News
- Information for Critical Access Hospitals
- 2023 Doctors & Clinicians Preview Period Closing August 21
- Nursing Home Care Compare Updates: Temporary Pause
- Ambulance Fee Schedule Ground Ambulance Services: Updated List of Advanced Life Support, Level 2 Procedures
Fraud, Waste & Abuse
Claims, Pricers & Codes
- Seasonal Flu Vaccine Pricing for 2025–2026 Season
- Integrated Outpatient Code Editor: Correcting Errors for Reason Code W7113
- Home Health Prospective Payment System Grouper: October Update
Publications & Multimedia
- Evaluation and Management Services — Revised
- Part C Organization Determinations, Appeals & Grievances — Revised
- Part D Coverage Determinations, Appeals & Grievances — Revised
News
Information for Critical Access Hospitals
The critical access hospital (CAH) bills for facility and professional outpatient services only when physicians or practitioners reassign their billing rights to the CAH.
Learn how CAHs can prevent Fiscal Intermediary Shared System (FISS) reason codes 31006 and 31007 (indicating that providers don’t have a reassignment on file in the Provider Enrollment, Chain, and Ownership System (PECOS)) claim denials:
- CAHs must submit the reassignment application through PECOS or the paper Form CMS-855I
- Starting in January 2026, we’ll deny CAH claims for professional services if a reassignment isn’t in PECOS
More Information:
- Information for Critical Access Hospitals (PDF) booklet revised to add reassignment information
- Editing for Duplicate Processing for Practitioner Professional Services and CAH Professional Services (PDF) Medicare Administrative Contractor instruction
- Medicare Part B Overpaid and Beneficiaries Incurred Cost-Share Overcharges of Over $1 Million for the Same Professional Services Office of the Inspector General report
2023 Doctors & Clinicians Preview Period Closing August 21
The Doctors and Clinicians Preview Period is closing on August 21 at 8 pm ET. Securely preview your 2023 Quality Payment Program performance information before it appears on clinician and group profile pages on the Medicare.gov compare tool and in the Provider Data Catalog.
For more information, visit the Care Compare: Doctors and Clinicians Initiative webpage.
Nursing Home Care Compare Updates: Temporary Pause
CMS recently transitioned to a cloud-based iQIES for nursing home survey and certification data. We’ll temporarily pause Nursing Home Care Compare updates starting July 30 and resume them in October 2025. This temporary pause allows us to ensure publicly reported nursing home quality information is accurate and reliable. For more information, read the Temporary Pause in Nursing Home Care Compare Updates special alert memo.
Ambulance Fee Schedule Ground Ambulance Services: Updated List of Advanced Life Support, Level 2 Procedures
CMS updated the list of advanced life support, level 2 procedures (ALS2) from the CY 2025 Physician Fee Schedule final rule. We added prehospital blood transfusion to the ALS2 list, which includes the administration of:
- Low titer O+ and O– whole blood
- Packed red blood cells
- Plasma
- Combination of packed red blood cells and plasma
More Information:
- Medicare Benefit Policy Manual, Chapter 10 (PDF), section 30.1.1
- Instruction to your Medicare Administrative Contractor (PDF)
Fraud, Waste & Abuse
Crushing Fraud Chili Cook-Off Competition
CMS announced the Crushing Fraud Chili Cook-Off Competition, a market-based research challenge aimed at harnessing explainable artificial intelligence, specifically machine learning models, to detect anomalies and trends in Medicare claims data that can be translated into novel indicators of fraud. This challenge also seeks scalable analytic and policy solutions designed to target and address these high-risk areas within the Medicare program. We invite research proposals from all interested parties.
Claims, Pricers & Codes
Seasonal Flu Vaccine Pricing for 2025–2026 Season
Get payment allowances and effective dates for the 2025–2026 season.
More Information:
- Flu Shot webpage: frequency, coverage, billing, codes, and resources
- Instruction to your Medicare Administrative Contractor (PDF)
Integrated Outpatient Code Editor: Correcting Errors for Reason Code W7113
CMS is aware of an issue with changes implemented in the April 2025 Integrated Outpatient Code Editor. Diagnosis codes added to edit 113 (FISS Reason Code W7113) are incorrectly causing claims for the following types of bills to edit in error: 013X, 014X, 023X, 032X, 034X, 071X, 072X, 074X, 075X, 076X, 077X, 085X, and 087X.
Your Medicare Administrative Contractor will suspend reason code W7113 and fix affected claims until we retroactively correct this issue in the October 2025 quarterly release. You don’t need to take any action.
Home Health Prospective Payment System Grouper: October Update
Get the October 2025 release (Version 06.1.25 (ZIP)). See Home Health Prospective Payment System Grouper Software for a summary of changes.
More Information:
- Claims Processing Manual, Chapter 10 (PDF), section 80
- Instruction to your Medicare Administrative Contractor (PDF)
Publications & Multimedia
Evaluation and Management Services — Revised
CMS updated billing and coding information (PDF) for:
- Office or outpatient evaluation and management visits
- Critical care services
- Hospital outpatient clinic visits
- Telehealth services
Part C Organization Determinations, Appeals & Grievances — Revised
CMS updated this web-based training course to clarify the number of days to file appeals.
Part D Coverage Determinations, Appeals & Grievances — Revised
CMS updated this web-based training course to clarify the number of days to file appeals.
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