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.
CY 2027 Physician Fee Schedule Final Rule: Conversion Factor, G2211 Retirement and Same-Day E/M Payment
Final conversion factors of $32.95 and $32.63, same-day E/M now pays 80% (not the proposed 50%), and G2211 is gone, replaced by modifiers B1 and B2.
Read the update →CY 2027 RPM/RTM Final Rule Changes: Established-Patient Limit and Staffing Delay
RTM is now established-patients-only, a separately billable initiating visit is required, and the employed-staff requirement doesn't apply until 2029.
Read the update →New Advance Care Planning Codes G0572 and G0573 for 2027
Two new G-codes separate clinical-staff advance care planning from physician time, and 99497/99498 now count only the billing practitioner's own minutes.
Read the update →Same-Day E/M With a Global Procedure: Final Rule Sets 80%, Not the Proposed 50%
The highest-paid same-day service still gets 100%; the other service now pays 80%, not the 50% CMS proposed in July, and it only applies to 0-day global procedures.
Read the update →FDA Moves to Bar Semaglutide, Tirzepatide and Liraglutide From the 503B Bulks List
FDA's 503B bulks exclusion proposal would cut off the bulk-compounded GLP-1 supply chain many telehealth and medical spa billing models depend on.
Read the update →Prior Authorization Denial Rates Are Now Public: What KFF's First Transparency Report Shows
ACA Marketplace insurers denied 18% of standard prior auth requests in 2025. The payer-level denial and appeal-overturn rates CMS now requires public.
Read the update →Aetna OfficeLink Updates: SGRT & ESRD Billing Changes
Aetna caps CPT 77436 (SGRT) at one payment per course of treatment and adds a place-of-service review for home ESRD codes 90963-90966.
Read the update →CPT 2026 Adds Short-Duration RPM and RTM Codes
Six new remote monitoring codes, 98979, 98984-98986, 99445 and 99470, cover 2-to-15-day windows and a new 10-minute management tier.
Read the update →No Surprises Act IDR Fee Drops From $115 to $15
A final rule cuts the federal IDR administrative fee by more than 85% and adds new CARC/RARC coding requirements for payors on all claims.
Read the update →CPT 2027 Maternity Care Code Overhaul
The AMA replaces the global OB package with phase-based antepartum, labor, delivery and postpartum codes, deleting 17 existing codes along the way.
Read the update →UHC Expands Allergy IgE Testing to 29 Allergens
UnitedHealthcare's commercial reimbursement policy raises reimbursable specific IgE allergy tests from 20 to 29 allergens a year for members 20 and up.
Read the update →Noridian DME MAC: 8 LCDs Revised
Noridian revised 8 DME LCDs and policy articles covering orthoses, AEDs, breast prostheses, three drug categories and manual wheelchairs.
Read the update →UHC Medicare Advantage: October 2026 Revisions
UnitedHealthcare updates Medicare Advantage code-level testing criteria for Lyme disease, testosterone, vitamin B12 and chronic heart failure.
Read the update →October 2026 CLFS/CLIA Update: New PLA Codes
CMS adds new Proprietary Laboratory Analysis codes and deletes 0556U, 0557U and 0585U in the October 2026 quarterly CLFS/CLIA update.
Read the update →SNF Consolidated Billing: October 2026 Update
Therapy HCPCS codes move off Part B SNF consolidated billing File #1 and are retained only on File #4.
Read the update →Home Health Consolidated Billing: October 2026 Update
19 new HCPCS codes join the home health consolidated billing non-routine supply list.
Read the update →October 2026 ICD-10 Updates to Coverage Rules
Routine quarterly ICD-10-CM coding revisions tied to National Coverage Determinations, the kind that quietly breaks old denial logic.
Read the update →RHC and FQHC Telehealth: G2025 Retired October 1, 2026
Rural health clinics and FQHCs now report the specific CPT or HCPCS code for distant site telehealth, with a revenue code and modifier 93 or 95, instead of G2025.
Read the update →October 2026 ASC Update: 10 New Category III Codes
Ambulatory surgical centers get 10 new Category III codes, a deleted HCPCS code, 12 pass-through drug codes, 21 drug status changes and 8 skin substitute codes.
Read the update →Cigna E/M Downcoding Policy: Maryland Orders a Stop
Maryland fined Cigna $80,000 and ordered a stop to automatic downcoding of 99204-99205, 99214-99215 and 99244-99245 claims without a documentation request first.
Read the update →OIG Spring 2026 Report: $5.56B in Recoveries
OIG's semiannual report to Congress logged $5.56 billion in recoveries, led by Kaiser's $556M and Aetna's $117.7M False Claims Act settlements.
Read the update →UnitedHealthcare October 2026 Policy Overview
UHC's October Network News covers Medicare, Medicaid, Exchange and commercial updates, plus Florida EPNA audits, Massachusetts taxonomy rules and a Michigan CGM pilot sunset.
Read the update →October 2026 I/OCE Update: Transmittal 13979
CMS moved the Integrated Outpatient Code Editor to version 27.3. Why a clean EDI acknowledgment doesn't guarantee a claim clears I/OCE.
Read the update →CY2026 Physician Fee Schedule: Conversion Factors
CMS-1832-F set two conversion factors, $33.57 for Advanced APM QPs and $33.40 for everyone else, plus a -2.5% efficiency adjustment on certain services.
Read the update →MA RADV Audits Reach Full Scale for 2026
CMS now audits every RADV-eligible Medicare Advantage contract every year, extrapolating findings under CMS-4185-F2 with no Fee-for-Service Adjuster offset.
Read the update →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 →Claim Rejections vs Denials (Clearinghouse and EDI Errors): How to Read 999 and 277CA Reports, Fix the Common Errors and Protect Your Filing Deadline
How a rejection differs from a denial, how to read 999 and 277CA reports, the most common clearinghouse errors with fixes, and why a rejected claim never stops the filing clock.
Read the article →Rural Health Clinic Billing 2026 (All-Inclusive Rate, 71X Claims): How Medicare Pays an RHC Visit, What Counts as One, and Where Claims Go Wrong
The $165 all-inclusive rate limit, what counts as a billable visit, 71X claim setup with revenue codes and modifier CG, IOP rates and the October telehealth change.
Read the article →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 →Browse every guide in the Rcmaxis billing blog, or see how we work by specialty and service.
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