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Thursday, October 6, 2022


Claims, Pricers, & Codes

MLN Matters® Articles

Information for Patients




Resources & Flexibilities to Assist with Public Health Emergency in South Carolina

CMS announced additional resources and flexibilities in response to Hurricane Ian in South Carolina. On September 30, HHS Secretary Xavier Becerra determined that a public health emergency exists in the State of South Carolina, retroactive to September 25. We’re ready to help with resources and waivers to ensure hospitals and other facilities can continue to operate and provide access to care.

More Information:


Implementation of Inflation Reduction Act Provision Addressing Medicare Payments for Biosimilars

In accordance with section 11403 of the Inflation Reduction Act, CMS is implementing a temporary increase in payment under Medicare for qualifying biosimilars. The new law provides for a temporary increase in the add-on payment for qualifying biosimilars whose average sales price (ASP) is not more than the price of the associated reference biological product. This provision encourages the creation and utilization of biosimilars to compete with original biologic products and incentivizes innovation for less costly access to these important therapies in the United States.

Prior to the implementation of the provisions in section 11403 of the Inflation Reduction Act, CMS paid biosimilars a rate of the biosimilar’s ASP plus an add-on of 6% of the reference biological product’s ASP. Under section 11403 of the Inflation Reduction Act, qualifying biosimilars will temporarily be paid ASP plus 8% (rather than plus 6%) of the reference biological product’s ASP for a 5-year period. For existing qualifying biosimilars for which payment was made using ASP as of September 30, 2022, the 5-year period begins on October 1, 2022. For new qualifying biosimilars for which payment is first made using ASP between October 1, 2022, and December 31, 2027, the applicable 5-year period begins on the first day of the calendar quarter during which such payment is made.

The goal of the temporary add-on payment for providers is to increase access to biosimilars, as well as to encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.

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CMS Asks for Public Input on Establishing First, National Directory of Health Care Providers and Services

As part of CMS’s ongoing work to improve access to care, reduce clinician burden, and support interoperability throughout the health sector, CMS released a Request for Information (RFI) seeking public input on the concept of CMS creating a directory with information on health care providers and services or a “National Directory of Healthcare Providers and Services” (NDH).

Health care directories can serve as an important resource for patients, helping them locate providers who meet their individual needs and preferences and allowing them to compare health plan networks. Directories also have the ability to facilitate care coordination, health information exchange, and public health data reporting.

CMS is seeking comment on how a CMS-led directory could reduce directory maintenance burden on providers and payers by creating a single, centralized system, promoting real-time accuracy for patients.

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Inflation Reduction Act Lowers Health Care Costs for Millions of Americans

Through the Inflation Reduction Act, President Biden is delivering on his promise to lower prescription drug costs, make health insurance more affordable, and make the economy work for working families. This law means millions of Americans across all 50 states, the United States territories, and the District of Columbia will save money from meaningful benefits like:

  • Lower prescription drug prices in Medicare through price negotiation with manufacturers
  • Yearly cap ($2,000 in 2025) on out-of-pocket prescription drug costs in Medicare
  • Continued lower health insurance premiums through HealthCare.gov and the state-based Marketplaces 

More Information:


Help Promote Efficiency, Reduce Burden, & Advance Equity: Submit Comments by November 4

CMS released the “Make Your Voice Heard” Request for Information to get your input.

We want to:

  • Understand your experience, including factors which affect provider wellness
  • Learn about strategies that successfully address drivers of health inequities
  • Assess the impact of waivers and flexibilities provided in response to the COVID-19 public health emergency

We encourage comments from all interested individuals and institutions, in particular:

  • Individuals serving and located in underserved communities
  • All CMS stakeholders serving populations facing disparities in health and health care

Submit comments by November 4.

More Information:


Inpatient Rehabilitation Facilities: IRF-PAI & September Care Compare Release

To address inpatient rehabilitation facility (IRF) concerns, CMS issued a statement (PDF) and Q&A (PDF) on:

  • IRF Patient Assessment Instrument (IRF-PAI) V4.0
  • Unplanned discharges
  • IRF Quality Reporting Program (QRP) compliance

Visit the IRF-PAI webpage for more information.

View the September release of IRF QRP data on the Care Compare webpage and in the Provider Data Catalog. Visit the Updates Section of the Public Reporting webpage to learn more.


Long-Term Care Hospitals: September Care Compare Release

View the September release of Long-term Care Hospital Quality Reporting Program data on the Care Compare webpage and in the Provider Data Catalog. Visit the Updates Section of the Public Reporting webpage to learn more.


Help Detect Breast Cancer Early

Almost 99% of women diagnosed with breast cancer at the earliest stage live for 5 years or more (see data snapshot (PDF)). During National Breast Cancer Awareness Month, talk with your patients about the best screening options for them to help detect breast cancer early.

Medicare covers:

Your patients pay nothing if you accept assignment. Find out when your patient is eligible for their next screening (PDF). If you need help, contact your eligibility service provider.

More Information:


Claims, Pricers, & Codes


October 2022 Integrated Outpatient Code Editor (I/OCE) Specifications Version 23.3

Learn about claims processing changes, effective October 1, 2022, for:

  • Hospital outpatient departments
  • Community mental health centers
  • Non-Outpatient Prospective Payment System (PPS) hospital providers
  • Limited services when provided in a home health (HH) agency that isn’t paid under the HH PPS
  • Hospice patients for non-terminal illness treatment

See the instruction to your Medicare Administrative Contractor (PDF).


MLN Matters® Articles


Ambulatory Surgical Center Payment System: October 2022 Update

Learn about updates effective October 1, 2022 (PDF), including new:

  • Outpatient Prospective Payment System device pass-through code
  • HCPCS codes for drugs and biologicals
  • Skin substitute products assigned to low or high-cost group


DMEPOS Fee Schedule: October 2022 Quarterly Update

Learn about updates effective October 1, 2022 (PDF), including fee schedule amounts for new and existing codes.


Inpatient Prospective Payment System Hospitals in the 9th Circuit: Updated Fiscal Years 2019 and 2020 Supplemental Security Income Medicare Beneficiary Data


Learn about updated data (PDF) based on the Supreme Court decision in Azar v. Empire Health Foundation.


Information for Patients


2023 Medicare & You Handbook


The 2023 Medicare & You Handbook is available. Encourage your patients to get it electronically! Go digital with electronic Medicare Summary Notices. Help Medicare save money by switching to the electronic versions. Share the online 2023 Medicare & You Handbook with your patients and their caregivers. New and important this year:

  • COVID-19 updates
  • Special enrollment periods
  • New start dates for coverage
  • Kidney transplants and immunosuppressive drug coverage: new benefit
  • Accountable Care Organizations
  • State help with Medicare health and drug costs
  • Mental health and wellness help in a crisis


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