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Thursday, January 4, 2024


Claims, Pricers, & Codes

MLN Matters® Articles





CMS Roundup (Dec 29, 2023)

You may be interested in these topics from the CMS Roundup:

  • Final Evaluation Report on Comprehensive Primary Care Plus Model
  • Major Actions on Federal Independent Dispute Resolution Process 
  • Proposed Rule Establishing Appeal Processes for Certain People with Medicare
  • New Laboratory Regulation Adjusts Fees, Revises Requirements & Permitted Sanctions


In-Home Vaccine Administration: Additional Payment

For certain Medicare patients, we pay an additional payment for in-home administration of these Part B preventive vaccines:

  • COVID-19
  • Flu
  • Hepatitis B
  • Pneumococcal

Flu, Hepatitis B, & Pneumococcal Shots: Additional Payments Started January 1

Visit In-Home Vaccine Administration: Additional Payment to learn more, including:

  • What’s the payment amount?
  • What billing codes do I use?
  • When can I get the additional in-home payment?
  • What locations qualify?
  • What other restrictions apply?

COVID-19 Shots

Visit Medicare COVID-19 Vaccine Shot Payment for more information, including the CY 2024 payment amount.


Organizational Providers: Do You Need to Revalidate Your Enrollment Record Soon?

Use the Medicare Revalidation List to find out if you must revalidate your enrollment record. CMS usually posts revalidation due dates 6–7 months in advance; but we’ll establish your date at least 90 days in advance. A due date of “TBD” means that we haven’t set your due date, and you don’t need to do anything now.

Currently, only organizational providers must revalidate; individual providers don’t. We’ll let you know if this changes. 

See Revalidations (Renewing Your Enrollment) for more information. 


Value-Based Insurance Design Model: Learn about the Hospice Benefit Component

Currently, when a patient enrolled in Medicare Advantage (MA) elects hospice, Fee-for-Service Medicare becomes responsible for coverage and payment of most services, while the MA plan remains responsible for certain services like supplemental benefits. Under the Hospice Benefit Component of the Value-Based Insurance Design (VBID) Model, participating MA plans are financially responsible for all Part A and B benefits, including the hospice and supplemental benefits. CMS is assessing how this affects care delivery and quality of care, especially for palliative and hospice care.

For CY 2024, 13 participating MA organizations offer 78 plan benefit packages through the Model. We sent information and resources to affected hospices in December. Learn more about the Hospice Benefit Component to prepare for future years.

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


CMS Health Information Handler Helps You Submit Medical Review Documentation Electronically

Learn about the CMS Health Information Handler (CMS HIH), a free service to help you upload and submit your medical documentation electronically to your Medicare Administrative Contractor using the following formats:

  • Portable document format (PDF)
  • Extensible markup language (XML)
  • JavaScript object notation (JSON)

Respond electronically to prior authorization and additional document requests: 

  • Unlimited number of transactions
  • Fast, safe, and secure environment
  • Easily accessible

The benefits of the CMS HIH include:

  • Hosted on CMS Amazon Web Services cloud
  • Adheres to all CMS security and privacy standards
  • Accommodates small or large users

Contact cmshih@cms.hhs.gov to learn more, and get started.


Cervical Health: Encourage Screening

All women are at risk for cervical cancer, but it occurs most often in women over age 30 (see CDC fact sheet). During Cervical Health Awareness Month, talk with your patients about cervical and vaginal cancer screenings.

Medicare covers:

Your patients pay nothing if you accept assignment. Find out when your patient is eligible for these screenings. If you need help, contact your eligibility service provider.

More Information:


Claims, Pricers, & Codes


Skilled Nursing Facility Consolidated Billing: CY 2024 HCPCS Codes

Get updated HCPCS codes (ZIP) to accurately bill for Part A skilled nursing facility stays. See the general explanation of the major categories (PDF), including additional exclusions.

More Information:


Integrated Outpatient Code Editor: Version 25.0

CMS posted the January 2024 Integrated Outpatient Code Editor files. Learn about claims processing changes effective January 1, 2024.

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


MLN Matters® Articles

Ambulatory Surgical Center Payment System: January 2024 Update

Learn about payment system updates for January (PDF), including new codes for:

  • Covered devices for pass-through payments
  • Biology-guided radiation therapy
  • Facility services for covered dental rehabilitation procedures
  • Surgical procedures
  • Drugs and biologicals (If you think Medicare paid you incorrectly because we retroactively corrected payment rates, you may ask your Medicare Administrative Contractor to adjust these claims)
  • Skin substitutes


New Condition Code 92: Billing Requirements for Intensive Outpatient Program Services

Learn about this new condition code (PDF) effective January 1, 2024:

  • Intensive Outpatient Program (IOP) services will get per diem payments under the Outpatient Prospective Payment System (OPPS) when billed by an OPPS provider
  • Medicare covers and pays for these services for people with mental health needs who require this level of care
  • These billing requirements apply when IOP is provided by:
    • Hospital and critical access hospital outpatient departments
    • Community mental health centers

Medicare Administrative Contractors will return your IOP service claim if it:

  • Overlaps partial hospitalization program claims with condition code 41
  • Has a line item date of service within 7 days prior to the “from date” for an incoming claim for the same patient and provider


Activation of Validation Edits for Providers with Multiple Service Locations — Revised 

Learn what’s changed (PDF):

  • Clarified that instructions don’t apply to separately enrolled provider-based rural health clinics
  • Added information on the 09/23 version of the paper-based enrollment form


New Waived Tests — Revised

Learn what’s changed (PDF):

  • Revised QW code information for Clinical Laboratory Improvement Amendments waived tests
  • Added 24 waived tests and QW codes


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