News
- Trump Administration Prioritizes Affordability by Announcing Major Crackdown on Health Care Fraud
- MAC MBI Lookup Tool: Keep Your Access During Enhanced Monitoring
- Medicare Outpatient Observation Notice: Get Updated Version in English & Spanish
- Laboratories: Paper Fee Coupons & CLIA Certificates Ending March 1
- Hospitals: One Month Left to Submit Data for OPPS Drug Acquisition Cost Survey
Compliance
Claims, Pricers & Codes
- Hypoglossal Nerve Neurostimulator: New Codes, Effective January 1, 2026
- Therapy Services: CY 2026 KX Modifier Threshold Amounts
- Screening for Hepatitis C Virus National Coverage Determination: Clarified Billing Requirements
- Medicare Physician Fee Schedule Database: April Update
MLN Matters® Articles
- Clinical Laboratory Fee Schedule & Laboratory Services Subject to Reasonable Charge Payment: April 2026 Update
- HCPCS Codes & Clinical Laboratory Improvement Amendments Edits: April 2026
- Vaccine Administration National Fee Schedule: April 2026 Update
Publications & Multimedia
- Intravenous Immune Globulin Items & Services – Revised
- Medicare Diabetes Prevention Program Expanded Model – Revised
News
Trump Administration Prioritizes Affordability by Announcing Major Crackdown on Health Care Fraud
On February 25, at the White House, Vice President J.D. Vance, HHS Secretary Robert F. Kennedy, Jr., and CMS Administrator Dr. Mehmet Oz announced new steps to crack down on fraud in Medicare and Medicaid to protect patients and taxpayers and improve affordability. The actions include deferring $259.5M of quarterly federal Medicaid funding in Minnesota to prevent payment of questionable claims while further investigation is completed; a nationwide moratorium on Medicare enrollment for certain DMEPOS suppliers; and a nationwide call to action for Americans to support fraud prevention, including stakeholder input on how CMS can continue to expand and strengthen its efforts. Together, these steps reflect a coordinated, data-driven strategy to prevent fraud before it occurs, hold bad actors accountable, and protect taxpayer dollars.
More Information:
- Full press release
- Nationwide Temporary Moratoria on Enrollment of DMEPOS Supplier Medical Supply Companies notice
- Request for Information: Comprehensive Regulations to Uncover Suspicious Healthcare proposed rule: Submit comments by March 20
- Crushing Fraud, Waste, & Abuse webpage
MAC MBI Lookup Tool: Keep Your Access During Enhanced Monitoring
CMS identified a concerning trend of malicious actors stealing MBIs and using them to commit Medicare fraud. Some are misusing Medicare Administrative Contractor (MAC) MBI lookup tools. We’re implementing enhanced monitoring controls to prevent this abuse.
What You Need to Know
Only use the MAC MBI lookup tool for people you intend to provide a service or product to that you’ll bill to Medicare. Our enhanced monitoring compares the MBIs you look up against actual claims submitted with NPIs. If we notice an unusually high rate of MBI lookups without associated claims, your access to the lookup tool may be removed.
Take Action to Maintain Access: Complete MAC Portal Updates by May 7
Make sure your MAC portal users are associated with NPIs in your organization on whose behalf they may perform MBI lookups. This helps us verify legitimate use and protects your access to the lookup tool.
Medicare Outpatient Observation Notice: Get Updated Version in English & Spanish
The Office of Management and Budget approved the updated Medicare Outpatient Observation Notice (MOON), effective now through February 28, 2029. Get the updated version in English and Spanish on the Beneficiary Notices Initiative webpage. CMS improved the readability and design.
You must use the updated notices starting April 21, 2026. We’ll accept the expired and updated versions through April 20, 2026.
You’re required to provide patients MOONs to inform them that they’re outpatients receiving observation services and aren’t inpatients of a hospital or critical access hospital. See the Medicare Claims Processing Manual, Chapter 30 (PDF), section 400 for more information.
Laboratories: Paper Fee Coupons & CLIA Certificates Ending March 1
CMS is improving the Clinical Laboratory Improvement Amendments (CLIA) program by switching to electronic fee coupons and CLIA certificates. After March 1, 2026, paper fee coupons and CLIA certificates will no longer be available; we’ll stop mailing paper versions after this date. In addition, you must pay your CLIA certification and survey fees online; checks will no longer be accepted.
This is the last chance for eligible laboratories and providers that perform laboratory testing to sign up for CMS email notifications to receive electronic CLIA fee coupons and certificates. Failure to switch may result in billing and certification issues.
You can switch to electronic notifications from CMS or update your email address by:
- Emailing your state agency (PDF)
- Contacting your Accreditation Organization if you’re an accredited laboratory
Note: This doesn’t apply to CLIA-exempt states.
Hospitals: One Month Left to Submit Data for OPPS Drug Acquisition Cost Survey
The Outpatient Prospective Payment System (OPPS) Drug Acquisition Cost Survey (ODACS) is live. Hospitals paid under OPPS and listed on this ODACS provider table (PDF) must submit their drug acquisition cost data to CMS by March 31, 2026, at 11:59 pm ET.
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 March 31
More Information:
- Visit the ODACS webpage for official guidance on the survey
- Read FAQs (PDF)
- Contact OPPSDrugSurvey@cms.hhs.gov with questions
Compliance
DME: Complying with Proof of Delivery Requirements
The Comprehensive Error Rate Testing (CERT) Task Force identified missing or incomplete proof of delivery (POD) documents for DME claims. You’re required to maintain POD documentation for 7 years from the date of service regardless of your delivery method.
Use the Complying with POD Requirements (PDF) work guide to learn what you must include and what’s required for each delivery method.
More Information:
- Standard Documentation Requirements for All Claims Submitted to DME MACs article
- Medicare Program Integrity Manual, Chapter 4 (PDF), section 4.7.3.1.1–4.7.3.1.3
- CERT webpage
Spinal Orthoses: Prevent Claim Denials
In 2024, the improper payment rate for lumbar-sacral orthosis was 54.4%, with a projected improper payment amount of $47.8M. Learn how to bill correctly for these services. Review the Spinal Orthoses provider compliance tip for more information, including:
- Billing codes
- Denial reasons and how to prevent them
- Documentation requirements
- Example of improper payments due to insufficient documentation
- Resources
Claims, Pricers & Codes
Hypoglossal Nerve Neurostimulator: New Codes, Effective January 1, 2026
CMS is aware of questions regarding coding for hypoglossal nerve neurostimulators for the treatment of obstructive sleep apnea and concerns that the current CPT codes don’t accurately describe some newer hypoglossal nerve neurostimulators.
To address this issue, we’ll add 6 new HCPCS codes to the April 2026 Integrated Outpatient Code Editor, effective January 1, 2026:
- C8007: Open implantation of hypoglossal nerve neurostimulator array and pulse generator, not requiring insertion of a separate distal respiratory sensor electrode or electrode array
- C8008: Revision or replacement of hypoglossal nerve neurostimulator array including connection to existing pulse generator
- C8009: Removal of hypoglossal nerve neurostimulator array and pulse generator
- C8011: Open implantation of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver, including external power source and all system components
- C8012: Revision or replacement of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver
- C8013: Removal of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver
Therapy Services: CY 2026 KX Modifier Threshold Amounts
The CY 2026 KX modifier threshold amount is $2,480 for:
- Physical therapy and speech-language pathology services combined
- Occupational therapy services
More Information:
- Therapy Services webpage, including CY 2026:
- Instruction to your Medicare Administrative Contractor (PDF)
Screening for Hepatitis C Virus National Coverage Determination: Clarified Billing Requirements
CMS clarified billing requirements for the Screening for Hepatitis C Virus in Adults National Coverage Determination 210.13. We’ll pay for HCPCS code G0567 with modifier QW when billed by Clinical Laboratory Improvement Amendment (CLIA) waived laboratories and without modifier QW when billed by non-CLIA waived laboratories, effective retroactive to June 27, 2024.
There’s no change to the policy. Your Medicare Administrative Contractor (MAC) will adjust claims you bring to their attention.
See the instruction to your MAC (PDF) for more information.
Medicare Physician Fee Schedule Database: April Update
See the instructions to your Medicare Administrative Contractor (MAC) (PDF) to learn about the April quarterly updates to the Medicare Physician Fee Schedule Database, including:
- New codes
- Procedure status changes
- Short descriptor code revisions
- Payment policy indicator changes
Your MAC will give you 30-days notice before they implement these changes. After that, they’ll adjust claims that you bring to their attention.
For more information, see the Medicare Claims Processing Manual, Chapter 23 (PDF), section 30.1.
MLN Matters® Articles
Clinical Laboratory Fee Schedule & Laboratory Services Subject to Reasonable Charge Payment: April 2026 Update
Learn about Clinical Laboratory Fee Schedule updates (PDF):
- The next data reporting period for clinical diagnostic laboratory tests
- New CPT codes, effective April 1, 2026
HCPCS Codes & Clinical Laboratory Improvement Amendments Edits: April 2026
Learn about updates (PDF), effective April 1:
- Discontinued codes
- New codes
- Codes subject to and excluded from Clinical Laboratory Improvement Amendments edits
Vaccine Administration National Fee Schedule: April 2026 Update
Learn about coding updates (PDF) for TYENNE® (tocilizumab-aazg) for intravenous administration in hospitalized adults with COVID-19.
Publications & Multimedia
Intravenous Immune Globulin Items & Services – Revised
CMS added the CY 2026 payment rate for HCPCS code Q2052 (PDF).
Medicare Diabetes Prevention Program Expanded Model – Revised
Learn what's changed (PDF):
- Updated the requirements for conducting Medicare Diabetes Prevention Program (MDPP) sessions in person, through virtual distance learning (live), or online (non-live)
- Extended the extended flexibilities period through December 31, 2029
- Updated the requirements for reporting patient weight, including self-reporting
- Removed the once-per-lifetime enrollment limit
- Expanded the list of organization types that can become MDPP suppliers to include virtual-only organizations
- Created a new HCPCS G-code for the online delivery modality and updated the 2026 Fee-for-Service amounts
Added G9871 to the list of HCPCS codes for which you can add modifier 76 to indicate a make-up session was held on the same day as a regularly scheduled MDPP session
Subscribe to the MLN Connects® newsletter, or read past editions.
View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).