News
- Medicare Shared Savings Program Continues to Deliver Meaningful Savings and High-Quality Health Care
Compliance
- Major Hip & Knee Replacement or Reattachment of Lower Extremity: Prevent Claim Denials
- Comprehensive Error Rate Testing Medical Record Requests: Respond Timely
Claims, Pricers, & Codes
Publications
- Prohibition on Billing Qualified Medicare Beneficiaries — Revised
- Provider Information on Medicare Diabetes Self-Management Training — Revised
News
Medicare Shared Savings Program Continues to Deliver Meaningful Savings and High-Quality Health Care
CMS announced that the Medicare Shared Savings Program continues to save Medicare money while supporting high-quality care. The Shared Savings Program yielded more than $2.1 billion in net savings in 2023 — the largest savings in the Program’s history.
More Information:
Compliance
Major Hip & Knee Replacement or Reattachment of Lower Extremity: Prevent Claim Denials
In 2023, the improper payment rate for major hip and knee replacement or reattachment of lower extremity was 40.6%, with a projected improper payment amount of $633.8 million. Learn how to bill correctly for these services. Review the Major Hip & Knee Replacement or Reattachment of Lower Extremity provider compliance tip for more information, including:
- Billing codes
- Denial reasons
- Medical record documentation requirements
- Medical review policies of 2-midnight rule
- Examples of total knee arthroplasty cases and rationale for payment determinations
- Resources
Comprehensive Error Rate Testing Medical Record Requests: Respond Timely
You’re required to respond in a timely manner to Comprehensive Error Rate Testing (CERT) requests for medical records. Read the latest message (PDF) from the CERT A/B MAC Education Task Force.
Claims, Pricers, & Codes
PrEP for HIV Billing: CMS Requires Diagnosis Codes
If you’re a physician or health care practitioner, you should include at least one valid ICD-10-CM diagnosis code on prescriptions you send to pharmacies to help them prepare their Medicare Part B claims.
There are multiple diagnosis codes that may be appropriate when you’re billing for PrEP, including codes for:
- Encounter for HIV pre-exposure prophylaxis
- Encounter for screening for human immunodeficiency virus
- Increased risk factors
For Information:
- PrEP for HIV & Related Preventive Services webpage
- Medicare Part B Coverage of PrEP for HIV Prevention (PDF) fact sheet
- PrEP for HIV National Coverage Determination (PDF) technical FAQs for pharmacies
Publications
Prohibition on Billing Qualified Medicare Beneficiaries — Revised
Billing Medicare beneficiaries in the Qualified Medicare Beneficiary (QMB) group for Medicare cost-sharing is prohibited (PDF) by federal law. Learn about:
- QMB billing protection laws
- Impact of improper billing
- How to ensure compliance
- Consequences of violating QMB billing protections
- Reminders and resources
Provider Information on Medicare Diabetes Self-Management Training — Revised
CMS clarified telehealth billing requirements (PDF).
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