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Watch for E/M scrutiny with diagnostic X-rays, as denials rise

01/26/2026

Some coders at this year’s Advanced Specialty Coding Virtual Summit reported increased denials for E/M visits billed at the same encounter as an X-ray. Practices should be watchful for these and challenge them when they occur, billing experts advise.

New CMMI model to award proposals on chronic conditions, ‘lifestyle’ interventions

01/26/2026

by: Roy Edroso

Up to 30 proposals will be accepted under a new $100 million Center for Medicare and Medicaid Innovation (CMMI) model. While details about the MAHA ELEVATE (Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence) model are scarce, early signs suggest that behavioral health providers, and those currently coordinating complex care, will have an advantage.

After Cigna’s downcoding policy, monitor claims and other payers

01/26/2026

by: Dom Nicastro

Cigna’s new E/M Coding Accuracy (R49) policy, which took effect October 1, will automatically review — and in some cases, downcode — level 4 and 5 E/M claims that the insurer believes are inconsistent with typical coding patterns.

You can use MDM or time when critical care becomes a hospital E/M

01/26/2026

by: Julia Kyles, CPC

Question: The provider performs a service that they believe meets the requirements for critical care services. They document the service and the total time. However, the documentation does not support the severity or complexity required for a critical care service. Can the practice use the time to report a level-based hospital E/M code, or does it have to use medical decision-making (MDM)?

Physician e-visit codes up, but version for QHPs shows struggles

01/26/2026

by: Roy Edroso

Utilization of the e-visit codes established before the pandemic in 2020, represented by 99421-99423 (Online E/M for physicians) and 98970-98972 (Online assessment and management [A/M] for non-physician qualified health professionals), suffered in the aftermath of the public health emergency.

Test your coding skills with the case of the PACU boarder

01/19/2026

by: Julia Kyles, CPC

Your billing practitioners work hard, especially when they perform critical care services. Training your clinical and coding staff with real-world examples can make sure your providers get full credit for their work.

The case of the PACU boarder: Discover the answer

01/19/2026

by: Julia Kyles, CPC

Your physicians and qualified health care professionals won’t get full payment for critical care services if their documentation falls short or coders miss key elements. During the 2025 Advanced Specialty Coding Virtual Summit: Anesthesia, Marcy Garuccio, ACS-AN, CANPC, CPMA, CPC, SME, AAPC Fellow and Laura McNeill, M.D., ABA, ASE, shared a critical care scenario. Read the case, decide which service or services McNeill can report and then check your answer below.

Don’t skip the latest NCCI, ICD-10-CM code and addendum updates

01/19/2026

by: Julia Kyles, CPC

Despite the record-breaking government shutdown in 2025, CMS released the 2026 National Correct Coding Initiative (NCCI) manual and the April ICD-10-CM code updates on time. The NCCI manual changes went into effect Jan. 1, and the ICD-10-CM update will go into effect April 1. You won’t find massive changes in the updates, but make sure your teammates know what’s new.

Lab panel descriptors — top 5 codes reported in the office

01/19/2026

by: Julia Kyles, CPC

Comprehensive metabolic and lipid lab panels ranked high on the list of lab panels reported in place of service 11 (Office), according to a review of Medicare Part B claims data.

ACCESS program gives outcomes-based payment for tech-forward chronic care

01/19/2026

by: Roy Edroso

A new CMS model offers opportunities for providers willing to replace fee-based payment for treatment of some chronic care patients with “outcome-aligned payments” based on clinical results, and to use new technology resources to do it. Even if you choose not to participate, you and your patients may still benefit from their involvement in the program via other providers.

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