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
October 2025 Newsletter
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.
Home Health Industry Threatened by Shutdown
The recent government shutdown is causing problems for the home health industry and home health care billing, pushing it over a telehealth cliff, limiting its patient pool, and adding administrative burden, according to Home Healthcare News. It’s also frozen the Acute Hospital Care at Home (AHCAH) program [1].
Risk Adjustment Audit Overhaul Struck Down
A federal judge in Texas has ruled that DHS violated the Administrative Procedure Act, failing to appropriately notify industry stakeholders and the general public about the changes in the medical coding audit rule. The suit was brought by Humana, challenging the September 2023 RADV overhaul. The ruling is being counted as a significant win for payers [2].
CMS Expects Medicare Advantage and Medicare Prescriptions Drug Programs to Remain Stable
The agency has announced that the average plan choices, premiums, and benefits for the MA program and Part D prescription drug program will be stable in 2026. Average premiums are expected to decline in both programs. CMS is releasing this information ahead of Medicare Open Enrollment [3].
Lab Developed Test Final Rule Rescinded
The FDA rescinded the final rule on laboratory developed tests. This action puts a formal end to a long-term effort to increase oversight in the industry. The agency has issued a new final rule, changing the definition of in vitro diagnostics to align with pre-2024 regulations [4]. Healthcare providers and medical billing companies should keep an eye out for changes that impact them.
HCPCS Quarterly File Updated
The previously released HCPCS quarterly update for October has been updated as of 9/23/2025. The medical billing updates can be reviewed and downloaded by the public on the CMS website under the file name: October 2025 Alpha-Numeric HCPCS File (ZIP) [5].
E/M Billing and Coding Updates Released by CMS
CMS has published a revised MLN booklet, covering E/M services. This update concerns billing and medical coding updates for home or residence services, telehealth services, hospital outpatient clinic visits, critical care services, and more [6].
The Impact of Federal Funding Cuts on Health Systems
Becker’s Hospital Review has published an overview of the impact of the One Big Beautiful Bill Act to multiple areas of healthcare including Medicaid reductions, ACA subsidies, Medicare Advantage, 340B drug pricing programs, and NIH funding [7].
New ICD-10-CM Codes Announced
CMS has announced new ICD-10-CM codes that are effective October 1, 2025 for revenue cycle management services. These codes will impact discharges from October 1, 2025 to September 30, 2026. They will also impact patient encounters between October 1, 2025 and September 30, 2026 [8].
Humana to Pay $32M in Fees in False Claims Settlement
Humana has been ordered by a federal court to pay over $32 million in fees, including attorney’s fees, costs, and interest connected with the resolution of a False Claims Act case from 2024. The lawsuit was filed in 2016 by a former actuary for Humana who claimed that the company sent CMS fraudulent bids for the Walmart Part D prescription drug plan [9].
The AHA Pursues Commitments on Prior Auth Reforms
The American Hospital Association has encouraged HHS leadership to keep the promises they’ve made on prior authorization reforms for the hospital revenue cycle. The association sent a letter to CMS and HHS leaders, emphasizing the fact that 95% of hospitals report that staff time spent on prior auth approval has increased in the last year, increasing patient frustration and burden on providers [10].
New Epic Interoperability Features
Epic has launched multiple new data-sharing features at a recent interoperability conference. They include more prior authorization APIs, MyChart changes, and updates to align with federal interoperability standards [11].
References
[1] M. Gonzales, “Government Shutdown Halts Telehealth Flexibilities, Hospital-at-Home Waiver, Threatening Home Health Industry,” Home Health Care News, 1 October 2025. Available: https://homehealthcarenews.com/2025/10/government-shutdown-halts-telehealth-flexibilities-hospital-at-home-waiver-threatening-home-health-industry/.
[2] P. Minemyer, “Federal judge strikes down 2023 risk adjustment audit overhaul in win for Medicare Advantage plans,” Fierce Healthcare, 26 September 2025. Available: https://www.fiercehealthcare.com/payers/federal-judge-strikes-down-2023-radv-audit-overhaul-win-medicare-advantage-plans.
[3] CMS, “Medicare Advantage and Medicare Prescription Drug Programs Expected to Remain Stable in 2026,” 26 September 2025. Available: https://www.cms.gov/newsroom/press-releases/medicare-advantage-medicare-prescription-drug-programs-expected-remain-stable-2026.
[4] S. Kelly, “FDA rescinds LDT final rule,” TechTarget, Inc., 19 September 2025. Available: https://www.medtechdive.com/news/FDA-rescinds-LDT-final-rule/760645/.
[5] CMS, “HCPCS Quarterly Update,” 23 September 2025. Available: https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update.
[6] CMS, “Evaluation and Management Services,” September 2025. Available: https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf.
[7] E. Cerutti, M. Ashley, J. Emerson and E. Casolo, “What ‘federal funding cuts’ really mean for health systems,” Beckers Hospital Review, 29 September 2025. Available: https://www.beckershospitalreview.com/finance/what-federal-funding-cuts-really-mean-for-health-systems/.
[8] CMS, “ICD-10 Codes,” 1 October 2025. Available: https://www.cms.gov/medicare/coding-billing/icd-10-codes.
[9] J. Emerson, “Court orders Humana to pay $32M in fees following False Claims settlement,” Beckers Payer, 30 September 2025. Available: https://www.beckerspayer.com/legal/court-orders-humana-to-pay-32m-in-fees-following-false-claims-case/.
[10] American Hospital Association, “AHA Supports Administration Facilitating Health Insurer Pledge to Reform Prior Authorization,” 29 September 2025. Available: https://www.aha.org/lettercomment/2025-09-29-aha-supports-administration-facilitating-health-insurer-pledge-reform-prior-authorization.
[11] G. Bruce, “Epic unveils new interoperability features: 7 things to know,” Beckers Hospital Review, 25 September 2025. Available: https://www.beckershospitalreview.com/healthcare-information-technology/ehrs/epic-unveils-new-interoperability-features-7-things-to-know/.
September 2025 Newsletter
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
August 2025 Newsletter
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 Releases HCPCS File Conversions for Spanish Translation
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].
CY 2026 Hospital OPPS and Ambulatory Surgical Center Proposed Rule
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].
Release of the 2026 Medicare Physician Fee Schedule
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 Cuts Prior Auth Requirements
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].
Quarterly DME Update
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].
CMS Issues RARC, CARC, MREP, and PC Print Update
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].
Laboratory NCD Edit Software Changes
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].
Medicare Business Partners Systems Security Manual Update Provided
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].
NUBC Condition Code “63” Update
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].
HHS Issues Technical Revisions to the CPM
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].
References
[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.
July 2025 Newsletter
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 Releases Hospital OPPS July Update
CMS has released the July 2025 update for the Hospital Outpatient Prospective Payment System. It impacts hospital billing, physicians, home health agencies, hospices, and other providers billing MACs for
