Proposed Payment Rule
News
- All Medicare Facility Types: Get Ready for the PEPPER Relaunch
- Clinical Diagnostic Laboratories: Report Your Data Through July 31
- Understanding Telehealth Enrollment Guide
Compliance
- Intermittent Urinary Catheters: Medicare Improperly Paid Suppliers
- Tracheostomy Supplies: Prevent Claim Denials
Claims, Pricers & Codes
MLN Matters® Articles
Publications & Multimedia
Proposed Payment Rule
CY 2027 End-Stage Renal Disease Prospective Payment System Proposed Rule
CMS issued a proposed rule to update payment rates and policies under the Medicare End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2027. This rule also proposes updates to the acute kidney injury dialysis payment rate for renal dialysis services furnished by ESRD facilities for CY 2027 and proposes to update requirements for the ESRD Quality Incentive Program.
For CY 2027, CMS is proposing to increase the ESRD PPS base rate to $299.55, which CMS expects will increase total payments to all ESRD facilities, both freestanding and hospital-based, by approximately 1.1%. This amount includes a proposed $15.96 increase to account for the incorporation of phosphate binders into the ESRD PPS base rate. The CY 2027 ESRD PPS proposed rule also proposes changes to the low-volume payment adjustment, changes to the payment adjustments for pediatric patients, an increase to the home and self-dialysis training add-on amount and technical modifications to the transitional drug add-on payment adjustment (TDAPA), and a post-TDAPA add-on payment adjustment.
More Information:
News
All Medicare Facility Types: Get Ready for the PEPPER Relaunch
The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is relaunching in the coming months for all Medicare facility types, including hospitals, post-acute care providers, and specialty facilities.
PEPPER is a free tool that helps you review your Medicare billing data so you can identify issues before problems arise and support accurate claims. Use it to:
- Spot billing patterns that may need review or improvement
- Identify areas that may need closer monitoring or internal audits
- Find services that may be under‑coded or over‑coded
- Track trends like longer patient stays
How to Get Your PEPPER
Authorized officials (AOs), access managers (AMs), and staff end users (SEUs) can access the reports through the PEPPER Portal.
How to become an SEU:
- Sign in to the CMS Identity & Access (I&A) System using your existing NPPES or PECOS credentials.
- Request the PEPPER business function for your organization. The Comparative Billing Report business function is also available and can be requested at the same time.
- Your AO or AM must approve your request.
More Information:
- Review the User Guide
- See the I&A Quick Reference Guide and FAQs: Step-by-step instructions for AOs and AMs
- Contact the External User Services Help Desk
Clinical Diagnostic Laboratories: Report Your Data Through July 31
Are you an independent laboratory, physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS)? If so, you must report your data by July 31, 2026, based on an updated data collection period of January 1 – June 30, 2025, including:
- Applicable HCPCS codes
- Associated private payor rates
- Volume data
How do I report?
- Review CLFS Data Collection System resources:
- Identity Management Registration Guide (PDF)
- Submitter: User manual (PDF) and demo video
- Certifier: User manual (PDF) and demo video
- View the applicable HCPCS codes (ZIP)
- Use the Data Reporting Template (ZIP); see training video
More Information:
- CLFS & PAMA Reporting and Resources webpage
- CLFS: Reporting Private Payor Data (PDF) booklet
- FAQs
- Is My Lab an Applicable Lab? video
Understanding Telehealth Enrollment Guide
Not sure how to enroll for telehealth services? Our Understanding Telehealth Enrollment (PDF) guide breaks down everything you need to know to enroll correctly.
Compliance
Intermittent Urinary Catheters: Medicare Improperly Paid Suppliers
In a report, the Office of Inspector General found that Medicare improperly paid for catheters and kits. To avoid improper payments, review the Urological Supplies provider compliance tip for more information, including:
- Billing codes
- Denial reasons and how to prevent them
- Refill and documentation requirements
- Resources
Tracheostomy Supplies: Prevent Claim Denials
In 2024, the improper payment rate for tracheostomy supplies was 25.6%, with a projected improper payment amount of $6.5M. Learn how to bill correctly for these services. Review the Tracheostomy Supplies provider compliance tip for more information, including:
- Billing codes
- Denial reasons and how to prevent them
- Refill and documentation requirements
Claims, Pricers & Codes
Medicare Part B Drug Pricing Files & Revisions: July Update
Learn about quarterly updates to the following average sales price and not otherwise classified pricing files:
- July 2026
- April 2026
- January 2026
- October 2025
- July 2025
See the instruction to your Medicare Administrative Contractor (PDF).
MLN Matters® Articles
Hospital Outpatient Prospective Payment System: July 2026 Update
Learn about updates (PDF), effective July 1, 2026:
- New COVID-19 monoclonal antibody products and administration codes
- CPT proprietary laboratory analyses coding changes
- New and reassigned Category III CPT codes
- Device pass-through and device offset information
- Ambulatory payment classification assignment and status indicator changes
- Drugs, biologicals, and radiopharmaceuticals
- Non-opioid treatments for pain relief
- Skin substitute products
Publications & Multimedia
Skilled Nursing Facility 3-day Rule Billing Fact Sheet – Revised
We included information (PDF) on the Transforming Episode Accountability Model Skilled Nursing Facility 3-Day Rule Waiver.
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