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Thursday, October 13, 2022



Claims, Pricers, & Codes

MLN Matters® Articles


From Our Federal Partners



Protect Your Patients in October: Give Them a Flu Shot & COVID-19 Vaccine

The CDC recommends annual flu shots for everyone 6 months and older. You can give flu shots and COVID-19 vaccines at the same visit. There are updated COVID-19 vaccines designed to protect your patients against the Omicron strain, which makes up almost all COVID-19 cases in the U.S.

Encourage your patients to get a flu shot and updated COVID-19 vaccine by the end of October — your recommendation makes a difference.

New for this flu season: Patients 65 and older should get a preferred vaccine if available. Preferred vaccines are potentially more effective than standard dose flu vaccines. There are 3 recommended vaccines:

  1. Fluzone High-Dose Quadrivalent vaccine
  2. Flublok Quadrivalent recombinant flu vaccine
  3. Fluad Quadrivalent adjuvanted flu vaccine

If one of these recommended vaccines isn’t available, give your patients a standard-dose flu vaccine instead.

Medicare Part B covers the seasonal flu shot and additional flu shots if medically necessary. Your patients pay nothing if you accept assignment. There’s no applicable copayment, coinsurance, or deductible for COVID-19 vaccines.  

You can now check eligibility (PDF) for the flu shot and COVID-19 vaccine. If you need help, contact your eligibility service provider.

More Information:


Vacating Differential Payment Rate for 340B-Acquired Drugs in 2022 Outpatient Prospective Payment System Final Rule with Comment Period

On September 28, 2022, the United States District Court for the District of Columbia vacated the differential payment rates for 340B-acquired drugs in the Calendar Year 2022 Outpatient Prospective Payment System (OPPS) final rule with respect to their prospective application. The Court ruled:

  • CMS can’t apply the average sales price (ASP) minus 22.5% drug payment rate for these drugs for the rest of the year
  • As a result, CMS will revert to paying the default rate (generally ASP plus 6%) under the Medicare statute for 340B-acquired drugs

CMS is uploading revised OPPS drug files that will apply the default rate (generally ASP plus 6%) to 340B-acquired drugs for the rest of the year. CMS also will reprocess claims our contractors paid on or after September 28, 2022, using the default rate (generally ASP plus 6%).


Clinical Laboratory Fee Schedule: Final Gapfill Recommendations

View the Final Gapfill Recommendations (ZIP) for calendar year (CY) 2023. Submit payment reconsideration requests by November 4. Once CMS posts final CY 2023 rates following this reconsideration period, the gapfilled payment amount is final.

See the CMS Clinical Laboratory Fee Schedule Annual Public Meeting webpage for more information.


Claims, Pricers, & Codes

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update Fiscal Year (FY) 2023

Learn about updates to payment rates for FY 2023, including the 5% cap.

More Information:


MLN Matters® Articles

Home Health Claims: New Grouper Edits

Learn about new edits (PDF). CMS will:

  • Identify error conditions
  • Send new informational responses
  • Reprocess some Notices of Admission


New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

Starting April 1, 2023, CMS will edit institutional claims to make sure providers don’t use organizational NPIs in place of individual NPIs. Learn about exceptions (PDF).



Medicare Preventive Services — Revised

Learn about updates to preventive services, including pneumococcal shot resources and new ICD-10 codes effective October 1, 2022:

  • 13 bone mass measurement codes
  • 3 hepatitis B screening codes


National Expansion of the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model — Revised

Learn how CMS processes claims for repetitive, scheduled non-emergent ambulance transports when you don’t request prior authorization (PDF). The Medicare ambulance benefit for non-emergent transports is limited, and prior authorization is voluntary.


From Our Federal Partners

Outbreak of Ebola Virus Disease in Central Uganda

The CDC issued a Health Alert Network Health Advisory about a recently confirmed outbreak of Ebola virus disease (EVD) in Uganda caused by the Sudan virus. It summarizes their recommendations for:

  • U.S. public health departments and clinicians
  • Case identification and testing
  • Clinical laboratory biosafety considerations 

No suspected, probable, or confirmed EVD cases related to this outbreak have been reported in the U.S. However, as a precaution and to remind clinicians about best practices, they’re communicating with public health departments, public health laboratories, and health care workers to raise awareness.


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