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Thursday, June 20, 2024



Claims, Pricers, & Codes


MLN Matters® Articles

From Our Federal Partners



CMS Preparing to Close Program that Addressed Medicare Funding Issues Resulting from Change Healthcare Cyber-Attack

CMS announced that payments under the Accelerated and Advance Payment Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will conclude on July 12, 2024. Launched in early March, the CHOPD payments were designed to ease cash flow disruptions experienced by some Medicare providers and suppliers, such as hospitals, physicians, and pharmacists, due to the unprecedented cyberattack that took health care electronic data interchange Change Healthcare offline in February.

More Information:

Federal Study Examines Care Following Nonfatal Overdose Among Medicare Beneficiaries; Identifies Effective Interventions & Gaps in Care

Researchers from SAMHSA, the National Institutes of Health’s National Institute on Drug Abuse, CMS, and the CDC found that among a cohort of 137,000 Medicare beneficiaries who experienced a nonfatal overdose in 2020, almost 24,000 (17.4%) experienced a subsequent nonfatal overdose, and about 1,300 (1%) died from overdose in the following year. Results were published in JAMA Internal Medicine, identifying both effective interventions and significant gaps in care.

See the full press release for more information.

CMS Roundup (June 14, 2024) 

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

  • Recipients of the 2024 CMS Health Equity Award
  • Comment on Data & Information to be Collected from Drug Manufacturers Under the Medicare Prescription Drug Inflation Rebate Program
  • Innovation Center Progress in Advancing Health Equity Strategies
  • Information on New Hospital Price Transparency Requirements Commencing July 1, 2024

Medical Records Request Scam: Watch out for Phishing 

CMS identified phishing scams for medical records. This may include scammers faxing you fraudulent medical records requests to get you to send patient records in response; see example (PDF).

When you review any requests, look for signs of a scam, including:

  • Directing you to send records to an unfamiliar fax number or address
  • Referencing Medicare.gov or @Medicare (.gov)
  • Indicating they need records to “update insurance accordingly” 

A scam request may include:

  • Poor grammar, misspellings, or strange wording
  • Incorrect phone numbers
  • Skewed or outdated logos
  • Graphics that are cut and pasted

If you think you got a fraudulent or questionable request, work with your Medical Review Contractor to confirm if it’s real. Submit medical documentation through the Electronic Submission of Medical Documentation (esMD) system or CMS medical review contractor secure internet portals, when available. 

Provider & Supplier Enrollment Site Visits: CMS has Authority to Conduct 

CMS conducts authorized enrollment site visits to verify operational status. Site visit inspectors carry a photo ID and CMS-issued letter of authorization that you may review but not retain or copy. 

Enrollment site visits are conducted by our 2 Site Verification Services Contractors:

  • East: Palmetto GBA and its subcontractors:
    • Overland Solutions, Inc., an affiliate of EXL
    • Information Discovery Services
    • Compliance Review, Inc.
    • National Creditors Connection, Inc.
  • West: Deloitte Consulting, LLP and its subcontractors:
    • Nationwide Management Services, Inc.
    • CSI Companies, Inc.
    • Arthur Lawrence Management, LLC
    • Computer Evidence Specialists, LLC 

More Information:

Cognitive Health: Medicare Covers Services 

83% of people with subjective cognitive decline have at least 1 chronic condition, which may make their condition more difficult to manage (see CDC). During Alzheimer’s & Brain Awareness Month, talk with your patients about the importance of brain health, risk factors, and early detection.

If your patient shows signs of cognitive impairment during a routine visit, Medicare covers a separate visit to assess their cognitive function and develop a care plan.

Find out when your patients are eligible for this service. We give information for:

  • CPT or HCPCS codes
  • Dates of service
  • NPIs who provided this service

If you need help, contact your eligibility service provider.

More Information:


Global Surgery: Bill Correctly 

In a report, the Office of the Inspector General found that providers didn’t always comply with federal requirements when they bill for surgical services, including missing co-surgery and assistant-at-surgery modifiers. Review the Global Surgery (PDF) booklet, and learn about: 

  • Coding  
  • Billing
  • Payment


Claims, Pricers, & Codes

Outpatient Institutional Providers: Find Out When to Split Claims for Updated Rates

If you submit outpatient claims (or inpatient ancillary claims reimbursed under Part B) that include Physician Fee Schedule pricing, you may want to split a single claim into 2 claims to get updated rates in certain situations. 

Examples of these situations include when CMS:

  • Applies the CY deductible
  • Implements an off-cycle Physician Fee Schedule quarterly release

Affected type of bills:

  • Hospital: 12X and 13X
  • Skilled nursing facility: 22X and 23X
  • Home health agency: 34X
  • Outpatient rehabilitation facility: 74X
  • Comprehensive outpatient rehabilitation facility: 75X



Clinical Laboratory Fee Schedule Annual Public Meeting: Now Virtual-Only on June 25 

Tuesday, June 25, 2024

Note: The CMS Central Office is currently closed. We canceled the in-person option for this meeting.

See Annual Public Meeting Regarding New and Reconsidered Clinical Diagnostic Laboratory Test Codes for CY 2025 to learn more. You don’t need to register to view or listen to the meeting virtually. 


MLN Matters® Articles

Ambulatory Surgical Center Payment Update – July 2024

Learn about payment system updates (PDF) effective July 1, 2024:

  • New CPT and HCPCS codes
  • Coverage of Elios System for patients with primary open-angle glaucoma
  • Skin substitutes

Medicare Benefit Policy Manual Update: DMEPOS Benefit Category Determinations

CMS added DMEPOS items and their national benefit category determinations (PDF).


From Our Federal Partners

Disrupted Access to Prescription Stimulant Medications Could Increase Risk of Injury & Overdose

The CDC issued a Health Alert Network Health Advisory to inform public health officials, clinicians, and affected patients, their families, and caregivers about potential disrupted access to care among individuals taking prescription stimulant medications and possible increased risks for injury and overdose. On June 13, 2024, the U.S. Department of Justice announced a federal health care fraud indictment against a large subscription-based telehealth company that provides attention-deficit/hyperactivity disorder (ADHD) treatment to patients ages 18 years and older across the United States. Patients who rely on prescription stimulant medications to treat their ADHD and have been using this or other similar subscription-based telehealth platforms could experience a disruption to their treatment and disrupted access to care. 

This potential disruption coincides with an ongoing prescription drug shortage involving several stimulant medications commonly prescribed to treat ADHD, including immediate-release formulation of amphetamine mixed salts (brand name Adderall®). Patients whose care or access to prescription stimulant medications is disrupted, and who seek medication outside of the regulated health care system, might significantly increase their risk of overdose due to the prevalence of counterfeit pills in the illegal drug market that could contain unexpected substances, including fentanyl. Given the national drug overdose crisis and threats associated with the illegal drug market, individuals struggling to access prescription stimulant medications are urged to avoid using medication obtained from anyone other than a licensed clinician and licensed pharmacy.

Recommendations for clinicians: 

  • Help patients who have lost health care access to find new licensed clinicians and pharmacies
  • Avoid stigmatizing patients affected by a disruption in care
  • Educate all patients about the health risks of using drugs or medications obtained from sources other than licensed clinicians and pharmacies, including family, friends, and social media contacts
  • As a safety precaution, in case a patient obtains medication outside the regulated health care system, prescribe naloxone and overdose prevention education to any patient who has difficulty accessing their stimulant medication or tell patients where they, their caregivers, or families, can access naloxone
  • Ensure that patients requesting care continuity for ADHD receive appropriate assessments and best-practice treatments
  • Discuss with patients, their caregivers, and families the possibility of difficulty filling a prescription due to current drug shortages and work with them to ensure they are able to fill prescriptions
  • Offer other FDA-approved treatment options for ADHD if a prescribed medication is unavailable when needed or facilitate a rapid referral to a clinician who can provide such treatment
  • If you believe a patient might have a stimulant use disorder or needs immediate mental health support, provide referrals and information about how to access treatment services, including hotlines: #988 or 800-662-HELP (4357)
  • Contact Poison Control (call 800-222-1222 or use the webPOISONCONTROL tool) for help with a poisoning emergency or for questions related to an unknown substance

See the full Health Advisory for more information.

Severe Illness Potentially Associated with Consuming Diamond Shruumz Brand Chocolate Bars, Cones, & Gummies 

The CDC issued a Health Alert Network Health Advisory. The CDC, FDA, America’s Poison Centers, and state and local partners are investigating reports of severe acute illnesses potentially associated with consuming Diamond Shruumz brand chocolate bars, cones, and gummies marketed as containing a proprietary blend of mushroom. As of June 11, 2024, 12 total illnesses and 10 hospitalizations have been reported in 8 U.S. states with ongoing efforts to identify other potential cases. The cause of the reported illnesses is not known at this time.

Recommendations for clinicians:

  • Counsel patients, caregivers, and guardians to: 
    • Not purchase, consume, or serve Diamond Shruumz brand chocolate bars, cones, or gummies
    • Avoid consuming mushroom-containing edible products claiming to produce neurologic, cognitive, or psychoactive effects
  • Be aware that “edibles” or food-like products marketed with nonspecific health benefits or implied psychoactive effects might contain undisclosed, misformulated, or unapproved ingredients that can cause severe adverse health effects
  • Have a high index of suspicion for severe illness in any patient who recently consumed any of these products presenting to a health care facility with any adverse effects
  • Obtain early consultation with a medical toxicologist with expertise in managing patients with acute unknown ingestions
  • Contact your local poison center (800-222-1222) for advice on medical management of these patients
  • Contact your local public health authority or regional poison center to report cases of illness after consuming mushroom-containing chocolate or other similar edible products

See the full Health Advisory for more information.

CHAMPVA Claims: Enroll in Direct Deposit — Reminder 

If you take patients under Civilian Health and Medical Program of VA (CHAMPVA), you must set up electronic funds transfer (EFT) to get your claims paid. 

You may have questions about making the required move. We have answers.

Is Switching to EFT Required or Optional?

Getting paid by EFT is a federal requirement, and it is not optional.

What’s in it for Me?

By enrolling in EFT payment, you help ensure CHAMPVA claim payments are secure, efficient, and compliant with federal mandates, while safeguarding Veteran family members’ access to benefits.   

How do I Enroll?

Visit the VA Financial Services Center (FSC) Customer Engagement Portal, and complete the Payment Account Setup webform to enroll. 

Who Do I Call for Help with the Webform?

Call the FSC help desk at 877-353-9791.


CHAMPVA is a health care program for qualified spouses, widows(ers), and children of eligible Veterans. Through CHAMPVA, VA shares the cost of certain health care services and supplies with eligible beneficiaries. 

More Information:

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