2025-01-08-MLNC

Annual increase in the Medicare Economic Index
Geographically-adjusted vaccine administration rates for HCPCS codes G0008, G0009, G0010, 90480, and M0201
Payment rates for administering Part B preventive vaccines in the patient’s home

More Information:

CY 2025 Physician Fee Schedule final rule
Vaccine Pricing webpage
Preventive Services webpage
Instruction to your Medicare Administrative Contractor (PDF)

Historically Excepted Tribal Federally Qualified Health Centers: CY 2025 Payment Rate

The CY 2025 historically excepted (previously called grandfathered) tribal Federally Qualified Health Center Prospective Payment System rate is $718 for medically necessary face-to-face visits.

CMS will adjust CY 2025 claims paid at the CY 2024 rate. You don’t need to take any action.

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

DMEPOS: Adding New Product Category to CMS-855S Enrollment Form on January 27

On January 27, 2025, CMS will include a new product category on the electronic CMS-855S DMEPOS Enrollment Form for multi-function respiratory devices (excluding ventilators).

You must be an enrolled DMEPOS supplier to get Medicare payment for furnishing these products.

Starting January 27, 2025, if you enroll in Medicare to supply these DMEPOS products or want to add them to your current enrollment:

If you submit an online application using PECOS, report the product in Section 2
If you enroll using a paper application, you must also submit a letter stating that you want to supply these products; we’re working to update this application

Hospitals: Apply for Additional Residency Positions by March 31

Apply for additional residency positions by March 31, 2025. See Direct Graduate Medical Education for information on additional residency positions under:

Section 126 of the Consolidated Appropriations Act, 2021 (round 4 applications):
Section 4122 of the Consolidated Appropriations Act, 2023:
- Information on how to apply (PDF)
- FAQs (PDF)

Opioid Treatment Programs: Get the Latest Updates

Visit Opioid Treatment Programs (OTP) and OTP Billing & Payment for updates, including:

Coverage
Claims
Billing
Payment codes & rates
Telecommunications

Advanced Primary Care Management Services: Get Information about Billing Medicare

Advanced Primary Care Management (APCM) Services combine elements of several existing care management and communication technology-based services you may have already been billing for your patients. Starting January 1, 2025, you may use a new payment bundle that reflects the essential elements of advanced primary care, including:

Principal care management: disease-specific services to help manage a patient’s care for a single, complex chronic condition that puts them at risk of hospitalization, physical or cognitive decline, or death
Transitional care management
Chronic care management

Get answers to these questions:

What are APCM services?
Who can bill and how often?
What are the HCPCS codes and billing requirements?
Can auxiliary personnel provide APCM services?
Where can I get more information?

Medicare Wellness Visits: Get Your Patients Off to a Healthy Start

The New Year is the perfect time to get your patients off to a healthy start by recommending Medicare wellness visits. Medicare covers 2 types of exams:

Initial preventive physical exam (IPPE) – one-time visit for new Medicare patients within 12 months of first Part B coverage period:
- Review medical and social health history
- Discuss preventive services
Annual wellness visit (AWV) – covered for patients who:
- Aren’t within 12 months after their first Part B coverage period’s effective date
- Haven’t had an IPPE or AWV within the past 12 months

Your patients pay nothing if you accept assignment. Find out when your patient is eligible for these exams. If you need help, contact your eligibility service provider.

Information for Your Patients:

Compliance

Opioid Treatment Program: Bill Correctly for Opioid Use Disorder Treatment Services

In a report, the Office of the Inspector General found that Opioid Treatment Program (OTP) providers didn’t always comply with federal requirements when they bill for opioid use disorder (OUD) treatment services, including intake activities. Review OTP Billing & Payment, and learn how to:

Bill for OUD services
Use the correct G-codes

Infusion Pumps: Prevent Claim Denials

In 2023, the improper payment rate for infusion pumps and related drugs was 12.5%, with a projected improper payment amount of $80.9 million (see 2023 Medicare Fee-for-Service Supplemental Improper Payment Data (PDF), Appendices D, G, K, and N). Learn how to bill correctly for these supplies and services. Review the Infusion Pumps & Related Drugs provider compliance tip for more information, including:

Billing codes
Denial reasons
External and implantable infusion pump: covered indications
Refill and documentation requirements

Claims, Pricers, & Codes

Medicare Part B Drug Pricing Files & Revisions: January Update

Learn about quarterly updates to the following average sales price and not otherwise classified pricing files:

January 2025
October 2024
July 2024
April 2024
January 2024

More Information:

Rural Health Clinics & Federally Qualified Health Centers: You May Need to Resubmit Claims

Starting October 1, 2024, CMS incorrectly returned certain Rural Health Clinic and Federally Qualified Health Center claims with reason code W7072:

Type of bill: 071X and 077X
HCPCS code 93010

Resubmit these claims that we returned in error.

Medicare Part A Place of Service: Use the Correct Codes

Place of service (POS) codes identify where a patient gets a service. Enter the correct 2-digit code on Medicare claims to ensure proper payment for physician services provided to patients in inpatient facilities like skilled nursing facilities (SNFs) and hospitals. Frequently used POS codes include:

Inpatient hospital: 21
SNF (with Part A coverage): 31
Nursing facility (or SNF with no Part A coverage): 32

For example, if a patient is seen in a physician’s office but is also:

An inpatient of a hospital, use POS code 21 for inpatient hospital
A patient of a SNF (with Part A), use POS code 31 for SNF
A patient of a nursing facility or SNF without Part A, use POS code 32 for nursing facility

The POS code reflects a different setting than the address and ZIP Code of the practice location.

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

MLN Matters® Articles

Billing Instructions: Expedited Determinations Based on Medicare Change of Status Notifications

Learn about changes (PDF) effective October 11, 2024:

When patients are eligible to appeal a hospital status change
Quality Improvement Organization (QIO) role in the appeals process
Claims processing based on QIO appeal decision

Don’t bill patients during the QIO appeals process if their appeal request was timely. If the appeal is untimely, you may bill a patient before the QIO process ends.

Clinical Laboratory Fee Schedule: 2025 Annual Update

Learn about changes and instructions (PDF) effective January 1, 2025:

Delay in data reporting period and the phase-in of payment reductions
Mapping for new test codes
Updates for tests subject to the reasonable charge payment

Claims processing instructions for the intravenous immune globulin (IVIG) permanent benefit, including place of service code 04
Coverage information
Q2052 payment rate and time increment table for CY 2025
New IVIG J-code for CY 2025

Medicare Provider Enrollment — Revised

The 2025 enrollment application fee is $730.

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