Knowledge Base
Billing and policy updates, decoded for billing teams
What changed, what it means for your claims and what to do about it. Each update links to the CMS source so you can check us.
October 2026 Medicare EDI Front-End Edits: What Changed
Medicare released its quarterly HIPAA front-end edits for Part A and B and the CEDI contractor. Here is how rejections surface and what to check first.
Read the update →FY 2027 Hospice Rates Corrected: $236.33 RHC, $36,175 Cap
CMS replaced the August rate tables after a hospice wage index error. A 2.3% update, new rates for all four levels of care and a $36,174.75 cap now apply.
Read the update →October 2026 OPPS Update: 39 PLA and 58 Category III Codes
New PLA and Category III codes, 29 new drug codes, skin substitute code changes and a clarified modifier CA definition take effect for hospital outpatient claims.
Read the update →CMS Meets IDR Entities: 7 Million Disputes and a New Portal
CMS, Labor, HHS and Treasury met all 17 certified IDR entities about costs, ineligible disputes and unpaid awards. A new IDR Gateway portal launches late 2026.
Read the update →Transparency in Coverage Final Rules: What Billing Teams Should Check
Health plans must post rate files quarterly instead of monthly, add three new files, and attest to accuracy. Your contracted rates are in those files.
Read the update →Medicare $90 Part B Premium Rebate: What to Tell Patients
About 20.8 million Original Medicare enrollees will get a one-time $90 rebate. Providers take no action, but patients will have questions.
Read the update →CY 2027 Clinical Laboratory Fee Schedule: Average Cuts of About 16%
Preliminary rates cut 1,171 of 1,528 priced codes, with molecular and genomic tests down more than 20%. Comments are due October 21.
Read the update →GLOBE Part B Drug Payment Model Final Rule: What Practices Do
A mandatory model ties Part B drug rebates to prices in 19 countries. Practices keep buying and billing, and patients in selected areas pay less coinsurance.
Read the update →UnitedHealthcare Drops Prior Authorization on About 1,700 Codes
About 30% of UnitedHealthcare's prior authorization requirements ended October 1, with separate code lists for commercial, exchange and Medicare Advantage plans.
Read the update →Hospice Election Statement Addendum: Mandatory From October 1
Every hospice election on or after October 1 needs a written addendum within 5 calendar days. Claims won't be denied for it until January 2027.
Read the update →WISeR Prior Authorization Model: New Exemption Program
Prior authorization for 13 service types in 6 states. At least 10 requests and a high approval rate can exempt an NPI for a year.
Read the update →October 2026 NCCI and HCPCS Update: 4,249 New Edit Pairs
New PTP pairs and MUEs take effect October 1, 96127 is capped at 4 per day, and Medicare loads the October HCPCS file October 5.
Read the update →CY 2027 OPPS and ASC Proposed Rule: 2.4% Update and IPO Cuts
A 2.4% update, an ASC conversion factor of $57.766, 637 more services off the Inpatient Only list and prior auth for 8 more Botox codes.
Read the update →FY 2027 IPPS Final Rule: 2.3% Update and Mandatory CJR-X
A 2.3% inpatient update for discharges from October 1, new MS-DRG and PCS changes, and mandatory joint replacement episodes from 2028.
Read the update →Medicare Telehealth Flexibilities Extended
Many Medicare telehealth flexibilities now run through December 31, 2027, including home as an originating site and audio-only visits.
Read the update →FY 2027 ICD-10-CM Code Set: 190 New, 30 Deleted, 4 Revised Codes
190 new, 30 deleted and 4 revised diagnosis codes take effect October 1, 2026. Update pick lists, templates and scrubber edits before that date.
Read the update →Modifier 59 and X{EPSU} (XE, XS, XP, XU)
Use the most specific X modifier before defaulting to 59, never put 59 on an E/M, and load the October 1 quarterly NCCI files on time.
Read the update →CY 2027 Physician Fee Schedule Proposed Rule: Conversion Factor and Same-Day E/M Payment
Proposed conversion factors of $33.17 and $32.84, a 100%/50% rule for same-day E/M with a global procedure, and new RPM and RTM limits.
Read the update →Medicare Claim Appeals 2026 (Redetermination to Federal Court): The Five Levels, the Deadlines That Cost You the Claim, and When an Appeal Is Worth Filing
All five levels of the Medicare appeals process, the filing deadlines, the 2026 dollar thresholds, and how to stop recoupment while an appeal is pending.
Read the article →Code Set Update Calendar 2026 (ICD-10, HCPCS, CPT, NCCI): The Quarterly Rhythm That Keeps Claims From Rejecting
Which code sets change when, what changed this October (190 new ICD-10-CM codes, 39 PLA codes, 58 Category III codes), and a workflow that holds claims safely.
Read the article →Skin Substitute Billing 2026 (Q4xxx, 15271-15278): What Changed When Medicare Stopped Paying Skin Substitutes Like Drugs
The flat per-square-centimeter payment, application codes 15271-15278, the WISeR prior authorization states, and the documentation auditors want.
Read the article →Browse every guide in the Rcmaxis billing blog, or see how we work by specialty and service.
Want a policy change translated into your own numbers?
Send us your payer mix and specialty. We'll show you what the latest changes mean for your collections.
Get a Free Revenue Assessment →