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Thursday, May 16, 2024



Claims, Pricers, & Codes


MLN Matters® Articles


Information for Patients



Administration Acts to Improve Access to Kidney Transplants

On May 8, HHS, through CMS, is announcing the Increasing Organ Transplant Access Model. The proposed model, which would be implemented by the CMS Innovation Center, aims to increase access to kidney transplants for all people living with ESRD, improve the quality of care for people seeking kidney transplants, reduce disparities among individuals undergoing the process to receive a kidney transplant, and increase the efficiency and capability of transplant hospitals selected to participate. This proposed model would build on the Biden-Harris Administration’s priority of improving the kidney transplant system and the collaborative efforts between CMS and the Health Resources and Services Administration to increase organ donation and improve clinical outcomes, system improvement, quality measurement, transparency, and regulatory oversight.

More Information:

DMEPOS: Updated List of Items Potentially Subject to Conditions of Payment

CMS updated the DMEPOS Master List:

  • Added 76 items
  • Deleted 3 items

If these items are selected for face-to-face encounter, written order prior to delivery, or prior authorization, you may be required to:

  • Meet with your patient and give them a written order before delivering the item
  • Ask your Medicare Administrative Contractor to authorize the item in advance

Learn more about extra order requirements:

Lymphedema Compression Treatment Items: New DMEPOS Benefit Category

Starting January 1, 2024, Medicare pays for lymphedema compression treatment items for Medicare Part B patients. CMS updated the following manuals with information on this new DMEPOS benefit category:

Hospice: New Requirement for Physicians Who Certify Patient Eligibility Effective June 3

For Medicare to pay for hospice services, the following physicians must enroll in Medicare or opt out by June 3, 2024:

  1. Hospice medical director or the physician member of the hospice interdisciplinary group who certifies the patient’s terminal condition
  2. Patient-designated attending physician (if they have one) who certifies their terminal condition

CMS will deny hospice claims if the certifying physician isn’t in our PECOS hospice ordering and referring files by then.

If you’re currently enrolled or opted out, you don’t need to do anything.

This new requirement:

  • Only applies to Fee-for-Service Medicare
  • Doesn’t prohibit the patient’s independent attending physician from treating them while in hospice and billing for these services under Part B
  • Applies to all written or oral certifications under § 418.22(c) 

Hospices can quickly verify a physician’s enrollment or opt-out status using the CMS order and referring data file, which lists all Medicare-enrolled and opted-out physicians.

More Information:

Medicare Physician Fee Schedule Database: July Update

See the attachment in the instruction to your Medicare Administrative Contractor (PDF) (MAC) to learn about the July quarterly changes to the Medicare Physician Fee Schedule Database:

  • New codes
  • Procedure status changes
  • Code short descriptor revisions
  • Payment policy indicator changes
  • Established codes that now have the TC and 26 modifiers

Your MAC will give you 30-days’ notice before they implement these changes. Then, they’ll adjust claims that you bring to their attention. 

Women’s Health: Talk with Your Patients About Prevention, Care, & Wellbeing

During National Women’s Health Week and National Osteoporosis Month, encourage your patients to prioritize whole health—prevention, care, and wellbeing. Medicare covers preventive services to help support a healthy lifestyle, including:

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

More Information:


Diabetic Shoes: Prevent Claim Denials

In 2022, the improper payment rate for diabetic shoes was 51%, and insufficient documentation accounted for 69% of improper payments (see 2022 Medicare Fee-for-Service Supplemental Improper Payment Data (PDF), Appendices D, E, and G). Learn how to bill correctly for these services. Review the diabetic shoes provider compliance tip for more information, including:

  • Codes
  • Coverage limitations and requirements for therapeutic shoes
  • Documentation requirements and example of improper payment
  • Resources

Claims, Pricers, & Codes

Home Health Claims: Additional Enforcement of Required County Codes

Effective October 1, 2024, you must report county codes (value code 85) on all home health claims with type of bill 032x. 

More Information:



Overcoming COVID-19 Vaccine Payment Challenges Webinar — May 30

Thursday, May 30, 2024, from 2–3 pm ET

Register for this webinar.

Target audience: This webinar is open to Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs), nursing home leaders, medical directors, directors of nursing, and billing supervisors interested in overcoming vaccine payment challenges to maximize immunization rates for COVID-19 at their facilities.

The commercialization of COVID-19 vaccines following the end of the public health emergency has led to vaccine payment challenges for nursing homes. Join CMS and the CDC to:

  • Hear directly from a Medicare payment expert
  • Learn how QIN-QIOs are connecting nursing homes with pharmacies to provide vaccines and handle billing
  • Get resources for navigating the vaccine payment process

If you have questions, contact dvacsupport@bizzellus.com.  

MLN Matters® Articles

Annual Wellness Visit: Social Determinants of Health Risk Assessment 

Learn about providing the social determinants of health risk assessment (PDF) during an annual wellness visit:

  • Optional element
  • Eligibility and billing requirements

Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update 

Learn about updates for laboratory billing (PDF) effective July 1, 2024, including:

  • Next private payor data reporting period: January 1 – March 31, 2025
  • New and deleted HCPCS codes

Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule 

Learn about updates to diabetes screening and definitions (PDF):

  • Revised definition of diabetes
  • Simplified screening frequency limits
  • Added Hemoglobin A1c (HbA1c) test coverage

Medicare Administrative Contractors will reprocess claims you bring to their attention.

ESRD Prospective Payment System: Quarterly Update

Learn more about changes effective July 1, 2024 (PDF), including:

  • Added Transitional Drug Add-On Payment Adjustment for HCPCS code J0911
  • Updated list of outlier services

Updates for Split or Shared Evaluation and Management Visits

Learn about updates effective January 1, 2024 (PDF):

  • Changes to what’s considered a substantive portion
  • How to bill


Skilled Nursing Facility Quality Reporting Program: Social Determinants of Health Video

Watch an animated CMS video on Social Determinants of Health (SDOH) Items: Using Sources Other Than the Resident to Code (4 min) for skilled nursing facility (SNF) providers. Learn how to accurately determine when you’re allowed to use other sources for these SDOH items:  

  • A1005 – Ethnicity
  • A1010 – Race
  • A1110 – Language
  • A1250 –Transportation
  • B1300 – Health Literacy 
  • D0700 – Social Isolation

Visit SNF Quality Reporting Training for more information.

Skilled Nursing Facility Quality Reporting Program: Annual Payment Update Webinar Materials

Get materials from the March webinar on Achieving a Full Annual Payment Update:

Visit SNF Quality Reporting Training for more information.

Information for Patients

Mental Health & Substance Use Disorders: Updated Medicare.gov Content

May is Mental Health Awareness Month, and CMS updated our Mental Health and Substance Use Disorders content on medicare.gov. These updates are part of our broader Behavioral Health Strategy and make it easier for users to access mental health and substance use disorder information. 


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