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/.

February 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.

Correction to Final Rulemaking and Comment Period for Ambulatory Surgical Center Payment
CMS has released correction to technical and typographical errors in a final rule (with comment period). This rule appeared in the Federal Register on November 27, 2024 under the title: “Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs, including the Hospital Inpatient Quality Reporting Program; Health and Safety Standards for Obstetrical Services in Hospitals and Critical Access Hospitals; Prior Authorization; Requests for Information; Medicaid and CHIP Continuous Eligibility; Medicaid Clinic Services Four Walls Exceptions; Individuals Currently or Formerly in Custody of Penal Authorities; Revision to Medicare Special Enrollment Period for Formerly Incarcerated Individuals; and All-Inclusive Rate Add-On Payment for High-Cost Drugs Provided by Indian Health Service and Tribal Facilities” [1].

Payment Year 2019 Rerun for Payment Recovery
CMS has notified all Medicare Advantage organizations and pertinent entities that have a practice of submitting risk adjustment data, that the agency will be running risk scores under payment year 2019 for the purpose of payment recovery during 2025. Entities have an obligation to delete incorrect data regardless of whether the Medicare Advantage organization identifies incorrect diagnosis data prior to the risk adjustment deadline [2]. This could impact revenue cycle management companies around the country. 

HHS Guidance for Evaluation of Sex Differences
The agency has published guidance on the opinions of the FDA on the topic of evaluation of sex differences in clinical investigations. Among other things, it lifts a restriction on women with childbearing potential from Phase 1 and Phase 2 trials [3]. Leaders involved in medical billing should take note. 

OIG Audit Reveals Improper Payment for Urinary Catheters
The report results were part of an audit spanning 2014 to 2021, in which CMS identified high levels of improper payments for urological supplies. These included intermittent urinary catheters. Of $303.3 million paid by Medicare, about $35.1 million was found to be paid improperly [4]. Hospital accounts receivable professionals could be impacted by this audit. 

50 New ICD-10-PCS Codes To Watch
CMS has announced an April release of an expansion of 50 additional ICD-10-PCS codes. They will be effective for any procedures performed between April 1, 2025 and September 30, 2025. The codes, which can impact hospital coding and healthcare revenue cycle solutions, will include both OR and non-OR procedures [5].

Release of 2025 PDE
CMS announced the planned release of the 2025 Prescription Drug Event Participant Guide. Available as of January 2025, the agency will release the guide broken into individual modules throughout the calendar year. These modules will be released sequentially and include Part D Payment Methodology, Data format, Employer Group Wavier Plans and Reports [6]. Physician revenue cycle management professionals should consider reviewing the guide. 

PDE Analysis Website News
CMS has provided information regarding the withheld and invoiced outliers, data quality review outliers, and reviews of manufacturer disputes related to postings on the Prescription Drug Event Analysis website. The memorandum updates any existing guidance, accounting for the Manufacturer Discount Program [7].

PDE Reports and Analysis Reporting Initiatives for 2025
CMS has provided an update on their continuing reporting initiatives for the 2025 benefit year. These initiatives support the agency’s efforts in improving the accuracy of sponsor PDE data. The agency is encouraging sponsors to take an “active and consistent approach” to addressing the accuracy of submitted PDE data and the work to resolve errors that lead to rejections of PDEs [8].

CMS Publishes MLN Fact Sheet
CMS has released the fact sheet for Complying with Documentation for Lab Services. The sheet describes Comprehensive Error Rate Testing program errors with medical documentation. It was created to help providers better understand their options in providing accurate and supportive documentation for the lab orders they create [9]. Billing companies and other revenue cycle management companies could find this useful.

References
[1] CMS, “Ambulatory Surgical Center Payment- Correction Notice to Final Rulemaking with Comment Period,” 2025. Available: https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc/asc-regulations-and-notices/cms-1809-cn.
[2] CMS, “Rerun of Payment Year (PY) 2019 for Purposes of Payment Recovery,” 17 January 2024. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/rerun_of_payment_year_2019_for_purposes_of_payment_recovery_g.pdf.
[3] U.S. Department of Health and Human Services, “Evaluation of Sex Differences in Clinical Investigations,” January 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/FDA/evaluation_of_sex_differences_in_clinical_investigations_january_2025.pdf.
[4] HHS Office of Inspector General, “Medicare Improperly Paid Suppliers for Intermittent Urinary Catheters,” 6 February 2025. Available: https://oig.hhs.gov/reports/all/2025/medicare-improperly-paid-suppliers-for-intermittent-urinary-catheters/.
[5] C. Geiger, “BEWARE: Fifty New ICD-10-PCS Codes are Coming!,” RACmonitor, 10 February 2025. Available: https://racmonitor.medlearn.com/beware-fifty-new-icd-10-pcs-codes-are-coming/.
[6] CMS, “2025 Prescription Drug Event Participant Guide,” 14 January 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/2025_prescription_drug_event_participant_guide_g.pdf.
[7] CMS, “Prescription Drug Event (PDE) Analysis Website for CMS Data Quality Review Outliers, Withheld and Invoiced Outliers, and Reviews of Invoiced Data Disputed by Manufacturers,” 17 January 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/prescription_drug_event_analysis_website_for_cms_data_quality_review_outliers_withheld_and_invoiced_outliers_and_reviews_of_invoiced_data_disputed_by_manufacturers_g.pdf.
[8] CMS, “Continuation of the Prescription Drug Event (PDE) Reports and PDE Analysis Reporting Initiatives for the 2025 Benefit Year,” 17 January 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/continuation_of_the_prescription_drug_event_reports_and_pde_analysis_reporting_initiatives_for_the_2025_benefit_year_g.pdf.
[9] U.S. Department of Health and Human Services, “Complying with Documentation Requirements for Lab Services,” December 2024. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/mln909221_complying_documentation_requirements_lab_services.pdf.

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