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NPI: What You Need to Know

Thursday, April 29, 2021




Claims, Pricers, & Codes

MLN Matters® Articles


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Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS

If you’re a laboratory, including an independent laboratory, a physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS), you must report information, including laboratory test HCPCS codes, associated private payor rates, and volume data. CMS recently updated resources:

  • Summary (PDF): Overview of key terms and concepts, how to determine whether your laboratory is an applicable laboratory, and timeline
  • FAQs (PDF): Responses to questions


  • Collect data:  January 1-June 30, 2019
  • Report data: January 1-March 31, 2022

For more information, visit the PAMA Regulations webpage.




Cardiac Device Credits: Medicare Billing

A 2018 Office of the Inspector General report noted that payments reviewed for recalled cardiac medical devices didn’t comply with Medicare requirements for reporting manufacturer credits. Manufacturers issued reportable credits to hospitals for recalled cardiac medical devices, but the hospitals didn’t adjust the claims with the right condition codes, value codes, or modifiers to reduce payment, as required.

Review the Medicare Billing for Cardiac Device Credits (PDF) fact sheet to avoid overpayment recoveries. Additional resources:


Claims, Pricers, & Codes


Coordination of Benefits: Parts A & B Crossover Claims Issue

Due to an April 8-15 systems issue, Medicare didn’t send Part A and Part B (including Durable Medical Equipment (DME)) crossover claims to some supplemental payers. We corrected this issue on April 16; however, it impacts claims finalized through approximately:

  • April 25 (electronic claims)
  • May 11 (paper claims)

If this issue affected your patients’ supplemental payer (ZIP), bill them using your normal procedures (if Medicare claims weren’t crossed over). Note: There are separate tabs for Part A, Part B, and DME.


MLN Matters® Articles


Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 87636

CMS issued a new MLN Matters Article MM12269 on Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 87636 (PDF). Learn about this change for certain COVID-19 and influenza laboratory tests.




SBIRT Services

CMS issued a new Medicare Learning Network SBIRT Services (PDF) booklet. Learn about:

  • Covered Screening, Brief Intervention, & Referral to Treatment (SBIRT) services
  • Eligible providers
  • Billing for dual eligibles


NPI: What You Need to Know — Revised

CMS revised the Medicare Learning Network NPI: What You Need to Know (PDF) booklet. Learn about:

  • Benefits
  • Categories
  • How to apply


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