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Thursday, December 8, 2022



Claims, Pricers, & Codes


MLN Matters® Articles

From Our Federal Partners




CMS Proposes Rule to Expand Access to Health Information and Improve the Prior Authorization Process

As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and investing in interoperability, CMS issued a proposed rule that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. CMS proposes to modernize the health care system by requiring certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent. The rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.

More Information:


Rural Emergency Hospitals: New Institutional Provider Type Starting January 1

CMS will implement a new rural emergency hospital (REH) provider type on January 1, 2023. If you're converting a rural hospital or critical access hospital to an REH, submit your application.

For more information, see REH Medicare Provider Instructions, and find out how to become an institutional provider.


Certificates of Medical Necessity & DME Information Forms Discontinued January 1

You don’t need to submit certificates of medical necessity (CMNs) and durable medical equipment (DME) information forms (DIFs) for claims with dates of service on or after January 1, 2023. If CMS gets a claim with a CMN or DIF, we’ll reject the claim and return it to you.

For services before January 1, 2023, continue to submit CMN and DIF forms if required.

See MLN Matters Article SE22002 for more information.


Drugs & Biologics: Reporting Average Sales Price Data

CMS is mailing a letter to manufacturers about their average sales price (ASP) reporting requirements under the Consolidations Appropriations Act 2021.

Starting January 1, 2022, drug manufacturers without a Medicaid drug rebate agreement must report ASP data to us for these drugs or biologicals every quarter. We believe some manufacturers haven’t reported or only reported for a subset of their product line.

See Medicare Part B Drug Average Sales Price for more information.


Provider Enrollment Application Fee: CY 2023

Effective January 1, the application fee is $688 for institutional providers (as defined in 42 CFR § 424.502) who are:

  • Initially enrolling in the Medicare or Medicaid programs or the Children's Health Insurance Program (CHIP)
  • Revalidating their Medicare, Medicaid, or CHIP enrollment
  • Adding a new Medicare practice location

CMS requires this fee with any of these enrollment applications submitted from January 1 – December 31, 2023. See the notice for more information.


Skilled Nursing Facility Value-Based Purchasing Program: December Feedback Report

Download your December quarterly feedback report for the FY 2024 Skilled Nursing Facility Value-Based Purchasing Program from the CASPER reporting system.

Submit corrections to your FY 2019 readmission measure rate until December 31. See Confidential Feedback & Review and Corrections for more information.


Bronchodilator Nebulizer Medications: Comparative Billing Report in December

This month, CMS will issue a Comparative Billing Report (CBR) on Medicare Part B claims for bronchodilator nebulizer medications. Use the data-driven report to compare your billing practices with those of your peers in your state and across the nation.

Look for an email from cbrpepper.noreply@religroupinc.com to access your report.

More Information:


Short-term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports

Third quarter FY 2022 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. Use the data to support auditing and monitoring activities.

More Information:


Flu Shots: Help Address Disparities

The CDC recommends annual flu shots for everyone 6 months and older, including people with chronic medical conditions who have a higher risk of serious complications (see CDC). Vaccination rates for Medicare Fee-for-Service patients vary by race, ethnicity, and geographic area (see data snapshot). National Influenza Vaccination Week is a perfect time to find out how you can help address these challenges, and encourage your patients to get flu shots.

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

You can give flu shots and COVID-19 vaccines at the same visit. Medicare Part B covers:

  • Flu shot: seasonal flu shot and additional flu shots if medically necessary. Your patients pay nothing if you accept assignment.
  • COVID-19 vaccine: no applicable copayment, coinsurance, or deductible.

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

More Information:




Bill Correctly: Power Mobility Device Repairs

See the clarified message in the December 15 edition.

An Office of Inspector General report stated that Medicare improperly paid claims for power mobility device (PMD) repairs when suppliers didn’t provide sufficient documentation to support billing charges. The Power Mobility Devices booklet explains how to properly document and bill for PMD repairs.

Follow these steps to bill for repair charges:

  • Check the Standard Written Order (SWO)
  • Make a prior authorization request
  • Complete a home assessment
  • Keep the following documents: SWO; face-to-face visit supporting documents; written home assessment report; proof of delivery; records describing repairs, including a detailed explanation that justifies components or parts replaced and labor time to fix the item
  • Review all information to avoid improper payments

More Information:


Claims, Pricers, & Codes


Medicare National Correct Coding Initiative: Annual Policy Manual Update

On December 1, CMS posted the updated Medicare National Correct Coding Initiative Policy Manual effective January 1, 2023. See red font for additions or revisions. See the policy manual archive on the left side to get prior versions of the manual.


National Correct Coding Initiative: January Update

Get the National Correct Coding Initiative (NCCI) fourth quarter edit files, effective January 1, 2023, on these Medicare NCCI webpages:




FY 2024 New Technology Town Hall Meeting — December 14

Wednesday, December 14 from 8:30 am – 4:30 pm ET

Attend this virtual public meeting to hear FY 2024 new technology add-on payment applicants present how their technologies meet the substantial clinical improvement criterion. Provide your input before CMS publishes the Inpatient Prospective Payment System and Long-Term Hospital prospective Payment System proposed rule.

See the agenda for a list of topics and information on how to join.


Medicare Ground Ambulance Data Collection System Webinar: Data Certifier Role — December 15

Thursday, December 15 from 2–3 pm ET

Register for this webinar.

Learn about the data certifier role in the Ground Ambulance Data Collection System (GADCS) portal. While everyone is welcome to participate, it will be most relevant to people who will be certifying data for ground ambulance organizations selected for Year 1 and Year 2, who must report their data starting in 2023.

A Q&A session will follow the presentation. You may send questions in advance to AmbulanceDataCollection@cms.hhs.gov with “December 15 Certifier Role Webinar” in the subject line. During the webinar, we’ll answer these and live questions from the chat box.

Visit GADCS for:

  • Lists of organizations, the year they’re selected for, and when reporting will begin
  • GADCS User Guide
  • FAQs


MLN Matters® Articles


Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2023 Changes

Learn about updates effective October 1, 2022, for:

  • Inpatient Prospective Payment System (IPPS)
  • Long-Term Care Hospital Prospective Payment System
  • Certain hospitals CMS excludes from the IPPS


National Coverage Determination 110.24: Chimeric Antigen Receptor T-cell Therapy

Learn about billing changes for this therapy:

  • Include additional place of service codes for office and independent clinics
  • Bill in 0.1-unit fractions
  • Use 3 modifiers, including new modifier-LU


Rural Health Clinic All-Inclusive Rate: CY 2023 Update

Learn about updates to the rate effective January 1, 2023, including:

  • Payment limit per visit
  • Payment limits for specified (grandfathered) provider-based rural health clinics
  • Cost report data requirements


From Our Federal Partners


Biosimilars & Interchangeable Products: Free Continuing Education Courses from FDA

Access these accredited continuing education courses for health care providers:

You must have a Medscape account to access the courses. Sign up for a free account.

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