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National Influenza Vaccination Week

Thursday, December 2, 2021


Claims, Pricers, & Codes

MLN Matters® Articles





National Influenza Vaccination Week

During National Influenza Vaccination Week, remind your patients that there’s still time to get the flu shot. Adults with certain other chronic health conditions like asthma, heart disease, and diabetes are at higher risk of developing potentially serious flu complications. Flu and COVID-19 are different diseases caused by different viruses. One vaccine isn’t a substitute for the other.

Medicare Part B covers 1 flu shot per flu season and additional flu shots, if medically necessary. Your patients pay nothing if you accept assignment.

Every office visit is an opportunity to talk to your patients about why it’s important to get a flu shot. Your strong recommendation can make a difference in whether your patients get vaccinated against the flu. If your practice doesn’t administer the flu vaccine, refer patients to a vaccine provider.

More Information:


Clinical Laboratory Fee Schedule: CY 2022 Final Payment Determinations

Download the Clinical Laboratory Fee Schedule (CLFS) Calendar Year (CY) 2022 Final Test Codes Payment Determinations (ZIP). For more information on the payment determination process, visit the CLFS Annual Public Meeting website.


Skilled Nursing Care & Skilled Therapy Services to Maintain Function or Prevent or Slow Decline: Reminder

Medicare covers skilled nursing care and skilled therapy services under skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline, as long as:

  • The beneficiary requires skilled care for the services to be provided safely and effectively
  • An individualized assessment of the patient's condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are needed for a safe and effective maintenance program

Visit the Jimmo Settlement Agreement webpage for more information.


Ambulance Prior Authorization Model Expands February 1

The Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model began in some states on December 1 and will expand to additional areas on February 1:

  • December 1, 2021: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas
  • February 1, 2022: Alabama, American Samoa, California, Georgia, Guam, Hawaii, Nevada, Northern Mariana Islands, and Tennessee

Visit the Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport webpage for the national implementation schedule and other information.


Claims, Pricers, & Codes


Hospital Inpatient EHR Reductions

Medicare Administrative Contractors (MACs) are reprocessing hospital inpatient claims for incorrectly-calculated Electronic Health Record (EHR) reduction amounts. The problem occurred when meaningful EHR users not subject to the EHR reduction penalty submitted an inpatient hospital (type of bill 11x) claim on or after October 1. You don’t have to resubmit affected claims.


ICD-10: New Diagnosis & Procedure Codes Effective April 1, 2022

In response to the ongoing COVID-19 national emergency, 3 new diagnosis codes and 7 new procedure codes describing introducing or infusing therapeutics, including vaccines for COVID-19 treatment, will be effective April 1, 2022. A new Medicare Code Editor (MCE) code edit and revised coverage edits will also be effective April 1. Download the code updates (ZIP).


MLN Matters® Articles


2022 Annual Update to the Therapy Code List

Learn about the updated calendar year 2022 therapy code list (PDF):

  • 5 new CPT codes
  • How to use the codes


Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2022

 Learn about the calendar year 2022 HH PPS rate update (PDF):

  • 30-day period payment rates
  • National per-visit amounts
  • Cost-per-unit payment amounts used for calculating outlier payments under the HH PPS


Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2022

Learn about the updated ESRD PPS (PDF):

  • Base rate, budget neutrality factor, and outlier threshold
  • AKI dialysis payment rate
  • Capital related assets for transitional add-on payment adjustment for new and innovative equipment and supplies


Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

Learn about the updated code sets (PDF):

  • Latest RARCs and CARCs
  • What to do if you use MREP or PC Print
  • Where to find the official code lists




Ordering External Breast Prostheses & Supplies — Revised

Learn about Medicare coverage and documentation requirements for ordering post-mastectomy breast prostheses and supplies (PDF), including:

  • Eligible HCPCS codes
  • Standard written orders from prescribing practitioners
  • Reasonable useful lifetime: expectancy, documentation, and replacement


Checking Medicare Eligibility — Revised

Learn about the 4 ways to check a patient’s Medicare eligibility (PDF), including considerations if your billing agency, clearinghouse or software vendor processes or stores your information outside the United States.


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