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Thursday, June 15, 2023


Claims, Pricers, & Codes

MLN Matters® Articles


Information for Patients




Inflation Reduction Act Continues to Lower Out-of-Pocket Prescription Drug Costs for Drugs with Price Increases Above Inflation

On June 9, HHS, through CMS, announced the list of 43 prescription drugs for which Part B beneficiary coinsurances may be lower between July 1 – September 30, 2023. CMS has released information about these 43 Part B drugs and biological products in the quarterly Average Sales Price (ASP) public files, available here. A fact sheet is available here.

This coinsurance adjustment applies to certain drugs and biologicals paid under Medicare Part B. The Part B drugs impacted by this coinsurance adjustment may change quarterly.

See the initial guidance detailing the requirements and procedures for the Medicare Prescription Drug Inflation Rebate Program here

More Information:


CMS Announces Multi-State Initiative to Strengthen Primary Care

CMS announced a new primary care model – the Making Care Primary (MCP) Model – that will be tested under the Center for Medicare and Medicaid Innovation in 8 states. Access to high-quality primary care is associated with better health outcomes and equity for people and communities. MCP is an important step in strengthening the primary care infrastructure in the country, especially for safety net and smaller or independent primary care organizations. 

The model seeks to improve care for patients by expanding and enhancing care management and care coordination, equipping primary care clinicians with tools to form partnerships with health care specialists, and leveraging community-based connections to address patients’ health needs as well as their health-related social needs.

More Information:


Critical Access Hospitals: Annual Average Patient Length of Stay Requirement

During the COVID-19 public health emergency (PHE), CMS waived the annual average 96-hour patient length of stay requirement for critical access hospitals. We’re resuming our standard practice to evaluate this requirement starting with your first full cost reporting period after May 11, 2023, that doesn’t include any of the months covered under the PHE blanket waiver.

See the Quality, Safety & Oversight Memorandum for more information.


Skilled Nursing Facility Probe and Educate Review

Do you bill correctly under the Patient Driven Payment Model?

Your Medicare Administrative Contractor will review 5 of your claims. Based on the findings, they’ll teach you how to bill correctly. If they ask you for documentation, respond promptly so we don’t deny your claims.

More Information:


Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance

Starting July 1, 2023, Part B coinsurance for a month’s supply of insulin used in an insulin pump covered under the DME benefit can’t exceed $35.

CMS will adjust payments to suppliers and pharmacies to account for the balance of the reduced coinsurance. Suppliers will continue to get the Medicare payment amount for the insulin (average sales price plus 6%) minus any applicable coinsurance, which is capped at $35 for a month’s supply.

Don’t bill for supplies of insulin for July or subsequent months before July 2023. We’ll complete the system updates to make sure patients aren’t charged more than the $35 maximum allowed for the month of July. Your DME Medicare Administrative Contractor will also educate you about billing during the May – June transition period.

We’re adding 2 new modifiers to the April 2023 HCPCS quarterly update file:

  • JK - Short Descriptor: Drug 1-month supply or less; Long Descriptor: One month supply or less of drug/biological
  • JL - Short Descriptor: Drug 3-month supply; Long Descriptor: Three month supply of drug/biological

Split Billing:

  • Before July 2023: For “from date of service” in May or June 2023, don’t bill a 3-month supply of insulin. Instead, bill a 1-month supply of insulin with the JK modifier.
  • Starting July 2023: For “from date of service” in July and later, bill a 3-month supply of insulin with the JL modifier or a 1-month supply with the JK modifier.

For more information, see the fact sheet.

Get information for your patients:


ESRD Prospective Payment System: July Update

See the instruction to your Medicare Administrative Contractor for updates to the ESRD Prospective Payment System, including:

  • Attachment A: CMS made routine changes to the list of outlier services effective July 1, 2023:
    • Updated the mean unit cost for renal dialysis drugs that are oral equivalents to injectable drugs based on the most recent prices from the Medicare Prescription Drug Plan Finder
    • Added or removed renal dialysis items and services
    • Revised the mean dispensing fee of qualifying National Drug Codes (NDCs) to $0.50 per NDC per month
  • Attachment B: We updated the Consolidated Billing list effective April 1, 2023, to replace J0610 with J0612 in the Bone and Mineral Metabolism category


Medicare Learning Network Web Refresh

CMS improved the content and organization of several Medicare Learning Network® (MLN) webpages to make it easier to find what you need. MLN webpages include:

  • Resources & training materials on CMS policies and programs
  • National Fee-for-Service news
  • Billing & coding compliance information

Check out the updated MLN homepage.


Men’s Health: Encourage Your Patients to Prioritize Their Health

Men’s Health Week is the perfect time to talk with your patients about preventable health issues, and encourage early detection and treatment. Medicare covers preventive services, including:

Find out when your patient is eligible for services. If you need help, contact your eligibility service provider.

More Information:


Claims, Pricers, & Codes


ICD-10-PCS Procedure Codes: FY 2024

Get FY 2024 ICD-10-PCS procedure codes effective for discharges on or after October 1, 2023.


MLN Matters® Articles


DMEPOS Fee Schedule: July 2023 Quarterly Update

Learn about the July updates:

  • Fee schedule adjustment relief for rural and non-contiguous areas
  • Supplier education on power wheelchair repair


Hospital Outpatient Prospective Payment System: July 2023 Update

Learn about payment system updates and new codes for:

  • COVID-19
  • Drugs, biologicals, and radiopharmaceuticals
  • Devices
  • Other items and services


New JZ Claims Modifier for Certain Medicare Part B Drugs

Learn about reporting requirements for the new modifier starting July 1, 2023.


Ambulatory Surgical Center Payment System: July 2023 Update — Revised

Learn what’s changed:

  • Section 5: revised the number of new drugs
  • Table 3: changed the descriptor for code J9323 and removed J9321
  • New information on device offsets for HCPCS codes 50080 and 50081




Expanded Home Health Value-Based Purchasing Model: Resource Index, FAQs, & Specifications  

Get information on the Expanded Home Health Value-Based Purchasing Model, including:


Information for Patients


New Tools to Lower Prescription Drug Costs for Low-Income Seniors and People with Disabilities

The Biden-Harris Administration announced new tools to lower prescription drug costs for low-income people with Medicare through the Extra Help program, which provides eligible seniors and disabled people with help paying for their Medicare Part D premiums and cost-sharing. These resources complement forthcoming expansions in Extra Help benefits and will ensure more people eligible for benefits are enrolled in this vital program.

More Information:


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