- Osteogenesis Stimulators: Prior Authorization Requirements Suspended
- Hospice Benefit: Expanding Prepayment Review in 4 States
- Skilled Nursing Facility Advance Beneficiary Notice: Revised Form & Instructions
- Hospital Price Transparency: Use a CMS Template Layout
- Healthy Aging: Recommend Medicare-Covered Services
- National Recovery Month: Take the First Step
- Alzheimer’s Monoclonal Antibody Treatment: New Code for Kisunla Drug
- Claim Status Category & Claim Status Codes
- DMEPOS: Provider Level Adjustment Codes on Remittance Advice
News
Osteogenesis Stimulators: Prior Authorization Requirements Suspended
There may be confusion over whether some noninvasive osteogenesis stimulators comply with the DME 3-year expected life requirement. Effective August 28, 2024, CMS suspended prior authorization requirements for HCPCS codes E0747, E0748, and E0760.
We’ll provide additional direction about this requirement in future notice and comment rulemaking.
More Information:
- DME Center webpage: Read the full notice
Prior Authorization and Pre-Claim Review Initiatives webpage: See recent updates
Hospice Benefit: Expanding Prepayment Review in 4 States
To combat fraud, waste, and abuse under the hospice benefit, CMS will expand prepayment medical review this September in Arizona, California, Nevada, and Texas. To help reduce burden on compliant providers, initial review volumes will be low and adjusted based on results.
If you’re noncompliant, we may implement extended review or take additional administrative actions.
Visit Hospice for coverage information.
Skilled Nursing Facility Advance Beneficiary Notice: Revised Form & Instructions
CMS revised the Skilled Nursing Facility Advance Beneficiary Notice:
You can start using the form now. It’s mandatory starting October 31, 2024.
Hospital Price Transparency: Use a CMS Template Layout
As of July 1, 2024, hospitals must conform to a CMS template layout and data specifications for making public their standard charge information in a comprehensive machine-readable file (MRF). Starting January 1, 2025, you’re also required to encode additional data elements.
We have resources to help you meet these new requirements:
- Visit the Data Dictionary GitHub Repository to access the CMS templates and data dictionary with technical instructions for encoding your required standard charge information
- Use the Online Validator Tool to check that your MRF complies with the CMS template layout and data encoding requirements
Hospital Price Transparency regulations require each hospital operating in the U.S. to publish a comprehensive MRF with the standard charges for all items and services they provide.
More Information:
- Register for the October 21 webinar on meeting the upcoming January 2025 requirements
- Email questions to PriceTransparencyHospitalCharges@cms.hhs.gov
Healthy Aging: Recommend Medicare-Covered Services
During Healthy Aging Month, encourage your patients to take advantage of Medicare services to maintain a healthy lifestyle, manage chronic conditions, and stay healthy and independent for as long as possible (see CDC).
Recommend appropriate services, including:
- Preventive services
- Cognitive assessment & care plan services
- Chronic care management services (PDF)
- Behavioral health integration services (PDF)
Information for Your Patients:
- Preventive & screening services
- Cognitive assessment & care plan services
- Chronic care management services
Behavioral health integration services
National Recovery Month: Take the First Step
During National Recovery Month, talk with your patients about appropriate Medicare screening and treatment options:
- Alcohol misuse screening & counseling
- Opioid use disorder screening & treatment
- Counseling to prevent tobacco use
More Information:
- Medicare & Mental Health Coverage (PDF) booklet
- Mental health & substance use disorders webpage: Get information for your patients
Compliance
Global Surgery: Bill Correctly
In a report, the Office of the Inspector General found that providers didn’t always comply with federal requirements when they bill for surgical services, including missing co-surgery and assistant-at-surgery modifiers. Review Global Surgery (PDF), and learn about:
- Coding
- Billing
- Payment
Claims, Pricers, & Codes
Alzheimer’s Monoclonal Antibody Treatment: New Code for Kisunla Drug
On July 2, 2024, the FDA approved the Kisunla (donanemab-azbt) injection to treat Alzheimer’s disease. Medicare covers Kisunla under National Coverage Determination 200.3: Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s; see the MLN Matters Article (PDF) for more information.
Use new HCPCS code J0175 effective July 2, 2024:
- Long descriptor: Injection, donanemab-azbt, 2 mg
- Short descriptor: Inj, donanemab-azbt, 2 mg
Claim Status Category & Claim Status Codes
Learn about claims status category and code updates effective July 1, 2024:
- Accredited Standards Committee (ASC) X12 code lists, including added, changed, or deleted codes
- Examples of the ASC X12 276 and ASC X12 277 request and response transactions
- Instruction to your Medicare Administrative Contractor (PDF)
DMEPOS: Provider Level Adjustment Codes on Remittance Advice
Learn about system changes to report DMEPOS provider level adjustment codes on the remittance advice. See the instruction to your Medicare Administrative Contractor (PDF).
MLN Matters® Articles
Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2025 Changes
Learn about FY 2025 updates (PDF) for:
- Inpatient Prospective Payment System (IPPS)
- Low-volume hospitals: Send your Medicare Administrative Contractor (MAC) a written request for this status no later than September 1, 2024
- Voluntary request of per discharge amount of interim uncompensated care payments: MACs will review your requests
- Long-Term Care Hospital Prospective Payment System
- Certain hospitals CMS excludes from the IPPS
New Waived Tests
Learn about billing for Clinical Laboratory Improvement Amendments waived laboratory tests (PDF):
- Requirements
- New test approved by the FDA
- Modifier QW
Medicare Administrative Contractors will adjust claims you bring to their attention.
Publications
Items & Services Not Covered Under Medicare — Revised
CMS added language about dental services (PDF).
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