Knowledge Base Category -

Background

 

What is PEPPER: “PEPPER is an electronic data report that contains a single hospital’s claims data statistics for Medicare Severity Diagnosis Related Groups (MS DRGs) and discharges at risk for improper payment due to billing, coding, and/or admission necessity issues… PEPPER does not identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts. A hospital can use PEPPER to compare its claims data over time to identify potential areas of concern, including significant changes in billing practices; possible over- or under-coding; and changes in length of stay.” ¹

 

PEPPER Target Areas: “In general, the target areas are constructed as ratios and expressed as percents; the numerator represents discharge that have been identified as problematic, and the denominator represents discharges of a larger comparison group.” ¹

 

Program Paused: On February 8, 2024, CMS temporarily paused PEPPER to "improve and update the program reporting system."

 

Program Resumption Key Takeaways

 

August 2025: A notice on the PEPPER website indicated “The site is currently testing with select PEPPER recipients and PEPPER Portal access is limited to these users. Thank you for your patience and please check back soon for updates on full availability.” Index Analytics (IA), and its partners Integrity Management Services, Inc. and GovCon Growth Solutions were listed in a limited release PEPPER User’s Guide as being under contract with CMS to develop and distribute the PEPPER.

 

December 10, 2025: A PEPPER Short-Term Acute Care User’s Guide was released.

 

What’s New in December 2025 PEPPER Short-Term Acute Care User’s Guide

As compared to the 36^th Edition of the User’s Guide, the same Target Area’s continue to be active for FY 2025. However, two Target Areas were impacted due to changes to the Percutaneous Cardiovascular Procedures DRGs effective October 1, 2023.

 

Target Area: Surgical Complication and Comorbidity (CC) Major Complication and Comorbidity (MCC) modification as of Quarter 1 (Q1) of Fiscal Year (FY) 2024 (Q1FY2024)

 

DRGs 246 and 248 were removed and replaced with the following two new DRGs effective October 1, 2023:

DRG 321: Percutaneous cardiovascular procedures with intraluminal device with MCC or 4+ Arteries/Intraluminal Devices, and

DRG 322: Percutaneous cardiovascular procedures with intraluminal device without MCC.

 

Target Area: Percutaneous Cardiovascular Procedures modification as of Q1FY 2024

DRGs 246, 247, 248, and 249 were removed and replaced with the above 2 new DRGs listed above (321 and 322).

 

PEPPER User’s Guide Suggested Intervention for Outliers

 

While there are no new Target Areas, I want to call your attention to the Target Area Respiratory Infection. If you are a high outlier, Table 3 of the User’s Guide lists the following suggestions:

• This could indicate potential coding or billing errors related to over-coding for DRGs 177 or 178.
• Review a sample of medical records for these DRGs to determine whether coding errors exist.
• To ensure documentation supports the principal diagnosis, hospitals may generate data profiles to identify cases with the following principal diagnosis codes:
  • International Classification of Diseases, Tenth Revision, Clinical Modifications (ICD-10-CM) code J69.0 (pneumonitis due to inhalation of food or vomit)
  • ICD-10-CM code J15.69 (Pneumonia due to other Gram-negative bacteria)
  • ICD-10-CM code J15.8 (pneumonia due to other specified bacteria)

   

  The User’s Guide does not include information regarding COVID-19. Specifically, when the COVID-19 ICD-10-CM code U07.1 is the principal diagnosis, a claim will group to the DRG group 177,178, and 179. Analysis of RealTime Medicare Data (RTMD) Medicare Fee-for-Service paid claims data tells us that in the first three quarters of the CMS FY 2025 (October 1, 2024 – June 30, 2025):

• Nationwide, DRGs 177 and 178 represented 34.97% of all volume for the six Respiratory Infections Target Area denominator DRGs (see Table 1), and
• ICD-10-CM diagnosis code U07.1 represented 41.95% of all volume for DRGs 177 and 178 (see Tables 2 and 3).

 

If you are a high outlier for this Target Area, a first step may be to identify the percentage of your claims where ICD-10-CM code U07.1 was the principal diagnosis.

 

Next Steps

CMS is hosting a webinar on January 6, 2026 from 1-2PM ET to provide guidance on recent changes made to PEPPER, review reports and provide a Q&A session. You will find a link to register for this webinar in the December 18, 2025 edition of the CMS MLN Connects Newsletter. ² Also, Palmetto GBA has posted an article about the relaunch of PEPPER that includes information about accessing PEPPER and download reports. ³

 

Appendix A: RTMD Medicare FFS Paid Claims Data for Dates of Service October 1, 2024 to June 30, 2025 ⁴

Table 1: Nationwide Claims Volume All DRGs in Respiratory Infections Target Area Denominator
DRG and Description	Volume	% of Volume
177-RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC	89,508	28.25%
178-RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC	21,299	6.72%
179-RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC	3,688	1.16%
193-SIMPLE PNEUMONIA AND PLEURISY WITH MCC	140,825	44.45%
194-SIMPLE PNEUMONIA AND PLEURISY WITH CC	51,734	16.33%
195-SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC	9,764	3.08%
Grand Total	316,818	100.00%

 

Key Takeaway: Collectively, nationwide claims for Q1, Q2, and Q3 of FY 2025, DRGs 177 and 178 represented 34.97% of all volume for the six DRGs included in the Respiratory Target Area Denominator.

 

Table 2: DRG 177 Claims with COVID-19 Principal Diagnosis
DRG 177-RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC	Volume	% of Volume
U07.1-COVID-19	37,367	41.75%
Grand Total all DRG 177 claims	89,508	100.00%

 

Table 3: DRG 178 Claims with COVID-19 Principal Diagnosis
DRG 178-RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC	Volume	% of Volume
U07.1-COVID-19	9,116	42.80%
Grand Total all DRG 178 claims	21,299	100.00%

 

Key Takeaway: COVID-19 was the top principal by volume for DRGs 177 and 178.

 

References

¹ Short-term Acute Care Hospitals December 2025 PEPPER User’s Guide accessed 12/16/2025 from https://pepper.cbrpepper.org/training-short-term-acute-care.html

 

² December 18, 2025 edition of CMS’ MLN Connects Newsletter accessed 12/18/2025 at https://www.cms.gov/training-education/medicare-learning-network/newsletter/mln-connects-newsletter-december-18-2025#_Toc216870501

 

³ Palmetto GBA Article: Relaunch of PEPPER for Short-Term Acute Care Hospitals: Published 12/19/2025 at https://palmettogba.com/jja/did/yw9jbpng4k#ls

 

⁴ RealTime Medicare Data (RTMD): https://www.rtmd.org

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.

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

Medicare Transmittals & MLN Articles

July 23, 2025: MLN MM14153: Laboratory National Coverage Determination Edit Software Updates: October 2025

Make sure your billing staff is aware of the ICD-10-CM codes that have been added to the National Coverage Determinations (NCDs). https://www.cms.gov/files/document/mm14153-laboratory-national-coverage-determination-edit-software-updates-october-2025.pdf

 

July 24, 2025: MLN MM14159: Acute Kidney Injury Renal Dialysis Billing: Additional Revenue Codes

Affected providers for this article includes ESRD facilities and other providers billing MACs for renal dialysis services. CMS advises that you make sure your billing staff is aware of changes to home dialysis billing for patients with acute kidney injury (AKI) starting January 1, 2025.  

https://www.cms.gov/files/document/mm14159-acute-kidney-injury-renal-dialysis-billing-additional-revenue-codes.pdf

 

July 31, 2025: MLN MM14130: Billing the Laboratory Specimen Collection Travel Allowance to the 10^th of a Mile

Effective January 1, 2026 providers will be allowed to bill HCPCS code P9603 calculated to the 10^th of a mile. This MLN article provides information on how to bill to the 10^th of a mile properly and when to bill using a whole number of miles. https://www.cms.gov/files/document/mm14130-billing-laboratory-specimen-collection-travel-allowance-10th-mile.pdf

 

August 4, 2025: MLN MM14101: Ambulatory Surgical Center Payment System: July 2025 Update

Initially released on June 6, 2025, this article was updated on Augusth 4, 2025 to update the number of new HCPCS code and coding information in the drugs, biologicals, and radiopharmaceuticals section. https://www.cms.gov/files/document/mm14101-ambulatory-surgical-center-payment-system-july-2025-update.pdf

 

August 5, 2025: MLN MM14185: Bypassing Common Working File Edits on Inpatient Medicare Part B Ancillary 12X Claims: Effective Date Change

CMS advises you to make sure your billing staff knows about the updates to the effective date for the bypass of Common Working File editing on inpatient Medicare Part B ancillary 12X claims previously added to Change Request 13810. https://www.cms.gov/files/document/mm14185-bypassing-common-working-file-edits-inpatient-medicare-part-b-ancillary-12x-claims-effective.pdf

 

August 22, 2025: MLN MM14197: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2026 Update (1 of 2)

Make sure your billing staff knows about updates to NCDs with new or deleted ICD-10-CM diagnosis codes effective January 1, 2026.

https://www.cms.gov/files/document/mm14197-icd-10-other-coding-revisions-national-coverage-determinations-january-2026-update-1-2.pdf-0

 

August 25, 2025: MLN MM14177: Home-Based Noninvasive Positive Pressure Ventilation to Treat Chronic Respiratory Failure Due to Chronic Obstructive Pulmonary Disease

Make sure your billing staff knows about updates effective June 9, 2025, including updated Medicare coverage guidance for respiratory assistance devices (RADs) and home mechanical ventilators (HMVs). https://www.cms.gov/files/document/mm14177-home-based-noninvasive-positive-pressure-ventilation-treat-chronic-respiratory-failure-due.pdf

 

August 26, 2025: MLN MM14194: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2026 Update (2 of 2)

Make sure your billing staff knows about updates to NCDs with new or deleted ICD-10-CM diagnosis codes effective January 1, 2026. https://www.cms.gov/files/document/mm14194-icd-10-other-coding-revisions-national-coverage-determinations-january-2026-update-2-2.pdf

 

Coverage Updates

June 2, 2025: Final Decision Memo (CAG-00468N) and NCD 20.38: Transcatheter Edge-to Edge Repair for Tricuspid Valve Regurgitation (T-TEER)

CMS has posted the final NCD and decision memo. This procedure is covered when furnished according to an FDA market-authorized indication and patient, physician and CED study criteria are met.

 

1. Patient Criteria: Despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve repair being considered as appropriate by a heart team.
   1. CMS noted in the Decision Memo that “we are finalizing the coverage indications without specifying TR severity. We note the final NCD criteria are consistent with the current FDA-approved label and will continue to align with FDA labeling for symptomatic TR if indication language on severity is updated.”

    

2. Physician Criteria: The patient (preoperatively and postoperatively) is under the care of a heart team, which includes, at minimum, a Cardiac Surgeon, Interventional Cardiologist, Cardiologist with training and experience in heart failure management, and an Interventional echocardiographer. Per the Decision Memo, all specialists must have experience in the care and treatment of tricuspid regurgitation.

    

3. Coverage with Evidence Development (CED) Study Criteria: The T-TEER items and services are furnished in the context of a CMS-approved CED study. CMS-approved CED study protocols must: include only those patients who meet the patient and physician criteria, and the study includes all the criteria listed in the NCD.

 

https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=316

 

Note: CMS published related MLN Matters Article MM14200 on August 20, 2025 and advises that you make sure your billing staff knows about the NCD criteria, coverage with evidence development (CED) study criteria, and claims processing requirements. https://www.cms.gov/files/document/mm14200-national-coverage-determination-2038-transcatheter-edge-edge-repair-tricuspid-valve.pdf

 

August 1, 2025: MLN Matters MM14149: National Coverage Determination 20.37: Transcatheter Tricuspid Valve Replacement (TTVR)

The Final Decision Memo for TTVR (CAG-00467N) was issued on March 19, 2025. This related MLN article provides detail about the coverage with evidence development (CED) study criteria and claims processing requirements. They also note that MACs will not search for files for TTVR claims processed with dates of service from March 19, 2025 to January 5, 2026; however, they’ll adjust any claims you bring to their attention. https://www.cms.gov/files/document/mm14149-national-coverage-determination-2037-transcatheter-tricuspid-valve-replacement.pdf

 

Note: CMS published related MLN Matters Article MM14149 on August 1^st and advises that you make sure your billing staff knows about the NCD criteria, coverage with evidence development (CED) study criteria, and claims processing requirements. https://www.cms.gov/files/document/mm14149-national-coverage-determination-2037-transcatheter-tricuspid-valve-replacement.pdf

 

Compliance Education Updates

June 2025: MLN Booklet: MLN909188: Chronic Care Services

CMS updated this booklet with information about Advanced Primary Care Management (APCM). https://www.cms.gov/files/document/chroniccaremanagement.pdf

 

July 2025: MLN Educational Tool: MLN006559: Medicare Preventive Services Updated

In the Thursday, August 14^th edition of MLN Connects, CMS included information about information added to several sections of the Medicare Preventive Services tool including:

• Alcohol misuse screening and counseling,
• Counseling to prevent tobacco use,
• Depression screening,
• Hepatitis C screening,
• PrEP using antiretroviral therapy to prevent HIV infection, and
• FAQ: billing the office and outpatient evaluation and management visit complexity add-on HCPCS code G2211 with Medicare Part B preventive services.

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

 

Other Updates

 

July 14, 2025: Livanta Provider Bulletin #24: Short Stay Reviews returning to the MACs

Livanta sent a bulletin to let providers know their contract as the National Claims Review Contractor concludes on August 11, 2025 that included the following about the transition of short stay reviews (SSR):

• September 1, 2025: Medicare Administrative Contractors will assume responsibility for conducting SSR.
• Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIO) will continue to conduct Higher Weighted Diagnosis-Related Group (HWDRG) reviews.

 

CMS noted during their July 30, 2025, webinar Inpatient Hospital Short Stay Review Transition, the short stay review policy has not changed, this shift in who will be reviewing records is an administrative change.

 

What is changing is the timing of the audit. Livanta reviewed claims post-payment, and the MACs will review claims pre-payment as part of the Targeted Probe and Education (TPE) program.

 

You will find a list of Inpatient Hospital FAQs re: Short Stays on the CMS website at https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/inpatient-hospital-reviews-faqs#FAQs-7/3/2025. As of August 1, 2025, the FAQs were last updated on July 3, 2025.

 

July 14, 2025: CMS Published CY 2026 Physician Fee Schedule Proposed Rule

CMS Fact Sheet: https://www.cms.gov/newsroom/press-releases/cms-proposes-physician-payment-rule-significantly-cut-spending-waste-enhance-quality-measures-and

 

July 15, 2025: CMS Publishes CY 2026 OPPS Proposed Rule

Like the 2020 Proposed Rule, CMS has proposed to eliminate the current IPO List (approximately 1,731 services), through a 3-year transition. For CY 2026 they have proposed to eliminate 285 mostly musculoskeletal-related services.

CMS notes “Given the significant number of services on the list and that we would establish new reimbursement rates for those services under the OPPS, we recognize that interested parties may need time to adjust to the removal of procedures from the list. Providers may need time to prepare to furnish newly removed procedures on an outpatient basis, update their billing systems, and gain experience with newly removed procedures eligible to be paid under either the IPPS or OPPS.

 

They go on to note that “there is already a set of C-APCs for musculoskeletal services for patients in the outpatient setting, which facilitates the removal of these types of services from the IPO list for CY 2026.” To further facilitate this process, CMS is proposing “to establish a 7 level Musculoskeletal Procedures APC series, which will allow for the assignment of musculoskeletal procedures removed from the IPO to an APC with an applicable range of estimated costs.”

 

https://public-inspection.federalregister.gov/2025-13360.pdf?utm_campaign=pi+subscription+mailing+list&utm_medium=email&utm_source=federalregister.gov

 

July 2025: CMS.Gov/Fraud: Hospice Fast Facts

CMS noted in the July 24^th edition of MLN Connects that they have posted a new Hospice Fast Facts document to inform the public about significant enhancements to address hospice fraud, including:

• What hospital fraud is,
• How CMS has enhanced oversight, and
• What CMS is doing to stop fraud.

https://www.cms.gov/files/document/cpi-hospice-fast-facts.pdf

 

July 31, 2025: CMS MLN Matters Special Edition Announcing Final Rules

 

FY 2026 IPPS  and Long-Term Care Hospital PPS Final Rule (CMS-1833-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0

 

FY 2026 Inpatient Rehabilitation Facilities PPS Final Rule (CMS-1829-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-inpatient-rehabilitation-facilities-prospective-payment-system-final-rule-cms-1829-f

 

FY 2026 Medicare Inpatient Psychiatric Facility PPS and Quality Reporting Final Rule (CMS-1831-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-medicare-inpatient-psychiatric-facility-prospective-payment-system-ipf-pps-and-quality

 

FY 2026 Skilled Nursing Facility (SNF) PPS Final Rule (CMS-1827-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-skilled-nursing-facility-snf-prospective-payment-system-final-rule-cms-1827-f

 

FY 2026 Hospice Wage Index and Payment Rate Update and Hospital Quality Reporting Program Requirements Final Rule (CMS-1835-F) Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2026-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting-program

Medicare Transmittals & MLN Articles

June 6, 2025: MLN MM14101: Ambulatory Surgical Center Payment System: July 2025 Update

This article provides payment system updates effective July 1, 2025 for your billing staff.

https://www.cms.gov/files/document/mm14101-ambulatory-surgical-center-payment-system-july-2025-update.pdf

 

June 9, 2025: MLN MM14089: ESRD Prospective Payment System: July 2025 Update

Make sure your billing staff are aware of changes to the outlier services listed under the ESRD PPS starting July 1, 2025.

https://www.cms.gov/files/document/mm14089-esrd-prospective-payment-system-july-2025-update.pdf

 

June 9, 2025: MLN 14041: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2025 Update

Make sure your billing staff knows about new codes and recent coding changes effective October 1, 2025 for the following NCDs:

 

20.9.1 Ventricular Assist Devices (VADs)

110.24 CAR T-cell Therapy

190.11 Home prothrombin time/international normalized ratio for monitoring for anticoagulation management

210.41 Counseling to Prevent Tobacco Use

210.13 Screening for Hepatitis C virus (HCV) in adults

 

https://www.cms.gov/files/document/mm14041-icd-10-other-coding-revisions-national-coverage-determinations-october-2025-update.pdf

 

June 10, 2025: MLN MM14031: Updates to Colorectal Cancer Screening & Hepatitis B Vaccine Policies

Make sure your billing staff knows about coverage changes for colorectal cancer (CRC) screening tests, policy clarification that applies to complete CRC screening, and expanded coverage and changes to billing policies for the hepatitis B vaccine. https://www.cms.gov/files/document/mm14031-updates-colorectal-cancer-screening-hepatitis-b-vaccine-policies.pdf

 

June 24, 2025: MLN Matters MM14132: Inpatient Rehabilitation Facility Prospective Payment System: FY 2026 Pricer Update

Per CMS actions needed that are listed in this MLN article includes FY 2026 IRF PPS rates, the rural transition policy, and the wage index cap. https://www.cms.gov/files/document/mm14132-inpatient-rehabilitation-facility-prospective-payment-system-fy-2026-pricer-update.pdf

 

June 30, 2025: MLN MM14091: Hospital Outpatient Prospective Payment System: July 2025 Update

This article highlights coding and billing changes effective July 1, 2025. For example, guidance is provided on how to bill for the split dose administration of AUCATZYL® (HCPCS code Q2058). https://www.cms.gov/files/document/mm14091-hospital-outpatient-prospective-payment-system-july-2025-update.pdf

 

Coverage Updates

June 9, 2025: Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to COPD Final National Coverage Determination

CMS posted this final NCD and decision memo establishing national Medicare coverage of respiratory assist devices and home mechanical ventilators. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=315

 

Compliance Education Updates

April 2025: MLN Booklet: MLN1986542: Medicare & Mental Health Coverage

CMS made several revisions to this MLN booklet, for example they added information on provider caregiver training, depression screening, and tobacco use cessation counseling services through telehealth, and information about adding coverage information for opioid treatment programs, including Brixadi® and Opvee®. https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf

 

May 2025: MLN Booklet: MLN9560465: Substance Use Screenings & Treatment

CMS made four changes to this MLN booklet, for example CMS has added safety planning intervention for patients in crisis and post-discharge phone follow-up contacts intervention. https://www.cms.gov/files/document/mln9560465-substance-use-screenings-treatment.pdf

 

May 2025: MLN Booklet: Screening, Brief Intervention & Referral to Treatment (SBIRT) Services

CMS made several changes to this MLN Booklet (MLN904084). For example, is the reminder that “you can prescribe controlled medications like buprenorphine using telehealth through December 31, 2025.” https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/sbirt_factsheet_icn904084.pdf

 

Other Updates

June 2, 2025: OIG Spring 2025 Semi-annual Report to Congress

In this report, the OIG has summarized their activities and accomplishments from October 1, 2024, through March 31, 2025. The OIG noted work during this period led to $16.61 billion total monetary impact, demonstrating the agency’s role in protecting taxpayer funds and improving program performance. https://oig.hhs.gov/documents/sar/10324/Spring_2025_SAR_508.pdf

 

June 5, 2025: MA Compliance Audit Results of Specific Diagnosis Codes

OIG completed this audit to examine diagnosis codes submitted by Coventry Health and Life Insurance Company. The OIG has identified the following 10 high-risk groups that include diagnoses at higher risk for being miscoded:

 

Acute stroke,

Acute myocardial infarction,

Embolism,

Sepsis,

Pressure Ulcer,

Lung cancer,

Breast cancer,

Colon cancer,

Prostate cancer, and

Ovarian Cancer.

 

Ultimately, OIG made three recommendations to Coventry, refund the Federal Government the $6.9 million in estimated net overpayments, identified similar instances of noncompliance after the audit period and refund any resulting overpayments, and continue to examine their existing compliance procedures to identify areas for improving compliance with Federal requirements. Coventry disagreed with some of the OIG findings and three of their recommendations. https://oig.hhs.gov/documents/audit/10329/A-02-22-01020.pdf

 

June 10, 2025: 2026 ICD-10-CM & PCS Files

CMS announced the October 1, 2025 procedure code and diagnosis code update files are now available. These codes are to be used for discharges occurring from October 1, 2025 to September 30, 2026, and for patient encounters for the same period.

 

The ICD-10-PCS Official Guidelines for Coding and Reporting for 2026 are available. As of June 26, 2025, CMS has not released the ICD-10-CM 2026 guidelines. https://www.cms.gov/medicare/coding-billing/icd-10-codes

 

June 23, 2025: Save the Date: July 30, 2025 CMS Teleconference on Transition of Short-Stay Reviews to the MACs

Effective September 1, 2025, MACs will assume responsibility for conducting short stay inpatient hospital medical reviews to determine appropriateness of the inpatient admission. This “save the date” announcement is to let providers know they will be holding a session on Wednesday, July 30, 2025 from 2-3PM ET to provide an overview about the transition of short stay reviews from the BFCC-QIOs to the MACs and address questions from beneficiary and industry stakeholders.

 

Prior to this session, you can find information about this transition on the CMS Inpatient Hospital Reviews webpage at https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/hospital-patient-status-reviews.

 

June 26, 2025: Medicare Fraud Alert: Phishing Fax Requests

CMS noted in the Thursday, June 26, 2025 edition of the MLN Connects Newsletter that they have “identified a fraud scheme targeting Medicare providers and suppliers. Scammers are impersonating CMS and sending phishing fax requests for medical records and documentation, falsely claiming to be part of a Medicare audit.

 

Important: CMS doesn’t initiate audits by requesting medical records via fax. Protect your information. If you receive a suspicious request, don’t respond. If you think you got a fraudulent or questionable request, work with your Medical Review Contractor to confirm if it’s real.” https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-06-26-mlnc

Medicare Transmittals & MLN Articles

May 9, 2025: MLN MM14025: New Waived Tests

FDA has approved six new waived tests under Clinical Laboratory Improvement Amendments (CLIA) that will be effective July 1, 2025.

https://www.cms.gov/files/document/mm14025-new-waived-tests.pdf

 

Coverage Updates

May 23, 2025: MLN MM14000: National Coverage Determination 20.36: Implantable Pulmonary Artery Pressure Sensors (IPAPS) for Heart Failure Management

For services performed on or after January 13, 2025, CMS determined the evidence is sufficient to cover IPAPS for heart failure (HF) management under Coverage with Evidence Development (CED) when provided according to an FDA market-authorized indication and indications in NCD 20.36 are met. CMS advises that your billing staff knows about the NCD, criteria for coverage, CED study criteria and claim processing requirements. https://www.cms.gov/files/document/mm14000-national-coverage-determination-2036-implantable-pulmonary-artery-pressure-sensors-heart.pdf

 

May 23, 2025: MLN MM13922: Qualifications for Speech-Language Pathologies Providing Outpatient Speech-Language Pathology Services

Make sure your billing staff knows about updates to the Medicare Benefit Policy Manual, Chapter 15, section 230.3 to match the regulatory provision for the qualifications of SLPs providing outpatient therapy services. The implementation and effective date for the updates was April 18, 2025. https://www.cms.gov/files/document/mm13922-qualifications-speech-language-pathologists-providing-outpatient-speech-language-pathology.pdf

 

Compliance Education Updates

May 2025: MLN Fact Sheet (MLN006951) Swing Bed Services Updates

This MLN Fact Sheet was updated to include the following:

• Billing Instructions for when a patient has a change of status review on their qualifying inpatient hospital stay,
• Swing bed services and the 96-hour certification requirement time exemption, and
• Home health and swing bed patients.

  https://www.cms.gov/files/document/mln006951-swing-bed-services.pdf

   

  Other Updates

  May 6, 2025: OIG Brief: $17 Billion in potential cost savings could be generated if Congress takes action based on these HHS-OIG reports

  This OIG notes in this brief that “some of the reports recommend legislative actions while others recommend program or process changes that Congress could address. The potential savings reflect the conditions and timeframes within the scope of each report. https://oig.hhs.gov/about-oig/hhs-oig-impact/potential-cost-savings-in-hhs-programs/potential-cost-savings-in-hhs-programs-legislative-actions/

   

  May 19, 2025: Palmetto GBA JM Adds Low Biller Targets to Active Medical Review List

  In the Medicare Fee-for-Service Payment Integrity Scorecard for the Q1 2025 reporting period, CMS noted that they are on track to begin the Low Biller program in May 2025. The Low Biller program is a modified version of Targeted Probe and Educate program which will allow the program to include more providers who may not bill enough claims of a particular service type to be included in the traditional program.

   

  On May 19, 2025, Palmetto GBA Jurisdiction M published an updated Medical Review List. Included in the list was a new Low Biller Probe and Educate Part A review of HCPCS J9271 (Pembrolizumab (Keytruda®).

   

  https://www.cfo.gov/wp-content/uploads/scorecards/FY25-Q1/Centers%20for%20Medicare%20&%20Medicaid%20(CMS)%20-%20Medicare%20Fee-for-Service%20(FFS).pdf

   

  https://palmettogba.com/jma/did/btpod0a22i

   

  May 21, 2025: CMS Strategy to Accelerate Medicare Advantage Audits

  In a press release, CMS notes “the last significant recovery of MA overpayments occurred following the audit of payment year (PY) 2007, despite federal estimates suggesting MA plans may overbill the government by approximately $17 billion annually.” To address the backlog a plan has been introduced to complete all remaining Risk Adjustment Data Validation (RADV) audits for PY 2018 to PY 2024 by early 2026. Two key elements of this plan include:

• Workforce expansion: CMS increasing its team of medical coders from 40 to approximately 2,000 by September 1, 2025. These coders will manually verify flagged diagnoses to ensure accuracy, and
• Increased audit volume: By leveraging technology, CMS will be able to increase audits to all eligible MA plans (approximately 550 MA plans) and increase auditing from 35 records per health plan to between 35 and 200 records based on the size of the health plan.

https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits

 

May 22, 2025: MACs to Resume Short Stay Inpatient Reviews

CMS announced that “beginning September 1, 2025, the MACs will assume responsibility for conducting patient status reviews to determine the appropriateness of Part A payment for short stay inpatient hospital claims, which previously were conducted by Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) (BFCC-QIO). While this change impacts where medical records will be sent and the contractor making claim review decisions, the policy for assessing short stay inpatient admissions remains unchanged.”

 

Short stay inpatient admissions have been closely scrutinized by contractors since the implementation of the 2 Midnight Rule on October 1, 2013. MACs are not new to this type of review as they conducted probe and educate reviews through September 30, 2015.

 

The CERT also focuses on inpatient denials by length of stay. In the 2024 report, 0- or 1-day stays continued to have the highest improper payment rate of all inpatient stays at 24.3% with project improper payments of $1.7 billion.

 

You can find more information about this notice on the CMS.gov Inpatient Hospital Reviews webpage at https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/hospital-patient-status-reviews.

 

For a look back at the history of short stay review and useful downloads can be found on the CMS Inpatient Hospital Reviews webpage at https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/inpatienthospitalreviews.

 

May 22, 2025: CMS Fast Facts: Annual Update

CMS noted in the Thursday, May 21, 2025, edition of MLN Connects that the CMS Fast Facts have been updated to include data for 2022-2025. This data can be used as a “quick reference statistical summary for information on Medicare and Medicaid enrollment, utilization, expenditures, and Medicare provider counts. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-05-22-mlnc#_Toc198712331

 

May 22, 2025: OIG Brief: Potential Cost Savings: HHS Actions

The OIG indicates in this brief that there is $50B in potential savings through recovery and payment program improvements based on their work. They cited 35 reports where they had identified this potential cost savings. The largest example of misspent funds was $783.6M that could be recovered from misspent COVID-19 Uninsured Program funds.

 

One example of “select reports with potential savings” is the report Medicare Could Save Millions if It Implements an Expanded Hospital Transfer Payment Policy for Discharges to Post-acute Care. Based on their sample results, the OIG “estimated that Medicare could have saved approximately $694 million, or an average of $6,470 per claim, from 2017 through 2019 if it had expanded its hospital transfer policy to include all MS-DRGs.”

https://oig.hhs.gov/about-oig/hhs-oig-impact/potential-cost-savings-in-hhs-programs/potential-cost-savings-50-billion/

 

May 30, 2025: HHS-OIG Fiscal Year 2026 Justification of Estimates for Congress

The OIG is requesting $454.4 million for FY 2026 with 81% of this money ($367.4 million) for oversight of Medicare and Medicaid. The OIG notes that for every $1 invested in OIG, there is an expected return of $11 in government recoveries and receivables. https://oig.hhs.gov/documents/budget/10322/FY%202026%20OIG%20CJ.pdf

Medicare Transmittals & MLN Articles

March 28, 2025: Transmittal 13079: January 2025 Update of the Ambulatory Surgical Center (ASC) Payment System

Transmittal 13079 replaces Transmittal 13044 that was issued January 10, 2025. The original document has been updated to add an additional requirement and note for MACs for their work implementing the updates. All the other information remained the same. https://www.cms.gov/files/document/r13079cp.pdf

 

April 1, 2025: MLN MM13993: Hospital Outpatient Prospective Payment System: April 2025 Update

This article highlights coding and billing changes for certain lab tests, COVID-19 monoclonal antibody therapy products, and hospital OPPS device categories. It also highlights changes to APCs, surgical and imaging procedures, drugs, biologicals, and radiopharmaceuticals, and skin substitute products.

https://www.cms.gov/files/document/mm13993-hospital-outpatient-prospective-payment-system-april-2025-update.pdf

 

April 3, 2025: MLN MM13990: DMEPOS Fee Schedule: April 2025 Quarterly Update

CMS advises that your billing staff needs to know about new HCPCS codes, new fee schedule amounts, new HCPCS codes on the fee schedule file for DMEPOS repairs and servicing, complex rehabilitative power wheelchair accessories, and lymphedema compressions treatment items. https://www.cms.gov/files/document/mm13990-dmepos-fee-schedule-april-2025-quarterly-update.pdf

 

April 25, 2025: MLN MM14017: Ambulatory Surgical Center Payment System: April 2025 Update

CMS advised that your billing staff be aware of updates effective April 1, 2025 (i.e., a new HCPCS code for simulation angiogram for radioembolization of tumors). https://www.cms.gov/files/document/mm14017-ambulatory-surgical-center-payment-system-april-2025-update.pdf

 

Coverage Updates

March 19, 2025: Transcatheter Tricuspid Valve Replacement (TTVR) Final Decision Memo (CAG-00467N)

CMS now covers TTVR for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) when provisions in the Decision Memo are met for patient, physician, and CED study criteria. Specific to that patient, it is covered when “despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve replacement being considered as appropriate by a heart team.” The heart team, at a minimum, must include a cardiac surgeon, interventional cardiologist, cardiologist with training and experience in heart failure management, electrophysiologist, multi-modality imaging specialists, and an interventional cardiographer. “All of the specialists listed above must have experience in the care and treatment of tricuspid regurgitation.” CMS also notes that “all CMS-approved CED studies must meet the patient and physician criteria. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=314&fromTracking=Y&

 

March 20, 2025: Change Request (CR) 13939: ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2025

This change request provides a quarterly maintenance update of ICD-10 coding conversions and other coding updates specific to NCDs. No policy change is being made. NCDs with updates:

 

NCD 80.2, 80.2.1, 80.3.1: OPT Verteporfin,

NCD 90.2 Next Generation Sequencing,

NCD 100.1 Bariatric Surgery,

NCD 110.18 Aprepitant,

NCD 110.23 Stem Cell Transplants,

NCD 110.24 CAR T-cell Therapy,

NCD 160.18 Vagus Nerve Stimulation,

NCD 210.3 Colorectal Cancer Screening, and

NCD 250.3 IVIG for Treatment Autoimmune Mucocutaneous Blistering Disease.

https://www.cms.gov/files/document/r13097otn.pdf

 

April 3, 2025: Proposed Decision Memo (CAG-00468N) Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER)

Just under a month after the final decision memo for Transcatheter Tricuspid Valve Replacement (TTVR) was published, CMS released a proposed decision memo for T-TEER procedure. The Benefit Category for this procedure is inpatient hospital services and physicians’ services.

 

Abbott submitted the request for a National Coverage Analysis (NCA) to evaluate this procedure indicating that “The T-TEER procedure is intended to treat patients with symptomatic tricuspid regurgitation (TR). T-TEER procedures are performed percutaneously using a catheter-based technology to approximate the leaflets of the tricuspid valve with a clip device.

 

The T-TEER procedure using Abbott’s TriClip™ system was developed leveraging the experience of the MitraClip™ therapy, which is used to treat mitral valve regurgitation using transcatheter edge-to-edge repair of the mitral valve.”

 

The TripClip™ G4 System received FDA premarket approval on April 1, 2024 as a Breakthrough Device. This system was granted new technology eligible for add-on payment status effective October 1, 2024. The maximum add-on payment for FY 2025 is $26,000.

 

The ICD-10-PCS code used to describe this procedure is 02UJ3JZ (supplement tricuspid valve with synthetic substitute, percutaneous approach). This procedure groups to DRG pair 266/267 (endovascular cardiac valve replacement and supplement procedures with MCC and without MCC respectively).

 

The public comment period for this NCA ends May 3, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=316

 

Compliance Education Updates

April 2025: MLN Booklet (MLN901705) Telehealth & Remote Patient Monitoring

CMS has updated this MLN booklet including information about some telehealth flexibilities that have been extended through September 30, 2025. https://www.cms.gov/files/document/mln901705-telehealth-remote-patient-monitoring.pdf

 

April 2025: MLN Educational Tool Medicare Preventive Services (MLN006559)

CMS has made changes to preventive screening for colorectal cancer and ultrasound abdominal aortic aneurysm. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#COLO_CAN

 

Other Updates

March 6, 2025: Livanta Publishes Year 3 Review Findings for Higher-Weighted DRG Validation

In their February 2025 edition of “The Livanta Claims Review Advisor,” Livanta shares their higher-weighted diagnosis related groups (HWDRG) validation reviews for reviews completed from November 1, 2023 through October 31, 2024. Of the 6,447 claims found to be in error, 5,744 (10%) were a result of DRG changes and 703 (1%) were a result of failure to meet the guidelines of the Two-Midnight Rule. CMS Region 4 (AL, FL, GA, KY, MS, NC, SC, and TN) have the highest volume of claims reviewed and the highest regional error rate at 14%. For the third review cycle, sepsis DRGs (871 and 872) collectively continue to account for the highest percentage of DRGs found to be in error. Livanta posts their newsletters on their Provider Education and Toolkit webpage at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/provider_education.html. 

Medicare Transmittals & MLN Articles

February 24, 2025: MLN MM13937: Roster Billing for Hepatitis B: July 2025 Release

For affected providers make sure your billing staff knows about the expanded coverage for more Medicare patients to receive the hepatitis B vaccine, that Medicare patients no longer need a doctor’s order for the administration of the vaccine, and that mass immunizers can use the roster billing process to submit Medicare Part B claims for hepatitis B vaccinations and their administration. https://www.cms.gov/files/document/mm13937-roster-billing-hepatitis-b-july-2025-release.pdf

 

March 14, 2025: MLN MM13959: HCPCS Codes & Clinical Laboratory Amendments Edits: April 2025

This article includes updates about discontinued and new HCPCS codes and HCPCS codes subject to and those that are excluded from Clinical Laboratory Improvement Amendments (CLIA) edits. https://www.cms.gov/files/document/mm13959-hcpcs-codes-clinical-laboratory-improvement-amendments-edits-april-2025.pdf

 

March 17, 2025: MLN MM13966: Clinical Laboratory Fee Schedule (CLFS) & Laboratory Services Subject to Reasonable Charge Payment: April 2025 Quarterly Update

Make sure your billing staff knows about when the next CLFS reporting period for Clinical Diagnostic Laboratory Tests (CDLTs) begins and new and deleted CPT codes effective April 1, 2025. https://www.cms.gov/files/document/mm13966-quarterly-update-clinical-laboratory-fee-schedule-clfs-and-laboratory-services-subject.pdf

 

March 21, 2025: MLN MM13946: Rural Health Clinic & Federally Qualified Health Center Medicare Benefit Policy Manual Update

CMS advises that your billing staff needs to know about the 2025 updates to the Medicare Benefit Policy Manual, Chapter 13, and all other revisions clarifying existing policy. https://www.cms.gov/files/document/mm13946-rural-health-clinic-federally-qualified-health-center-medicare-benefit-policy-manual-update.pdf

 

Coverage Updates

March 11, 205: Proposed Decision Memo (CAG-00465N) Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure consequent to COPD

CMS has published a proposed Decision Memo in response to a request for reconsideration of NCD 280.1, to establish coverage policies for the use of noninvasive home mechanical ventilators and respiratory assist devices for Medicare beneficiaries with various respiratory conditions. CMS accepted the request for the indication of COPD.  The public comment period for this proposed Decision Memo is from March 11, 2025 through April 10, 2025.  https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=315

 

March 19, 2025: Transcatheter Tricuspid Valve Replacement (TTVR) Final Decision Memo (CAG-00467N)

CMS now covers TTVR for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) when provisions in the Decision Memo are met for patient, physician and CED study criteria. Specific to that patient, it is covered when “despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve replacement being considered as appropriate by a heart team.” The heart team, at a minimum, must include a cardiac surgeon, interventional cardiologist, cardiologist with training and experience in heart failure management, electrophysiologist, multi-modality imaging specialists, and an interventional cardiographer. “All of the specialists listed above must have experience in the care and treatment of tricuspid regurgitation.” CMS also notes that “all CMS-approved CED studies must meet the patient and physician criteria. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=314&fromTracking=Y&

 

Compliance Education Updates

December 2024: MLN Fact Sheet: Complying with Medical Record Documentation Requirements

CMS updated this MLN Fact Sheet (MLN909160) to add documentation guidelines for medical services and additional resources for Medicare documentation requirements. For example, “if providers don’t include sufficient documentation on claims we’ve already paid, we may consider the payment an overpayment, which we can partially or fully recover.” https://www.cms.gov/files/mln909160-complying-with-medical-record-documentation-requirements.pdf

 

February 2025: MLN Fact Sheet: Medicare Coverage of Diabetes Supplies

CMS updates this MLN Fact Sheet (MLN7674574) to add coverage information on continuous glucose monitors. https://www.cms.gov/files/document/mln7674574-medicare-coverage-diabetes-supplies.pdf

 

March 2025: MLN Fact Sheet: Hospital Price Transparency

This new fact sheet (MLN7215754) opens with the following: “On February 25, 2025, the White House issued an Executive Order to empower consumers with clear, accurate, and actionable health care pricing information. Read this White House fact sheet for more information.”  https://www.cms.gov/files/document/mln7215754-hospital-price-transparency.pdf

 

Other Updates

February 26, 2025: ICD-10-CM/PCS What’s New Effective April 1, 2025

CMS has updated the ICD-10 webpage to announce 50 new ICD-10-PCS codes, effective April 1, 2025 and to let providers know there are no new ICD-10-CM codes. https://www.cms.gov/medicare/coding-billing/icd-10-codes

 

March 6, 2025: Livanta Published Year 3 Review Findings for Higher-Weighted DRG Validation

In their February 2025 edition of “The Livanta Claims Review Advisor,” Livanta shares their higher-weighted diagnosis related groups (HWDRG) validation reviews for reviews completed from November 1, 2023 through October 31, 2024. Of the 6,447 claims found to be in error, 5,744 (10%) were a result of DRG changes and 703 (1%) were a result of failure to meet the guidelines of the Two-Midnight Rule. CMS Region 4 (AL, FL, GA, KY, MS, NC, SC, and TN) have the highest volume of claims reviewed and the highest regional error rate at 14%. For the third review cycle, sepsis DRGs (871 and 872) collectively continue to account for the highest percentage of DRGs found to be in error. Livanta posts their newsletters on their Provider Education and Toolkit webpage at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/provider_education.html.

 

Medicare Transmittals & MLN Articles

December 19, 2024: MLN MM13898: Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations Policy

Make sure your billing staff knows about updated Medicare coverage requirements for pneumococcal vaccinations and changes to align with the Advisory Committee on Immunization Practices (ACIP) recommendations for pneumococcal vaccination coverage.  https://www.cms.gov/files/document/mm13898-revisions-medicare-part-b-coverage-pneumococcal-vaccinations-policy.pdf

 

December 26, 2024: MLN MM13473: How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211

This MLN article was released on January 1, 2024 and updated on December 26, 2024. CMS has added information on how to use G2211 with modifier 25 for certain Medicare Part B services starting January 1, 2025. Substantive content changes are in dark red. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf

 

Coverage Updates

December 12, 2024: MLN MM13843: National Coverage Determination 210.15: Pre-Exposure Prophylaxis (PrEP) for HIV Prevention

CMS advises that you make sure your billing staff knows about the national coverage of PrEP using FDA-approved antiretroviral drugs to prevent HIV, HCPCS and diagnosis codes, and billing and payment requirements. https://www.cms.gov/files/document/mm13843-national-coverage-determination-21015-pre-exposure-prophylaxis-prep-hiv-prevention.pdf

 

December 19, 2024: Proposed Decision Memo (CAG-00467N): Transcatheter Tricuspid Valve Replacement (TTVR)

CMS has proposed to cover TTVR under Coverage with Evidence Development (CED) for the treatment of symptomatic tricuspid regurgitation (TR) when furnished with an FDA-approved complete TTVR system, the TR is graded as at least severe and meets the coverage criteria listed in the proposed decision memo. The comment period for this proposed decision memo is from December 19, 2024 through January 18, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=314

 

Other Updates

December 2, 2024: Beneficiary Notices Initiative (BNI) Fee for Service Medicare Change of Status Notice (MCSN) Webpage Updated

CMS updated this webpage to provide information about this new notice and appeals process for Original Medicare beginning February 14, 2025. https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative-bni/ffs-mcsn

 

December 2024: New ICD-10-PCS Codes Effective April 1, 2025

CMS announced 50 new ICD-10-PCS codes, effective April 1, 2025. Of note, 35 of the new ICD-10-PCS codes are new technology, group 10 X-codes. CMS also noted that the April 1, 2025 code update files are now available. Use these codes for discharges occurring from April 1, 2025 – September 30, 2025, and for patient encounters occurring from April 1, 2025 – September 30, 2025. https://www.cms.gov/medicare/coding-billing/icd-10-codes

 

December 20, 2024: Review and Decision Timeframe Update Reminder from Palmetto GBA

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M published an article reminding providers that effective January 1, 2025, CMS will reduce the timeframe requirements for MACs to provide a hospital outpatient department (OPD) prior authorization request (PAR) provisional affirmed or non-affirmed decision within seven calendar days of receipt of the request. https://www.palmettogba.com/palmetto/jja.nsf/DID/QIXFKBAMOI#ls

 

December 27, 2024: Proposed HIPAA Security Rule to Strengthen Cybersecurity for Electronic Protected Health Information

The Office for Civil Rights (OCR) at HHS issued a Notice of Proposed Rulemaking (NPRM) to modify the HIPAA Security Rule to strengthen cybersecurity protections for electronic protected health information (ePHI). Read about the NPRM in a related HHS Fact Sheet at https://www.hhs.gov/hipaa/for-professionals/security/hipaa-security-rule-nprm/factsheet/index.html.

 

 

 

Medicare Transmittals & MLN Articles

January 2, 2025: MLN Matters MM13918: Billing Instructions: Expedited Determinations Based on Medicare Change of Status Notifications

The implementation date for this new process is February 15, 2025. CMS advised that you make sure your billing staff knows about when patients are eligible to appeal a hospital status discharge, the Beneficiary and Family Centered Care (BFCC-QIO) role in the appeals process, and about claims processing based on the BFCC-QIO appeal decision. https://www.cms.gov/files/document/mm13918-billing-instructions-expedited-determinations-based-medicare-change-status-notifications.pdf

 

January 13, 2025: MLN MM13947: Travel Allowance Fees for Specimen Collection – 2025 Updates

Change Request (CR) 13947) revised travel allowance payment for CY 2025 when billed on a per mileage basis using HCPCS code P9603 or billed on a flat rate basis using HCPCS code P9604. Make sure your billing staff knows about the update to the CY 2025 specimen collection fees and travel allowance mileage rate, how to determine eligibility for the specimen collection fee, and know the travel allowance policies. https://www.cms.gov/files/document/mm13947-travel-allowance-fees-specimen-collection-2025-updates.pdf

 

January 14, 2025: MLN MM13934: Ambulatory Surgical Center Payment Update – January 2025

Make sure your billing staff knows about January payment system updates for new device categories, CPT, and HCPCS codes, drugs and biologicals, skin substitutes, and non-opioid treatments for pain relief.

 

January 15, 2025: MLN MM13933: Hospital Outpatient Prospective Payment System: January 2025 Update

CMS advises that you make sure your billing staff knows about January 1, 2025 coding updates, device pass-through status updates, changes to the comprehensive ambulatory payment classification, updates related to drugs, biologicals, and pharmaceuticals, and changes to the Outpatient Prospective Payment System (OPPS) Pricer logic. https://www.cms.gov/files/document/mm13933-hospital-outpatient-prospective-payment-system-january-2025-update.pdf

 

January 16, 2025: MLN MM13923: Payment for Medicare Part B Preventive Vaccines & Their Administration for Rural Health Clinics & Federally Qualified Health Centers

Make sure your billing staff knows that Hepatitis B vaccines are paid like other Part B preventive vaccines starting January 1, 2025, and new claim-based payments for Part B preventive vaccines and their administration are starting July 1, 2025. https://www.cms.gov/files/document/mm13923-payment-medicare-part-b-preventive-vaccines-their-administration-rural-health-clinics.pdf

 

Coverage Updates

January 10, 2025: National Coverage Analysis: Cardiac Contractility Modulation (CCM) for Heart Failure

The NCA issue is that despite advancements in treatment options, mortality in heart failure (HF) patients is high. “CCM is designed to treat select HF patients who continue to have persistent symptoms despite guideline-directed medical therapy (GDMT) and are ineligible for cardiac resynchronization therapy (CRT). CCM devices deliver electrical stimulation to the heart muscle to increase the strength of the heart’s contractions. CMS notes, this technology may improve symptoms, quality of life, functional capacity, and exercise tolerance.

 

CMS has received a formal request to provide coverage for CCM for heart failure. This is a Transitional Coverage for Emerging Technologies (TECT) pilot that tested the processes and concepts of TECT. The scope of this NCA is limited to CCM for heart failure.

 

The public comment period is from January 1, 2025 to February 9, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=317

 

January 13, 2025: Final Decision Memo (CAG-00466N): Implantable Pulmonary Artery Pressure Sensors (IPAPS) for Heart Failure Management

In this final Decision Memo CMS indicates that they will cover IPAPA for heart failure management under coverage with evidence development when all listed patient criteria in this document are met. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=313

 

January 13, 2025: National Coverage Analysis (NCA CAG-0047ON) Renal Denervation for Uncontrolled Hypertension

In December 2024, Medtronic submitted a letter requesting a National Coverage Determination (NCD) for renal denervation (RDN). Medtronic’s Symplicity Spyral™ RDN System was granted premarket approval on November 17, 2023. This system is described as an option for hypertension treatment that is adjunctive to medications to help lower blood pressure.

 

The scope of this NCA is limited to radiofrequency and ultrasound-based denervation procedures. CMS is soliciting public comment. They are particularly interested in comments that include scientific evidence describing the role of RDN. They are also interested in health disparities and equity aspects that should be considered in this review. The public comment period ends February 12, 2025 with an expected proposed decision memo in mid- July 2025.

 

Of note, effective October 1, 2024, this system was approved for a new technology add-on payment in the hospital IPPS final rule. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=318

 

 

Other Updates

January 14, 2025: CY 2025 Therapy Services Updates

CMS updated this webpage to reflect the 2025 threshold amounts for rehabilitative services. The following is a compare of 2024 and 2025 threshold amounts.

 

Calendar Year	Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined	Occupational Therapy (OT) Services
2024	$2,330	$2,330
2025	$2,410	$2,410
Source: CMS Therapy Caps webpage: https://www.cms.gov/medicare/coding-billing/therapy-services

 

Links to more information is available in the Thursday January 16, 2025 edition of MLN Connects at https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-01-16-mlnc.