Florida and U.S. Virgin Islands Part A POE-AG minutes - November 11, 2025
Jurisdiction N
Medicare Part A
November 11, 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, and dates and times of provider education events.
Prior quarter activities
The highest and lowest attended prior quarter activities were reviewed, and feedback was requested. No feedback was provided from the group regarding prior events. 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 providers with how to 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 is in development.
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.
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.
October 2025 update of the Hospital Outpatient Prospective Payment System (OPPS)
Each quarter, the OPPS update will describe various billing instructions and various payment policies. This can impact HCPCS, APCs, HCPCS modifiers, and revenue codes - those categories can be affected by additions, changes, and deletions. Each update will also indicate if an IOM has updates made and what section was impacted.
Some of the highlights are:
- New COVID-19, influenza and respiratory syncytial virus vaccines
- Retroactive status indicator change for CPT codes 98980 and 98981
- New CPT category III codes
For more information, review the MLN Matters Article associated with this update, MM14223.
October 2025 quarterly Average Sales Price (ASP) Medicare Part B drug pricing files and revisions to prior quarterly pricing files
This CR was released to announce the quarterly update for drug pricing files. Please review CR 14117 for a complete listing of updates.
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.
Continuation of system changes to automate processing of inpatient claims for chimeric antigen receptor (CAR) T-cell and other immunotherapy cases
CMS recently became aware that there are other instances in which the immunotherapy product is not purchased in the usual manner, such as provided at no cost. Beginning in FY 2026, in cases where the immunotherapy product is not purchased in the usual manner, such as provided at no cost, the payment adjustment will be applied.
To notify the Medicare Administrative Contractor (MAC) of a case where the immunotherapy product is not purchased in the usual manner, such as provided at no cost, the provider may enter billing note "PROD NO COST" on the electronic claim 837I or a remark "PROD NO COST" on a paper or Direct Data Entry (DDE) claim, and the Shared System Maintainer (SSM) shall populate condition code ZD so that the Inpatient Prospective Payment System Pricer (IPPS) will apply the payment adjustment in calculating the payment for the case.
Update on Inpatient Hospital short stay patient status reviews
Previously, CMS notified the public that Medicare Administrative Contractors (MACs) will begin performing short stay inpatient hospital medical reviews of patient status reviews, instead of the QIO. We don’t have a lot of information other than what CMS has released. This started September 1, 2025, and each MAC’s Targeted Probe and Educate (TPE) program will be performing the reviews. For more information, visit the CMS website.
Preparing for FY/CY 2026
It is getting close to the end of FY/CY 2025, which means it's time to prepare for the FY/CY 2026. For the final rules such as Medicare Physicians Fee Schedule, you can access the CMS Newsroom for updates. Make sure you are subscribed to the CMS MLN Connects Newsletter.
Quarterly updates do occur in January, April, July and October. Those updates will assist with learning what updates are occurring on a quarterly basis. Some of the quarterly updates include OPPS, Medicare Physician Fee Schedule, NCCI (which consists of the PTP edits), add-on codes, and medically unlikely edits. Also, ensure you are reviewing the updates located in the following manuals:
- CPT
- HCPCS
- ICD-10
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.
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.
Each month, there are hundreds of national and international celebrations to help raise awareness or support meaningful causes. November includes National Diabetes Month. For more information, please visit the CMS website.
Influenza vaccine payment allowances - amount update for 2025-2026 season
Flu season is right around the corner. CMS recently issued a recuring update that 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% of the average wholesale price (AWP). Note, the implementation date is September 30, 2025, however, updates apply 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.
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 communication between all stakeholders. To view current status of a claim under CERT review, enter the CID number in the 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.
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.