CMS recently announced updates to the January 2025 Integrated Outpatient Code Editor, including new HCPCS codes and changes to a handful of status indicators.
The American Medical Association recently announced new codes, deletions, and revisions included in the 2025 CPT code set. Explore these notable updates to the code set.
According to a recent analysis, healthcare organizations are submitting more prior authorization requests to Medicare Advantage plans and more of those requests are being denied. Review the analysis’ findings to be more aware of prior authorization processes and CMS’ efforts to streamline them.
Patients who self-reported housing instability often didn’t have the correct ICD-10-CM codes documented in their record, according to a recent study. Review the results of the study and be more aware of the importance of properly documenting housing insecurity to ensure appropriate housing and medical services are delivered.
CMS’ proposed rule to revise the Medicare hospital Outpatient Prospective Payment System for calendar year 2025 has been released. Review some of the proposals that could directly impact your organization.
CMS recently released an updated MLN fact sheet reminding providers about documentation requirements for requests from its Comprehensive Error Rate Testing (CERT) program.
CMS updated its July 2024 HCPCS Quarterly update file in May with a total of 70 new HCPCS codes, 11 discontinued codes, and 32 revised codes. All code changes will be implemented July 1.
The Food and Drug Administration’s (FDA) emergency use authorization for Pemgarda, a pre-exposure COVID-19 prophylaxis, has led to the release of HCPCS Level II codes for the drug and its administration.
CMS published a summary of its first quarter 2024 HCPCS Level II code update application decisions. There were 48 additions, two code definition revisions, and seven discontinuations.
CMS proposed hundreds of ICD-10-CM code changes in the 2025 IPPS proposed rule, published April 10, including 252 new codes, 13 revised codes, 36 invalidated codes.
CMS published its HCPCS Quarterly Update in March, which heralded the sum of 94 HCPCS Level II code additions, discontinuations, and definition revisions. The changes became effective April 1.
The Journal of the American Medical Association (JAMA) published a study in March found that “foot and ankle care was associated with an 11% lower likelihood of death…and a 9% lower likelihood of major amputation (above or below knee).”
CMS retroactively added two new CPT codes for respiratory syncytial virus (RSV) vaccine administration. The codes affect services rendered on or after October 6, 2023.
A JAMA study published in January found that patients with the highest risk for severe COVID-19 infection received outpatient therapy less often than those with the least risk.
CMS published a summary of its fourth quarter 2023 HCPCS Level II code update application decisions, including 36 additions, four revisions, and 18 deletions.
CMS posted its 2024 Therapy Code List and Dispositions on December 28. This list indicates whether therapy services, as distinguished by HCPCS Level II and CPT codes, are recognized under CMS as “sometimes therapy” or “always therapy.”
Michael Lonski, Ph.D., a licensed psychologist, was sentenced to 27 months of imprisonment and three years of supervised release for conducting $2.6 million in Medicare and Medicaid fraud, the Department of Justice announced December 19.
CMS released its January 2024 HCPCS Level II code update December 7, outlining 344 new and 74 discontinued codes. The code changes will become effective January 1, 2024.
A recent Office of Inspector General audit of inpatient and outpatient Medicare claims estimated that nearly 20% of cases including codes for abuse or neglect were not reported to law enforcement.
CMS recently published a summary of its third quarter 2023 HCPCS Level II code update application decisions, accepting 51 of 61 submissions. There were also 10 codes that will be discontinued and one code whose definition will be revised. The additional codes mostly consist of injections and skin substitutes.
CMS estimated $4.4 billion in improper payments in 2022 for hospital outpatient services, according to a Comprehensive Error Rate Test review recently published in the Medicare Provider Compliance Newsletter. According to the report, of the 1,899 inspected claims, 5.4% were improperly paid.
CMS' recently implemented October OPPS update brings with it a slew of new, revised, and deleted CPT and HCPCS Level II codes with effective dates ranging from April 18 to October 1. Among the additions are codes for vaccines, vaccine administration, skin substitutes, renal histotripsy, and breast imaging.
AMA published the 2024 CPT code set with 349 total editorial changes, including 230 additions, 49 deletions, and 70 revisions. The press release announced revisions for immunization/administration sections, E/M clarification, and new Spanish procedure descriptions.
CMS updated its E/M Services Guide in August, reflecting changes for E/M services that went into effect January 1. The guide includes plain-language explanations of policy changes, but some do not align perfectly with AMA guidance.
CMS recently released a national coverage determination update to the Medicare Claims Processing Manual . This update covers new requirements for CPT coding associated with acupuncture and dry needling services.
CMS recently published a summary of its second quarter 2023 HCPCS Level II code update application decisions, accepting 16 of 24 submissions. Many of the changes addressed in the announcement have an effective date of October 1, but one code revision and one code discontinuation will take effect before then.
CMS published the 2024 Medicare Physician Fee Schedule (MPFS) proposed rule on July 13 with new potential policies and codes affecting physician reporting, including new HCPCS codes for E/M services and behavioral health.
The Office of Inspector General (OIG) recently released the results of an audit of Medicare billing requirements for psychotherapy services submitted from March 2020 through February 2021 as providers adapted to changes introduced as a result of the COVID-19 public health emergency.
CMS released Transmittal 12053 in May, outlining CMS’ intended changes in the July 2023 OPPS update. The new HCPCS codes will be used to report gastric procedures, insulin pump equipment, echocardiography processing, and more.
CMS published its first quarter 2023 HCPCS Application Summaries and Coding Recommendations April 27, which summarizes the final decisions on HCPCS Level II code assignments. CMS created 58 new HCPCS codes, deleted seven codes, and revised one code. Most changes will be implemented July 1.
CMS released the fiscal year (FY) 2024 IPPS proposed rule on April 10. The document contains proposals for 395 new, 12 revised, and 25 invalidated ICD-10-CM codes.
The American Medical Association’s (AMA) CPT Editorial Panel recently approved a new vaccine administration code for COVID-19. It also released a summary of panel actions, which includes accepted and deleted code and guideline revisions for July 2023, January 2024, and January 2025.
CMS has published CPT and HCPCS Level II updates that take effect in April. Review highlights of the code and modifier changes in the April 2023 HCPCS Level II and OPPS updates.
CMS recently published its fourth quarter 2022 HCPCS Application Summaries and Coding Recommendations. The new codes will be used to report injections and skin substitutes and are scheduled to take effect April 1.
The HCPCS first quarter 2023 update, released in December, introduced several new codes and modifiers for medical products and procedural services. Most of the changes took effect January 1.
CMS recently published an FAQ document on the use of drug waste modifiers. The resource addresses how the modifiers affect Medicare policy, to which products they can be appended, billing concerns, and more.
The CPT Editorial Panel released 20 new Category III CPT codes. These new codes, along with two revisions, are mainly for cardiovascular procedures and take effect July 1.
The Centers for Disease Control and Prevention and the National Center for Health Statistics published updates to the ICD-10-CM coding guidelines and files, which take effect April 1. The updates include 42 new diagnosis codes, seven deletions, and one revision.
CMS recently released Transmittal 11737, detailing January 2023 updates to the OPPS. The transmittal offers information on new COVID-19 vaccine and administration codes, dental coding updates, coding clarification, and remote behavioral health service codes.
The CPT Editorial Panel recently announced that it approved new CPT codes for Pfizer’s bivalent COVID-19 vaccine booster and its administration for children six months to 4 years old after they have received administration of the first and second doses of the product.
The Office of Inspector General (OIG) recently released a report investigating instances of incorrect co-surgery and assistant-at-surgery modifier usage, which found that 69 of 100 sampled procedural services did not meet federal requirements.
CMS released its 2023 OPPS final rule on November 1. The document finalizes most proposed policies, including a new provider type for rural emergency hospitals (REH), continued coverage of telehealth services, and implementation of new skin substitute HCPCS codes, among other changes, which largely take effect January 1, 2023.
The Office of Inspector General (OIG) released a report in October to assess the results of 12 Medicare hospital and identify CMS’ actions as a result of OIG recommendations made in those audits.
CMS recently published Transmittal 11594 , outlining HCPCS codes for drugs that received pass-through status, new proprietary laboratory analysis (PLA) codes for tests, code revisions for pharmaceutical drugs, and skin substitute product codes, all of which became effective October 1.
The American Medical Association (AMA) released the calendar year 2023 CPT code set on September 9. Learn about new codes pertaining to virtual reality technology, cognitive behavioral therapy, and abdominal hernia procedures.
On August 31, the American Medical Association (AMA) announced eight new CPT codes for bivalent COVID-19 vaccine booster doses. The vaccine boosters are designed to combat both the original COVID-19 strain and omicron subvariants BA.4 and BA.5. Of the eight new CPT codes, four are to be used for Moderna booster vaccines and four are to be used for Pfizer-BioNTech boosters.
A recent Medicare Provider Compliance Newsletter highlights accurate documentation and CPT coding for total hip arthroplasty (THA) surgery. This newsletter explains relevant codes and reminders when reporting these procedures.
CMS published a notice in the Federal Register on August 9 stating that it will be suspending prior authorization requirements for specific durable medical equipment, prosthetics/orthotics, and supply (DMEPOS) codes under certain circumstances, beginning January 1, 2023. All claims submitted before that date will require prior authorization documentation.
The American Medical Association (AMA) released the Category I vaccine product codes for monkeypox tests and vaccines. The organization made them effective immediately upon their approval by the CPT Editorial Panel on July 26. The new codes are scheduled to appear in the in the 2024 CPT Manual.
The current year (CY) 2023 OPPS proposed rule, released July 15, details hospital payment updates, remote behavioral services, and enrollment requirements for rural emergency hospitals, among other proposals.
The American Medical Association’s (AMA) CPT Editorial Panel recently published changes to its E/M Services Guidelines. The update includes code revisions, additions, and deletions, which are scheduled to take effect January 1, 2023.
CMS recently announced that it released a new HCPCS Level II code for AstraZeneca's EVUSHELD COVID-19 antibody treatment, effective for dates of service on or after February 24. The initial dose authorized for use during the public health emergency has been changed to 600 mg for pre-exposure prevention of COVID-19.
The American Medical Association (AMA) recently announced an editorial update to the CPT code set for COVID-19 vaccines that includes new codes for Pfizer-BioNTech’s booster vaccine and Sanofi-GlaxoSmithKline’s (Sanofi-GSK) vaccine candidate.
CMS’ recently released fiscal year (FY) 2023 IPPS proposed rule includes 1,179 proposed ICD-10-CM code additions, mainly affecting reporting for dementia, concussions, and injuries due to motor vehicle collisions. The code changes, if finalized, would take effect October 1, 2022.
A New York City provider received an estimated $1.1 million in Medicare overpayments for behavioral health services that did not comply with billing requirements, according to a recent Office of Inspector General (OIG) report.
CMS recently released an update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit files, introducing more than 4,000 new CPT code pairs. The PTP edits took effect April 1 and primarily involve codes found in the pathology and laboratory section of the CPT Manual .
Following the release of the Medicare Payment Advisory Commission’s March report to Congress, the American Medical Association (AMA) urged Congress to revise the Medicare Physician Fee Schedule (MPFS) to include stable, annual payment updates that keep up with inflation and practice costs.
CMS recently announced a new HCPCS Level II code for COVID-19 convalescent plasma administered in the outpatient setting, effective for claims submitted on or after December 28, 2021.
The American Medical Association (AMA) recently announced three new CPT codes for administration of Pfizer’s COVID-19 vaccine in children 6 months to under 5 years old.
CMS recently issued a new HCPCS code for the antiviral medication remdesivir when administered in the outpatient setting. The new code is a response to a statement from the National Institutes of Health regarding therapies for the COVID-19 omicron variant.
The American Medical Association (AMA) recently announced that it updated the CPT code set to include a new code for a third dose of Pfizer’s COVID-19 vaccine in children 5 through 11 years old.
Between 2016 and 2019, Medicare payments to laboratories for genetic tests quadrupled from $351 million to $1.41 billion. This sharp increase in spending on genetic testing is likely linked to excessive and fraudulent billing, according to a recent Office of Inspector General (OIG) report.
Between January 2019 and August 2020, CMS overpaid physicians an estimated $9.5 million in unallowable Medicare payments associated with facet joint denervation procedures, according to a recent Office of Inspector General (OIG) report.
Effective January 1, CMS is expanding coverage for the use of telehealth technology to include the delivery of mental health services in underserved areas.
CMS recently released the 2022 Medicare Physician Fee Schedule (MPFS) and OPPS final rules, revising E/M coding guidelines for split visit services, retaining Category 3 telehealth codes through 2023, and increasing monetary penalties for hospital price transparency noncompliance.
The American Medical Association (AMA) recently announced that it updated the CPT code set to include a new code for a booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine.
Between 2016 and 2017, CMS overpaid hospitals and other providers an estimated $636 million in unallowable Medicare payments associated with neurostimulator implantation surgeries, according to a recent Office of Inspector General (OIG) report.
The October 2021 quarterly update to the OPPS announces new HCPCS codes for endoscopic submucosal dissection and central venous catheterization. It also introduces new HCPCS drug codes and revisions to the list of those qualifying for pass-through payment status.
John Peter Smith Hospital in Tarrant County, Texas, has agreed to pay $3.3 million to settle allegations that it was in violation of the False Claims Act by upcoding certain claims.
CMS overpaid physicians an estimated $1.7 million for transitional care management (TCM) services over a two-year period, according to a recent Office of Inspector General (OIG) report. Overpayments were due to CPT coding and billing errors.
Medicare overcompensated providers for complex and noncomplex chronic care management (CCM) services billed over a two-year period, according to a recent OIG report. These overpayments occurred because CMS did not have claim edits in place to prevent billing of overlapping care management services.
The American Medical Association (AMA) recently announced that it updated the CPT code set to include new codes for third doses of the Moderna and Pfizer/BioNTech COVID-19 vaccines.
Staten Island University Hospital overcharged Medicare an estimated $11.8 million for inpatient and outpatient services billed over a two-year period, according to a recent Office of Inspector General (OIG) report.
University of Michigan Health System overcharged Medicare an estimated $12.5k for polysomnography services submitted over a two-year period, according to a recent Office of Inspector General (OIG) report. Overpayments were due to insufficient documentation and CPT coding errors.
CPT codes 63685 and 63688 for spinal neurostimulator procedures have been removed from the list of services that would require Medicare prior authorization when performed in a hospital outpatient department, CMS announced on May 13.
The American Medical Association (AMA) recently updated the CPT code set to include immunization and administration codes for a COVID-19 vaccine under development by Novavax Inc.
CMS’ recently released fiscal year (FY) 2022 IPPS proposed rule includes 153 proposed ICD-10-CM code additions, mainly affecting reporting for immune effector cell-associated neurotoxicity syndrome, gastric intestinal metaplasia, and poisonings by cannabis and synthetic cannabinoids.
CMS recently added 24 audiology and speech-language pathology services to its list of telehealth services covered under Medicare during the COVID-19 public health emergency (PHE). These services include speech, hearing, and swallowing assessments, and cognitive interventions.
Physician and non-physician practitioners may benefit from reviewing documentation requirements and HCPCS Level II codes for knee orthoses, according to a recent Medicare Quarterly Compliance Newsletter .
The American Medical Association’s (AMA) CPT Editorial Panel at its February meeting approved technical corrections to the E/M coding guidelines for outpatient visits. The corrections were uploaded to the AMA website on March 9 and go into effect retroactively from January 1.
CMS recently added six codes to the list of services that may be reported with HCPCS modifier -CS (cost-sharing), which requires Medicare to cover beneficiary cost-sharing during office visits and other encounters for the duration of the COVID-19 public health emergency.
The Food and Drug Administration (FDA) recently issued an emergency use authorization (EUA) for the combination treatment of bamlanivimab and etesevimab for COVID-19 patients at high risk for severe infection.
A recent analysis of electronic health record data from 2015 to 2019 shows that providers underreported ICD-10-CM codes in categories Z55-Z65 for social determinants of health.
The January 2021 quarterly update to the OPPS , released by CMS December 31, announces new HCPCS codes for vitrectomy, nasal endoscopy, and intravascular lithotripsy procedures. The update also...
The American Medical Association (AMA) on November 10 announced a handful of new CPT codes for reporting COVID-19 vaccine products and immunization administration.
CMS on October 28 released an interim final rule that ensures physician reimbursement for the administration of a COVID-19 vaccine and outpatient hospital reimbursement for COVID-19 drug services provided at the same time as a comprehensive APC service.
Baylor Scott & White-College Station didn't properly bill Medicare for supplemental outlier payments, according to a September Office of Inspector General (OIG) report. Reviewed claims contained errors due to overcharging and inaccurate coding, resulting in $189,276 in overpayments, said the report.
The American Medical Association (AMA) on September 8 published two new CPT codes for novel coronavirus (COVID-19)-related services, including one that accounts for additional supplies and clinical staff time used to mitigate the spread of the virus.
The 2021 MPFS proposed rule, released August 3, introduces new policies under the Quality Payment Program (QPP) including plans to delay implementation of the Merit-based Incentive Payment System Value Payment (MVP) model and introduce 108 new quality measures.
Medicare Recovery Audit Contractors (RAC) reported that several outpatient claims did not meet medical necessity requirements for hyperbaric oxygen (HBO) therapy for diabetic wounds of the lower extremities, according to the July 2020 Medicare Quarterly Provider Compliance Newsletter .
The American Medical Association (AMA) recently announced a new CPT® code for reporting antigen testing performed on patients suspected of being infected with the novel coronavirus (COVID-19). The new code is intended to improve reporting of antigen tests using an immunofluorescent or immunochromatographic technique for detection of COVID-19.
