Part B News | Benchmark of the Week

Few outpatient hospital E/M claims, but they beat the denial spread

08/18/2025

The small number of outpatient E/M codes (99202-99215) performed in hospital outpatient clinics and claimed with the outpatient place of service (POS) codes saw only modest growth in 2023. But they had better denial rates than you might expect.

Sudden impact: Proposed payment chart highlights CMS’ pay plans

08/11/2025

by: Julia Kyles, CPC

CMS has big plans for your Part B payments in 2026. For example, it wants to restructure reimbursement to favor services performed in non-facility settings, such as the office, and slash payments for services performed in the facility setting.

Expect big pay jump for E/M services in non-facility settings

08/04/2025

by: Richard Scott

You can welcome a significant pay increase for a wide range of non-facility E/M services, including office visits, critical care, home visits and care management services, should fee proposals from CMS take effect in 2026.

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.

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.

PCPs embraced new prolonged service, chronic pain in 2023

07/14/2025

by: Julia Kyles, CPC

Higher-than-average reporting and relatively low denial rates indicate smooth adoption of several new HCPCS G codes that were introduced in 2023. In addition, a few specialties took the lead in using the new codes, according to the latest Medicare Part B claims data.

Aside from XS, denial rates on X modifiers diverge widely

06/30/2025

by: Richard Scott

Practices turned to two of the X-series modifiers in place of modifier 59 (Distinct procedural service) more than 7 million times in 2023 and saw mixed results with denial rates on the top-billed codes.

Primary care, oncology specialties dominate substitute physician services

06/23/2025

by: Julia Kyles, CPC

Analysis of Medicare Part B claims data indicates that when practices bring in a substitute physician, they favor the fee-for-time arrangements over reciprocal billing arrangements. A closer review of the claims data reveals the specialists who are most likely to bring in a substitute when they take time off.

Payer negotiations, burden fuel private practice selloff

06/16/2025

by: Richard Scott

Amid the ongoing decline of private practice ownership, provider groups point to one determining factor that overshadows the rest: the desire to hold better negotiating power with their payers.

Survey: Patient wait times rising across specialties, except ortho

06/09/2025

by: Roy Edroso

You may have suspected as much, and now a survey of 1,391 physician offices located in 15 metropolitan areas offers evidence that wait times for patients to get physician appointment have gone up substantially in recent years, at least in many metropolitan areas.

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