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Thursday, July 13, 2023



Claims, Pricers, & Codes


MLN Matters® Articles

Publications & Multimedia

From Our Federal Partners




Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022

On July 7, 2023, in light of the Supreme Court’s decision in American Hospital Association v. Becerra (142 S. Ct. 1896 (2022)) and the district court’s remand to the agency, CMS issued a proposed rule outlining the proposed remedy for the 340B-acquired drug payment policy for C Ys 2018-2022. CMS is publishing this proposed rule to remedy the payment rates the Court held were invalid. Aspects of this proposed policy will affect nearly all hospitals paid under the OPPS.

More Information:


National Coverage Determination: Pre-exposure Prophylaxis Using Antiretroviral Drugs to Prevent HIV Infection

CMS announced the posting of a proposed National Coverage Determination for Pre-Exposure Prophylaxis (PrEP) Using Antiretroviral Drugs to Prevent Human Immunodeficiency Virus (HIV) Infection. CMS proposes coverage of PrEP using antiretroviral drugs (whether oral or injectable) approved by the FDA to prevent HIV infection in individuals at high risk of HIV acquisition. CMS also proposes to cover the administration of injectable PrEP using antiretroviral drugs to prevent HIV infection. PrEP involves the use of antiretroviral drugs on an ongoing basis or before and after HIV exposure. When taken as directed, PrEP is highly effective for preventing HIV. Further, CMS is also proposing to cover additional HIV screenings up to 7 times annually and a single screening for hepatitis B virus (HBV) for these high risk patients.

PrEP medications are currently covered under Medicare Part D but may have cost-sharing and deductibles. Under the proposal, both oral and injectable forms of the medication would be covered for certain individuals under Part B as an “additional preventive service,” and without requiring payment of Part B coinsurance or meeting the deductible. People with Medicare should talk to their doctor or health care provider to see if this medication is right for them.

Find more details, and how to submit a comment on this proposed National Coverage Determination.


Medicare Dental Services: Learn What’s Covered

Learn about dental services:

  • What Medicare does and doesn’t cover, including multiple visits
  • What are inextricably linked dental services
  • Who can provide dental services
  • Who can bill
  • How to submit a claim


Claims, Pricers, & Codes

Institutional Providers: Resubmit Audiology Claims Returned with Reason Code 34963

CMS incorrectly returned some institutional claims to audiologists who provided diagnostic tests for nonacute hearing conditions without an order from a physician or non-physician practitioner. When all lines on a claim include the AB modifier, you don’t need to report the attending provider’s NPI. If you got a returned claim with reason code 34963, resubmit it.

When claims also contain codes without the AB modifier, continue to bill the billing provider’s NPI in the Attending field.  


Inpatient Prospective Payment System-Excluded Hospitals: Correcting Issue with Excluded Units

CMS identified an issue that may cause Inpatient Prospective Payment System (IPPS)-excluded hospital claims for IPPS-excluded psychiatric or rehabilitation units to reject or deny incorrectly. We’ll implement a system update to correct this issue on October 2, 2023. See the instruction to your Medicare Administrative Contractor (MAC).

Contact your MAC if your claims for IPPS-excluded unit were processed incorrectly. Find your MAC's website.


ICD-10-CM Diagnosis Codes: FY 2024 Coding Guidelines & Conversion Table

Get FY 2024 ICD-10-CM diagnosis codes effective for discharges on or after October 1, 2023, along with coding guidelines and the conversion table.



Expanded Home Health Value-Based Purchasing Model: Overview of the Interim Performance Report Webcast — July 27

Thursday, July 27 from 2–3 pm ET

Register for this webcast.

Learn about the data and information available in the Interim Performance Report (IPR) to help you monitor your performance during the CY 2023 performance year. Only CMS certification numbers with a Medicare-certification date before January 1, 2022, will get a July 2023 IPR.

See the Expanded Home Health Value-Based Purchasing Model for more information.


MLN Matters® Articles

ICD-10 & Other Coding Revisions to Laboratory National Coverage Determinations: October 2023 Update

Learn about this quarterly update:

  • New codes
  • Recent changes
  • How to find coding information


Ambulatory Surgical Center Payment System: July 2023 Update — Revised

CMS changed the number of separately payable drugs in Section 5.a because we corrected the payment indicator for HCPCS J9322.


New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI — Revised

Learn about changes to the exceptions list:

  • Added:
    • Over-the-counter claims with HCPCS K1034
    • Medicare Administrative Contractor adjustments
    • Claims with AB modifier on all lines
  • Removed type of bill 71X for rural health clinic claims


Publications & Multimedia

Period of Enhanced Oversight for New Hospices in Arizona, California, Nevada, & Texas

CMS is placing newly enrolling hospices in Arizona, California, Nevada, and Texas in a provisional period of enhanced oversight, which includes medical review. Find out more.


Expanded Home Health Value-Based Purchasing Model: New Resources

Find these new resources and more on the Expanded Home Health Value-Based Purchasing (HHVBP) Model webpage under Quality Improvement:

Questions? Email the HHVBP Model Help Desk.


From Our Federal Partners

Rural Emergency Hospitals: Requirements in CMS Emergency Preparedness Final Rule

Review this crosswalk from the Administration for Strategic Preparedness and Response's Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) to learn more about the CMS emergency preparedness rule that affects your facility.


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