Switching out legacy IT systems can be a time of change and disruption for healthcare revenue cycle leaders – but it can also be a time of opportunity. While many leaders will look for ways to identify high-performing replacement solutions or even consolidate technologies, dropping a legacy system is also an excellent time to consider
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
Split or shared visit coding has seen multiple updates over the last year, including new CPT codes, deletions, and revisions for 2025. For healthcare providers, medical coding services, and medical coding companies in USA regions, understanding these changes is essential to proper billing, a healthy revenue cycle, and
Revenue cycle leaders face increasing pressure to manage costs, optimize revenue, and improve revenue cycle functions. This has included more responsibility in understanding the intersection between risk adjustment coding and social determinants of health (SDOH). This intersection is critical to ensuring accurate reimbursement and optimizing revenue cycle outcomes, especially for Medicare Advantage and Medicaid populations, where SDOH significantly influences health outcomes and
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.
