April 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. 

CMS Releases Guidance for Hospital Price Transparency

CMS has published a public notice that impacts hospital coding. It educates hospitals on requirements around hospital price transparency. This notice was released on 3/20/2025 and is available in PDF format for review and download [1].

2026 Payment Policy Updates for Medicare Advantage and Part D Programs Finalized

CMS has released the CY 2026 announcement for Medicare Part D Prescription Drug Programs and Medicare Advantage Programs, finalizing the payment policies for both and impacting healthcare accounts receivable management. When combined with the CY 2026 MA and Part D final rule releases, this completes annual routine and technical updates to the MA and Part D programs [2].

Medicare HIPAA Eligibility Transaction System Release Complete

Released as of 4/5/2025, this announces the completion of installation of the HETS2025-1. It has been validated and all maintenance has been completed. Both a release summary and companion guide are available for review and download by revenue cycle management companies and leadership [3].

HCPCS Quarterly Update Released

CMS has released the April 2025 HCPCS codes for medical coding in the USA. Updated as of 3/26/2025, the fully searchable and sortable file is available in ZIP form under the name, April 2025 Alpha-Numberic HCPCS File (ZIP) [4].

CMS Announces Contract Year 2026 Technical Changes

CMS has issued a final rule to modernize and improve Medicare Advantage, Medicare Prescription Drug Benefit, Medicare cost plan, and PACE programs. This final rule impacts revenue cycle management services and implements changes around prescription drug coverage, D-SNPs, Star Ratings, the Medicare Prescription Payment Plan, and other areas [5].

Coding Considerations for Malnutrition

Revenue Cycle Advisor is covering medical coding considerations based on a study of over 4,500 older adults. They advise that coders stay alert to comorbidities and key documentation concerns. They also cover social determinants of health and how they should be considered in assessment and treatment plans [6].

CMS Releases Final CY Part D Redesign Program Instructions

The agency has released the CY 2026 Part D Redesign Program Instructions, concurrently with their announcement of CY 2026 Medicare Advantage Capitation Rates as well as Part C and Part D Payment Policies. These instructions provide guidance around medical billing and the implementation of the Inflation Reduction Act of 2022’s changes to the defined standard Part D drug benefit [7].

CMS Has Fined 7 Payers for Medicare Part D Violations

The agency has reportedly fined seven payers for more than $430,000 in total for violation of Medicare requirements relating to Part D prescription drug benefits, important news for medical billing providers. CMS penalized them for error in formulary and benefit administration, as well as coverage determinations and appeals processes. Audits were conducted throughout 2024 [8].

2025 Update to ASC Payment System

CMS has released a change request to provide medical billing instructions for and changes to various payment policies. This request impacts payment policies implemented in the April 2025 ASC payment system update. Issue date is April 10, 2025 [9]. 

Incoming File: Beneficiary-Level File Supporting 2026 Part D Bids

CMS has pushed out a beneficiary-level file that actuaries will be using to develop 2026 Part D bids. This has been sent to MA-PD plans, 1876 Cost Plans, PACE organizations, and standalone PDPs. It was sent on April 10, 2025 [10].