2023-04-20-MLNC

CMS will adjust payments to suppliers and pharmacies to account for the balance of the reduced coinsurance. Suppliers will continue to get the Medicare payment amount for the insulin (average sales price plus 6%) minus any applicable coinsurance, which is capped at $35 for a month’s supply.

Don’t bill for supplies of insulin for July or subsequent months before July 2023. We’ll complete the system updates to make sure patients aren’t charged more than the $35 maximum allowed for the month of July. Your DME Medicare Administrative Contractor will also educate you about billing during the May – June transition period.

We’re adding 2 new modifiers to the April 2023 HCPCS quarterly update file:

JK - Short Descriptor: Drug 1-month supply or less; Long Descriptor: One month supply or less of drug/biological
JL - Short Descriptor: Drug 3-month supply; Long Descriptor: Three month supply of drug/biological

Split Billing:

Before July 2023: For “from date of service” in May or June 2023, don’t bill a 3-month supply of insulin. Instead, bill a 1-month supply of insulin with the JK modifier.
Starting July 2023: For “from date of service” in July and later, bill a 3-month supply of insulin with the JL modifier or a 1-month supply with the JK modifier.

For more information, see the fact sheet (PDF).

Get information for your patients:

Medical Review & Compliance: Respond to Additional Documentation Requests

Providers selected for medical review must respond timely to additional documentation requests to:

Support payment of items or services reported on claims
Ensure compliance with Medicare's coverage, coding, payment and billing policies

See Medical Review and Education for more information.

Hospice: Comparative Billing Report in April

This month, CMS will issue a Comparative Billing Report (CBR) on Medicare Part B claims for hospice care. Use the data-driven report to compare your billing practices with those of your peers in your specialty and across the nation.

Look for an email from cbrpepper.noreply@religroupinc.com to access your report.

More Information:

View a webinar recording
Visit the CBR website
Register for a live webinar May 3 from 3–4 pm ET

Compliance

Home Health Rural Add-On Policy

Section 4137 of the Consolidated Appropriations Act, 2023 extends the rural add-on policy by providing an increase of 1% of the payment amount made for home health services provided in the ‘‘low population density’’ category for CY 2023.

Home health agencies should continue to report value code 85 and an associated Federal Information Processing System (FIPS) state and county code on all claims.

View the Home Health Claims Processing Manual (PDF) for more information.

Claims, Pricers, & Codes

Grandfathered Tribal Federally Qualified Health Centers: CY 2023 Rate

The CY 2023 grandfathered tribal Federally Qualified Health Center Prospective Payment System rate is $620.00 for medically necessary face-to-face visits.

CMS will adjust CY 2023 claims paid at the CY 2022 rate starting July 1. You don’t need to take any action.

See the instruction to your Medicare Administrative Contractor (PDF).

Events

Medicare Ground Ambulance Data Collection System: Office Hours Session — April 27

Thursday, April 27 from 2–3 pm ET

We divided the office hours session into 2 topics:

2–2:30 pm: CMS will answer live questions on the data collection requirements (such as, “What am I required to collect?” and, “When do I report?”). This part of the session is for all selected organizations in Years 1–4.

2:30–3 pm: We’ll answer live questions about registering and requesting access to the Medicare Ground Ambulance Data Collection System portal. This part is for selected organizations in Years 1–2 who are required to report beginning in 2023.

Visit Medicare Ground Ambulance Data Collection System for:

Lists of ground ambulance organizations selected in Years 1–2 required to collect information starting in 2022 and report information starting in 2023
Organizations selected in Years 3–4 required to collect information starting in 2023 and report information starting in 2024
FAQs (PDF)

Medicare Shared Savings Program: Navigating the Application Webinar — May 8

Monday, May 8 from 1–2:30 pm ET

Accountable Care Organizations (ACOs): Learn how to use the application toolkit to prepare your application for the upcoming cycle. We’ll also discuss the new Advance Investment Payments option to encourage health care providers in rural and underserved areas to join together as ACOs.

More Information:

Application Types and Timeline
Key Application Dates and Deadlines (PDF)
Email questions to SharedSavingsProgram@cms.hhs.gov

Clinical Laboratory Fee Schedule: Present or Speak at Upcoming Meetings

Learn about opportunities to present or speak at these upcoming meetings:

June 22– Annual Public Meeting Regarding New and Reconsidered Clinical Diagnostic Laboratory Test Codes for CY 2024: Register to present by June 1
July 19–20– Medicare Advisory Panel on Clinical Diagnostic Laboratory Tests: Register as a stand-by speaker by June 27

Multimedia

Medicare Home Health Prospective Payment System CY 2023: Materials from March Webinar

CMS posted materials from the Medicare Home Health Prospective Payment System CY 2023 Behavior Change Recap, 60-Day Episode Construction Overview, and Payment Rate Development webinar.

Updated presentation (PDF): updates to slides 35 and 42
Audio (passcode: =u.#r7XD)
Transcript (PDF)

See Home Health Patient-Driven Groupings Model for more information.

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