Part B News | Benchmark of the Week

Claims rates for E/M modifiers 57, 24 hold steady, but denials inch up

12/15/2025

Utilization of the operation-related modifiers 24 (Unrelated evaluation and management service by the same physician during a postoperative period) and 57 (Decision for surgery) has held relatively stable in recent years, and 2024 was no exception.

Prior auth requests swelled, but denials didn’t follow

12/08/2025

by: Julia Kyles, CPC

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.

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