Monday Morning Rounds with CMS

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Posted By: HHS/ONC/CMS Communications November 24, 2025

ICYMI, here is recent communication from CMS.

News

Update on Processing of Medicare Claims Impacted During the Government Shutdown – November 20, 2025
Multiple expiring Medicare statutory payment provisions lapsed on October 1, 2025, due to the absence of Congressional action. With the passage of the Continuing Appropriations, Agriculture, Legislative Branch, Military Construction and Veterans Affairs, and Extensions Act, 2026 (Pub. L. 119-37), Congress retroactively restored many of these payment provisions, effective from October 1, 2025, through January 30, 2026. This includes retroactively restoring the suspension of statutory provisions that restrict payment for telehealth services provided to beneficiaries in their homes and outside of rural areas.

During the shutdown, in general, the Medicare Administrative Contractors (MACs) processed claims consistent with the pricer software, fee, and payment schedules available on cms.gov. CMS has instructed the MACs to perform mass adjustments to any paid claims that are inconsistent with the most recent Congressional action, including a payment adjustment for low volume inpatient hospitals and a payment adjustment for the Medicare-dependent hospital program.

On November 6, 2025, CMS instructed the MACs (see Update on Processing of Telehealth and Acute Hospital Care at Home Claims) to return a subset of telehealth claims submitted on or before November 10, 2025, that, at that time, were no longer payable because the statutory provisions temporarily suspending various Medicare telehealth requirements expired on October 1, 2025, or were claims CMS could not identify as payable under current law. For professional claims, those claims were returned with the following messages: CARC 16 and RARC M77. These claims are now payable, provided they meet all applicable Medicare requirements. Practitioners may resubmit those returned claims to CMS, as well as submit any other telehealth claims held in anticipation of possible Congressional action. Practitioners are also encouraged to identify which beneficiaries were charged for telehealth services with dates of service on or after October 1, 2025, that are retroactively payable and instead submit applicable claims to Medicare, refunding any overpayment to beneficiaries. Our instruction to practitioners to append the GY modifier on certain telehealth claims is rescinded and providers may resubmit previously denied claims.

Similarly, beginning on November 10, 2025, CMS instructed the MACs to return claims for the Acute Hospital Care at Home initiative for dates of service of October 1, 2025, or later. Hospitals may resubmit those claims to CMS.

Facilities, practitioners, and suppliers should be observing a return to normal processing operations over the coming days across the MACs and do not need to contact the MACs unless you observe specific discrepancies.

Physician Fee Schedule: CY 2026 Final Rule – Learn What’s New
CMS issued the CY 2026 Physician Fee Schedule (PFS) final rule that announces final policy changes for Medicare payments under the PFS and other Medicare Part B issues.

See a summary of key provisions effective on or after January 1, 2026.

Average Sales Price Files: October 2025
CMS posted the October Average Sales Price (ASP) and Not Otherwise Classified (NOC) pricing files and crosswalks on the 2025 ASP Drug Pricing Files webpage.

Appropriate use of place-of-service codes
Review the revised Skilled Nursing Facility 3-Day Rule Billing (PDF) fact sheet and the SNF PPS section of Medicare Payment Systems to learn more about place-of-service codes.

CMS Announces New Drug Payment Model to Strengthen Medicaid and Better Serve Vulnerable Americans
The Centers for Medicare & Medicaid Services (CMS) is tackling high drug prices and protecting the American taxpayers through a landmark Innovation Center initiative designed to lower prescription drug spending in Medicaid, improve health outcomes by increasing access to critical medications, and strengthen the Medicaid program overall. State Medicaid programs that choose to participate in the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) Model will be able to purchase drugs included in the pilot at prices aligned with those paid in select other countries, allowing Americans to benefit from fairer, more competitive pricing.

Help Improve the MIPS Final Performance Feedback Experience
Have you reviewed your 2024 payment year Merit-based Incentive Payment System (MIPS) final performance feedback in the QPP Website? They would like to hear about your experience. Please fill out this short survey to help them understand how participants interact with their MIPS final performance feedback. The results will be used to improve how this information is delivered in the future and to ensure it meets the needs of MIPS participants.

Quality Payment Program

Visit the QPP Resource Library to Access the Updated 2025 Qualified Clinical Data Registry (QCDR) and Qualified Registry Qualified Postings
The 2025 QCDR and Qualified Registry Qualified Postings have 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 following updated resources:

Review the Version History tab within the qualified postings for more detailed information.

MIPS News

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

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