Florida and U.S. Virgin Islands Part B POE-AG minutes - November 13, 2025

Jurisdiction N

Medicare Part B

November 13, 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 highest and lowest attended prior quarter activities were reviewed, and feedback was requested. Positive feedback was received. Please email Janice Mumma at Janice.mumma@novitas-solutions.com, if you would like any comments or have any suggestions regarding education.   

CMS activities

Janice reviewed the CMS website Newsroom page. This page offers the latest information on what is happening in the Medicare world. Make sure you are subscribed to the CMS MLN Connects Newsletter. Please review both pages for the most up to date releases. 

First Coast Learning Center

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. The upcoming topics that will be covered were reviewed. Watch our events calendar for monthly updates. 

The upcoming activities for the remainder of November 2025 were reviewed. December calendar has been posted to the website. 

On-Demand training

First Coast has a number of on-demand learning resources. These resources are intended for you to participate in Medicare education at your own pace, on your schedule. We are constantly adding new webinar recordings, and we are in the process of adding new training videos monthly.  

Social media 

Social media is also part of the 2025 educational strategy. First Coast is active in social media platforms: LinkedIn and YouTube. Subscribe today and please promote these social media tools to your colleagues. 

Comprehensive error rate testing (CERT)

CMS developed the CERT program to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. First Coast has compiled two new resources to help providers navigate the CERT program: CERT Insider's Guide and CERT Fast Facts. The Insider's Guide will be issued quarterly, and the Fast Facts will be issued monthly. Both publications can be accessed from the CERT center on our website. 

The CERT process was discussed. You can use the Comprehensive Error Rate Testing (CERT) claim identifier (CID) lookup on our website. This tool was created so that providers can obtain a status of their CERT sampled claims. When you receive your letter from CERT, you will find your CID number on that letter. You can also use the CID number in the lookup tool on the C3Hub website. 

The C3Hub website was designed to provide Medicare providers, suppliers, and contractors with information about the CERT program and to facilitate coordination, collaboration, and communications between all stakeholders. To view current status of a claim under CERT review, enter CID number in claim status search tool. 

If you are unable to obtain an updated CERT claim status, you can send an email request to medical review: QuestCERT2@fcso.com. Please ensure that you do not include any protected health information (PHI) or personally identifiable information (PII), only the CID number is needed.

NCD 20.36 Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management

CMS has developed criteria for coverage for an implantable pulmonary artery pressure sensor (IPAPS) for heart failure management, which include: 

• Patient criteria
• Physician criteria
• Billing and coding specifics
• Coverage with evidence development (CED) study requirements

Claim processing requirements apply to claims with dates of service on and after January 13, 2025. For more information on this topic, please review MM14000.

Transcatheter Tricuspid Value Replacement (TTVR) (NCD 20.37)

Coverage for this NCD include:

Patient must have symptomatic Tricuspid Regurgitation. 
The patient has to be under the care of a heart team, which includes at a minimum: 

• Cardiac surgeon
• Interventional cardiologist
• Cardiologist with training and experience in heart failure management
• Electrophysiologist
• Multi-modality imaging specialists and
• Interventional echocardiographer

Services furnished in the context of a CMS-approved CED Study. 

Transcatheter tricuspid value replacement (TTVR) is not covered for patients outside of a CMS-approved study. Please review CR 14149 for complete information on this NCD.

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) - October 2025

NCD coding changes are the result of newly available ICD-10-CM codes, coding revisions to NCDs released separately, or coding feedback received.

Multiple NCDs affected:

• NCD 20.9.1 – Ventricular assist devices
• NCD 110.24 – Chimeric antigen receptor (CAR) T-cell therapy
• NCD 190.11 – Home prothrombin time/international normalized ratio monitoring for anticoagulation management
• NCD 210.4.1 – Counseling to prevent tobacco use
• NCD 210.13 – Screening for hepatitis C virus (HCV) in adults

No policy changes with this update. Please review MM14041 for more information. 

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2025

October quarterly updates to the Medicare Physician Fee Schedule Database include:

• New codes
• Procedure status changes
• Short descriptor code revisions
• Payment policy indicator changes

For more information, please review CR 14208.

Quarterly Update to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule - October 2025

October quarterly updates to the DMEPOS fee schedule include new DMEPOS codes added to the (HCPCS) file (A4453, A4459, E0658, E0659). 

Within this quarterly update, CMS also identified an error affecting several of the of the 2024 deflation factors listed in the January 2025 DMEPOS Fee Schedule. This update will apply to the following payment categories:

• Surgical Dressings
• Parenteral and Enteral Nutrition (PEN)
• Splints and Casts
• Intraocular Lenses (IOL)

For more information, please review CR 14214.

Clinical Laboratory Fee Schedule & Laboratory Services Subject to Reasonable Charge Payment - October 2025 Update

This quarterly update for clinical laboratory fee schedule (CLFS) and laboratory services subject to reasonable charge payment included updated information on the CLFS data reporting period for clinical diagnostic laboratory tests (CDLT) that are not advanced diagnostic laboratory tests (ADLT):

Next data reporting period – January 1, 2026 - March 31, 2026, based on January 1, 2019 - June 30, 2019, data collection period:

• 0% payment reduction applied for CY 2025
• For CY 2026-2028 – payment may not be reduced more than 15% compared to the preceding year

Additional data reporting periods will be every 3 years (i.e., 2029, 2032, etc.)

This update also included codes that were added and deleted effective October 1, 2025:

• Lists of new and deleted codes are linked in transmittal under “Key Updates“ section
• New codes are contractor-priced until they are nationally priced and undergo CLFS annual payment determination process 

Please review MM14211 for a complete listing of updates. 

Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files - October 2025

This CR was released to announce the quarterly update for drug pricing files. Please review CR 14117 for a complete listing of updates. 

Telehealth Guidance After October 1

Due to the government shutdown, many of the statutory limitations in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency took effect again for services that are not behavioral health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. 
Ensure that you are monitoring any Congressional action. You may choose to hold claims associated with telehealth services not payable by Medicare in the absence of Congressional action.
For further information, review the CMS guidelines on Telehealth.

Eligibility Elimination from the IVR

Effective December 1, 2025, for all our JN providers and suppliers, access to patient eligibility information will be eliminated from the IVR and only be available through the SPOT portal. Providers are encouraged to initiate the enrollment process for SPOT as soon as possible to avoid access disruptions. All other states will be required to obtain patient eligibility information via the SPOT portal in the near future. Additional phases will be communicated as they are scheduled.

Prior Authorization (PA) of Certain Services in the Ambulatory Surgical Center (ASC) Setting

Effective for dates of service (DOS) on and after December 15, 2025, CMS is implementing a 5-year demonstration project for the PA of certain services provided in ASCs located in a limited number of demonstration states, which includes Florida. This demonstration will test a program which ASCs submit a prior authorization request (PAR) and obtain a provisional affirmation before providing a service or be subject to prepayment review and potentially be denied payment if services are deemed ineligible.

ASC services part of the PA demonstration include:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

Providers may begin submitting PARs on December 1, 2025, for DOS on or after December 15, 2025.

Prior Authorization (PA) Code Lookup Tool

Providers can use the tool to verify if a code is subject to PA programs which include:

• Hospital outpatient departments (OPD)
• Ambulatory surgical centers (ASCs)
• Repetitive scheduled non-emergent ambulance transports (RSNAT)

When accessing the tool:

• Accept the disclaimer
• Select Part A or Part B for the type of claim the provider will be submitting
• Enter any Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code
• Select “Search”
• Results will indicate if the code is subject to PA

Please visit our website to use this self-service tool. 

Claims Hold Update

CMS instructed all MACs to lift the claims hold and process claims with dates of service October 1, 2025, and later for certain services which include:

• Claims paid under the Medicare Physician Fee Schedule
• Ground ambulance transport claims
• Federally Qualified Health Center (FQHC) claims
• Telehealth claims that CMS can confirm are definitively for behavioral and mental health services

CMS has directed all MACs to continue to temporarily hold claims for other telehealth services (i.e. those that CMS cannot confirm are definitively for behavioral and mental health services) and for acute Hospital Care at Home claims. 

National Correct Coding Initiative 

CMS developed NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. There are three components for NCCI: Procedure to Procedure (PTP) Edit Pairs, Add-On-Codes (AOC), and Medically Unlikely Edits (MUEs). The PTP, AOC and MUE edits are updated on a quarterly basis. To minimize coding and billing errors providers are encouraged to review the updates on the CMS website.

PTP Edit Pairs

NCCI PTP edits prevent inappropriate payment of services that should not be reported together. A PTP code pair is subject to automated prepayment edits when two services are performed:

• By the same physician or provider
• For the same beneficiary
• On the same date of service

A modifier is appropriate to use when the modifiers associated with NCCI are allowed with the PTP code pair. Documentation supporting the PTP code pair and the modifier is appropriate when a clinical circumstance justifies the use of a modifier.

First Coast is dedicated to helping our providers with the correct submission of claims. To assist providers, we have developed the NCCI Procedure to Procedure (PTP) Lookup Tool. This tool will assist with easy identification of proper code pair selection and modifier reporting. 

Add-On-Codes 

An AOC is a HCPCS or CPT code that describes a service that, is always performed in conjunction with another primary service. Primary and AOC procedures need to be reported on the same claim. If the primary and AOC are not included on the same claim, the AOC service will deny.     

The listings are organized into three separate payment type groups: 

• Type I add-on codes are identified in the CPT, HCPCS and other CMS policy which define primary procedures
• Type II add-on-codes don't have a specific list of primary procedure codes
• Type III have add-on codes with the primary procedure codes that are specifically identifiable

Medically Unlikely Edits (MUEs) Updates

A MUE for a HCPCS/CPT code is the maximum units of service a provider will report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have a MUE. Units of service are determined by the MUE Adjudication Indicator (MAI):

• MAI of 1 – MUE based on claim service line
• MAI of 2 or 3 – MUE based on date of service

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 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.

Influenza Vaccine Payment Allowances - Amount Update for 2025-2026 Season

Flu season is right around the corner. CMS recently issued a recuring update which provides the flu allowances for the 2025 – 2026 Flu season.  Flu season runs from August 1, 2025 – July 31, 2026. These codes are updated on an annual basis and are based on 95 percent of the Average Wholesale Price (AWP). Note, the implementation date is September 30, 2025, however updates applies to dates of service on and after August 1, 2025.  Claims that were paid at the prior flu season rate will be automatically adjusted at the correct payment rate. For more information, please review CR 14182.

Pre-exposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent HIV Infection

CMS has established two new Healthcare Common Procedure Coding System (HCPCS) codes effective October 1, 2025, for PrEP for HIV services:

• J0738: Injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)
• J0752: Oral, lenacapavir, 300 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv)

For more information, visit the CMS website. 

Open discussion

Any additional suggestions on topics, dates and times can be emailed to Janice.Mumma@novitas-solutions.com.

2026 POE AG meeting dates are in development. 

A question was asked if there was any update to labs denying due to CLIA files not being sent to FCSO timely. Janice asked that they send an email to her and she will look into this issue further since they are not able to find anything on the websites on this issue. 

A suggestion was received asking if CMS could do an in-depth session on Provider Adverse-History. Brad advised that we are always taking education suggestions and we will look into providing this topic in 2026. Brad advised that we do host a number of enrollment sessions, but we will look into adding this specific topic into these webinars. 

A question was asked specifically about nail debridement and other foot LCDs. Both include the 11721 code, but when billing for nails with the B35.1, claims deny because B35.2 is only valid with one LCD. Janice advised, if possible, they should appeal any denials. Janice also sent the LCD reconsideration information in the chat. 

A question was asked that in the AMA guidance Quick Reference guide, it states that “in the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter.” For chemotherapy plans with labs attached, do these count as “recurring” labs? What is CMS guidance on how to count this. Janice advised that she will take this question back to her E/M Education Specialists and have them provide a response.