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Thursday, August 31, 2023


Claims, Pricers, & Codes

From Our Federal Partners




HHS Selects the First Drugs for Medicare Drug Price Negotiation

For the first time, thanks to the Inflation Reduction Act – the historic law lowering health care costs – Medicare is able to negotiate the prices of prescription drugs. HHS, through CMS, announced the first 10 drugs covered under Medicare Part D selected for negotiation. The negotiations with participating drug companies will occur in 2023 and 2024, and any negotiated prices will become effective beginning in 2026.

Medicare enrollees taking the 10 drugs covered under Part D selected for negotiation paid a total of $3.4 billion in out-of-pocket costs in 2022 for these drugs.

These selected drugs accounted for $50.5 billion in total Part D gross covered prescription drug costs, or about 20%, of total Part D gross covered prescription drug costs between June 1, 2022, and May 31, 2023, which is the time period used to determine which drugs were eligible for negotiation.

More Information:


Medicare Shared Savings Program Saves Medicare More Than $1.8 Billion in 2022 and Continues to Deliver High-quality Care

CMS announced that the Medicare Shared Savings Program saved money for Medicare while continuing to support high-quality care. Specifically, the program saved Medicare $1.8 billion in 2022 compared to spending targets for the year. This marks the sixth consecutive year the program has generated overall savings and high-quality performance results. This represents the second-highest annual savings accrued for Medicare since the program’s inception more than ten years ago. 

In the CY 2024 Physician Fee Schedule proposed rule, CMS proposed changes to the Medicare Shared Savings Program. Comments are due by September 11.

More Information:


CMS Issues Draft Guidance on New Program to Allow People with Medicare to Pay Out-of-Pocket Prescription Drug Costs in Monthly Payments

The Inflation Reduction Act gives people with Medicare prescription drug coverage (Medicare Part D) the option to pay out-of-pocket costs in monthly payments spread out over the year, starting in 2025. CMS released draft guidance for comment that outlines the requirements and procedures for certain aspects of the new Medicare Prescription Payment Plan. By enabling seniors and people with disabilities with Medicare Part D coverage to spread out cost sharing over the year, the program could reduce the burden of high upfront out-of-pocket prescription drug costs.

CMS will develop a broad range of educational materials and tools for Part D enrollees, pharmacies, prescribers, and others that will be ready in advance of open enrollment for plan year 2025.

More Information:


CMS Roundup (Aug. 25, 2023)

You may be interested in this topic from the CMS Roundup: CMS Highlights Hospice Program Integrity Actions and Strategies to Combat Fraudulent Billing.


CMS.gov Website Refresh – Provide Feedback on Test Website by September 5

On August 15, CMS launched a preview version of CMS.gov that features new information architecture, navigation, and refreshed home page. We worked with stakeholders to develop the improvements, and the new website reflects their input.

There’s still time to send feedback:

  • Click the link in the CMS.gov banner directing you to the new preview test site. The content is identical on CMS.gov and this preview test site – the preview site just showcases changes to the site navigation and home page.
  • Provide your input via the Feedback button available on every page on the preview test site.


Claims, Pricers, & Codes


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

CMS published the First Biannual 2023 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 Prospective Payment System Grouper: October Update

Get the October 2023 release (v04.2.23). See Home Health Prospective Payment System Grouper Software for a summary of changes.

More Information:


Updated ICD-10 Medicare Severity Diagnosis-Related Group Version 41

See Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications and Software for:


From Our Federal Partners


Locally Acquired Malaria Cases Identified in Florida, Texas, & Maryland — Important Updates

The CDC issued a Health Alert Network Health Update to share new information about locally acquired malaria cases identified in the U.S. In addition to routinely considering malaria as a cause of febrile illness among patients with a history of international travel to areas where malaria is transmitted, clinicians should consider a malaria diagnosis in any person with an unexplained cause of fever, regardless of their travel history.

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