Medicare changes beginning this month


The following is a summary of the changes that are being implemented with the January 6, 2014 release and links to references with additional information.

On December 27, 2013, President Obama signed the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment reduction and extends several Medicare fee-for-service policies.

Updates to the Medicare deductible, coinsurance and premium rates for 2014 have been published in MLN Matters article MM8527. The Part B deductible remains at $147.00 per year and the premium is $104.90 per month. The Part A inpatient deductible is $1,216.00.

The therapy caps for 2014 is $1,920. Additional information including any extension of the exception process will be posted to the CMS Therapy Cap website. The Pathway for SGR Reform Act of 2013 extends the exception process through March 31, 2014.

The list of therapy codes classified as sometimes therapy or always therapy has been published on the CMS Annual Therapy Update webpage. Always therapy codes must be reported with a GN, GO or GP modifier regardless of the performing specialty. Sometimes therapy codes must be reported with a GN, GO or GP modifier when performed by a therapist specialty.

Revised Claims Form: The CMS-1500 Claim Form has been revised to support the ICD-10 diagnosis codes. Medicare will begin accepting the revised forms on January 6, 2014. Starting April 1, 2014, Medicare will accept only the revised version of the form. Only providers who qualify for exemptions from electronic submission may submit the CMS-1500 claim form. Additional information is posted to the September 12, 2013 MLN Connects Provider e-news.

The referring or ordering NPI must be submitted for laboratory and image services. If the NPI is not submitted on the claim or the NPI submitted is not valid, the claim will reject. Please refer to Publication 100-04, Chapter 1, section 80.3.2 for the data elements required for claim processing.

Effective January 1, 2014, it is mandatory to report the 8-digit clinical trial number on claims for items or services provided in clinical trials that are qualified for coverage. Claims submitted without the clinical trial number will be returned to the provider. Clinical trials that are also Investigational Device Exemption (IDE) must continue to report the associated IDE number on the claim form. Additional information is published in MLN Matters MM8401. Please note, for physicians, providers, and suppliers who do not have the capacity at this time to report the clinical trials identifier number associated with trial-related claims, CMS is providing an option to submit a generic number in place of the actual National Clinical Trials (NCT) number. Beginning January 1, 2014, and continuing no later than through December 31, 2014, those above-mentioned physicians, providers, and suppliers may instead report an 8-digit, generic number 99999999 using the instructions in CR 8401.  CMS encourages those affected by CR 8401 to update their internal claims processing procedures as expeditiously as possible so they can begin reporting the actual clinical trial identifier number as CR 8401 instructs. This in no way precludes those already reporting and/or able to report the actual clinical trial number on clinical trial-related claims from doing so.  Beginning January 1, 2015, without further notice, CR 8401 shall be fully implemented.

Beginning with January 1, 2014 services Ambulatory Surgical Centers that do not meet the Quality Reporting Program requirements will be subject to a 2% payment reduction. ASC drugs are not subject to the payment penalty reductions. MLN Matters MM8349 offers additional information about this change.


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