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Discover new behavioral health codes, conditions for coverage

07/28/2025

CMS created add-on codes to more smoothly integrate some behavioral health services with its advanced primary care management (APCM) services, on the theory that “behavioral health integration services are complementary to APCM services and that behavioral health is important in the context of overall health,” the agency states.

Facility-based fees get slashed as CMS prioritizes the office

07/28/2025

by: Richard Scott

CMS is proposing to significantly disrupt two key elements that feed into the valuation of Medicare professional service fees — indirect practice expenses and physician work relative value units (RVU) — and the results would send a shockwave through specialty providers’ expected payments depending on their site-of-service patterns.

CY 2026 work RVUs for new, revised and potentially misvalued codes

07/25/2025

by: DecisionHealth staff

You'll find a preview of more than 90 CPT codes that CMS plans to cover in 2026 inside the proposed 2026 Medicare physician fee schedule. While the codes themselves take a placeholder five-digit sequence, the full descriptors and work relative value units (RVU) are available, providing insight on the services soon to be and the monetary value placed on them.

CMS ups 2026 fees, favors non-facility sites of service; previews new codes, models

07/21/2025

by: DecisionHealth staff

Professional Part B Medicare fees are on the upswing overall, but site of service will be a huge factor in reimbursement in 2026. The proposed 2026 Medicare physician fee schedule, released July 14, boosts the Part B conversion factor for CY 2026, adds billing opportunities for behavioral health services, previews new codes and updates the agency’s quality reporting programs.

Final budget bill may mean 4% Medicare sequester, fewer covered patients

07/21/2025

by: Roy Edroso

The budget bill signed into law on July 4 adds a 2.5% raise to the physician fee schedule (PFS). But because the law increases the deficit, other laws previously passed by Congress mandate an increase in the sequestration cuts to Medicare revenue from the current 2% to 4% — and potentially higher — unless a new law is passed to cut it off. Other impacts on Medicare practices, including a reduction in covered patients, also are expected.

Interested in AI adoption? Watch for the green lights, heed red lights

07/21/2025

by: Julia Kyles, CPC

You are likely encountering updates about artificial intelligence, or AI, everywhere, including in the medical industry. But when a practice wants to know whether it’s ready to adopt AI, look for certain green lights that indicate your practice is ready for AI adoption. But also beware of the red lights.

Discover highlights from FY2026 ICD-10-CM official guidelines

07/21/2025

by: Megan Perry

The FY2026 ICD-10-CM guidelines are out and include updated language around coding for patients with human immunodeficiency virus (HIV) infections, hypertension/heart disease and antineoplastic chemotherapy.

Unplanned return modifier 78 reverses slide, but gets denied a lot

07/21/2025

by: Roy Edroso

Use of the modifier 78 (Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period) has been in steep decline in the past 10 years, falling from more than 531,000 claims in 2015 to 87,826 claims in 2020 and 51,177 in 2022. But in 2023, the most recent year for which Medicare data is available, there was a slight reversal.

With WISeR demo, CMS adds prior auth for Medicare services in six states

07/14/2025

by: Roy Edroso

After earlier reforms that sought to reduce the impact of prior authorization on providers and patients, CMS has created a demonstration model that will add prior authorization for regular Medicare for a select group of regional providers.

HIPAA reproductive care PHI overturned, but law still mostly protects it

07/14/2025

by: Roy Edroso

Most of a Biden era reproductive health HIPAA policy has been stopped by a federal court decision. Be clear, though, about your remaining duties to safeguard this kind of protected health information (PHI).

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