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Last Modified: 7/30/2025 Location: FL, USVI Business: Part A

Florida and U.S. Virgin Islands Part A POE-AG minutes – July 22, 2025

Jurisdiction N
Medicare Part A
July 22, 2025

Welcome and introductions

Janice Mumma, Supervisor, welcomed the members and reviewed current committee guidelines.
Janice advised the purpose of the POE AG is to assist the contactor in the creation, implementation, and review of provider education events. We conduct this meeting to allow provider feedback on training topics, provider education materials, dates, and times of provider education events.

Prior quarter activities

The group discussed the attendance at the prior webinars. The highest and lowest attended prior quarter activities were reviewed, and feedback was requested.

Next quarter activities

The upcoming activities for the remainder of July 2025 were reviewed. The August calendar is in development and will be posted soon.

CMS activities

Janice reviewed the CMS website, specifically the Newsroom external link page. The Newsroom page offers the latest information on what is happening in the Medicare world. Please review for the most up to date releases. There was a CMS Listserv message sent July 9th that advised that registration is now open for the Inpatient Hospital Short Stay Patient Status Review Transition Teleconference. Register now! external link

Education strategy

We offer a wide array of educational opportunities. The topics offered in our live webinars are specialty specific and widespread incorporating real-time Medicare requirements, processes, and instructions regarding how to prevent frequent and costly errors.
The StayConnected webinar workshop series consists of topically related events focused on outlining CMS requirements, including coverage, billing, etc. Our Medicare Navigator webinar workshop series consists of events focused on assisting provider navigate to, identify, perform, and submit necessary Medicare tasks. For more information, please visit our website. The upcoming topics that will be covered were reviewed. Watch our events calendar for monthly updates.

2025 Virtual Symposium

The 2025 First Coast Virtual Symposium is coming soon. The dates are October 21 - 23, 2025. Our focus will be on Medicare compliance, risk mitigation, program integrity, and fraud prevention. Watch our website and email communications for updates! Janice asked the group to send in suggestions on how to communicate our educational opportunities to the provider community.

On-Demand training

First Coast has a wide array of on-demand learning resources. These resources are intended for you to participate in Medicare education at your own pace, on your schedule.

Social media

First Coast is active in social media. LinkedIn and YouTube are live. Subscribe today and please promote these social media tools to your colleagues.

New Website Coming

First Coast is getting a new website! We will be issuing email communications as well as hosting navigation webinars prior to the release this fall.

Comprehensive error rate testing (CERT)

CMS developed the CERT program to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. We recently revamped the CERT page and have provided a number of new resources. Please visit the CERT page on our website for more information. The CERT process was also discussed. Ensure you have the correct mailing address on file so that you can receive Additional Documentation Requests (ADRs) timely. If you do not respond to these ADRs, you will receive claim denials.
For the 2024 reporting period, one of the Medicare FFS improper payment drivers included skilled nursing facilities. The national projected improper payment amount for SNF services during the 2024 reporting period was $5.9 billion, resulting in an improper payment rate of 17.2 percent.
Most common reasons for SNF denials:
• HIPPS coding errors does not support MDS reporting of item(s)
• Missing completely or missing timely certifications/recertifications/delayed certifications
• Missing authenticated physician orders for SNF services, rehabilitative therapies, and/or mechanically altered diets
• Missing physician and/or nursing documentation to support reasonable and necessary SNF services and/or therapy services
• Missing 5-day MDS with ARD in repository
• Non-response to ADR
Overpayments occur when a provider is paid more than the amount due and payable according to existing laws and regulations. When an overpayment has been identified from the CERT claim review, we are required to pursue the money owed. We will adjust the original claim accordingly and sends a demand letter to the provider who was paid for the service(s) billed. The demand letter specifies the reason for the CERT denial/reduction and includes information regarding recourse under this process.
Providers can appeal CERT determinations and should direct appeal requests to us. For specific instructions on filing an appeal with us, please visit our appeals webpage.
A comment was received asking about a non-compliance letter that was sent out by CMS. Janice asked for a copy of this letter, and Ursula advised that she would look into it.

Quarterly Updates

Updates to the National Correct Coding Initiative (NCCI) edits occur on a quarterly basis. Along with NCCI updates, there are also updates to the procedure to procedure (PTP) edits, Add on codes (AOCs), and medically unlikely edits (MUEs). To minimize coding and billing errors providers are encouraged to review the updates on the CMS website external link.

July 2025 Update of the Hospital Outpatient Prospective Payment System (OPPS)

The quarterly OPPS update has been released. Some of the highlights are new Covid-19, Influenza and Respiratory Syncytial Virus Vaccines, the AMA CPT Editorial Panel established 23 new PLA codes, specifically, CPT codes 0552U through 0574U, retroactive status indicator change for CPT Codes 98980 and 98981, and new CPT Category III codes. For more information on these updates, please review MM14091 external pdf file.

Quarterly Update to the End Stage Renal Disease Prospective Payment System (ESRD PPS)

Effective July 1, 2025, CMS is making the following changes:
Updating the most recent mean unit cost for renal dialysis drugs that are oral equivalents to injectable drugs based on the most recent prices obtained from the Medicare Prescription Drug Plan Finder, effective July 1, 2025.
Adding or removing any renal dialysis items and services from the list of outlier services, as necessary.
Revising the mean dispensing fee of the National Drug Codes (NDCs) qualifying for outlier to $0.56 per NDC per month for claims with dates of service on or after July 1, 2025
Please review CR 14089 external pdf file for more information.

Implementation of New Condition Code (CC) KX and Value Code (VC) 92

For claims received on or after July 1, 2025, there is a new Condition Code (CC) KX. There must be documentation on file to support requirements specified in the medical policy have been met. In addition, there is a new Value Code (VC) 92 effective for claims received on or after January 1, 2026. This VC is to allow providers to report invoice cost for drugs and biologicals when required by federal regulation. This is to be used with revenue category 0636. Please review CR 13803 external pdf file for more information.

Update on Inpatient Hospital short stay patient status reviews

Beginning September 1, 2025, Inpatient Hospital short stay patient status reviews for acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities will transition from the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIOs) (BFCC-QIO) to the MACs. MACs will perform reviews on a sample of Medicare pre-payment Part A claims as part of our current Targeted Probe and Educate (TPE) program. For more details on this program, please review the CMS website external link

Top Claim Errors

Claims will be processed and review one of the following status:
PB9997 - Approved to pay
DB9997 - Denial
RB9997 - Rejection
TB9997 - RTP

Top RTP Codes

The top RTP codes for the first quarter of 2025 were: reason code (RC) 34963, reason code (RC) U5065, and reason code (RC) 34977.
RC 34963: This RC indicates that the attending physician reported on page 3 is invalid or the name reported does not match what’s in PECOS. We see this reason codes most commonly on outpatient therapy claims where the provider is reporting the NPI and name of the therapist when in fact, the name and NPI should be that of the physician that certified the plan of care. To correct this reason code, if you entered the therapist’s NPI and name, replace it with the physician that signed the therapy plan of care and resubmit.
RC U5065: This RC indicates that the claim from date is prior to the Medicare Beneficiary Identifier (MBI) effective date on the Common Working File (CWF) Xwalk file and the MBI is the oldest occurrence in the HIC XWALK file for the beneficiary at CWF. The patient may have received a new MBI card. Make sure you validate eligibility for each encounter, use SPOT to validate the patient’s MBI, correct and resubmit the claim.
RC 34977: This RC indicates that the practice location reported on the claim, the outpatient “off-campus” location does not match the address in PECOS. The match must be exactly even if there are typos. Using DDE, check the provider practice address query screen, option 10 to see how the practice locations were reported in PECOS. If the address is listed, correct the address reported on the claim and resubmit.

Top Reject Reason Codes

The top reject reason codes for the first quarter of 2025 were: RC 38200, RC U5233, RC C7010.
RC 38200: This RC indicates this claim is an exact duplicate of a previously submitted claim. You will want to verify and review services submitted against claims history. If additional charges must be included on prior claim, then you would submit an adjustment rather than a new claim. If the rejected claim is an exact duplicate to a previously processed and finalized claim, no action is necessary.
RC U5223: This RC indicates no Medicare payment can be made because the statement covered period falls within, or overlaps, a Medicare Advantage plan enrollment period. To resolve this reason code, it is important to verify patient eligibility for your date(s) of service prior to submitting your claim. The best practice is to obtain all insurance cards the beneficiary may hold and verify that the information is correct and current. If the statement covered period falls within, or overlaps, a Medicare Advantage plan enrollment period, submit the claim to the Medicare Advantage plan for payment.
RC C7010: This RC indicates that the date of service overlaps with a hospice episode. This means that the patient selected hospice, or the hospice agency has not submitted their last claim closing the episode. If that is the case, you may need to reach out to the hospice agency and ask them to submit their last claim. Once that is done you can adjust and resubmit your claims. If the services rendered are not related to the terminal illness, you need to adjust your claim to add condition code 07.

Top Denial Reason Codes

The top reject reason codes for the first quarter of 2025 were: RC 5ARAN, RC 39928, RC 54NCD.
RC 5ARAN: This RC indicates that the information provided does not support the need for the service or item. These are non-covered services because this is not deemed reasonable and necessary by the payer. Review your claim pages and medical records. If a covered diagnosis code was missing during claim submission, follow the reopening process. If the claim was coded appropriately, follow the appeal process with medical records to support.
RC 39928: This RC is a claim level reason code for claims that have all line items denied. Check the line level to determine why the lines were denied and who is liable. Line level denials may be available on Claim page 2 that will provide additional denial information.
RC 54NCD: This RC indicates that that none of the diagnoses on the claim support the medical necessity of the service, and no documentation to support medical necessity was provided. Validate the NCD to make sure the coverage criteria are being met. If a dx code was omitted, request a redetermination.

Identify Your Top Errors

To help your facility avoid the errors discussed, generate and review monthly reports, including the 201 DDE report, from office or billing software company, monitor trends, identify and resolve problems promptly, and communicate this information to your staff.

Discuss Preventive Services and Screenings with your Patients

Medicare pays for a full range of preventive services and screenings: Promoting, providing and educating Medicare patients about potentially life-saving preventive services are essential.
CMS has developed an interactive Preventive Service Chart external link to assist the health care community in identifying HCPCS/CPT codes, diagnosis codes, coverage requirements, frequency requirements and beneficiary liability for each Medicare preventive service. When you are using this tool – it will also identify the preventive services eligible for telehealth. Those preventive services will have the “telehealth eligible” icon.

Open discussion

A comment was received regarding clarification on Reject Code C7010. One Aetna MA plan would not pay a physician service stating the following: "MA plan enrollees may revoke hospice election at any time, but claim will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following the date hospice was revoked". Ursula advised that this information is correct. Social Security Administration needs to be contacted so they know that they patient is revoking their hospice election.
Suggestions on topics, dates and times can be emailed to Janice.Mumma@novitas-solutions.com.
Our next POE AG meeting will be November 11, 2025.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.