Thursday, December 19, 2024
News
- MBI Lookup Tools: CMS Seeks Input by February 17
- CMS Roundup (December 13, 2024)
- Long-Term Care Hospital Provider Preview Reports: Review by January 15
- Inpatient Rehabilitation Facility Provider Preview Reports: Review by January 15
- Medicare Advantage Organizations & Prescription Drug Plans: Comment on Draft Medicare Transaction Facilitator Agreements by January 31
- Health Professional Shortage Area: CY 2025 Bonus Payments
- Home Health Quality Reporting Program: Final OASIS-E1 Instruments & Manual
- Quarterly Credit Balance Reports No Longer Required
Compliance
Claims, Pricers, & Codes
- HIV Pre-Exposure Prophylaxis: Coding Updates
- Coding for Appropriate Use Criteria Program for Advanced Diagnostic Imaging Ends December 31
- Federally Qualified Health Center Prospective Payment System: CY 2025 Pricer
- Skilled Nursing Facility Consolidated Billing: CY 2025 HCPCS Codes
MLN Matters® Articles
- CY 2025 Update: DMEPOS Fee Schedule
- National Coverage Determination 210.15: Pre-Exposure Prophylaxis (PrEP) for HIV Prevention
From Our Federal Partners
News
MBI Lookup Tools: CMS Seeks Input by February 17
CMS solicits comments to inform future decision-making regarding how we can best protect MBIs and Medicare beneficiaries. MBIs have been targeted by individuals seeking to commit Medicare fraud, including the use of MBI lookup tools to commit MBI theft. We want your input on these MBI lookup tool topic areas:
- How organizations operate externally-controlled MBI lookup tools
- How individuals or organizations use both CMS-operated and externally-controlled MBI lookup tools
- Potential benefit or impact of prohibiting or restricting externally-controlled MBI lookup tools
- Safeguards or best practices from inside or outside health care that we should consider for preventing MBI theft and misuse
We want to hear from you. Visit the MBI Lookup Tools webpage for more information and the full list of questions. Fill out the survey to provide comments by Monday, February 17, 2025.
CMS Roundup (December 13, 2024)
You may be interested in these topics from the CMS Roundup:
- Information & Resources for Those Living with HIV/AIDS
- Comprehensive Care for Joint Replacement Model Evaluation Report
- Framework for Improving Health Care Delivery and Care Experience
Long-Term Care Hospital Provider Preview Reports: Review by January 15
Review your data by January 15, 2025, and contact CMS if you have questions. We’ll publish the data on Care Compare and in the Provider Data Catalog in March.
Visit Public Reporting for more information.
Inpatient Rehabilitation Facility Provider Preview Reports: Review by January 15
Review your data by January 15, 2025, and contact CMS if you have questions. We’ll publish the data on Care Compare and in the Provider Data Catalog in March.
Visit Public Reporting for more information.
Medicare Advantage Organizations & Prescription Drug Plans: Comment on Draft Medicare Transaction Facilitator Agreements by January 31
Visit the Resources for Pharmacies and Dispensing Entities webpage to get draft Medicare Transaction Facilitator Agreements. CMS invites public feedback on the draft agreements until January 31, 2025.
Health Professional Shortage Area: CY 2025 Bonus Payments
See ZIP Codes designated as Health Professional Shortage Areas in 2025 that are eligible for a Medicare Physician Bonus:
See the instruction to your Medicare Administrative Contractor (PDF).
Home Health Quality Reporting Program: Final OASIS-E1 Instruments & Manual
CMS posted the final OASIS-E1 data set effective January 1, 2025:
More Information:
- OASIS Data Sets webpage
- OASIS User Manuals webpage
Quarterly Credit Balance Reports No Longer Required
Starting December 1, 2024, providers aren’t required to submit Credit Balance Reports (PDF) (CMS-838) on a quarterly basis. You’re still required to report self-identified overpayments, but you should only use a Credit Balance Report when they occur.
Compliance
Immunosuppressive Drugs: Prevent Claim Denials
In 2023, the improper payment rate for immunosuppressive drugs was 15.7%, with a projected improper payment amount of $43.2 million (see 2023 Medicare Fee-for-Service Supplemental Improper Payment Data (PDF), appendices D, G, and N). Learn how to bill correctly for these drugs. Review the Immunosuppressive Drugs provider compliance tip for more information, including:
- Billing codes
- Denial reasons and how to prevent them
- Coverage criteria
- Refill and documentation requirements
Claims, Pricers, & Codes
HIV Pre-Exposure Prophylaxis: Coding Updates
Visit PrEP for HIV & Related Preventive Services to get the latest information about the codes, including how to bill:
- Through December 31, 2024
- Starting January 1, 2025
Coding for Appropriate Use Criteria Program for Advanced Diagnostic Imaging Ends December 31
In early 2024, CMS announced a pause in the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging (PDF) and instructed providers and suppliers to stop including AUC consultation coding on Medicare Fee-for-Service claims starting January 1, 2024. CMS will stop processing these codes after December 31, 2024:
- G codes 1000–1024
- Modifiers MA – MH and QQ
See Appropriate Use Criteria Program for more information.
Federally Qualified Health Center Prospective Payment System: CY 2025 Pricer
Based on data through June 2024, the CY 2025 Federally Qualified Health Center (FQHC) Prospective Payment System base payment rate is $202.65, which is 3.4% higher than 2024. Find your geographic adjustment factor.
More Information:
Skilled Nursing Facility Consolidated Billing: CY 2025 HCPCS Codes
Get updated HCPCS codes (ZIP) to accurately bill for Part A skilled nursing facility stays. See the general explanation of the major categories (PDF), including additional exclusions.
More Information:
MLN Matters® Articles
CY 2025 Update: DMEPOS Fee Schedule
Learn about updates effective January 1, 2025 (PDF):
- New and updated codes
- Payment policy changes
National Coverage Determination 210.15: Pre-Exposure Prophylaxis (PrEP) for HIV Prevention
Starting September 30, 2024, CMS covers FDA-approved PrEP using antiretroviral drugs (PDF) for patients at an increased risk for HIV. Get information on:
- What we cover
- HCPCS and diagnosis codes
- Billing and payment requirements
From Our Federal Partners
CHAMPVA Policy on Weight Loss Medications Effective January 1
Starting January 1, 2025, the Civilian Health and Medical Program of VA (CHAMPVA) will only cover the medications Ozempic and Mounjaro if a patient has a Type 2 diabetes diagnosis. These medications are FDA-approved for the management of Type 2 diabetes and aren’t covered for any other uses, like pre-diabetes, weight loss, or managing obesity. If other diagnosis codes are used, CHAMPVA will reject the prescription until there’s documentation of the patient’s Type 2 diabetes diagnosis.
For questions:
- CHAMPVA: 800-733-8387
- Optum Rx Pharmacy Help: 888-546-5503
More information:
- CHAMPVA–Information for Providers webpage
- Optum Rx website
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