News
- HHS & CMS Announce Healthcare Advisory Committee Members to Improve Patient Care and Modernize the U.S. Healthcare System
- CMS Marks Milestone in Expanding Patient-Centered Innovation with Substance Access Beneficiary Engagement Incentive
- Accountable Care Organizations: Apply to the New LEAD Model
- New ASPIRE Model to Deliver Support to Children and Youth with Complex Medical Needs
- Hospitals: OPPS Drug Acquisition Cost Survey Deadline Extended to April 7
- ESRD Prospective Payment System: XPHOZAHTM Included in Bundled Payment
- Clinical Diagnostic Laboratory Reporting: Are You an Applicable Lab?
Compliance
- Evaluation and Management Services & Intravitreal Injections: Bill Correctly
- Therapeutic Footwear: Prevent Claim Denials
Claims, Pricers & Codes
Events
MLN Matters® Articles
- HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2026 Quarterly Update
- Hospital Outpatient Prospective Payment System: April 2026 Update – Revised
National Coverage Determination 20.40: Renal Denervation for Uncontrolled Hypertension – Revised
News
HHS & CMS Announce Healthcare Advisory Committee Members to Improve Patient Care and Modernize the U.S. Healthcare System
HHS and CMS announced the members of the Healthcare Advisory Committee, a new federal advisory body comprised of leaders from across the healthcare system to provide expert advice on improving, strengthening, and modernizing U.S. healthcare.
Read the full press release.
CMS Marks Milestone in Expanding Patient-Centered Innovation with Substance Access Beneficiary Engagement Incentive
CMS, through the CMS Innovation Center, announced that organizations participating in certain Innovation Center models may begin offering a new Substance Access Beneficiary Engagement Incentive starting April 1, 2026. Through this optional incentive, eligible hemp-derived products can be incorporated into patient care plans under clinician guidance, consistent with model requirements and applicable law.
Read the full press release.
Accountable Care Organizations: Apply to the New LEAD Model
What’s New
CMS released the Request for Applications (RFA) for the Long-term Enhanced ACO Design (LEAD) Model, which aims to expand the benefits of Accountable Care Organizations (ACOs) to more Medicare beneficiaries; the model supports a broad range of participants and providers by offering enhanced support to small, independent, and rural practices delivering primary care, as well as those serving high-needs beneficiaries, and introduces new flexibilities and opportunities for specialist integration and health promotion.
Why It Matters
LEAD builds on the CMS Innovation Center’s accountable care work and addresses long-standing barriers to ACO participation through improved benchmarking that supports both new and established ACOs, enhanced population-based payments, and new flexibilities to support healthy living and preventive care.
What to Expect
ACOs interested in the voluntary, 10-year model have until May 17, 2026, to respond to the RFA; the model will launch January 1, 2027.
The Big Picture
By appealing to a broader range of health care providers, LEAD will help more people—including those with complex health needs—benefit from better coordinated, accountable care; ACOs have been shown to improve access to preventive screenings and chronic disease management while reducing the need for emergency care, all of which support healthier lives and more affordable health care.
More information:
- LEAD Model webpage
- Request for Applications (PDF)
- LEAD Model Application
- CMS Innovation Center Strategic Direction
- Value-Based Care Spotlight
- Innovation Insights
New ASPIRE Model to Deliver Support to Children and Youth with Complex Medical Needs
What’s New
CMS is launching the Accelerating State Pediatric Innovation Readiness and Effectiveness (ASPIRE) Model to help children up to age 21 with complex medical and behavioral needs live healthier lives through whole-person care delivery in Medicaid and the Children's Health Insurance Program, including wrap-around services to address physical and behavioral health needs.
Why It Matters
Identifying and addressing the needs of these children early in life can help them thrive in less restrictive, lower cost settings, while empowering caregivers with resources to support their long-term health and wellness; improving care for this population can ensure they receive the right care at the right time, while also improving the quality of life for children and their families.
What to Expect
CMS will select up to 5 state Medicaid agencies to take part in the voluntary model through a cooperative agreement; a Notice of Funding Opportunity will be available in 2026.
The Big Picture
ASPIRE reflects the CMS Innovation Center’s commitment to helping children and youth live healthier lives by using evidence-based approaches to preventive care and empowering families with greater access to comprehensive and coordinated services aligned with the goals of their child.
More Information:
- ASPIRE Model webpage
- CMS Innovation Center Strategic Direction
- Value-Based Care Spotlight
- Innovation Insights
Hospitals: OPPS Drug Acquisition Cost Survey Deadline Extended to April 7
The deadline for the Outpatient Prospective Payment System (OPPS) Drug Acquisition Cost Survey (ODACS) is extended to April 7, 2026. Hospitals paid under OPPS and listed on this ODACS provider table (PDF) must submit their drug acquisition cost data to CMS by the new deadline.
To complete the survey, you must:
- Follow the steps in the Registration User Guide (PDF) to register for the online system
- Upload your drug acquisition cost data using this template (ZIP)
- Follow the steps in the Submitter User Guide (PDF) to complete the online attestation form
- Submit your data by April 7
More Information:
- Visit the ODACS webpage for official guidance on the survey
- Read FAQs (PDF)
- Contact OPPSDrugSurvey@cms.hhs.gov with questions
ESRD Prospective Payment System: XPHOZAHTM Included in Bundled Payment
CMS pays for XPHOZAHTM (tenapapnor) under the ESRD Prospective Payment System (PPS) bundled payment, effective January 1, 2025. You’re responsible for furnishing renal dialysis service drugs either directly or under arrangements. Note: Drug manufacturer distribution or reimbursement strategies don’t override Medicare ESRD PPS requirements.
See operational guidance (PDF) to learn about:
- ESRD facility responsibility
- Guidance on manufacturer communications
- Operational expectations
- Program integrity and access considerations
- Action required
Clinical Diagnostic Laboratory Reporting: Are You an Applicable Lab?
Watch Is My Lab an Applicable Lab?, and find out if you meet the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS). If so, you must report your data from May 1 – July 31, 2026.
See the CLFS & PAMA Reporting and Resources webpage for more information.
Compliance
Evaluation and Management Services & Intravitreal Injections: Bill Correctly
In a report, the Office of Inspector General found that Medicare providers improperly billed for evaluation and management (E/M) services provided on the same day as intravitreal injections using modifier 25. Only a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure should be separately reported with modifier 25.
Learn when to use modifier 25 to prevent improper payments:
- E/M Services (PDF) booklet
- Medicare Vision Services (PDF) booklet
Therapeutic Footwear: Prevent Claim Denials
In 2024, the improper payment rate for diabetic shoes was 47.1%, with a projected improper payment amount of $35.7M. Learn how to bill correctly. Review the Therapeutic Footwear provider compliance tip for more information, including:
- Billing codes
- Denial reasons and how to prevent them
- Coverage limitations
- Documentation requirements
- Resources
Claims, Pricers & Codes
Method II Critical Access Hospitals: Reprocessing Certain Claims with Reassigned Billing Rights
Method II critical access hospitals (CAHs) bill for facility and professional outpatient services only when physicians or practitioners reassign their billing rights to the CAH. CAHs must submit the reassignment application through PECOS or the paper Form CMS-855I.
Certain CAH claims were incorrectly returned with Fiscal Intermediary Shared System (FISS) reason codes 31006 and 31007 indicating that providers don’t have a reassignment on file in PECOS. To address this issue, Medicare Administrative Contractors (MACs) stopped returning these claims with dates of service in 2025 and 2026. They will reprocess claims that incorrectly returned since January 1, 2026. Payments should be issued in approximately 2 weeks. CAHs do not need to take any action.
You can get claims status information on your MAC portal and through FISS Direct Data Entry. If you identify any discrepancies, contact your MAC.
Physicians and practitioners: Make sure you accurately reassign benefits to CAHs; see the Information for CAHs (PDF) booklet for more information.
Events
Quarter 4 FY 2025 PEPPER for Short-Term Acute Care Hospitals Webinar – April 7
Tuesday, April 7 from 1–2 pm ET
Register for the webinar.
Join CMS to review the Quarter 4 FY 2025 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) for short-term acute care hospitals. The session will provide participants with guidance on navigating the recent changes, including a review of the reports published in March 2026.
Prior to the webinar, send your questions to CMS_CBRPEPPER@cms.hhs.gov.
MLN Matters® Articles
HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2026 Quarterly Update
Learn about coding updates (PDF):
- Angiography, Lymphatic, Venous & Related Procedures Category
- Chemotherapy Category
- Added codes
Terminated codes
Hospital Outpatient Prospective Payment System: April 2026 Update – Revised
CMS changed the status indicator (PDF) for HCPCS code Q0599 from status indicator “E1” to status indicator “K.”
National Coverage Determination 20.40: Renal Denervation for Uncontrolled Hypertension – Revised
Learn what’s changed (PDF):
- Place of service code 24 is allowable for professional claims
- We don’t pay physicians for HCPCS codes C1735 and C1736
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