This week in Medicare—11/13/2024
January 2025 Alpha-Numeric HCPCS File
On November 4, CMS updated the January 2025 Alpha-Numeric HCPCS file.
Implementation of a New NUBC Condition Code and a New NUBC Value Code
On November 5, CMS published One-Time Notification Transmittal 12947, which rescinds and replaces Transmittal 12882, dated October 11, to update the effective date of new NUBC value code “92” from 7/1/2025 to 1/1/2026 and to revise business requirements 13803.1 and 13803.2.
The original transmittal was issued regarding the implementation of two new NUBC codes, including value code “92” to allow providers to report invoice cost when required by federal regulation.
Effective date: April 1, 2025; July 1, 2025 – for claims with condition code KX received on or
after the effective date; January 1, 2026 - for claims with Value Code 92 received on or after the
effective date.
Implementation date: April 7, 2025
Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) National Coverage Determination (NCD) 110.23
On November 6, CMS published Medicare National Coverage Determinations Transmittal 12948 and Medicare Claims Processing Transmittal 12948, which rescind and replace Transmittals 12868, dated October 7, to revise BR 04.4.2 and messaging, add new BR 04.4.2.1, and to update the ICD-10 spreadsheet and IOM for the Claims Processing Manual.
The original transmittals were issued to announce expanded coverage for allogeneic HSCT using bone marrow, peripheral blood, or umbilical cord blood stem cell products for Medicare patients with MDS. CMS issued a final decision regarding this expanded coverage in March 2024 and has revised these transmittals numerous times.
CMS revised MLN Matters 13604 to accompany the revised transmittals.
Effective date: March 6, 2024
Implementation date: October 7, 2024
Discarded Drugs and Biologicals: Updated HCPCS Codes
On November 7, CMS published an updated List of billing and payment codes for single-dose containers paid separately under Part B that may require the JW and JZ modifiers. This list is updated semi-annually.
Medicare Financial Management Manual Chapter 3 – Overpayments 10-90 Updates 2024
On November 8, CMS published Medicare Financial Management Transmittal 12946 regarding updates to language in the manual about how to handle overpayments determined by the Medicare contractor, aggregate overpayments, individual overpayments, and more.
Effective date: December 10, 2024
Implementation date: December 10, 2024
National Fee Schedule for Medicare Part B Vaccine Administration CMS – January 2025
On November 8, CMS published Medicare Claims Processing Transmittal 12949 to provide instructions for the Medicare contractors to implement the annual Part B Preventive Vaccine Administration file. The file is made available for download in mid-November.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for CY 2025
On November 8, CMS published Medicare Claims Processing Transmittal 12950 regarding the 2025 update to the payment limit for RHCs, which is $152.00 per visit.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for CY 2025
On November 8, CMS published Medicare Claims Processing Transmittal 12951 to implement the 2025 FQHC PPS base payment rate and the geographic adjustment factors for the FQHC Pricer.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Update in Performance Based Adjustments (PBA) Processing for Kidney Care Choices (KCC) Model - Implementation
On November 8, CMS published Demonstrations Transmittal 12952 regarding updates to the current processing of PBAs from the KCC model. There has been an issue with processing claims correctly for this model since July 1, 2023, because the provider file included incorrect dates. There are details on the exact types of claims that need to be reprocessed in the business requirements.
Effective date: April 1, 2025
Implementation date: April 7, 2025
Updates of Chapter 4 and Exhibits in Medicare Program Integrity Manual, Including the Unified Program Integrity Contractor (UPIC) and Medical Review Accuracy Contractor (MRAC) Coordination Process
On November 8, CMS published Medicare Program Integrity Transmittal 12954 regarding the addition of a section within Chapter 4 on the UPIC and MRAC coordination process and an update to sections within the exhibits to edit the points of contact list. The updates solely relate to contractor technical processes and procedures; they do not affect the provider/beneficiary populations.
Effective date: December 10, 2024
Implementation date: December 10, 2024
Implementation CR – To Send Provider-Based Practice Location Types to the FISS on PECOS Extract Files and for FISS to Process so MACs Don’t Have to Check Manually for These Locations
On November 8, CMS published One-Time Notification Transmittal 12955 to implement a process where provider-based practice location types get sent to the FISS on PECOS extract files and the FISS processes it so MACs don’t have to manually check for these locations.
Effective date: July 7, 2025
Implementation date: April 7, 2025 – Begin design and coding. Note: With the April release, the one-time extract process will be informally NDM’d to the VDCs to be used in the creation of the PECOS daily extract file needed for the July release; July 7, 2025 – Complete coding, testing, and implementation
Implementation of System Changes for the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury (AKI) for CY 2025
On November 8, CMS published Medicare Claims Processing Transmittal 12957, which rescinds and replaces Transmittal 12724, dated July 18, to revise the CR title, attachment 3 API Contract as well as the background and policy sections to reflect the final CY 2025 ESRD PPS policies. This transmittal is no longer sensitive and may now be posted to the internet.
The original transmittal was published internally to implement policies finalized in the CY 2025 ESRD PPS Final Rule.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Not All Selected Hospitals Complied with the Hospital Price Transparency Rule
On November 8, the OIG published a Review regarding whether selected hospitals made standard charges available to the public as required by the hospital price transparency rule. The OIG randomly selected 100 hospitals to review and conducted searches of their websites between January 17 – March 14, 2023, to see whether those hospitals had machine-readable files and a consumer-friendly list of shoppable services publicly available.
The OIG found that 37 of the 100 hospitals included in the review did not comply with either one or both of the hospital price transparency rule requirements. There were 34 hospitals that did not comply with the machine-readable files requirement and 14 hospitals that did not comply with the shoppable services requirements. On the basis of the sample, the OIG estimates that 46% of hospitals required to comply with the hospital price transparency rule likely did not comply with requirements.
The OIG recommends CMS review the noncompliant hospitals found through the OIG’s review and exercise enforcement measures as applicable, consider implementing changes suggested by hospitals regarding written guidance clarifying the definition of shoppable services and develop a training and compliance program tailored for smaller hospitals, and strengthen internal CMS controls to ensure a robust program of reviews of hospitals and compliance with the price transparency rule. CMS concurred with all recommendations.
2025 Medicare Parts A & B Premiums and Deductibles
On November 8, CMS published a Fact Sheet regarding the 2025 Medicare Parts A & B premiums, deductibles, and coinsurance amounts. The standard 2025 amounts are:
- Part A inpatient hospital deductible - $1,676
- Part A daily coinsurance (61st - 90th day) - $419
- Part A daily coinsurance (lifetime reserve days) - $838
- Part B monthly premium - $185.00
- Part B annual deductible - $257
- Skilled nursing facility coinsurance - $209.50
CMS will publish these amounts in the Federal Register on November 14.
October Livanta Claims Review Advisor
On November 8, Livanta published the October edition of the Claims Review Advisor. This issue examines correct reporting of type 2 myocardial infarction on Part A claims. It walks through severity levels, documentation requirements, clinical indicators, code assignments, and more.