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Thursday, April 25, 2024



Claims, Pricers, & Codes

MLN Matters® Articles

From Our Federal Partners



Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule

On April 22, 2024, CMS affirmed its commitment to hold nursing homes accountable for providing safe and high-quality care for the nearly 1.2 million residents living in Medicare- and Medicaid-certified long-term care facilities by issuing the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule.

CMS is also finalizing enhanced facility assessment requirements and a requirement to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care. 

More Information:

CMS Roundup (Apr 19, 2024)

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

  • 2024 Quality Conference Focuses on Building Resiliency and Innovation in Health System
  • Initiative Addresses Climate Change in Health Care Industry

Hospice Requirement for Certifying Physicians to Enroll in or Opt-Out of Medicare: Delayed until June 3

CMS updated this message on April 25, because we delayed the effective date until June 3, 2024.

CMS delayed the date that physicians who certify hospice services must enroll in or opt-out of Medicare until June 3. CMS will deny hospice claims if the certifying physician isn’t in our PECOS hospice ordering and referring files by then.

More Information:

Comprehensive Error Rate Testing Program: Reduced Sample Size Starting with Reporting Year 2025 

CMS will permanently reduce the Comprehensive Error Rate Testing (CERT) program sample size starting with reporting year (RY) 2025. The sample size for improper payment measurement review will decrease from 50,000 to 37,500 claims annually.

If the CERT Review Contractor completes the RY 2025 review but removes your claim from the sample, they’ll send you a letter. 

Your Medicare Administrative Contractor will:

  • Adjust the claim if required to reflect the correct codes and payment
  • Pay or collect if needed

Skilled Nursing Facility Value-Based Purchasing Program: FY 2026 Early Look Performance Score Report 

Download your FY 2026 Early Look Performance Score Report for the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program from iQIES. CMS will expand the SNF VBP Program to assess performance on multiple quality measures, rather than a single measure. Use your report to get familiar with:

  • Planned format of the official Performance Score Report
  • Scoring and payment methodology
  • Your past performance on the 4 quality measures and model performance

Visit Confidential Feedback Reporting & Review and Corrections for more information.



Opioid Treatment Program: Bill Correctly for Opioid Use Disorder Treatment Services

In a report, the Office of the Inspector General found that Opioid Treatment Program (OTP) providers didn’t always comply with federal requirements when they bill for opioid use disorder (OUD) treatment services, including intake activities. Review OTP Billing & Payment, and learn how to: 

  • Bill for OUD services
  • Use the correct G-codes for treatment 

Claims, Pricers, & Codes

Hospital Outpatient Prospective Payment System: Correcting Errors to Codes 0621T, J7353, & C9167

CMS will correct these errors in the July 2024 Hospital Outpatient Prospective Payment System update:

  • CPT code 0621T:
    • Correct status indicator is J1 with assignment to ambulatory payment classification (APC) 5492 (Level 2 Intraocular Procedures)
    • Retroactive to claims with dates of service starting January 1, 2024
  • HCPCS code J7353:
    • Correct status indicator is G, with assignment to APC 0742 (Anacaulase-bcdb 8.8% gel 1 g)
    • Payment rate is $60.709 for January 1–March 31, 2024, and $58.311 effective April 1, 2024
    • Retroactive to claims with dates of service starting January 1, 2024
  • HCPCS code C9167:
    • Correct long descriptor is “Injection, adamts13, recombinant-krhn, 10 iu”
    • Correct short descriptor is “Inj, adzynma, 10 iu”
    • Change effective April 1, 2024

We included corrections in the updated January 2024 and April 2024 OPPS quarterly addenda. Hospitals don’t need to take any action.

MLN Matters® Articles

Medicare Claims Processing Manual Update: Inpatient Rehabilitation Facility 

Learn about updates to the manual (PDF), including:

  • Hospitals may open a new inpatient rehabilitation facility (IRF) unit at any time during the cost reporting year 
  • Any IRF unit excluded during a cost reporting year will stay excluded for the rest of the cost reporting year

National Coverage Determination 20.7: Percutaneous Transluminal Angioplasty

Learn about changes in coverage for percutaneous transluminal angioplasty of the carotid artery concurrent with stenting (PDF) effective October 11, 2023:

  • Patients don’t have to enroll in a clinical trial
  • Facilities don’t need CMS approval to perform this service
  • You must engage in formal shared decision-making with the patient 
  • Medicare Administrative Contractors (MACs) can decide if this service is covered if it’s not addressed in this national coverage determination

Your MAC will adjust claims processed in error that you bring to their attention.

DMEPOS Fee Schedule: April 2024 Quarterly Update — Revised

Learn what’s changed (PDF). CMS added 4 HCPCS Level II codes.

From Our Federal Partners

Adverse Effects Linked to Counterfeit or Mishandled Botulinum Toxin Injections

The CDC issued a Health Alert Network Health Advisory to alert clinicians about risks of counterfeit or mishandled botulinum toxin injections. CDC, FDA, and state and local partners are investigating clusters of 22 people in 11 U.S. states reporting adverse effects after receiving injections with counterfeit botulinum toxin or injections administered by unlicensed or untrained individuals or in non-healthcare settings, such as homes or spas.

Recommendations for clinicians:

  • Consider the possibility of adverse effects from botulinum toxin injections, including those given for cosmetic reasons, in patients presenting with localized paralysis near the injection site. Ask patients about history of botulinum toxin injections, including the dose.
  • Be aware of symptom overlap between the presentation of localized adverse effects from injection of botulinum toxin and the early symptoms of botulism.
  • If botulism is suspected, call your health department immediately for consultation.
  • If public health clinical consultation supports botulism, request antitoxin and begin treatment as soon as it is available. Don’t wait for laboratory confirmation to begin treatment.

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