Thursday, January 10, 2019
- Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18
- New Medicare Card: Transition Period Ends December 31
- January is Cervical Health Awareness Month
- ESRD Quality Incentive Program: CY 2019 ESRD PPS Final Rule Call — January 15
- Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call —January 22
- New Electronic System for Provider Reimbursement Review Board Appeals Call — February 5
- Home Health Patient-Driven Groupings Model Call — February 12
- New Part D Opioid Overutilization Policies Call — February 14
Medicare Learning Network® Publications & Multimedia
- Orders for DMEPOS Items: What Suppliers Need to Know MLN Matters Article — New
- ASC Payment System: January 2019 Update MLN Matters Article — New
- Hospital OPPS: January 2019 Update MLN Matters Article — New
- CLFS and Laboratory Services: CY 2019 Update MLN Matters Article — New
- Immunosuppressive Guidance: Updates MLN Matters Article — New
- Home Health Rural Add-on Payment MLN Matters Article — Revised
- Implantable Defibrillators: NCD 20.4 MLN Matters Article — Revised
- Medicare Billing: Form CMS-1500 and the 837 Professional Web-Based Training Course — Revised
View this edition as PDF (PDF)
News & Announcements
Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18
CMS is accepting Notices of Intent to Apply (NOIAs) via the Accountable Care Organization (ACO) Management System (ACO-MS) for the July 1, 2019, start date for the redesigned Medicare Shared Savings Program – Pathways to Success. You must submit a NOIA if you intend to apply to the new BASIC track or ENHANCED track of the Medicare Shared Savings Program, to apply for a Skilled Nursing Facility (SNF) 3-Day Rule Waiver, and/or to establish a Beneficiary Incentive Program.
NOIA submissions are due no later than January 18 at noon ET. A NOIA submission does not bind an organization to submit an application; however, you must submit a NOIA to be eligible to apply. Each ACO should submit only one NOIA. ACOs will have an opportunity to make changes to their tracks, repayment mechanisms, and other NOIA information during the application submission period. ACOs may submit additional documents with your NOIA submission (sample ACO Participant/SNF Affiliate Agreements, and draft repayment mechanism documentation) and receive feedback early, which may save your ACO time and effort during the application submission process.
Application Submission Period:
- The application submission period for a July 1, 2019, start date will be open from January 22 to February 19, 2019, at noon ET
- Additional resources on the application submission process will be available in mid-January
For more information, review the NOIA Guidance (PDF) and the Application Types & Timeline webpage. For questions, email .
New Medicare Card: Transition Period Ends December 31
We are halfway through the transition period that began April 1, 2018:
- To ensure your Medicare patients continue to get care, you can use either the former Social Security number-based Health Insurance Claim Number or the new alpha-numeric Medicare Beneficiary Identifier (MBI) for all Medicare transactions through December 31
- Beginning January 1, 2020, you must use the MBI on all Medicare transactions with a
About the MBI:
- MBIs are random and use numbers 0-9 and uppercase letters, except for S, L, O, I, B, and Z. We exclude these letters to avoid confusion when differentiating between these letters and numbers (e.g., between “0” and “O”). Read MLN Matters® Article New MBI Get It, Use It (PDF) for helpful information, including what to do if an MBI changes.
- Learn about Getting MBIs.
- Learn about Using MBIs.
If your patients accidentally threw away their new Medicare card, ask them to call 1-800-MEDICARE and request a replacement. Your patients can also sign into MyMedicare.gov to print an official card. They must create an account if they do not already have one.
For More Information:
- Transition to New Medicare Numbers and Cards (PDF) Fact Sheet
- Frequently Asked Questions (PDF)
- Provider and Office Manager webpage
January is Cervical Health Awareness Month
Cervical cancer can often be prevented with regular screening tests and follow-up care. Talk to your patients about cervical health and encourage them to take advantage of Medicare-covered preventive services, including the screening Pap test and screening pelvic examination.
For More Information:
- Educational Tool
Visit the Preventive Services website to learn more about Medicare-covered services.
Provider Compliance
Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims — Reminder
A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B for claims using the KX modifier for immunosuppressive drugs. It is estimated that Medicare paid $4.6 million for these claims that did not comply with Medicare requirements.
In response to this report, CMS clarified manual instructions on the use of the KX modifier to help pharmacies document the medical necessity of organ transplant and eligibility for Medicare coverage. Resources for pharmacies:
- Pharmacy Billing of Immunosuppressive Drugs (PDF) MLN Matters® Article
- Clarification of the Billing of Immunosuppressive Drugs (PDF) MLN Matters Article
- Change Request 10235 (PDF)
- OIG Report on the proper use of the KX modifier for Part B immunosuppressive drug claims
Upcoming Events
ESRD Quality Incentive Program: CY 2019 ESRD PPS Final Rule Call — January 15
Tuesday, January 15 from 2 to 3 pm ET
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During this call, learn about provisions for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) in the CY 2019 ESRD Prospective Payment System (PPS) final rule. Find out how CMS will conduct ESRD QIP for Payment Years 2021 and 2022. Topics include:
- Legislative framework
- Updates to ESRD QIP measures, domain structure, and weights
- Modifications to data submission requirements and the National Healthcare Safety Network Validation Study
Target Audience: Dialysis facilities that participate in the ESRD QIP.
Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call —January 22
Tuesday, January 22 from 2 to 3 pm ET
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Do you need to submit data required by the Clinical Diagnostic Test Payment System final rule? Laboratories, including physician offices laboratories and hospital outreach laboratories that bill using a 14X TOB are required to report laboratory test HCPCS codes, associated private payor rates, and volume data if they:
- Have more than $12,500 in Medicare revenues from laboratory services on the Clinical Laboratory Fee Schedule (CLFS), and
- Receive more than 50 percent of their Medicare revenues from CLFS and physician fee schedule services during a data collection period
This call provides a refresher on how to collect and submit required data. CMS will use this data to set Medicare payment rates effective January 1, 2021.
A question and answer session follows the presentation; however, you may email questions in advance to with “January 22 Call” in the subject line. These questions may be addressed during the call or used for other materials following the call. For more information, visit the PAMA Regulations webpage.
Target Audience: Clinical diagnostic laboratories, including physician offices and hospital outreach laboratories.
New Electronic System for Provider Reimbursement Review Board Appeals Call — February 5
Tuesday, February 5 from 1:30 to 3 pm ET
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Do you want to file or manage a Provider Reimbursement Review Board (PRRB) appeal? Learn how to use the new Office of Hearings Case and Document Management System (OH CDMS) to submit new appeals, transfer issues, file position papers, and manage all aspects of your PRRB appeals. For more information, visit the PRRB OH CDMS webpage.
During this call, PRRB staff discuss:
- How to access the system
- Detailed overview of the system and its capabilities
- Frequently asked questions
A question and answer session follows the presentation; however, attendees may email questions in advance to with “Office of Hearings Case and Document Management System Conference Call” in the subject line. These questions may be addressed during the call or used for other materials following the call.
Target Audience: All PRRB appeal stakeholders.
Home Health Patient-Driven Groupings Model Call — February 12
Tuesday, February 12 from 1:30 to 3 pm ET
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During this call, learn about the Patient-Driven Groupings Model (PDGM) that will be implemented on January 1, 2020. CMS will use the PDGM to reimburse home health agencies for providing home health services under Medicare fee-for-service. Topics include:
- Overview of PDGM model
- Walkthrough of payment adjustments, including low utilization payment adjustments, partial payment adjustments, and outliers payments
A question and answer session follows the presentation. For more information, visit the Home Health Prospective Payment System webpage; review the CY 2019 final rule and Overview of the PDGM (PDF).
Target Audience: Home health agencies, administrators, clinicians, and other interested stakeholders.
New Part D Opioid Overutilization Policies Call — February 14
Thursday, February 14 from 1:30 to 3 pm ET
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CMS implemented new opioid policies for Medicare drug plans effective January 1. The new policies include:
- Improved safety alerts when patients fill opioid prescriptions at the pharmacy
- Drug management programs for patients at-risk for misuse or abuse of opioids or other drugs
During this call, CMS experts discuss the new policies and answer questions.
Prior to the call, participants should review the following materials:
- Training materials, including slide decks and tip sheets for prescribers (ZIP), pharmacists (ZIP), and patients (ZIP)
- A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019 (PDF) MLN Matters® Article
- Reducing Opioid Misuse webpage for more information on the CMS strategy
Target Audience: Physicians; physician assistants; nurses; nurse practitioners; dentists and other prescribers; case managers; and other interested stakeholders.
Medicare Learning Network® Publications & Multimedia
Orders for DMEPOS Items: What Suppliers Need to Know MLN Matters Article — New
A new MLN Matters Article SE18009 on What Suppliers Need to Know about Orders for Durable Medical Equipment Prosthetics, Orthotics Supplies (DMEPOS) Items (PDF) is available. Learn about orders from telemarketers and/or telemedicine companies.
ASC Payment System: January 2019 Update MLN Matters Article — New
A new MLN Matters Article MM11108 on January 2019 Update of the Ambulatory Surgical Center (ASC) Payment System (PDF) is available. Learn about changes to billing instructions.
Hospital OPPS: January 2019 Update MLN Matters Article — New
A new MLN Matters Article MM11099 on January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) (PDF) is available. Learn about changes and billing instructions for various payment policies.
CLFS and Laboratory Services: CY 2019 Update MLN Matters Article — New
A new MLN Matters Article MM11076 on Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment (PDF) is available. Learn about mapping for new codes and updates for laboratory costs.
Immunosuppressive Guidance: Updates MLN Matters Article — New
A new MLN Matters Article MM11072 on Updates to Immunosuppressive Guidance (PDF)is available. Learn about updated guidance on covered drugs after a transplant procedure.
Home Health Rural Add-on Payment MLN Matters Article — Revised
A revised MLN Matters Article MM10782 on Home Health Rural Add-on Payments Based on County of Residence (PDF) is available. Learn about changes to add-on payments.
Implantable Defibrillators: NCD 20.4 MLN Matters Article — Revised
A revised MLN Matters Article MM10865 on National Coverage Determinations (NCD) 20.4 Implantable Defibrillators (ICDs) (PDF) is available. Learn about the final decision.
Medicare Billing: Form CMS-1500 and the 837 Professional Web-Based Training Course — Revised
With Continuing Education Credit
A revised Medicare Billing: Form CMS-1500 and the 837 Professional Web-Based Training (WBT) course is available through the Learning Management System - Opens in a new window . Learn about:
- Key aspects and requirements for electronic and paper claims
- Information required when submitting claims
- Important claims processing actions
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