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2% Payment Adjustment (Sequestration) Changes

Thursday, December 16, 2021


Claims, Pricers, & Codes


MLN Matters® Articles


Information for Medicare Patients




Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Changes

The Protecting Medicare and American Farmers from Sequester Cuts Act impacts payments for all Medicare Fee-for-Service (FFS) claims:

  • No payment adjustment through March 31, 2022
  • 1% payment adjustment April 1 – June 30, 2022
  • 2% payment adjustment beginning July 1, 2022


Flu Shot Disparities

According to the CDC, people of racial and ethnic communities experience higher rates of severe flu-related illness and hospitalization, and they historically have lower vaccination rates than non-Hispanic White people.

Hospitalization Rates:

  • Non-Hispanic Black people (69 per 100,000)
  • Non-Hispanic American Indian or Alaskan Native people (49 per 100,000)
  • Hispanic or Latino people (45 per 100,000)
  • Non-Hispanic White people (38 per 100,000)
  • Non-Hispanic Asian people (32 per 100,000)

Adult Flu Vaccination Percentages:

  • 38.6% Hispanic or Latino people
  • 40.4% non-Hispanic Black people
  • 41.5 % non-Hispanic American Indian or Alaskan Native people
  • 54.5% non-Hispanic Asian people
  • 55.5% non-Hispanic White people

You can help reduce these disparities and increase flu shot use:

  • Use each office visit to talk to your patients about why it’s important to get the flu shot
  • Share handouts with patients who want additional information, have questions, or decline the flu shot
  • Refer patients to a vaccine provider if your practice doesn’t administer the flu shot

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.

More Information:


Opioid Treatment Programs: New Information for 2022

The Calendar Year (CY) 2022 Physician Fee Schedule final rule includes information for Medicare-enrolled Opioid Treatment Programs (OTPs):

  • After the end of the COVID-19 public health emergency (PHE), CMS will allow audio-only interactions (like telephone calls) when audio-video communication isn’t available to the patient or the patient can’t or won’t agree to 2-way audio-video communication
  • CMS established HCPCS code G1028 for a higher dose of naloxone hydrochloride nasal spray in response to the increase in overdoses from illicitly-manufactured fentanyl, which can require a more potent overdose reversal drug

After the PHE ends, CMS expects OTPs to add the following modifiers on claims for HCPCS code G2080:

  • Modifier 95: for counseling and therapy provided using audio-video telecommunications
  • Modifier FQ: for counseling and therapy provided using audio-only telecommunications

Additionally, CMS issued an interim final rule with comment period to keep the methadone payment amount at the CY 2021 rate for the duration of CY 2022. We encourage OTPs to review the rule and submit formal comments by January 3, 2022.

We updated the OTP webpages and the Billing & Payment (PDF) booklet with this and other new information.


Medicare Clinical Laboratory Fee Schedule Private Payor Data Reporting – Delayed until 2023

On December 10, the Protecting Medicare and American Farmers from Sequester Cuts Act delayed the Clinical Laboratory Fee Schedule private payor reporting requirement:

  • Next data reporting period is January 1 – March 31, 2023
  • Reporting is based on the original data collection period, January 1 – June 30, 2019

The Act also extended the statutory phase-in of payment reductions resulting from private payor rate implementation:

  • No payment reductions for Calendar Years (CYs) 2021 and 2022
  • Payment won’t be reduced by more than 15% for CYs 2023 through 2025

Visit the PAMA Regulations webpage for more information on what data you need to collect and how to report it.


PEPPERs for Short-Term Acute Care Hospitals

Third quarter FY 2021 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) are available for short-term acute care hospitals. These reports summarize provider-specific data for Medicare services that may be at risk for improper payments. Review the PEPPER data with your management team and develop auditing and monitoring action items.

For More Information:


COVID-19 Vaccine & Monoclonal Antibody Products: Changes for MA Plan Claims Starting January 1, 2022

If you vaccinate or administer monoclonal antibody treatment to patients enrolled in Medicare Advantage (MA) plans on or after January 1, 2022, submit claims to the MA Plan. Original Medicare won’t pay these claims.

More Information:


Claims, Pricers, & Codes


Pneumococcal Conjugate Vaccine, 15 Valent

Medicare began covering pneumococcal conjugate vaccine,15 valent on July 16. CMS suggests submitting separate claims for this vaccine (HCPCS code 90671).

  • Part A and B Medicare Administrative Contractors will hold claims for vaccines provided after December 31 until pricing is set
  • CMS will deny claims for vaccines provided before July 16


Average Sales Price Files: January 2022

CMS posted the January 2022 Average Sales Price (ASP) and Not Otherwise Classified (NOC) pricing files and crosswalks on the 2022 ASP Drug Pricing Files webpage.


Skin Substitute Codes

Physicians and nonphysician practitioners who perform CPT codes 15271 – 15278:

  • You may bill separately for skin substitute codes A2001 – A2010 when applied in a non-facility setting
  • Report the appropriate application of skin substitute CPT code(s) 15271 – 15278 and the appropriate charge on the same claim with the skin substitute “A” code
  • We will pay for skin substitutes assigned “A” codes separately from the physician’s office for the application procedure, similar to skin substitutes with “Q” code and their application
  • Codes A2001 – A2010 will be priced by your Medicare Administrative Contractor when billed with CPT codes 15271 – 15278


National Correct Coding Initiative Medicare Policy Manual: Annual Update

The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services annual update is effective January 1. See red font for additions or revisions. Visit the NCCI Policy Manual Archive for more information and prior versions of the manual.




Medicare Ground Ambulance Data Collection System: Q&A Session — January 18

Tuesday, January 18 from 2 – 3 pm ET

Register for the session.

Do you have questions about the Medicare Ground Ambulance Data Collection System? Join this live Q&A session. You may also send your questions in advance to AmbulanceDataCollection@cms.hhs.gov with “January 18 Q&A” in the subject line. We’ll update documents on our Ambulances Services Center webpage with answers to common questions from this session.

More Information:


MLN Matters® Articles


Calendar Year 2022 Update for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

Read about the Calendar Year 2022 DMEPOS fee schedule annual update (PDF):

  • New and existing code amounts
  • Payment policy changes


Incorporation of Recent Provider Enrollment Regulatory Changes into Chapter 10 of CMS Publication (Pub.) 100-08

Learn about Medicare enrollment changes that affect a variety of provider types, including physician assistants (PDF).


Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List — Revised

Learn about revisions to telehealth service coverage (PDF).




Opioid Treatment Programs (OTPs) Medicare Billing & Payment — Revised

Learn about new HCPCS codes and modifiers (PDF):

  • Use HCPCS code G1028 – Take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 mL nasal spray
  • Use HCPCS code G2215 – Take-home supply of nasal naloxone; 2-pack of 4mg per 0.1 mL nasal spray
  • Add Modifier 95 to your claim for counseling and therapy you provide by audio-video telecommunications using HCPCS code G2080 after the Public Health Emergency (PHE) ends
  • Add Modifier FQ if you provide audio-only counseling or therapy services after the PHE ends
  • See updated Table 1: MAT Codes, Descriptors, & National Medicare Payment Rates to include updated rates, new HCPCS code G1028 and revised definition of HCPCS code G2215


Information for Medicare Patients


2022 Medicare & You Handbook

Share the 2022 Medicare & You Handbook with your patients and their caregivers. It’s also available in hard copy, accessible formats, and other languages. New and important this year:

  • COVID-19-related items & services
  • Cognitive assessment & care plan services
  • Blood-based biomarker screening test for colorectal cancer
  • Continuous updates to gov make it easier for patients to find and use information



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