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.

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].