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 outpatient hospital services [1].
Traditional Medicare Will Be Subject to Prior Authorization in 2026
Traditional fee-for-service Medicare will implement prior authorization in six states starting next year. These are New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. This goes into effect January 1, 2026 and will use the Wasteful and Inappropriate Service Reduction Model to perform evaluations. It stands to be seen if it will be rolled out across all of USA medical billing [2].
OIG Releases Semiannual Report to Congress
The Office of the Inspector General has made its Semiannual Report to Congress available. It summarizes activities of HHS for the period running through March 31, 2025. The report summarizes agency accomplishments, activities, recommendations, as well as a look at financial integrity, public health, beneficiary safety, and data and tech security among other topics [3].
End-Stage Renal Disease PPS Proposed Rule
CMS issued a proposed medical billing rule that would update payment rates and policies that fall under the ESRD PPS. This covers renal dialysis services for Medicare beneficiaries on or after January 1, 2026. The rule would serve as an update to the AKI dialysis payment rate. The proposal includes a potential increase to the ESRD PPOS base rate [4].
Home Health PPOS Proposed Rule Fact Sheet Available
The agency has released a fact sheet for the proposed rule that covers potential updates to Medicare rates and payment policies for home health agencies. The rule is published under legal requirements to update payment policies for Medicare for HHAs every year. The fact sheet covers major provisions of the proposed rule and impacts home health billing and home health coding [5].
ICD-10 Revision Change Request
CMS has released a change request for a quarterly maintenance update of coding conversions under ICD-10, which impacts medical billing providers and medical billing services in general. This request also covers other coding updates that are specific to National Coverage Determinations. No policy changes result from these updates [6].
Newly Created Payer Only Codes for Medicare Claims Processing Manual
This change request updates Chapter One of the Medical Claims Processing Manual. It updates the manual to include newly created and utilized codes for payers only. It is issued as of June 25, 2025. Anyone responsible for medical coding should familiarize themselves with this manual update [7].
Information on MARx July 2025 Payments
CMS has published a letter providing information about the July 2025 Medicare Advantage/Prescription Drug payment. It covers the mid-year risk adjustment reconciliation, sequestration suspension, and submitting MAPD help desk trouble tickets that involve premium/payment information [8].
Data Submission Deadline for Risk Adjustment Data Validation Sampling Passed
This HPMS email is a reminder of the deadline to submit all closed period deletes for the coming Risk Adjustment Data Validation (RADV) audit sample of PY 2022. No extensions were granted. Revenue cycle management services questions about submission and overpayment recovery should be directed to the email addresses indicated [9].
Change Request for Quarterly Average Sales Price Medicare Part B Drug Pricing
CMS has released a change request intended to supply the contracts with ASP and NOC drug pricing files for drugs under Medicare Part B on a quarterly basis. The limits are calculated quarterly based on data submitted by manufacturers. It is effective as of October 1, 2025 [10].
References
[1] CMS, “Hospital Outpatient Prospective Payment System: July 2025 Update,” 23 June 2025. Available: https://www.cms.gov/files/document/mm14091-hospital-outpatient-prospective-payment-system-july-2025-update.pdf.
[2] D. LeValley, “Prior Authorization Coming to Traditional Medicare Starting in 2026,” Kiplinger, 8 July 2025. Available: https://www.kiplinger.com/retirement/medicare/prior-authorization-coming-to-traditional-medicare.
[3] OIG, “Semiannual Report to Congress,” 30 May 2025. Available: https://oig.hhs.gov/documents/sar/10324/Spring_2025_SAR_508.pdf.
[4] CMS, “Calendar Year (CY) 2026 End-Stage Renal Disease (ESRD) Prospective Payment System Proposed Rule – CMS-1830-P,” 30 June 2025. Available: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-end-stage-renal-disease-esrd-prospective-payment-system-proposed-rule-cms-1830.
[5] CMS, “Calendar Year (CY) 2026 Home Health Prospective Payment System Proposed Rule Fact Sheet (CMS-1828-P),” 30 June 2025. Available: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-home-health-prospective-payment-system-proposed-rule-fact-sheet-cms-1828-p.
[6] U.S. Department of Health & Human Services, “International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2025,” 25 June 2025. Available: https://www.hhs.gov/guidance/document/international-classification-diseases-10th-revision-icd-10-and-other-coding-revisions-50.
[7] U.S. Department of Health & Human Services, “Updates to Chapter 1 of the Medicare Claims Processing Manual (Publication (Pub.) 100-04) to Include Newly Created and Utilized Payer Only Codes,” 25 June 2025. Available: https://www.hhs.gov/guidance/document/updates-chapter-1-medicare-claims-processing-manual-publication-pub-100-04-include-newly-1.
[8] Department of Health & Human Services, “Medicare Advantage/Prescription Drug System (MARx),” 27 June 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/medicare_advantage_prescription_drug_system_july_2025_payment_information_g.pdf.
[9] Department of Health and Human Services, “Reminder: PY 2022 Deadline for the Submission of Risk Adjustment Data for Risk Adjustment Data Validation Sampling,” 27 June 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/reminder_py_2022_deadline_for_the_submission_of_risk_adjustment_data_for_risk_adjustment_data_validation_sampling_g.pdf.
[10] CMS, “Transmittal 13270 Change Request 14117,” 2 July 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/r13270cp.pdf.
