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Thursday, March 16, 2023



Claims, Pricers, & Codes





HHS Releases Initial Guidance for Historic Medicare Drug Price Negotiation Program for Price Applicability Year 2026

For the first time in history, Medicare will have the ability to negotiate lower prescription drug prices because of the Inflation Reduction Act, President Biden’s historic law which lowers health care and prescription drug costs. On March 15, HHS, through the CMS, issued initial guidance detailing the requirements and parameters—including requests for public comment—on key elements of the new Medicare Drug Price Negotiation Program for 2026, the first year the negotiated prices will apply. Alongside other provisions in the new drug law, the Medicare Drug Price Negotiation Program will strengthen Medicare’s ability to serve people currently in Medicare and for generations to come.

More Information:


Quality Payment Program: 2021 Care Compare Performance Information

CMS added new 2021 Quality Payment Program performance information to the Doctors and Clinicians section of Medicare Care Compare and in the Provider Data Catalog. For more information, see Care Compare: Doctors and Clinicians Initiative.


Short-Term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports

Fourth quarter FY 2022 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) are available for short-term acute care hospitals. These reports summarize provider-specific data for Medicare services that may be at risk for improper payments. Use the data to support auditing and monitoring activities.

Target Area Update:

The Spinal Fusion target area now includes outpatient claims, in addition to inpatient claims. See the User’s Guide to learn more.

More Information:


Skilled Nursing Facility Value-Based Purchasing Program: March Feedback Report

Download your March quarterly feedback report for the FY 2024 Skilled Nursing Facility Value-Based Purchasing Program from the CASPER reporting system. Review data for upcoming measure and scoring calculations, including planned and unplanned readmissions.

This data isn’t eligible for the review and correction process because it isn’t final. We’ll include final data and measure results in your June report.



Audiologists Can Furnish Certain Diagnostic Tests Without a Physician Order

Starting January 1, 2023, audiologists can furnish certain diagnostic audiology tests without a physician or non-physician practitioner (NPP) order using the AB modifier:

  • Covered once per patient per 12-month period
  • Limited to non-acute hearing conditions
  • Excludes services related to:
    • Disequilibrium
    • Hearing aids
    • Exams for prescribing, fitting, or changing hearing aids

Tips when you bill with the AB modifier:

  • Document good faith efforts were made to provide services for non-acute hearing conditions without the order of a treating physician or NPP so that the claim won’t deny if you unexpectedly discover an acute condition
  • You can leave box 17 A & B (name and NPI of the referring provider) blank or incomplete

More Information:


Colorectal Cancer: Screening Saves Lives

Colorectal cancer affects men and women of all racial and ethnic groups, and risk increases with age (see CDC). Colorectal Cancer Awareness Month is the perfect time to encourage screening and help find this cancer early when treatment is most effective.

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

More Information:


Claims, Pricers, & Codes

COVID-19: Don’t Report CR Modifier & DR Condition Code After Public Health Emergency

See the corrected message in the March 30 edition.

The end of the COVID-19 public health emergency (PHE) is expected to occur on May 11, 2023. Since the CR modifier and DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023.

For more information, see Section 10 of the Medicare Claims Processing Manual, Chapter 38.


Split (or Shared) Critical Care Visits: Billing Correction

Learn about corrected billing for CPT code 99292 when you deliver critical care as a split (or shared) visit. CMS corrected an error in Section of the Medicare Claims Processing Manual, Chapter 12 to align with current policy. In the third paragraph, we changed the number of cumulative total minutes from 75 to 104.

For more information, see the instruction to your Medicare Administrative Contractor.


ICD-10 Coordination & Maintenance Committee: Meeting Materials & Deadlines

Get materials from the March ICD-10 Coordination & Maintenance Committee meeting:

Submit comments on proposed new codes, addenda, and revisions by these dates:

  • April 7 to implement on October 1, 2023
  • May 5 to implement on October 1, 2024

Send comments to:


HCPCS Application Summaries & Coding Decisions: Non-Drug & Non-Biological Items and Services

CMS published the Second Biannual 2022 HCPCS Application Summaries & Coding Recommendations for non-drug and non-biological items and services. See HCPCS Level II Coding Decisions for more information.



Home Health Value-Based Purchasing Model Webinar: Strategies for Success Self-Assessment Tool — March 30

Thursday, March 30 at 2:30 pm ET

Register for this webinar.

Learn about the new quality improvement resource for home health agencies:

  • Identify strategies to improve quality performance results
  • Evaluate the application of 9 recommended best practices

Attendees can submit questions during the event.



Medicare Secondary Payer: Don’t Deny Services & Bill Correctly

If your patient has an open Medicare secondary payer (MSP) record on their file, don’t deny medical services, treatment, or entry to skilled nursing facilities or hospitals.

Continue to see and treat Medicare patients, even if we previously mistakenly denied or rejected a claim you submitted as Medicare primary. Sometimes claims are mistakenly denied or rejected by Medicare when the claim diagnosis code is related to the patient’s MSP liability, no-fault, or workers’ compensation record found on the eligibility response. You can appeal these claim denials or rejections with your Medicare Administrative Contractor. Part A providers can submit adjustments. 

Learn how to bill correctly for liability, no-fault, and worker’s compensation claims.


Behavioral Health Integration Services — Revised

Learn what’s changed, including new codes:

  • HCPCS code G0323 describing general behavioral health integration where a clinical psychologist or social worker, serving as the focal point of care integration, furnishes the mental health services
  • CPT code 90791 as an eligible initiating visit for G0323


Medicare Preventive Services — Revised

Learn about what’s changed:

  • Cardiovascular disease screening tests: Added information on lipid testing national coverage determination
  • Glaucoma screening: Added information on local coverage article
  • Medical nutrition therapy: Clarified frequency for subsequent years
  • Medicare Diabetes Prevention Program: Clarified information on A1c test values for diagnosing prediabetes or diabetes
  • Prostate cancer screening: Added CPT code 0359U effective January 1, 2023


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