Part B News | Benchmark of the Week

Prior auth requests swelled, but denials didn’t follow

12/08/2025

Prior authorization requests for eight types of services performed in the hospital outpatient setting took a great leap forward in fiscal year (FY) 2024. But there’s good news: While requests nearly doubled from FY2023 to FY2024, denials did not keep pace.

2026 top code payments a far cry from the lean years

11/24/2025

by: Roy Edroso with additional reporting by Laura Evans, CPC, and Julia Kyles, CPC

In the 2026 physician fee schedule final rule, the difference between the non-facility fees for non-APM participants and APM participants – a signal feature of the new rule, with two distinct conversion factors (CF) – may seem small at first glance. But it gets bigger as the number rise and compares favorably with recent years’ fees.

POS priority: CMS favors non-facility sites of care in 2026 PFS

11/17/2025

by: Richard Scott

Capture a sense of how relative value unit (RVU) fluctuations depending on a provider’s place of service (POS) are expected to impact specialties’ reimbursement in 2026, after CMS finalized several initiatives to modernize its ratesetting mechanisms.

Hospital, nursing facility prolonged services saw a denial spike in year two

11/10/2025

by: Julia Kyles, CPC

Refresh your staff on the add-on codes for prolonged E/M encounters in the hospital (G0316), nursing facility (G0317), home or residence (G0318) and office or other outpatient (G2212) settings, with a focus on nursing facility visits.

Practices reap $295M in first year of E/M complexity code G2211

11/03/2025

by: Richard Scott

Claims for visit-complexity code G2211 took the #48 spot on the most-billed Part B Medicare services in 2024, showcasing the code’s rapid rise into relevance.

Care management codes rise from COVID depths; so do some denials

10/27/2025

by: Roy Edroso

You might imagine that the suite of Medicare chronic care management (CCM) and transitional care management (TCM) codes would take a hit in the COVID pandemic and then bounce back. And they did. But a look at the denial numbers between 2020 and 2024 shows a more complicated picture.

Critical care: Split/shared claims rose, unrelated encounters stayed flat

10/20/2025

by: Julia Kyles, CPC

Three years of data for critical care services (99291-99292) showed a steady increase for split/shared critical care services. Over the same period critical care services during a procedure’s global period stayed flat.

Denials on most-billed modifier 25 claims are up across the board

10/13/2025

by: Richard Scott

Pay attention to your same-day E/M claims when reporting modifier 25 (Significant, separately identifiable E/M service). Denial rates climbed across the board on the codes most frequently billed with the E/M modifier.

After big change in hospital E/M reporting, use held steady

10/06/2025

by: Roy Edroso

Despite significant changes in standards that came in 2023 for hospital inpatient and observation E/M codes, 2024 was a year of stasis for service utilization — and denials.

Top of the class: An add-on code outpaced services introduced in 2024

09/29/2025

by: Julia Kyles, CPC

The top new service of 2024 was an E/M add-on code that paid approximately $23 when it was introduced. Analysis of the latest available Medicare Part B data shows that pelvic examination code 99459 topped the list of CPT service codes that went into effect Jan. 1, 2024. The code also ranked in the top five for submitted charges.

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