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 Guidance for Hospital Price Transparency
CMS has published a public notice that impacts hospital coding. It educates hospitals on requirements around hospital price transparency. This notice was released on 3/20/2025 and is available in PDF format for review and download [1].
2026 Payment Policy Updates for Medicare Advantage and Part D Programs Finalized
CMS has released the CY 2026 announcement for Medicare Part D Prescription Drug Programs and Medicare Advantage Programs, finalizing the payment policies for both and impacting healthcare accounts receivable management. When combined with the CY 2026 MA and Part D final rule releases, this completes annual routine and technical updates to the MA and Part D programs [2].
Medicare HIPAA Eligibility Transaction System Release Complete
Released as of 4/5/2025, this announces the completion of installation of the HETS2025-1. It has been validated and all maintenance has been completed. Both a release summary and companion guide are available for review and download by revenue cycle management companies and leadership [3].
HCPCS Quarterly Update Released
CMS has released the April 2025 HCPCS codes for medical coding in the USA. Updated as of 3/26/2025, the fully searchable and sortable file is available in ZIP form under the name, April 2025 Alpha-Numberic HCPCS File (ZIP) [4].
CMS Announces Contract Year 2026 Technical Changes
CMS has issued a final rule to modernize and improve Medicare Advantage, Medicare Prescription Drug Benefit, Medicare cost plan, and PACE programs. This final rule impacts revenue cycle management services and implements changes around prescription drug coverage, D-SNPs, Star Ratings, the Medicare Prescription Payment Plan, and other areas [5].
Coding Considerations for Malnutrition
Revenue Cycle Advisor is covering medical coding considerations based on a study of over 4,500 older adults. They advise that coders stay alert to comorbidities and key documentation concerns. They also cover social determinants of health and how they should be considered in assessment and treatment plans [6].
CMS Releases Final CY Part D Redesign Program Instructions
The agency has released the CY 2026 Part D Redesign Program Instructions, concurrently with their announcement of CY 2026 Medicare Advantage Capitation Rates as well as Part C and Part D Payment Policies. These instructions provide guidance around medical billing and the implementation of the Inflation Reduction Act of 2022’s changes to the defined standard Part D drug benefit [7].
CMS Has Fined 7 Payers for Medicare Part D Violations
The agency has reportedly fined seven payers for more than $430,000 in total for violation of Medicare requirements relating to Part D prescription drug benefits, important news for medical billing providers. CMS penalized them for error in formulary and benefit administration, as well as coverage determinations and appeals processes. Audits were conducted throughout 2024 [8].
2025 Update to ASC Payment System
CMS has released a change request to provide medical billing instructions for and changes to various payment policies. This request impacts payment policies implemented in the April 2025 ASC payment system update. Issue date is April 10, 2025 [9].
Incoming File: Beneficiary-Level File Supporting 2026 Part D Bids
CMS has pushed out a beneficiary-level file that actuaries will be using to develop 2026 Part D bids. This has been sent to MA-PD plans, 1876 Cost Plans, PACE organizations, and standalone PDPs. It was sent on April 10, 2025 [10].
References
[1] CMS, “Hospital Price Transparency,” March 2025. Available: https://www.cms.gov/sites/default/files/2025-03/hospitalpricetransparency_mln7215754.pdf.
[2] CMS, “CMS Finalizes 2026 Payment Policy Updates for Medicare Advantage and Part D Programs,” 7 April 2025. Available: https://www.cms.gov/newsroom/press-releases/cms-finalizes-2026-payment-policy-updates-medicare-advantage-and-part-d-programs.
[3] CMS, “Medicare HETS205-1 System Release is Complete – 4/5/2025,” 5 April 2025. Available: https://www.cms.gov/data-research/cms-information-technology/hipaa-eligibility-transaction-system/mcare-notifications/medicare-hets205-1-system-release-complete-4/5/2025.
[4] CMS, “HCPCS Quarterly Update,” 26 March 2025. Available: https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update.
[5] CMS, “Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4208-F),” 4 April 2025. Available: https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final.
[6] L. Prescott and S. E. McCall, “Key coding considerations for malnutrition,” HCPro LLC, 2 April 2025. Available: https://revenuecycleadvisor.com/news-analysis/key-coding-considerations-malnutrition.
[7] CMS, “Final CY 2026 Part D Redesign Program Instructions,” 7 April 2025. [Online]. Available: https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions.
[8] J. Emerson, “CMS fines 7 payers over Medicare Part D violations,” Becker’s Healthcare, 7 April 2025. Available: https://www.beckerspayer.com/payer/cms-fines-7-payers-over-medicare-part-d-violations/.
[9] CMS, “April 2025 Update of the Ambulatory Surgical Center [ASC] Payment System,” 10 April 2025. Available: https://www.hhs.gov/guidance/document/april-2025-update-ambulatory-surgical-center-asc-payment-system.
[10] CMS, “Incoming File From CMS: Beneficiary-level File to Support 2026 Part D Bids,” 10 April 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/incoming_file_from_cms_beneficiary_level_file_to_support_2026_part_d_bids_g.pdf.
