MLN Connects Newsletter for December 11, 2025

CMS finalized significant changes to the DMEPOS accreditation program as part of our ongoing commitment to program integrity. These provisions, included in the CY 2026 Home Health Prospective Payment System final rule address vulnerabilities in the accreditation process and strengthen quality standards for DMEPOS suppliers.

Find out how these provisions affect DMEPOS suppliers (PDF).

Skilled Nursing Facilities: January 1 Revalidation Deadline Indefinitely Suspended

Enrolled skilled nursing facilities (SNFs) should continue collecting data on ownership, managerial, and related party information and submit their revalidation. However, there is no submission deadline until further notice.

More Information:

Short-Term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports

CMS relaunched the Program for Evaluating Payment Patterns Electronic Report (PEPPER) for short-term acute care hospitals. At this time, only authorized officials (AOs) and access managers (AMs) with active Identity & Access Management System accounts can download their reports from the PEPPER Portal. Coordinate with your AO or AM to get your report.

PEPPER helps hospitals review their billing data to make sure claims are accurate. They can use it to:

Spot billing patterns that may need improvement
Identify areas that may need audits or closer monitoring
Find Diagnosis-Related Groups that may be under-coded or over-coded
Track areas where patient stays are getting longer

Review the Short-Term PEPPER User Guide for more information.

Institutional Provider Enrollment Application Fee: CY 2026

Effective January 1, the application fee is $750 for institutional providers who are:

Initially enrolling in the Medicare or Medicaid programs or the Children's Health Insurance Program (CHIP)
Revalidating their Medicare, Medicaid, or CHIP enrollment
Adding a new Medicare practice location

CMS requires this fee with any of these enrollment applications submitted from January 1 – December 31, 2026. See the notice for more information.

Outpatient Prospective Payment System Drug Acquisition Cost Survey: Register & Create Your Account

Register for the Outpatient Prospective Payment System (OPPS) Drug Acquisition Cost Survey (ODACS) before it launches on January 1. CMS encourages hospital representatives to create accounts in the CMS Enterprise Portal and complete the identity verification process to access the system. Find out how to prepare for the survey (PDF).

Hospitals that received OPPS payments for outpatient drugs from July 1, 2024 – June 30, 2025, must complete the survey and report data on all payable outpatient drugs purchased during this period. If you haven’t confirmed your Point of Contact for this initiative, email OPPSDrugSurvey@cms.hhs.gov and include your hospital's CMS Certification Number.

Visit the ODACS webpage for more information.

Home Intravenous Immune Globulin Items & Services: CY 2026 Rate Update

The CY 2026 payment rate for Q2052 (Services, Supplies, and Accessories used in the Home for the Administration of Intravenous Immune Globulin) is $442.19.

Program of All-Inclusive Care for the Elderly: Eligibility Response for Medicare Advantage Plan

Medicare doesn’t make a separate payment for Indirect Medical Education or Direct Graduate Medical Education on inpatient claims for beneficiaries enrolled in a Program of All-Inclusive Care for the Elderly (PACE) plan.

We’ll return “PACE Plan” with other Medicare Advantage enrollee plan information so you can identify these patients. See the Checking Medicare Eligibility (PDF) fact sheet for more information.

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 reason codes 31006 and 31007 (indicating that providers don’t have a reassignment on file in PECOS) claim denials:

CAHs must submit the reassignment application through PECOS or the paper Form CMS-855I
Starting on January 2, 2026, we’ll return to provider (RTP) CAH claims for professional services if a reassignment isn’t in PECOS

More Information:

Information for Critical Access Hospitals (PDF) booklet
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

Compliance

Skilled Nursing Facilities: Identify & Prevent Improper Part D Payments for Drugs

In a report, the Office of the Inspector General found that Medicare Part D improperly paid for drugs during Part A skilled nursing facility (SNF) stays. Drugs prescribed for a Part D-enrolled patient aren’t covered by Part D if Part A or B can pay for them.

Learn how to avoid improper payments. See the SNF Billing Reference educational tool to find out when to bill your patients prescription drugs to Part A, instead of their Part D drug plan.

Claims, Pricers & Codes

Clinical Laboratory Improvement Act Waived Tests: Reprocessing Incorrectly Denied Claims

Certain claims for clinical laboratory tests were incorrectly denied for dates of service on or after October 1 – December 1, 2025. Your Medicare Administrative Contractor will reprocess these claims. You don’t need to take any action.

Home Health Prospective Payment System Grouper: January Update

Get the January 2026 release (Version 07.0.26 (ZIP)). See the Home Health Prospective Payment System Grouper Software webpage for a summary of changes.

More Information:

MLN Matters® Articles

Clinical Laboratory Fee Schedule: 2026 Annual Update

Learn about changes and instructions (PDF) for CY 2026:

Data reporting period and the phase-in of payment reductions
Mapping for new test codes
Updates for tests subject to the reasonable charge payment

Federally Qualified Health Center & Intensive Outpatient Program Payment Rates: CY 2026 Update

Learn about payment rates (PDF) for CY 2026:

Federally Qualified Health Center Prospective Payment System base payment rate
Intensive outpatient program service rates

Long-Term Hospice Stay: New Edit to Prevent Overpayment

Learn about a new edit (PDF) that will help identify and prevent overpayments of long-term hospice care for claims submitted with matching “admission” and “from” dates.

Medicare Deductible, Coinsurance & Premium Rates: CY 2026 Update

Learn about CY 2026 Medicare Part A and Medicare Part B (PDF):

Deductibles
Coinsurance rates
Premiums

Medicare Physician Fee Schedule Final Rule Summary: CY 2026

Learn about payment rates and policies (PDF) for CY 2026:

Telehealth, therapy, behavioral health, and advanced primary care management services
Evaluation and management visits
Practice expense and skin substitutes

Rural Health Clinic & Intensive Outpatient Program Payment Rates: CY 2026 Update

Learn about payment rates (PDF) for CY 2026:

All-inclusive rate payment limit
Specified provider-based payment limit
Intensive outpatient program services rates

Publications & Multimedia

Medicare Preventive Services — Revised

Learn what’s changed:

Colorectal cancer screening tests: Updated the ICD-10 code link, which added Z15.060 and Z15.068 and revised the descriptor for Z83.718, effective October 1, 2025
COVID-19 vaccine and administration:
- Added CPT code 91323, effective August 27, 2025
- Removed CPT code 91318, effective August 27, 2025
PrEP using antiretroviral therapy to prevent HIV infection: Added information about Yeztugo® (lenacapavir)
Screening pap test and screening pelvic exam: Added R87.612, R87.810, Z84.A, and Z91.B to high-risk ICD-10 codes, effective October 1, 2025

From Our Federal Partners

First Reported Outbreak Caused by Marburg Virus in Ethiopia

The CDC issued this Health Alert Network (HAN) Health Advisory to inform clinicians and health departments about a new outbreak of Marburg virus disease (MVD) in Ethiopia's South Ethiopia and Sidama regions. MVD is a severe illness that can be fatal.

No suspected, probable, or conﬁrmed cases of MVD related to this outbreak have been reported in the United States or other countries outside of Ethiopia as of December 3, 2025. The risk of spread to the United States is considered low at this time; however, clinicians should be aware of the potential for imported cases.

See the full Health Advisory for more information, including recommendations for clinicians and health care facilities.

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