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Thursday, June 8, 2023



Claims, Pricers, & Codes

MLN Matters® Articles





CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the Territory of Guam Due to Recent Typhoon

CMS announced additional resources and flexibilities available in response to the recent typhoon in Guam. CMS is working closely with the Territory of Guam to put these flexibilities in place to ensure those affected by this natural disaster have access to the care they need – when they need it most.

On June 2, 2023, HHS Secretary Xavier Becerra determined that a Public Health Emergency exists in the Territory of Guam as a result of the consequences of Typhoon Mawar beginning on May 22, 2023, and continuing.

CMS stands ready to assist with resources and waivers to ensure hospitals and other facilities can continue to operate and provide access to care to those impacted by the consequences of the typhoon.

More Information:


CMS Roundup (June 2, 2023)

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

  • CMS Innovation Center Issues Latest Evaluation Reports on Several Care-Delivery Models
  • CMS Releases Information & Resources Focusing on Improving Health Care for LGBTQI+ Individuals


Gender-Specific Services: Billing Correctly and Usage of the Condition Code/Modifier

CMS may reject or return Medicare Part A and Part B claims inappropriately if it appears there’s a mismatch between the procedure or diagnosis code and the reported sex of the patient.  This is a reminder to institutional providers and clinicians that bill for Part B professional claims that a condition code/modifier are available to allow these claims to process correctly.

Effective July 1, 2023, the National Uniform Billing Committee revised Condition Code 45 to Gender Incongruence, defined as “characterized by a marked and persistent incongruence between an individual’s experienced gender and sex at birth.”

For any procedure codes often considered appropriate for only one gender, indicate on the claim detail line if the patient’s experienced gender is different than their sex at birth.  For claims to process correctly:

Institutional providers: Continue to report condition code 45 (Ambiguous Gender Category) for inpatient and outpatient claims related to transgender, intersex, and gender-expansive systems issues.

Clinicians that bill for Part B professional claims: Report the KX modifier for any claims related to transgender, intersex, and gender-expansive systems issues.


Medicare Shared Savings Program: Apply for January 1 Start Date by June 15

Accountable Care Organizations (ACOs): Apply for the Medicare Shared Savings Program through the ACO Management System by June 15 at noon ET. See the Application Toolkit to get resources for the upcoming application submission cycle.

We’re offering a new Advance Investment Payments option to encourage providers in rural and underserved areas to join together as ACOs.

More Information:


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

Download your June quarterly feedback report for the FY 2024 Skilled Nursing Facility (SNF) Value-Based Purchasing Program from iQIES. Review facility and stay-level data for the SNF 30-Day All-Cause Readmission Measure for FY 2022.

Submit corrections until July 1. See Confidential Feedback Reporting & Review and Corrections for more information.



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

First quarter FY 2023 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:


Medicare Providers: Deadlines for Joining an Accountable Care Organization

To participate in an Accountable Care Organization (ACO) for performance year 2024, work with an ACO to join their participant list. ACOs must submit their lists to CMS by August 1 at:

Participant taxpayer identification numbers can’t overlap multiple ACO participant lists. Resolve any overlaps by September 5.

More Information:


Help Address Disparities in the LGBTQI+ Community

While members of the Lesbian, Gay, Bisexual, Transgender, Queer and Questioning, Intersex, Asexual, and Two Spirit (LGBTQI+) community share the burden of stigma surrounding their sexual orientation or gender identity and expression, their individual experiences related to health care outcomes vary by race, ethnicity, income, and other characteristics. During Pride Month, find out how you can help address the unique health care challenges and barriers facing this community.

More Information:


Claims, Pricers, & Codes


National Correct Coding Initiative: July Update

Get the National Correct Coding Initiative (NCCI) third quarter edit files, effective July 1, 2023, on these Medicare NCCI webpages:


Integrated Outpatient Code Editor: Version 24.2

CMS posted the July 2023 Integrated Outpatient Code Editor files. Learn about claims processing changes effective July 1, 2023.

See the instruction to your Medicare Administrative Contractor.


MLN Matters® Articles


Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order

Learn about billing and coding requirements for diagnostic tests using the AB modifier:

  • Limited to non-acute hearing conditions and diagnostic services related to implanted auditory prosthetic devices
  • Excludes audiology services that are related to disequilibrium, hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids
  • Covered once per patient per 12-month period
  • Unexpected discovery of an acute condition


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