The Pathologist’s RCM Checklist Are Your Pathology Billing Systems Doing You Justice
Posted on

The Pathologist’s RCM Checklist: Are Your Pathology Billing Systems Doing You Justice?

Your pathologists are diagnosing cancer. But your billing team? They’re diagnosing something else entirely: denials, underpayments, and revenue holes no one can seem to plug.

If that hits a little too close to home, you’re not alone.

We’ve worked with pathology labs across the U.S. – hospital-based, private groups, national reference labs – to know the symptoms: clean claims on paper but shrinking cash flow; pathology coding that looks fine until an audit hits; contract rates that haven’t changed in 5 years, but test complexity has doubled.

Before you hire another FTE or switch your pathology billing company again, run through this checklist. You’ll find out exactly where your pathology revenue cycle is bleeding – and how to fix it.

  1. Pathology Billing Services: Are You Getting Paid for Everything You Do?

Let’s be honest: pathology billing isn’t just billing. It’s a battlefield. 

If your medical billing partner isn’t a pathology billing company, they’re likely missing revenue opportunities you don’t even know exist.

Any of this sound familiar?

  • You’re billing Level 3s and 4s instead of 5s because it’s “safer”
  • Your team’s constantly cleaning up modifier messes (26, TC, 59, 91)
  • Reflex panels (IHC, FISH, NGS) aren’t billing downstream accurately
  • Tech/pro splits at hospital-based sites are inconsistent
  • You get clean claims… but collections are flatlining

3Gen Consulting’s pathology billing services use AI-powered claim scrubbing, modifier audits, test panel logic, and denial trend analysis to capture every reimbursable dollar while keeping you fully compliant.

  • Pathology Coding: Clean Claims Don’t Always Mean Correct

Let’s talk about the invisible revenue killer: pathology coding.

Pathology coding is one of the most overlooked revenue drains. Coders must go beyond basic CPT knowledge – they must understand stains, panels, molecular techniques, and payor nuances.

Ask yourself:

  • Are coders certified in pathology-specific coding?
  • Are they accurately coding for IHC, molecular, or genetic testing?
  • Is there QA in place to review coding before submission?
  • Is documentation of medical necessity being validated?

Even the cleanest billing process can’t save incomplete or inaccurate coding. If your team isn’t fluent in pathology coding nuance, you’re flying blind. With 3Gen’s team of certified pathology coders, clients achieve 95%+ accuracy, layered QA, audit-ready documentation, and real-time dashboards.

  • Payer Contracting: Are Your Rates Keeping Up With Test Complexity?

When’s the last time you renegotiated your payer contracts?

Most pathology groups haven’t touched their payer contracts in years. Meanwhile, payers tweak fee schedules, apply edits, and bundle services that should be billed separately.

Time to self-audit:

  • Have you renegotiated rates for molecular pathology?
  • Do your reimbursement rates align with MRF benchmark data?
  • Are just 2–3 poor-performing payers dragging down overall collections?
  • Have you tracked high-volume tests against peer lab payments?

Contracts are no longer “set and forget.” If you’re not renegotiating smarter and backing it up with data, you’re likely being underpaid for advanced pathology services. Our payer contracting team uses denial trends, test-level reimbursement data, and MRF benchmarking to arm you with hard facts to negotiate smarter.

  • Clinical Pathology Laboratories & Risk Adjustment: The New Revenue Frontier

Risk adjustment coding isn’t just for primary care. If your pathology lab serves Medicare Advantage or ACO populations, you’re sitting on untapped value. Pathology findings often uncover conditions that impact HCC coding and RAF scores – but most labs aren’t capturing them.

Here’s what to ask:

  • Are your coders flagging incidental findings like malignancies or chronic disease markers?
  • Do you have a system to track pathology-related HCC conditions?
  • Are your pathologists trained to document with risk adjustment in mind?

3Gen Consulting’s RiskGen-i platform integrates seamlessly with your LIS and EHR to identify, code, and track pathology-related risk conditions, aligning pathology with value-based care incentives.

  • Compliance, Audits & Denials: Are You Audit-Ready?

The scariest phrase in revenue cycle today: payer audit.

From CMS RADV audits to private payer clawbacks, pathology is under the microscope. And if your documentation, modifiers, or LCD coverage aren’t airtight, you’re exposed.

Sound familiar?

  • You’re still reacting to denials – not tracking patterns.
  • Appeals are a scramble, not a strategy.
  • You’re not sure if you’re compliant with No Surprises Act or new NCCI edits.
  • You haven’t done a proactive audit in over 6 months.

Compliance isn’t a checkbox. It’s a daily discipline – especially in pathology, where coding and documentation must be bulletproof. 3Gen Consulting supports labs with real-time denial analytics, audit response prep, and compliance documentation support, so you’re never caught off guard.

Final Diagnosis

It’s time to ask: Is your current pathology RCM partner keeping up – or holding you back? Most generic medical billing companies lack the clinical knowledge and test-level nuance needed to optimize pathology revenue. That’s where 3Gen Consulting steps in – with pathology-trained billers, coders, and contracting experts who understand your lab like it’s their own.

Want to see what your pathology revenue cycle is really doing behind the scenes? Let 3Gen Consulting run a free pathology medical billing health check. No fluff. No obligation. Just data-backed insight from a pathology billing company that knows your specialty. Book Your RCM Checkup Today.

The HOPE Assessment Tool is Replacing HIS. Here's What Revenue Cycle Leaders Need to Know Today
Posted on

The HOPE Assessment Tool is Replacing HIS. Here’s What Hospice Revenue Cycle Leaders Must Do Before October 2025.

The Centers for Medicare and Medicaid Services (CMS) has released a significant number of changes and updates in recent months. The Hospice Outcomes and Patient Evaluation (HOPE) assessment is one of the most pertinent for revenue cycle leaders in hospice organizations. 

The launch of the HOPE assessment tool is the premiere of a patient assessment method that is meant to standardize data collection for hospice patients. It will have a direct impact on hospice billing services, meaning that revenue cycle leaders who want to stay ahead of changes coming down from CMS will benefit from familiarizing themselves with the origin, differences from previous standards, and implications for healthcare providers. This article will walk you through a foundational understanding of the assessment tool and prepare you for application of deeper response strategies at your organization. 

The HOPE Assessment Tool Is a Shift for Hospice Billing Services

The HOPE assessment tool, developed by CMS, marks a pivotal shift in hospice care evaluation, replacing the Hospice Item Set (HIS) as part of the Hospice Quality Reporting Program (HQRP). Finalized in the FY 2025 Hospice Wage Index Final Rule, this tool is designed to standardize data collection while providing a more dynamic understanding of patient needs, care planning, and potential reimbursement refinements. Unlike HIS, which relied on retrospective chart abstraction, the HOPE Hospice Tool captures real-time clinical data through structured assessments, enabling more responsive care adjustments.

The development of the HOPE assessment checklist involved a rigorous, multi-phase process that included stakeholder feedback, cognitive testing, and national beta trials. CMS engaged with hospice providers, clinicians, and technical experts to ensure the tool’s practicality and alignment with real-world workflows. The result is a system that not only meets regulatory requirements but also enhances clinical decision-making. 

When fully implemented in October 2025, the HOPE assessment tool is expected to equip providers with actionable insights to refine care strategies, improve patient outcomes, and strengthen operational efficiency.

HOPE vs. HIS: What Hospice Providers Need to Change in 2025

While HIS was limited to verifying care processes through post-discharge chart reviews, the HOPE assessment tool introduces a proactive, multi-point assessment framework. HIS data was collected only at admission and discharge, but HOPE expands the scope with HOPE Update Visits (HUVs) and Symptom Follow-Up Visits (SFVs), offering a more granular view of patient needs over time.

HUVs, conducted between days 6–15 and 16–30 of a patient’s stay, require in-person skilled nursing assessments to update care plans based on evolving conditions. These visits ensure CMS captures critical data during the first 30 days of hospice care, a period often marked by significant symptom fluctuations. Meanwhile, SFVs – triggered by moderate or severe symptom impact – must be completed within two calendar days of the initial assessment. Unlike traditional symptom checks, SFVs focus on the impact of symptoms (e.g., disruptions to sleep or daily activities) rather than their severity alone. This distinction underscores CMS’s emphasis on patient-centered outcomes.

For providers, adapting to these changes requires both operational and technological adjustments. Staff must be trained to complete the HOPE assessment checklist accurately, while EMR systems need updates to support new data fields and submission requirements. The HOPE guidance manual provides detailed instructions, but agencies should begin internal audits now to identify workflow gaps and ensure compliance ahead of the October 2025 deadline.

HOPE has Strategic Implications for Hospice Leadership

The HOPE hospice tool is a catalyst for improving care quality and operational transparency. Two initial quality measures, focused on timely symptom follow-ups, will take effect in FY 2028, with more metrics likely as CMS refines the tool. These measures will eventually factor into public reporting, making adherence a priority for agencies aiming to maintain competitive reputations. 

To prepare, hospice leaders should:

  • Conduct a workflow analysis to identify how HUVs and SFVs will integrate with existing care and billing processes.
  • Collaborate with EMR vendors to ensure systems can generate compliant HOPE records and submission files.
  • Invest in staff training using CMS resources, emphasizing the differences between HIS and HOPE documentation.

For hospice billing services, the shift to HOPE introduces both challenges and opportunities. Accurate, timely data submission will be critical to avoid penalties and secure optimal reimbursement. Agencies that leverage the HOPE system effectively will not only meet compliance standards but also gain insights to streamline revenue cycles and reduce claim denials.

Engaging with CMS and Staying Ahead

CMS has committed to ongoing stakeholder engagement, offering forums, webinars, and help desk support to ease the transition. Hospice revenue cycle leaders should actively participate in these opportunities, providing feedback on pain points and advocating for practical refinements. 

Leaders should consider regularly monitoring the HQRP website for updates and assigning a team member to oversee HOPE-related communications. This will help ensure agencies remain agile as policies evolve. By embracing the HOPE assessment tool as a strategic asset, rather than a mere compliance obligation, hospice leaders can position their organizations for long-term success in an increasingly data-driven landscape.

Preparing Your Revenue Cycle Strategy for HOPE

To help you successfully navigate this new assessment standard, 3Gen Consulting offers tested expertise in hospice billing services. Our experts support hospice agencies with end-to-end revenue cycle management—keeping you ahead of changes to minimize negative impact and maximize your strategic response. We have documented results, saving a leading home health and hospice company 42% in costs. 

Whether you’re helping your internal teams adapt to the HOPE assessment tool or looking for a partner to support hospice billing services, we’re here to help. Contact us today to get started.  

2025 CPT Code Updates for Anesthesia Billing- Fascial Plane Blocks, Modifiers & More Image
Posted on

2025 CPT Code Updates for Anesthesia Billing: Fascial Plane Blocks, Modifiers & More

Anesthesia billing is increasing in complexity, and healthcare revenue cycle leaders should be ready to make adjustments to their billing, training, and compliance strategies. 

The anesthesia revenue cycle has received recent updates, so we’ve summarized those in the context of anesthesia billing as a whole. This article will walk you through updates to fascial plane block CPT codes as well as training options for your leadership and staff who want to stay on top of changes to anesthesia billing services. 

The Basics of Anesthesia Billing

Anesthesia revenue cycle management is uniquely complex [1]. Unlike standard medical billing, it works from a precise formula – base units + time units × conversion factor. 

Each anesthesia CPT code corresponds to a surgical procedure family and carries predetermined base units. Time units, which are calculated by anesthesia duration, vary by payer. Medicare calculates to one decimal (e.g., 129 minutes = 8.6 units), while some commercial payers round up (e.g., 9 units). For example, a total knee arthroplasty (CPT code 27447) crosswalks to anesthesia code 01402 (7 base units). With 129 minutes of anesthesia time, Medicare bills 15.6 units (7 + 8.6), while a commercial payer might bill 16 units (7 + 9). The result is a measurable financial impact. Medicare’s 2022 conversion factor ($21.5623) translates to $336.37, whereas a median commercial factor ($78.00) generates $1,216.80.

Staffing modifiers also complicate reimbursement. Medicare requires that payment be allocated between anesthesiologists and CRNAs. This split breaks down differently depending on the modifier, for example:

  • Personally performed (AA): 100% to physician
  • Medical direction of nonphysician anesthetist (QK/QY or QX): 50/50 split
  • CRNA service without medical direction (QZ): 100% to nonphysician

Commercial payers often do not follow modifiers, instead paying a single clinician. This misapplication increases the risk of underpayment or denials – making anesthesia billing services a critical investment.

Additionally, separately billable procedures (e.g., arterial lines, nerve blocks) should not be bundled into anesthesia payments. Payer contracts should explicitly exclude this type of bundling. For example, a post-operative femoral nerve block (CPT code 64447) should be billed separately. Working with an experienced anesthesia billing company improves the chances that this type of nuance is reflected in your payer contracting.

2025 CPT Code Updates for Anesthesia Billing

The American Society of Anesthesiologists (ASA) has successfully advocated for the creation of new fascial plane block CPT codes [2]. These take effect in January 2025. We encourage you to review the original announcement from the ASA for details and accuracy. 

The updates reflect the growing adoption of ultrasound-guided regional anesthesia techniques. They also aim to support proper reimbursement for anesthesiologists providing advanced pain management services. The changes establish dedicated codes for thoracic and lower extremity fascial plane blocks while clarifying the application of existing abdominal block codes.

Thoracic Fascial Plane Blocks (64466–64469)
In an effort to move away from the frequent use of unlisted CPT code 64999, the 2025 updates have introduced four dedicated codes for thoracic fascial plane blocks. These procedures, which previously lacked specific coding guidance, now have clearer pathways for billing and documentation. These address procedures including:

  • Erector spinae plane (ESP) blocks
  • Serratus anterior plane blocks
  • Parasternal intercostal blocks
  • Pectoserratus (PECS) blocks

These codes distinguish between single-injection (CPT code 64466 and CPT code 64468) and continuous infusion (CPT code 64467 and CPT code 64469) techniques, with imaging guidance included when performed. The codes apply only when the injection site is within the thoracic fascial plane. ESP blocks administered in the lumbar region, for example, should still be reported with the unlisted code 64999, since a dedicated lumbar code does not exist.

Lower Extremity Fascial Plane Blocks (64473–64474)
For lower extremity pain management, two new codes cover:

  • Fascia iliaca blocks
  • PENG (pericapsular nerve group) blocks
  • IPACK (infiltration between the popliteal artery and knee capsule) blocks

CPT code 64473 applies to single-injection blocks, while CPT code 64474 covers continuous infusions. Both include imaging guidance. Bilateral procedures require modifier -50 or separate line-item billing, depending on payer preferences.

Clarifications to Abdominal Fascial Plane Blocks (64486–64489)
While the descriptors for existing abdominal codes remain unchanged, the 2025 CPT manual now explicitly outlines that codes 64486–64489 encompass all abdominal fascial plane blocks, including:

  • Transversus abdominis plane (TAP) blocks
  • Rectus sheath blocks
  • Quadratus lumborum blocks
  • External oblique intercostal blocks

Financial Impact and RVU Values
The new codes introduced in the 2025 CPT updates carry varying RVUs. Continuous infusion blocks are generally reimbursed at higher rates (e.g., 1.74 RVUs for CPT code 64467 vs. 1.50 for CPT code 64466). 

These values are based on the 2025 Medicare Physician Fee Schedule and may vary slightly by geographic region due to GPCI adjustments.

Proper utilization of these codes, particularly for continuous catheters, can significantly enhance revenue for practices offering advanced regional anesthesia services.

Training: Bridging Knowledge Gaps for Optimal Billing

The American Society of Anesthesiologists (ASA) is offering a 1.0 CME/CEU webinar to master these changes [3]. Designed for coders, pain physicians, and revenue cycle leaders, it covers:

  1. Rationale for new FPB codes
  2. How to best apply the new FPB codes for lower extremity and thoracic regions
  3. Documentation, compliance, and anesthesia billing best practices

Outsourcing Anesthesia Billing

Outsourcing anesthesia billing requires careful evaluation to make sure your revenue cycle remains both efficient and compliant. Look for a vendor who demonstrates deep specialization in anesthesia revenue cycle management, not just general medical billing expertise. Prioritize partners who demonstrate that they stay current with evolving requirements, such as the 2025 fascial plane block codes.

At 3Gen Consulting, we offer end-to-end anesthesia billing services tailored to meet the demands of today’s evolving RCM landscape. Providers across the U.S. turn to our anesthesia medical billing experts to improve accuracy, reduce denials, and capture every dollar earned. Whether you’re optimizing financial performance or looking for a partner who can ensure compliance, we’re here to help.

References

[1] American Society of Anesthesiologists, “Anesthesia Payment Basics Series: #3 Payment, Conversion Factors, Modifiers,” December 2022. Available: https://www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/anesthesia-payment-basics-series-3-payment-conversion-factors-modifiers.
[2] American Society of Anesthesiologists, “New and Updated Fascial Plane Block CPT Codes,” 23 June 2025. Available: https://www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/2025-updated-fascial-plane-block-cpt-codes.
[3] American Society of Anesthesiologists, “Training on the New Fascial Plane Block CPT Codes,” 1 January 2025. Available: e024fc00w00.

Posted on

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

Read More
Study Supports New Codes in Radiology Billing to Support Uncompensated Work Image
Posted on

Study Supports New Codes in Radiology Billing to Support Uncompensated Work

The nature of radiology billing services could soon be changing. 

As radiology medical billing stands now, revenue cycle processes don’t accurately reflect the extensive work they do outside of image interpretation. These tasks can take up anywhere from 35% to 60% of their time. They can include work like consultations for their colleagues or traveling to attend conferences to review cases with professionals from other specialties. 

But a recent study from Yale School of Medicine examines this dynamic, looking at gaps in billing for services performed by radiologists and making recommendations to close gaps in radiology medical coding and billing [1]. Revenue cycle leaders who bill for radiology services should consider reviewing this study and the recommendations to better understand the challenges your clinicians face and the changes that could soon be coming to radiology medical billing. 

The Complexities of Radiology Billing Services

Radiology billing requires significant attention to detail because of the nature of imaging procedures.

Billers and coders must properly capture charges for X-rays, CT scans, and MRIs. Services like interventional radiology require precise coding with appropriate modifiers to avoid denials and delays in payment. One thing that sets radiology medical billing apart is the separation between the professional component (physician interpretation) and the technical component (equipment and staff). When a single entity provides both, a global charge applies, but in hospitals, split billing is common since radiologists bill separately for interpretations. 

Compliance is also a challenge in radiology billing. It is complicated by supervision requirements, payer-specific policies, and the need for thorough documentation, which must align to avoid denials. High-cost imaging also demands rigorous validation to support medical necessity. Revenue cycle leaders must invest the time and training in their staff to achieve these fundamentals. Without them, the risk of revenue leakage increases, making expertise in radiology medical coding indispensable.

The Hidden Workload: Unbilled Consultations in Radiology

Uncompensated efforts from radiologists should be a concern for healthcare leaders. 

These differences can impact patient care, but unfortunately, current contract and billing structures aren’t set up to capture their efforts or generate reimbursement. Even electronic consultation codes for interprofessional calls or assessment and management services that occur through the electronic health record (EHR) which could serve as a temporary solution, are underutilized due to documentation hurdles. 

According to the study authors, “such codes could theoretically provide a means of billing consultative work by radiologists, though there are practical barriers to use. Billing requires documentation of patient consent, which would likely need to be performed by the requesting physician in the case of ad hoc radiology consultation. These codes are [generally] reimbursed at lower RVU per unit time than E&M codes (as well as pathology consultation codes), which may not provide sufficient incentive for practices to implement new workflows, unless streamlined documentation and billing mechanisms can be put in place.”

The absence of structured billing processes for these services creates a financial gap, forcing providers to absorb the cost of unreimbursed labor. As radiology billing evolves, the demand for consultative roles will only grow. This inevitable growth makes it critical for leaders in radiology billing services to advocate for solutions that reflect the full scope of their radiologists’ contributions.

Burnout in Radiologists Is a Pressing Issue

The hidden workload of radiologists should be a priority for healthcare leaders, largely because of their risk of burnout. 

Burnout in radiologists often shows up as exhaustion, cynicism, and diminished self-worth. It’s also reached critical levels. 65% of female and 44% of male radiologists report that they feel burned out or both burned out and depressed. Even though physician burnout rates have stabilized some in recent years, 71% of affected radiologists have endured it for more than 13 months [2].

Burnout is associated with higher rates of turnover, reduced productivity, and an increase in medical errors – issues that cost health systems millions in recruitment and lost revenue. The American Association of Medical Colleges (AAMC) warns that radiology can’t afford to lose any more talent, since the specialty is already dealing with imaging overuse, stagnant residency slots, and the “silver tsunami” of aging Boomers. 

Closing the Gap: Strategies for Fair Compensation

To address these inefficiencies, Yale researchers propose a few solutions. One is dedicated CPT codes similar to those in pathology. These could account for ad-hoc and multidisciplinary consultations. Another is negotiating hospital contracts to include stipends for noninterpretive work or implementing academic RVU models to track unbilled hours for individual radiologists.  

Health systems can benefit from long-term incentives for consultations, especially as AI is used to streamline routine interpretations and free radiologists up for more complex case discussions. 

Academic and referral centers could benefit the most from restructured reimbursement models since consultative work is most prevalent in these organizations. 

Get in Front of Changes in Radiology Billing Services

As more professionals rethink this area of the healthcare revenue cycle, expect to see changes in radiology billing and even growing opportunities to improve reimbursement. These changes will have reverberating effects across your organization and aren’t something providers should try to navigate alone. 

We invite you to learn more about how 3Gen Consulting can support you in your radiology billing strategy and to contact us to learn more about the range of options you have in leveraging our expertise. Start your journey to improvements in your revenue cycle strategy here.

 

References

[1] S. Iftikhar, S. Rahmani, O. A. Zaree, A. Kertam, T. Farquhar and L. H. Tu, “The Value of Radiology Consultation: Effort Allocation, Clinical Impact, and Untapped Opportunities,” Journal of the American College of Radiology, 7 April 2025.
[2] C. E. Hudnall, “Burnout Fueling Workforce Woes,” 3 July 2024. Available: https://www.acr.org/Clinical-Resources/Publications-and-Research/ACR-Bulletin/Burnout-Fueling-Workforce-Woes.

1 2 3 … 36
Get In Touch!
close slider

    Get In Touch!