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.
Guidance of Health Related Social Needs Rescinded
CMS has announced the recission of medical billing guidance on health-related social needs. The decision was made to support the implementation of coverage of services that address health-related social needs (HRSN) that fall under State Medicaid Programs and Children’s Health Insurance Programs (CHIP) [1].
HHS Releases Instructions on Downloading Medicare Zip Code File
CMS has posted a medical coding Change Request that describes the process for updating two Medicare Zip Code files (ZIP5 and ZIP9). This is for the April 2025 quarter and the update applies to Chapter 15, section 20.1.5(B) [2].
Updates to Medicare Benefit Policy Manual Now Available
CMS has posted USA medical billing updates to the Medicare Benefit Policy Manual and the Medicare Claims Processing Manual for Opioid Treatment Programs (OTPs). This update became effective January 1, 2025 and is implemented as of March 25, 2025. The Change Request revises the Medicare Benefit Policy Manual, Chapter 17 along with the Medicare Claims Processing Manual Chapter 39 to reflect changes made in the Calendar Year 2025 Physician Fee Schedule Final Rule [3].
UnitedHealthcare Cutting Prior Authorization by 10%
UnitedHealthcare has announced its plans to cut home health care billing prior authorization requirements by around 10%. In a notice sent on March 1 to providers, it announced the elimination of prior authorizations for home health services that are managed by Optum Home & Community. These changes go into effect April 1 and apply to Medicare Advantage and dual special needs plans across more than 30 states [4].
CMS Releases Manual Updates to Home Health Adjustments
The Agency has released a Change Request that updates instructions for adjustments to home health claims. This request applies when a beneficiary is discharged unexpectedly after a “Still Patient” claim has been submitted. The request additionally revises and deletes home health coding sections of the Medicare Claims Processing Manual containing pricer information. This is to reflect the conversion of programs from mainframe COBOL to Java in the Cloud [5].
Roster Billing for Hepatitis B Released
A Change Request effective January 1, 2025 and implemented July 7, 2025 has been released by CMS pertinent to revenue cycle management services. This request provides updates that ensure mass immunizers have the ability to use the roster billing process when submitting Medicare Part B claims for hepatitis B vaccines and in their administration [6].
Senator Introduces Legislation to Double Fines for Hospital Price Transparency
Senator John Kennedy from Louisiana reintroduced legislation that would increase penalties for hospitals found not complying with price transparency laws. Among other points that impact the hospital revenue cycle, it would double the current government penalties for hospitals that are non-compliant and prohibit hospitals from shielding information on websites through coding [7].
Clinical Lab Fee Schedule Rescinded and Replaced
CMS has announced that transmittal 13037, issued on January 10, 2025 is being rescinded and subsequently replaced by medical coding USA Transmittal 13078 which is dated February 21, 2025. This action was done to change the implementation date from January 6, 2025 to “30 days from issuance.). No other changes are indicated [8].
April HCPCS Update Available
CMS has published the HCPCS Quarterly Update for April 2025. The file is titled “April 2025 Alpha-Numberic HCPCS File (ZIP)”. It was updated as of 02/28/2025 and is available for public download and use for anyone interested in medical coding in USA [9].
United Is Subject of Billing Probe
UnitedHealth is the target of an inquiry led by Senator Chuck Grassley. The inquiry examines UnitedHealth Group’s Medicare Advantage medical billing practices in response to a report from The Wall Street Journal that covered their investigation by the U.S. Department of Justice for improper inflation of member diagnosis codes to increase reimbursements [10].
References
[1] CMS, “Rescission of Guidance on Health-Related Social Needs,” 4 March 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/AID/cib03042025.pdf.
[2] CMS, “Transmittal 13072 Change Request 13950,” 21 February 2025. [Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/r13072cp_0.pdf.
[3] CMS, “Transmittal 13088 Change Request 13948,” 21 February 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/r13088cp.pdf.
[4] R. Wilson, “UnitedHealthcare to cut prior authorization by 10%,” Becker’s Healthcare, 3 March 2025. Available: https://www.beckerspayer.com/policy-updates/unitedhealth-to-cut-prior-authorization-by-10.html.
[5] CMS, “Transmittal 13089 Change Request 13955,” 21 February 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/r13089cp.pdf.
[6] CMS, “Transmittal 13091 Change Request 13937,” 21 February 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/r13091cp.pdf.
[7] “Kennedy champions bill to make hospital prices clear to patients,” 25 February 2025. Available: https://www.kennedy.senate.gov/public/2025/2/kennedy-champions-bill-to-make-hospital-prices-clear-to-patients.
[8] CMS, “Transmittal 13078 Change Request 13947,” 21 February 2025. Available: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/r13078cp.pdf.
[9] CMS, “HCPCS Quarterly Update,” 28 February 2025. [Available: https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update.
[10] J. Emerson, “Senator launches probe into UnitedHealth’s Medicare Advantage billing practices,” Becker’s Healthcare, 25 February 2025. Available: https://www.beckershospitalreview.com/legal-regulatory-issues/senator-launches-probe-into-unitedhealths-medicare-advantage-billing-practices.html.
