MLN Connects Newsletter for December 18, 2025

CMS announced the Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence (MAHA ELEVATE) Model, a voluntary model to fund up to 30 chronic disease prevention and health promotion programs to assess evidence-based functional or lifestyle medicine interventions currently not covered by Original Medicare.

Why it matters

These types of interventions, including those focused on nutrition and physical activity, may slow or prevent chronic disease; MAHA ELEVATE will gather and evaluate necessary data on cost and quality to inform decisions about the feasibility of including such lifestyle-based interventions in Original Medicare in the future.

What to expect

CMS will release a Notice of Funding Opportunity in early 2026 for the first cohort. The model will begin on September 1, 2026. The second cohort will begin 1 year later.

Visit the MAHA ELEVATE Model webpage for more information.

Outpatient Prospective Payment System Drug Acquisition Cost Survey: Are You Prepared?

CMS will launch the Outpatient Prospective Payment System (OPPS) Drug Acquisition Cost Survey (ODACS) on January 1, 2026. Hospital representatives: Find out how to prepare for the survey (PDF):

Register for the survey. Create an account in the CMS Enterprise Portal, and complete the identity verification process.
Confirm 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 resources.

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. The deadline to submit your data is 11:59 pm ET on March 31, 2026.

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

Acute Care Hospital Outpatient Services for Hospice Enrollees: Reduce Improper Payments

In a report, the Office of the Inspector General found that Medicare improperly paid acute-care hospitals for outpatient services provided to hospice enrollees. To avoid improper payments, request and analyze hospice election statement addendums for these enrollees.

Review the Acute Care Hospital Inpatient Prospective Payment System educational tool for more information:

We don’t pay for services given to palliate or manage a terminal illness and related conditions. Services should be provided under arrangements with the hospice provider.
We only pay for Part B outpatient services that are unrelated to the terminal illness and related conditions.

Claims, Pricers & Codes

Programs of All-Inclusive Care for the Elderly: Claims Processing Updates Effective July 1, 2026

CMS will implement system updates, effective July 1, 2026, for Programs of All-Inclusive Care for the Elderly (PACE) plan claims:

Inpatient: We’ll make sure Medicare doesn’t make a separate payment for Indirect Medical Education or Direct Graduate Medical Education
Institutional: We’ll find and correct claims paid incorrectly

See the instruction to your Medicare Administrative Contractor (PDF).

Skilled Nursing Facility Consolidated Billing: CY 2026 HCPCS Codes

Get updated HCPCS codes to accurately bill for 2026 skilled nursing facility stays:

See the Instruction to your Medicare Administrative Contractor (PDF).

Events

Short-Term Acute Care Hospitals: PEPPER Webinar — January 6

Tuesday, January 6 from 1–2 pm ET

Get guidance on the recent changes CMS made to the Program for Evaluating Payment Patterns Electronic Report (PEPPER) for short-term acute care hospitals, and review the reports we published in December 2025.

This webinar will include a Q&A session. Send your questions to CMS_CBRPEPPER@cms.hhs.gov.

MLN Matters® Articles

Adding Extravascular Defibrillator Codes to National Coverage Determination 20.4: Implantable Cardiac Defibrillators

Learn about changes to the National Coverage Determination (PDF) for Implantable Cardioverter Defibrillators (ICDs):

Coverage of additional procedure codes for the Aurora™ extravascular ICD system, effective October 20, 2023
Updates to the coding requirements in the Medicare Claims Processing Manual, Chapter 32, section 270

Chimeric Antigen Receptor T-Cell Therapy Claims: End of Risk Evaluation Mitigation Strategy & KX Modifier Requirement

Learn about changes, effective June 26, 2025 (PDF). CMS no longer requires:

Providers to administer chimeric antigen receptor (CAR) T-cell therapy in an FDA Risk Evaluation Mitigation Strategy-approved facility
The KX modifier on Medicare Part B claims for CAR T-cell therapy

Home Health Prospective Payment System: CY 2026 Rate Update

Learn about updated payment rates (PDF) for CY 2026:

30-day period payments
National per-visit amounts
Disposable negative pressure wound therapy devices
Cost-per-unit payment amounts used to calculate outlier payments

ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2026 Update

Learn about the CPT additions to the National Coverage Determination (PDF) for Sacral Nerve Stimulation for Urinary Incontinence, effective June 17, 2025.

Inpatient Psychiatric Facilities Prospective Payment System: FY 2026 Updates

Learn about FY 2026 updates (PDF) to the Inpatient Psychiatric Facility Prospective Payment System:

Facility-level adjustment factors
Market basket
Wage index
Quality reporting program
Rural adjustment

Publications & Multimedia

Medicare Provider Compliance Tips — Revised Webpage

CMS updated the improper payment rate and denial reasons for the 2024 reporting period. Learn what’s changed:

Hospice services: We added language clarifying the attestation requirement
Immunosuppressive drugs: We updated the quantity of immunosuppressive drugs dispensed from a 30-day supply to a 90-day supply effective for service dates on or after January 1, 2025
Lower limb orthoses: We added HCPCS codes L1933 and L1952 to the list of covered ankle-foot-orthoses codes
Lower limb prostheses: We added functional level characteristics
Pneumatic compression devices and accessories: We added information about lymphedema compression treatment
Outpatient psychiatric care — we added language about:
- Principal illness navigation services provided by auxiliary staff, including peer support specialists
- Caregiver training services
- Providers in the same practice billing on the same day for unrelated services
Respiratory assist devices: We added information about noninvasive positive pressure ventilation in the home for treating chronic respiratory failure consequent to chronic obstructive pulmonary disease
Wheelchair options and accessories: We added HCPCS code E1032

Medicare Provider Compliance Tips is now a CMS.gov webpage. We’re changing some Medicare Learning Network® products to webpages to improve user experience and content accessibility.

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