medicare-signature-requirements.pdf

 

September 2025: MLN Booklet: MLN006764: Evaluation and Management Services

CMS has made changes to several sections of this document including adding information regarding office or outpatient (O/O) Evaluation and Management (E/M) visits, critical care services, hospital outpatient clinic visits, and telehealth services.

 

Specific to telehealth services, if Congress takes no action prior to October 1, 2025, the statutory limitations that were in place for Medicare telehealth services before the COVID-19 public health emergency (PHE) will retake effect for most telehealth services. https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf

 

September 2025: Palmetto GBA Targeted Probe and Educate Checklist

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M published this checklist “to assist providers in all rounds of TPE to provide a better understanding of the Additional Documentation Request (ADR) process.” https://palmettogba.com/jja/did/4jklzyhi3t#ls

 

Other Updates

September 3, 2025: New Prior Authorization Demonstration for ASCs

CMS announced a new prior authorization demonstration for ASCs set to begin with discharges on or after December 15, 2025. Like the Prior authorization for Certain Hospital Outpatient (OPD) Services that began July 1, 2020, services targeted include:

• Blepharoplasty,
• Botulinum toxin injections,
• Panniculectomy,
• Rhinoplasty, and
• Vein ablation.

 

This demonstration will last for five years for ASCs in California, Florida, Texas, Arizona, Tennessee, Pennsylvania, Maryland, Georgia, and New York. You can read more about this demonstration on the CMS website at https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-demonstration-certain-ambulatory-surgical-center-asc-services.

 

September 5, 2025: CMS Memorandum QS)-25-24-Hospitals: Updates to the State Operations Manual (SOM) Appendix A – New Interpretive Guidelines and Survey Processes reflecting Discharge Planning Conditions of Participation (COP)

Over five years later, CMS finally published sub-regulatory guidance related to the Discharge Planning Conditions of Participation (CoP) released in 2019 and 2020.

 

For example, in Appendix A §483.43(a) Standard: Discharge Planning Process, the interpretive guidelines indicate “the discharge planning process is expected to begin in the early stages in the hospitalization of the patient…However, no noncompliance deficiency citations will be made if the identification of patients likely to need discharge planning is completed at least 48 hours in advance of the patient’s discharge and there is no evidence that:

1. The patient’s discharge was delayed due to the hospital’s failure to complete an appropriate discharge planning evaluation on a timely basis, or
2. The patient was placed unnecessarily in a setting other than that from which he/she was admitted primarily due to a delay in discharge planning. For example, a delay in identification of a patient in need of discharge planning might result in discharging the patient to a nursing facility, because such placements can be arranged comparatively quickly, when the patient preferred to return home, and could have been supported in the home environment with arrangement of appropriate community services.”

 

In addition to interpretive guidelines for the Discharge Planning CoPs, there are also updates incorporating prior memorandums involving life safety code updates, co-location, electronic reporting for deaths in restraint and seclusion, infection prevention and control, Quality Assessment and Performance Improvement (QAPI), and ligature risk and assessments. I recommend sharing this Memorandum with key stakeholders within your facility. https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/policy-memos/policy-memos-states-and-cms-locations/revisions-hospital-appendix-state-operations-manual