Monday Morning Rounds with CMS

ICYMI, here is recent communication from CMS.

2026 Merit-based Incentive Payment System (MIPS) Performance Year Virtual Group Election Period
If you’re interested in forming a virtual group for the 2026 MIPS performance year, the election period will begin on October 1, 2025. To form a virtual group, an election must be submitted to CMS via email at MIPS_VirtualGroups@cms.hhs.gov between October 1, 2025, and December 31, 2025 (11:59 p.m. ET).

MIPS MVP Adoption Survey Now Open
CMS is seeking feedback from individuals and organizations who submitted Payment Year (PY) 2024 data to the Quality Payment Program (QPP), including through Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs), Traditional MIPS, or other options. Your insights will help improve the MIPS MVP reporting experience and identify what’s working well.

• The survey takes approximately 15 minutes to complete.
• Participation is voluntary and confidential.
  • Results will be reported in a way that prevents identification of any individual, group, or entity.
• Eligible clinicians may receive Improvement Activity (IA) credit for completing the survey.

How to Participate
Take the survey by clicking on this link: The MVP Adoption Survey

CMS Releases Final Guidance for Initial Price Applicability Year 2028 and Manufacturer Effectuation of the Maximum Fair Price in 2026, 2027, and 2028
CMS released final guidance for the third cycle of negotiations under the Medicare Drug Price Negotiation Program (Negotiation Program). This final guidance incorporates significant policy refinements based on public feedback, with a particular focus on increasing transparency, and implements expanded protections for orphan drugs enacted in the Working Families Tax Cuts Act (Public Law 119-21).

Information for Critical Access Hospitals
The critical access hospital (CAH) bills for facility and professional outpatient services only when physicians or practitioners reassign their billing rights to the CAH. Learn how CAHs can prevent Fiscal Intermediary Shared System (FISS) reason codes 31006 and 31007 (indicating that providers don’t have a reassignment on file in PECOS) claim denials:

• CAHs must submit the reassignment application through PECOS or the paper Form CMS-855I
• Starting in January 2026, we’ll deny CAH claims for professional services if a reassignment isn’t in PECOS

Visit the Quality Payment Program (QPP) Resource Library to Access Updated 2025 Qualified Registry Qualified Posting
The 2025 Qualified Registry Qualified Posting has been updated to reflect new or resolved remedial actions and/or terminations applied to the third party intermediaries included within these resources. Visit the QPP Resource Library to access the updated 2025 Qualified Registry Qualified Posting and review the Version History tab within the qualified posting for more detailed information.

2025 QPP Exception Applications are Now Available
The 2025 Quality Payment Program (QPP) Exception applications are available now through December 31, 2025, at 8 p.m. ET. There are 2 types of exception applications that allow users to indicate the reason they’re unable to report data for one or more Merit-based Incentive Payment System (MIPS) performance categories: MIPS Promoting Interoperability Performance Category Hardship Exception Application and MIPS Extreme and Uncontrollable Circumstances Exception Application.

• Hospice Payments: FY 2026 Update
• Inpatient & Long-Term Care Hospital Prospective Payment Systems: FY 2026 Changes
• Medicare Claims Processing Manual, Chapter 18 Update: Hepatitis C Virus Preventive & Screening Services
• Medical Severity Diagnosis-Related Groups Subject to Inpatient Prospective Payment System Replaced Devices Policy: FY 2026 Update
• Clinical Laboratory Fee Schedule & Laboratory Services Subject to Reasonable Charge Payment: October 2025 Update
• DMEPOS Fee Schedule: October 2025 Quarterly Update
• National Fee Schedule for Vaccine Administration: October 2025 Update
• Implementing the Transforming Episode Accountability Model: Skilled Nursing Facility 3-Day Rule Waiver
• Home-Based Noninvasive Positive Pressure Ventilation to Treat Chronic Respiratory Failure Due to Chronic Obstructive Pulmonary Disease
• ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2026 Update
• National Coverage Determination 20.38: Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation

• Clinical Laboratory Fee Schedule: COVID-19 & Influenza Virus Types A and B Test Code
• Drug Claims: Billing for Zero Charges
• COVID-19 Vaccine Pricing for 2025–2026 Season
• Ambulatory Surgical Center: Medicare Approved New High-Cost Gene Therapy Drug
• Medicare Part B Drug Pricing Files & Revisions: October Update
• Medicare Physician Fee Schedule Database: October Update
• Clinical Laboratory Fee Schedule: Revised Third Quarter File
• National Correct Coding Initiative: October Update
• Rural Health Clinic & Federal Qualified Health Center: Adjusting Claims for Care Coordination Services
• HCPCS Application Summaries & Coding Determinations: Non-Drug & Non-Biological Items and Services
• Seasonal Flu Vaccine Pricing for 2025–2026 Season
• Integrated Outpatient Code Editor: Correcting Errors for Reason Code W7113
• Home Health Prospective Payment System Grouper: October Update

Maternal Opioid Misuse (MOM) Model
The MOM Model is a patient-centered service delivery model that aims to improve the quality of care for pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD) and their infants. The CMS Innovation Center supported awardees in seven States (Colorado, Indiana, Maine, New Hampshire, Tennessee, Texas, and West Virginia) to implement the MOM Model with care delivery partners through December 2024.

Enhancing Oncology Model (EOM)
The Enhancing Oncology Model (EOM) is a voluntary model that uses financial and quality incentives to improve care and reduce Medicare spending for patients with seven prevalent cancer types. The goal of the model is to reshape cancer care by encouraging oncology practices to provide high-quality, patient-centered care while reducing Medicare spending. It is an episode-based payment model where participants are financially accountable for the total cost of a 6-month episode of care involving systemic cancer therapies. EOM builds on the Oncology Care Model (OCM) (July 2016–June 2022) by focusing on cancer types that showed savings, focusing financial incentives, requiring practices to collect electronic Patient-Reported Outcomes, and encouraging shared decision-making to empower patients.

End-Stage Renal Disease Treatment Choices (ETC) Model
The End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model is intended to encourage greater use of home dialysis and kidney transplantation among ESRD Medicare patients, while reducing Medicare expenditures and preserving or enhancing quality of care. The ETC Model is proposed to end December 31, 2025.