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

June 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 HPMS Memo for May 26

CMS has published memos for week five, May 26-30. This applies to the reporting period 2025. Download is available under file name 5th-week-of-may-26-30-2025.zip [1]. This change can directly impact USA medical billing

MA Prescription Drug Information Released

CMS has released the Medicare Advantage Prescription Drug System payment information for June of 2025. It was issued as of May 30, 2025. The file is available for download under the name “medicare_advantage_prescription_drug_system_june_2025_payment_information_g.pdf” [2]. This release is pertinent for revenue cycle management services

Update to HETS Companion Guide

The agency has released the updated versions of the HETS Companion Guides. This applies to the current implementation (HETS2025-1) and the upcoming HETS2025-2 release. The guide updates are associated with changes to SOAP + WSDL (“SOAP”) and MIME connectivity options [3]. Multiple sections cover impact to medical billing.  

Sustainability Changes to ACO REACH Model

CMS has announced changes to the ACO REACH model. This includes financial methodology with a goal of ensuring future cost savings for the accountable care pilot program. These changes to improve ACO REACH will be applied beginning in 2026 [4]. This update pertains to any provider engaging in medical billing for attributed beneficiaries. 

Shared Savings Program Application Dates Posted

CMS has posted the Shared Savings Program Applications dates for the January 1, 2026 start date. These dates include phase 1 submission, RFI-1, RFI-2, final disposition, as well as phase 2 dates [5].

HCPCS Quarterly Update Available

CMS has published the official update of the HCPCS medical coding system for public use. It was updated May 13, 2025 and is available under file name “July 2025 Alpha-Numeric HCPCS File (ZIP)” [6]. This update impacts medical coding in USA

CMS Issues New Guidance on Price Transparency

The agency has released updated price transparency guidance which can impact the hospital revenue cycle. The guidance falls under the presidential executive order, “Making America Health Again by Empowering Patients with Clear, Accurate and Actionable Healthcare Pricing Information”. The guidance falls under executive order 14221 [7].

CMS Accelerates Medicare Advantage Audits

In revenue cycle services news, CMS has premiered a strategy for expanding its auditing of Medicare Advantage plans. The announcement explains that, beginning immediately, CMS plans to audit all eligible Medicare Advantage contracts for each corresponding payment year under all newly initiated audits. The agency will also be investing additional resources to speed completions of audits for payment years 2024 going back to 2018 [8].

Public Meeting Replay for CMS’ First Biannual 2025 HCPCS

CMS announced the public meeting agenda for the 2025 Healthcare Common Procedure Coding System. The meeting was available in-person and virtually, taking place on June 2, 2025. The event featured speaker presentations and an opportunity for questions, including those pertaining to medical coding in USA [9]. Replays are archived on the CMS website.

340B Oversight Could Fall to CMS

The Department of Health and Human Services has proposed that oversight of the 340B drug pricing program fall under CMS as a component of reorganization plans. It would fall under the agency’s Program Management authority [10]. This change could impact hospital accounts receivable

 

References

[1] CMS, “HPMS Memos for WK 5 May 26-30,” 30 May 2025. Available: https://www.cms.gov/about-cms/information-systems/hpms/hpms-memos-archive-weekly/hpms-memos-wk-5-may-26-30.
[2] CMS, “Medicare_Advantage_Prescription_Drug_System_June_2025_Payment,” June 2025. Available: https://www.cms.gov/node/2104336.
[3] CMS, “Medicare HETS 270/271 – Information Bulletin – Updated HETS Companion Guides – 6/2/2025,” 2 June 2025. Available: https://www.cms.gov/data-research/cms-information-technology/hipaa-eligibility-transaction-system/mcare-notifications/medicare-hets-270/271-information-bulletin-updated-hets-companion-guides-6/2/2025.
[4] CMS, “Innovation Insight: CMS Updates Accountable Care Model to Improve Model Sustainability,” 3 June 2025. Available: https://www.cms.gov/innovation-insight-cms-updates-accountable-care-model-improve-model-sustainability.
[5] CMS, “Shared Savings Program Application Types & Timeline,” 17 March 2025. Available: https://www.cms.gov/medicare/payment/fee-for-service-providers/shared-savings-program-ssp-acos/application-types-timeline.
[6] CMS, “HCPCS Quarterly Update,” 13 May 2025. Available: https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update.
[7] CMS, “Updated Hospital Price Transparency Guidance Implementing the President’s Executive Order “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information”,” 22 May 2025. Available: https://www.cms.gov/files/document/updated-hpt-guidance-encoding-allowed-amounts.pdf.
[8] CMS, “CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits,” 21 May 2025. Available: https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits.
[9] CMS, “Centers for Medicare & Medicaid Services’ (CMS’) First Biannual 2025 Healthcare Common Procedure Coding System (HCPCS) Public Meeting Agenda,” 2 June 2025. Available: https://www.cms.gov/files/document/b1-2025-public-meeting-agenda-june-2-2025-updated-05/19/2025.pdf.
[10] A. Murphy, “HHS proposes transferring 340B oversight to CMS,” Becker’s Healthcare, 2 June 2025. Available: https://www.beckershospitalreview.com/pharmacy/hhs-proposes-transferring-340b-oversight-to-cms/.

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