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Thursday, September 14, 2023



Claims, Pricers, & Codes

MLN Matters® Articles

Publications & Multimedia





Inflation Reduction Act Continues to Lower Out-of-Pocket Prescription Drug Costs for Drugs with Price Increases Above Inflation

On September 13, CMS announced the list of 34 prescription drugs for which Part B beneficiary coinsurances may be lower between October 1 – December 31, 2023. CMS has released information about these 34 Part B drugs and biological products in the quarterly Average Sales Price (ASP) public files, available here. A fact sheet is available here.

This coinsurance adjustment applies to certain drugs and biologicals paid under Medicare Part B. The Part B drugs impacted by this coinsurance adjustment may change quarterly.

See the initial guidance detailing the requirements and procedures for the Medicare Prescription Drug Inflation Rebate Program here.

More Information:


CMS Roundup (Sep 8, 2023)

You may be interested in this topic from the CMS Roundup: CMS Highlights Initiative for a Quicker Path to Medicare Coverage of Break Through FDA-Approved Medical Devices for Patients with Life-Threatening Diseases and Conditions.


New Provider Types 2024: Marriage and Family Therapists & Mental Health Counselors

CMS will implement marriage and family therapist and mental health counselor provider types on January 1.

You must enroll in Medicare to submit claims and get paid for covered items or services. You can start submitting enrollment applications after the CY 2024 Physician Fee Schedule final rule is on display at the Federal Register, usually around November 1:

  • Your effective enrollment date won’t be earlier than January 1
  • We’ll send an MLN Connects newsletter when it displays

In the meantime, find out how to become a Medicare provider, and get ready to enroll:

More Information:


PECOS 2.0 Is Coming Soon

Benefits of PECOS 2.0 include:

  • Faster application times
  • Quick and easy revalidation process
  • Real-time status tracking

Watch these videos to learn more:

CMS will provide updates on the launch in future editions.


Medicare Secondary Payer: Are You Getting Diagnosis Codes?

CMS gives Non-Group Health Plan (NGHP) Medicare secondary payer (MSP) diagnosis codes on eligibility responses, so you know the health care services primary payer. If you aren’t getting diagnosis codes, contact your vendor.

Read Medicare Secondary Payer: Don’t Deny Services & Bill Correctly to learn how to:

  • Determine payer order
  • Bill when you get both MSP Group Health Plan and NGHP on eligibility responses
  • Appeal mistakenly denied or rejected MSP claims


Social Determinants of Health: Collect Data with ICD-10-CM Z Codes

Learn about Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. This new CMS infographic helps you understand and use Z codes to improve the quality and collection of health equity data.

Using social determinants of health can:

  • Enhance quality improvement activities
  • Track factors that influence people’s health
  • Provide insight into existing health inequities

More Information:


ESRD: Submitting Dialysis Claims That Include Capital Related Assets Eligible for the TPNIES

See MLN Matters Article MM12347 for information on getting the capital related asset (CRA) for the Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES) under the ESRD Prospective Payment System.

To get the payment adjustment, submit the following to your Medicare Administrative Contractor (MAC):

  • Claim: Report the appropriate revenue code and the CRA HCPCS with modifier AX for each treatment performed using the CRA machine
  • CRA Invoice

If your MAC returned claims with CRA HCPCS codes, address the issues, and resubmit the claims.


Medicare Physician Fee Schedule Database: October Update

See the attachment in the instruction to your Medicare Administrative Contractor to learn about the October quarterly changes to the Medicare Physician Fee Schedule Database:

  • New codes
  • Procedure status changes


Prostate Cancer:  Encourage Your Patients to Get Screened

Prostate cancer is the most common cancer diagnosed in North American men, excluding skin cancers (see cancer.gov). During Prostate Cancer Awareness Month, talk with your patients about their risk, and help them make an informed decision about screening.

Medicare covers prostate cancer screenings. Find out when your patient is eligible for screening. If you need help, contact your eligibility service provider.

More Information:


Claims, Pricers, & Codes


National Correct Coding Initiative: October Update

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

Integrated Outpatient Code Editor: Version 24.3

CMS posted the October 2023 Integrated Outpatient Code Editor files. Learn about claims processing changes effective October 1, 2023.

See the instruction to your Medicare Administrative Contractor.


MLN Matters® Articles


Ambulatory Surgical Center Payment System: October 2023 Update

Learn about payment system updates for October, including new codes for:

  • Renal or kidney histotripsy
  • Drugs and biologicals
  • Skin substitute


DMEPOS Fee Schedule: October 2023 Quarterly Update

Learn about the October updates:

  • Fee schedule adjustment relief for rural and non-contiguous areas
  • New HCPCS codes
  • New fee schedule amounts


Hospital Outpatient Prospective Payment System: October 2023 Update

Learn about payment system updates for October:

  • New Covid-19 CPT codes for vaccines and administration
  • HCPCS and CPT coding changes, including:
    • Proprietary laboratory analyses
    • Multianalyte assays with algorithmic analyses
  • Advanced diagnostic laboratory tests under the clinical lab fee schedule


Publications & Multimedia


Expanded Home Health Value-Based Purchasing Model: Updated Resource & Event Materials

Learn about the Expanded Home Health Value-Based Purchasing Model:


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