2024-09-12-MLNC

Date
2024-09-12
Title
Weekly Edition
MLN Connects logo

Thursday, September 12, 2024

News

Claims, Pricers, & Codes

MLN Matters® Articles

 

 

News 

COVID-19: Updated Vaccines for 2024–2025 Season

The FDA approved updated COVID-19 vaccines for the 2024–2025 season:

These vaccines target currently circulating variants and provide better protection against serious consequences of COVID-19, including hospitalization and death:

  • Pfizer-BioNTech and Moderna COVID-19 vaccines include a monovalent (single) component that corresponds to the Omicron variant KP.2 strain of SARS-CoV-2
  • Novavax COVID-19 Vaccine, Adjuvanted includes a monovalent (single) component that corresponds to the Omicron variant JN.1 strain of SARS-CoV-2

CMS updated COVID-19 vaccine pricing for the 2024–2025 season:

  • CPT codes 91318–91322 effective August 22, 2024 (Note: no change to payment allowances from last season for 91318–91319)
  • CPT code 91304 effective August 30, 2024 

Use CPT code 90480 to bill for the administration of the vaccine.

Visit the COVID-19 Vaccine Provider Toolkit for more information. Note: You may need to refresh your browser if you recently visited this webpage.

 

Rural Emergency Hospital Provisions, Conversion Process, & Conditions of Participation: Revised Guidance 

CMS released guidance (PDF) on the enrollment and conversion process for eligible facilities interested in participating in the Medicare and Medicaid programs as a rural emergency hospital (PDF) (REH).

REHs are a new provider type established by the Consolidated Appropriations Act of 2021 to address concerns over rural hospital closures. They provide emergency and outpatient medical and health services to patients that generally stay less than 24 hours.

As of January 1, 2023, Medicare pays REHs an additional 5% over the Hospital Outpatient Prospective Payment System (OPPS) rate to deliver emergency hospital, observation, and other outpatient services to Medicare patients. Medicare-covered REH services include all covered outpatient services, including radiology, laboratory, outpatient rehabilitation, surgical, maternal health, and behavioral health. Copayments for REH services are based on the standard OPPS rate (excluding the 5% increase).

 

CMS Roundup (September 6, 2024)

You may be interested in these topics from the CMS Roundup:

  • FAQs Addressing BD BACTEC™ Blood Culture Bottle Shortage
  • Request for Information on Potential Consolidation of Some Medicare Administrative Contractor Jurisdictions

 

Organizational Providers: Do You Need to Revalidate Your Enrollment Record Soon? 

Use the Medicare Revalidation List to find out if you need to revalidate your enrollment record. CMS usually posts revalidation due dates 6–7 months in advance, but we’ll establish your date at least 90 days in advance. A due date of “TBD” means that we haven’t set your due date, and you don’t need to do anything now.

We won’t issue new revalidation due dates for November 2024 – April 2025 and will resume in May 2025.

See Revalidations (Renewing Your Enrollment) for more information. 

 

Prostate Cancer: Talk to Your Patients about Screening 

Prostate cancer is the most common cancer diagnosed in North American men, excluding skin cancers (see Cancer.gov). During Prostate Cancer Awareness Month, talk with your patients about their risk, and help them make an informed decision about screening.

Medicare covers prostate cancer screenings. Find out when your patient is eligible for screening. If you need help, contact your eligibility service provider.

 More Information:

Advance Health Equity During National Sickle Cell Awareness Month

Sickle cell disease (SCD) disproportionately affects minority communities. It affects about 100,000 people in the U.S., of which more than 90% are Black and 3–9% are Hispanic or Latino. During Sickle Cell Awareness Month, look for ways to address disparities that affect communities you serve. You can also learn about efforts to eliminate barriers, reduce health disparities, and improve health outcomes (PDF) for individuals with SCD.  

More information:

 

Claims, Pricers, & Codes

National Correct Coding Initiative: October Update

Get the National Correct Coding Initiative (NCCI) fourth quarter edit files, effective October 1, 2024, on these Medicare NCCI webpages:

 

Integrated Outpatient Code Editor Version 25.3 

CMS posted the October 2024 Integrated Outpatient Code Editor files. Learn about claims processing changes effective October 1, 2024.

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

 

 

MLN Matters® Articles

Ambulatory Surgical Center Payment Update – October 2024

Learn about payment system updates (PDF):

  • CPT and HCPCS codes
  • Drugs and biologicals: 
    • Your Medicare Administrative Contractor (MAC) will adjust previously processed claims that have corrected payment rates
    • Your MAC will identify and reprocess claims for HCPCS J3424: retroactive change associated with April 2024 payment rate
  • Skin substitutes

 

Changes to the Laboratory National Coverage Determination Edit Software: January 2025 Update

Learn about edit software updates (PDF) effective January 1, 2025:

  • New and changed codes
  • How to find coding information

Your Medicare Administrative Contractor will adjust claims they processed in error that you bring to their attention.

 

Hospital Outpatient Prospective Payment System: October 2024 Update

Learn about October updates (PDF) for:

  • Proprietary laboratory analyses codes
  • Device pass-through
  • Drugs, biologicals, and radiopharmaceuticals
  • Skin substitutes
  • Blood products

  • Coding

     

 

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