The upcoming ICD-10 codes for 2026 promise pertinent changes for revenue cycle departments. To help your leadership prepare and make positive strategic choices that support the financial health of your organization, we’ve compiled this summary of the newest ICD-10 code updates. Delaying implementing these changes can have a significant negative impact on your organization and team. This includes increased stress for your staff, worsening denial rates, and increasing costs of training and
Physicians have expressed concern over payers using artificial intelligence automation, and with good reason. The AMA reports that AI tools contribute to a dizzying increase in denial rates – up to 16 times the norm [1]. So it’s only logical that many providers are looking for ways to “fight AI with AI”, especially in the area of risk adjustment services for U.S. healthcare organizations.
Medical risk coding risk adjustment in healthcare is an excellent use case for AI solutions. When well trained, these models can improve coding accuracy – they stay on top of guidelines to support compliant coding practices, even identifying risk adjusted codes in both unstructured and structured text. It’s a huge potential benefit in supporting complete code capture. At the same time, it can grant leadership increased visibility through improved reporting and project management support – critical for effective medical coding risk adjustment operations.
Looking at the range of potential benefits that AI offers in enhancing risk adjustment services, many leaders see an opportunity (or threat) as a replacement for human coders. This is a misguided way of looking at the technology. It’s critical to remember that, even though the work of coding is heavily numerical and structured, the complexity of medical records and the variation in documentation styles of clinicians means that a human touch is still needed. Even the best-trained AI cannot fully understand a medical record the way a certified coder can.
This means that leaders looking for options to implement AI in risk adjustment in healthcare should move away from either-or thinking, instead taking a both-and approach to how they implement AI and human coders. This is the spirit we’ve leaned into when developing RiskGen-i our AI-powered platform for the nuances of HCC medical coding risk adjustment management. Built to complement the efforts of certified coders, this platform is an ideal solution for leaders who want to do more with the coding resources they have.
And for organizations seeking a fully human-led model, our RiskGen-Core platform delivers the same high standards of accuracy, compliance, and productivity – without AI assistance.
We invite U.S. healthcare leaders to explore how RiskGen-i and RiskGen-Core can help transform your risk adjustment services – boosting compliance, accuracy, and efficiency in today’s challenging reimbursement landscape.
References
[1] American Medical Association, “Physicians concerned AI increases prior authorization denials,” 24 February 2025. Available: https://www.ama-assn.org/press-center/ama-press-releases/physicians-concerned-ai-increases-prior-authorization-denials.
Hemant Apte, Chief Executive Officer in
Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.
Your pathologists are diagnosing cancer. But your billing team? They’re diagnosing something else entirely: denials, underpayments, and revenue holes no one can seem to plug.
If that hits a little too close to home, you’re not alone.
We’ve worked with pathology labs across the U.S. – hospital-based, private groups, national reference labs – to know the symptoms: clean claims on paper but shrinking cash flow; pathology coding that looks fine until an audit hits; contract rates that haven’t changed in 5 years, but test complexity has doubled.
Before you hire another FTE or switch your pathology billing company again, run through this checklist. You’ll find out exactly where your pathology revenue cycle is bleeding – and how to fix it.
Let’s be honest: pathology billing isn’t just billing. It’s a battlefield.
If your medical billing partner isn’t a pathology billing company, they’re likely missing revenue opportunities you don’t even know exist.
Any of this sound familiar?
3Gen Consulting’s pathology billing services use AI-powered claim scrubbing, modifier audits, test panel logic, and denial trend analysis to capture every reimbursable dollar while keeping you fully compliant.
Let’s talk about the invisible revenue killer: pathology coding.
Pathology coding is one of the most overlooked revenue drains. Coders must go beyond basic CPT knowledge – they must understand stains, panels, molecular techniques, and payor nuances.
Ask yourself:
Even the cleanest billing process can’t save incomplete or inaccurate coding. If your team isn’t fluent in pathology coding nuance, you’re flying blind. With 3Gen’s team of certified pathology coders, clients achieve 95%+ accuracy, layered QA, audit-ready documentation, and real-time dashboards.
When’s the last time you renegotiated your payer contracts?
Most pathology groups haven’t touched their payer contracts in years. Meanwhile, payers tweak fee schedules, apply edits, and bundle services that should be billed separately.
Time to self-audit:
Contracts are no longer “set and forget.” If you’re not renegotiating smarter and backing it up with data, you’re likely being underpaid for advanced pathology services. Our payer contracting team uses denial trends, test-level reimbursement data, and MRF benchmarking to arm you with hard facts to negotiate smarter.
Risk adjustment coding isn’t just for primary care. If your pathology lab serves Medicare Advantage or ACO populations, you’re sitting on untapped value. Pathology findings often uncover conditions that impact HCC coding and RAF scores – but most labs aren’t capturing them.
Here’s what to ask:
3Gen Consulting’s RiskGen-i platform integrates seamlessly with your LIS and EHR to identify, code, and track pathology-related risk conditions, aligning pathology with value-based care incentives.
The scariest phrase in revenue cycle today: payer audit.
From CMS RADV audits to private payer clawbacks, pathology is under the microscope. And if your documentation, modifiers, or LCD coverage aren’t airtight, you’re exposed.
Sound familiar?
Compliance isn’t a checkbox. It’s a daily discipline – especially in pathology, where coding and documentation must be bulletproof. 3Gen Consulting supports labs with real-time denial analytics, audit response prep, and compliance documentation support, so you’re never caught off guard.
Final Diagnosis
It’s time to ask: Is your current pathology RCM partner keeping up – or holding you back? Most generic medical billing companies lack the clinical knowledge and test-level nuance needed to optimize pathology revenue. That’s where 3Gen Consulting steps in – with pathology-trained billers, coders, and contracting experts who understand your lab like it’s their own.
Want to see what your pathology revenue cycle is really doing behind the scenes? Let 3Gen Consulting run a free pathology medical billing health check. No fluff. No obligation. Just data-backed insight from a pathology billing company that knows your specialty. Book Your RCM Checkup Today.
The Centers for Medicare and Medicaid Services (CMS) has released a significant number of changes and updates in recent months. The Hospice Outcomes and Patient Evaluation (HOPE) assessment is one of the most pertinent for revenue cycle leaders in hospice organizations.
The launch of the HOPE assessment tool is the premiere of a patient assessment method that is meant to standardize data collection for hospice patients. It will have a direct impact on hospice billing services, meaning that revenue cycle leaders who want to stay ahead of changes coming down from CMS will benefit from familiarizing themselves with the origin, differences from previous standards, and implications for healthcare providers. This article will walk you through a foundational understanding of the assessment tool and prepare you for application of deeper response strategies at your organization.
The HOPE Assessment Tool Is a Shift for Hospice Billing Services
The HOPE assessment tool, developed by CMS, marks a pivotal shift in hospice care evaluation, replacing the Hospice Item Set (HIS) as part of the Hospice Quality Reporting Program (HQRP). Finalized in the FY 2025 Hospice Wage Index Final Rule, this tool is designed to standardize data collection while providing a more dynamic understanding of patient needs, care planning, and potential reimbursement refinements. Unlike HIS, which relied on retrospective chart abstraction, the HOPE Hospice Tool captures real-time clinical data through structured assessments, enabling more responsive care adjustments.
The development of the HOPE assessment checklist involved a rigorous, multi-phase process that included stakeholder feedback, cognitive testing, and national beta trials. CMS engaged with hospice providers, clinicians, and technical experts to ensure the tool’s practicality and alignment with real-world workflows. The result is a system that not only meets regulatory requirements but also enhances clinical decision-making.
When fully implemented in October 2025, the HOPE assessment tool is expected to equip providers with actionable insights to refine care strategies, improve patient outcomes, and strengthen operational efficiency.
HOPE vs. HIS: What Hospice Providers Need to Change in 2025
While HIS was limited to verifying care processes through post-discharge chart reviews, the HOPE assessment tool introduces a proactive, multi-point assessment framework. HIS data was collected only at admission and discharge, but HOPE expands the scope with HOPE Update Visits (HUVs) and Symptom Follow-Up Visits (SFVs), offering a more granular view of patient needs over time.
HUVs, conducted between days 6–15 and 16–30 of a patient’s stay, require in-person skilled nursing assessments to update care plans based on evolving conditions. These visits ensure CMS captures critical data during the first 30 days of hospice care, a period often marked by significant symptom fluctuations. Meanwhile, SFVs – triggered by moderate or severe symptom impact – must be completed within two calendar days of the initial assessment. Unlike traditional symptom checks, SFVs focus on the impact of symptoms (e.g., disruptions to sleep or daily activities) rather than their severity alone. This distinction underscores CMS’s emphasis on patient-centered outcomes.
For providers, adapting to these changes requires both operational and technological adjustments. Staff must be trained to complete the HOPE assessment checklist accurately, while EMR systems need updates to support new data fields and submission requirements. The HOPE guidance manual provides detailed instructions, but agencies should begin internal audits now to identify workflow gaps and ensure compliance ahead of the October 2025 deadline.
HOPE has Strategic Implications for Hospice Leadership
The HOPE hospice tool is a catalyst for improving care quality and operational transparency. Two initial quality measures, focused on timely symptom follow-ups, will take effect in FY 2028, with more metrics likely as CMS refines the tool. These measures will eventually factor into public reporting, making adherence a priority for agencies aiming to maintain competitive reputations.
To prepare, hospice leaders should:
For hospice billing services, the shift to HOPE introduces both challenges and opportunities. Accurate, timely data submission will be critical to avoid penalties and secure optimal reimbursement. Agencies that leverage the HOPE system effectively will not only meet compliance standards but also gain insights to streamline revenue cycles and reduce claim denials.
Engaging with CMS and Staying Ahead
CMS has committed to ongoing stakeholder engagement, offering forums, webinars, and help desk support to ease the transition. Hospice revenue cycle leaders should actively participate in these opportunities, providing feedback on pain points and advocating for practical refinements.
Leaders should consider regularly monitoring the HQRP website for updates and assigning a team member to oversee HOPE-related communications. This will help ensure agencies remain agile as policies evolve. By embracing the HOPE assessment tool as a strategic asset, rather than a mere compliance obligation, hospice leaders can position their organizations for long-term success in an increasingly data-driven landscape.
Preparing Your Revenue Cycle Strategy for HOPE
To help you successfully navigate this new assessment standard, 3Gen Consulting offers tested expertise in hospice billing services. Our experts support hospice agencies with end-to-end revenue cycle management—keeping you ahead of changes to minimize negative impact and maximize your strategic response. We have documented results, saving a leading home health and hospice company 42% in costs.
Whether you’re helping your internal teams adapt to the HOPE assessment tool or looking for a partner to support hospice billing services, we’re here to help. Contact us today to get started.
We’ve assembled the latest news for healthcare revenue cycle leaders to help you stay on top of industry challenges and adapt your revenue cycle management services to the challenges of USA medical billing.
CMS has released file conversions related to the Spanish translation of the Healthcare Common Procedure Coding System (HCPCS) medical coding descriptions. The change request provides direction for contractors who need to perform file conversions of HCPCS descriptions from First Coast Service Options quarterly [1].
CMS has issued a proposed rule on July 15, 2025. It covers updates to Medicare payment rates and policies that apply to the hospital outpatient and Ambulatory Surgical Center (ASC) services under the Hospital Outpatient Prospective Payment System (OPPS) and the ASC Payment System Proposed rule. The hospital billing policies impact approximately 3,500 hospitals and about 6,100 ASCs [2].
July 14, 2025, CMS released a proposed rule that announces and requests public comments on potential policy changes for Medicare payments under the Physician Fee Schedule along with other Medicare Part B topics. These physician revenue cycle management changes would go into effect on or after January 1, 2026 [3].
Humana has sped up its work in reforming their prior authorization process, a change that impacts physician billing services. The company states that, by January 1, 2026, it will eliminate one third of its prior authorization requirements for multiple outpatient diagnostic services, including select CT scans and MRIs, colonoscopies, and transthoracic echocardiograms [4].
CMS has issued the quarterly update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Competitive Bidding Program (CBP). These files implement necessary changes to the HCPCS, and ZIP code, as well as single payment amount files. The update impacts home health billing and is issued as of July 21, 2025 [5].
The agency has issued a change request that updates the RARC and CARC lists and instructs the ViPS Medicare System (VMS) and the Fiscal Intermediary Shared System (FISS) to update the MREP and the PC Print. The USA medical billing update applies to Chapter 22, Sections 40.5, 60.2, and 60.3 of Publication (Pub.) 100-04 and was issued on July 21, 2025 [6].
CMS has published a change request announcing changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2025. It was issued July 21, 2025 and applies to Chapter 16, Section 120.2, Publication 100-04. The full guidance document for medical coding USA is available on the HHS.gov website [7].
The Information Security and Privacy Group (ISPG) has issued updated security requirements, specifically the Acceptable Risk Safeguards (ARS). In response, the CMS Medicare Contractor Management Group (MCMG) has updated its Internet Only Manual (IOM) 100-17. More details can be found on the HHS.gov website [8].
Issued July 17, 2025, this HHS change request updates the National Uniform Billing Committee (NUBC) condition code “63”. It allows providers to indicate that services that have been rendered to a prisoner or patient in state or local custody meet requirements under 42 CFR 411.4(b) for payment [9].
Issued July 15, 2025, this change request announces technical changes to the Claims Processing Manual (CPM), under Publication 100-04, Chapters 18 and 32. The full guidance document for medical coding USA is available for download and review on the HHS website [10].
[1] CMS, “File Conversions Related to the Spanish Translation of the Healthcare Common Procedure Coding System (HCPCS) Descriptions,” 29 July 2025. Available: https://www.cms.gov/node/2106216.
[2] CMS, “Calendar Year 2026 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Proposed Rule (CMS-1834-P),” 15 July 2025. Available: https://www.cms.gov/newsroom/fact-sheets/calendar-year-2026-hospital-outpatient-prospective-payment-system-opps-and-ambulatory-surgical.
[3] CMS, “Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule (CMS-1832-P),” 14 July 2025. Available: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-pfs-proposed-rule-cms-1832-p.
[4] J. Emerson, “Humana to cut prior auth requirements, introduce gold card program,” Becker’s Healthcare, 22 July 2025. Available: https://www.beckerspayer.com/payer/humana-to-cut-prior-auth-requirements-introduce-gold-card-program/.
[5] CMS, “Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – October 2025,” 21 July 2025. Available: https://www.hhs.gov/guidance/document/quarterly-update-durable-medical-equipment-prosthetics-orthotics-and-supplies-dmepos-37.
[6] CMS, “Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update,” 21 July 2025. Available: https://www.hhs.gov/guidance/document/remittance-advice-remark-code-rarc-claims-adjustment-reason-code-carc-medicare-remit-27.
[7] CMS, “Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2025,” 21 July 2025. Available: https://www.hhs.gov/guidance/document/changes-laboratory-national-coverage-determination-ncd-edit-software-october-2025.
[8] CMS, “Pub 100-17 Medicare Business Partners Systems Security Manual Update,” 17 July 2025. Available: https://www.hhs.gov/guidance/document/pub-100-17-medicare-business-partners-systems-security-manual-update.
[9] CMS, “Update of a National Uniform Billing Committee (NUBC) Condition Code “63”, “Incarcerated Beneficiaries,” 17 July 2025. Available: https://www.hhs.gov/guidance/document/update-national-uniform-billing-committee-nubc-condition-code-63-incarcerated.
[10] CMS, “Update of a National Uniform Billing Committee (NUBC) Condition Code “63”, “Incarcerated Beneficiaries,” 17 July 2025. Available: https://www.hhs.gov/guidance/document/technical-revisions-only-claims-processing-manual-cpm-publication-pub-100-04-chapter-18-0.
