Reimbursement Intelligence

Clinical Lab LCD L40140: Allograft Rejection Molecular Testing — Bill by August 30

CGS LCD L40140 finalizes Medicare coverage criteria for molecular allograft rejection testing in KY and OH, effective August 30, 2026.

Retroactive — effective Aug 30, 2026

CERT Program: Chapter 12 and Exhibit 46 Revised — Update Documentation Protocols by August 28

CMS Transmittal R13890PI revises CERT Program Chapter 12 and Exhibit 46, requiring updated medical record submission protocols before August 28, 2026.

Retroactive — effective Aug 28, 2026

Influenza Vaccine Fee Schedule: 22 HCPCS Codes Updated — Charge Master Action by August 17

CMS Transmittal R13859CP updates payment allowances for 22 flu vaccine HCPCS codes including Q2035–Q2039 and 90685–90688, effective August 17, 2026.

Retroactive — effective Aug 17, 2026

Clinical Laboratory: New LCD on Biomarker Testing — Submit Claims by August 10

LCD L40197 establishes coverage for MASLD testing — comply by submitting claims starting August 10, 2026.

Retroactive — effective Aug 10, 2026

Understanding Medicaid Community Engagement Requirements: Key Impacts for Multi-Specialty Coders by 2026

What Changed The Medicaid payment system will undergo significant changes effective July 30, 2026, with the introduction of a community engagement requirement as outlined in the Federal Register Final

Retroactive — effective Jul 31, 2026

Ophthalmology LCD L39905: WPS Cataract Surgery Coverage — Audit Claims Now

WPS LCD L39905 finalizes cataract surgery coverage criteria for J5/J8 MAC jurisdictions; billing managers must audit claims against medical necessity thresholds.

OPPS/ASC CY2027 Proposed Rule: Botulinum Toxin Prior Authorization Expansion

FR-2026-13656 proposes expanding Medicare prior authorization requirements for Botulinum Toxin under the CY2027 OPPS/ASC payment system.

DME Transmittal R13846CP: July 2026 DMEPOS Fee Schedule — Verify Now

CMS Transmittal R13846CP updates DMEPOS fee schedule values effective July 6, 2026 (verify against source document) — confirm charge master and encoder settings now.

Retroactive — effective Jul 6, 2026

PFS Quarterly MPFSDB Update July 2026: Verify Fee Schedule Changes Now

CMS Transmittal R13845CP updates the MPFSDB effective July 6, 2026 (verify against source document) — review affected PFS codes before claims submission.

Retroactive — effective Jul 6, 2026

New ESRD Payment Adjustments: Key Changes for Dialysis Facilities by 2026

What Changed The Centers for Medicare & Medicaid Services (CMS) has announced updates to the End Stage Renal Disease Prospective Payment System (ESRD PPS), effective July 6, 2026. This transmittal, id

Retroactive — effective Jul 6, 2026

Clinical Laboratory Update: July 2026 Fee Schedule Changes — Act by July 6

CMS updates to CLFS require immediate action for billing by July 6, 2026.

Retroactive — effective Jul 6, 2026

IOTA Model Launch: Key Changes for Transplant Billing Effective July 2026

What Changed

Retroactive — effective Jul 1, 2026

Understanding Interoperability Standards: Prepare for Medicare Advantage Changes by June 15, 2026

What Changed The proposed rule outlined in the Federal Register (Policy ID: FR-2026-07205) aims to enhance the efficiency of billing processes within Medicare Advantage programs by improving the elect

Retroactive — effective Jun 15, 2026

Medicare Advantage 2027: Key Billing Updates for Contract Year Compliance

Medicare Advantage 2027: Key Billing Updates for Contract Year Compliance

Retroactive — effective Jun 1, 2026

Master List Update: Key Prior Authorization Changes Affecting Coders by April 2026

What Changed The recent updates to the Medicare Physician Fee Schedule (PFS), effective April 13, 2026, introduce significant modifications to the Master List of items potentially requiring a face-to-

Retroactive — effective Apr 13, 2026

Skilled Nursing Facility Alert: Proposed Payment System Changes — Action Required

Proposed updates to SNF payment system for FY 2027 require immediate attention.

Medicaid Funding Preservation Rule: Key Tax Loophole Closure Effective April 2026

What Changed

Retroactive — effective Apr 3, 2026

Dialysis Billers: Navigating the 2026 ESRD Payment and Quality Incentive Overhaul

What Changed

Retroactive — effective Jan 1, 2026

PFS 2026: Key Part B Payment Adjustments for January 1 Implementation

What Changed

Retroactive — effective Jan 1, 2026

Hospital Outpatient Alert: Payment System Changes — Action Required by 2026

Significant changes to OPPS and ASC payment systems effective January 1, 2026.

Retroactive — effective Jan 1, 2026

Medicare Part B PFS 2026: Key Revisions Affecting Physician Fee Schedule Billing

What Changed

Retroactive — effective Nov 28, 2025

Medicare Advantage 2026: Provider Directory Format Changes Effective November 17

What Changed The Medicare Advantage payment system will undergo significant changes effective November 17, 2025, as outlined in the Federal Register Final Rule (Policy ID: FR-2025-18236). The updates

Retroactive — effective Nov 17, 2025

FY 2026 SNF PPS Final Rule: Key Billing Updates Effective October 2025

What Changed

Retroactive — effective Oct 1, 2025

Medicare PFS 2026 Proposed Changes: Comment by September 12 for Impactful Updates

Medicare PFS 2026 Proposed Changes: Comment by September 12 for Impactful Updates

Medicare Advantage Alert: Policy Changes — Action Required by June 2025

Significant updates to Medicare Advantage and Part D programs effective June 3, 2025.

Retroactive — effective Jun 3, 2025

ESRD Alert: New IOTA Model — Compliance Required by January 2025

The IOTA Model enhances kidney transplant access and requires compliance by January 3, 2025.

Retroactive — effective Jan 3, 2025

ESRD Billing Overhaul: New Payment System and Quality Incentives Effective January 2025

What Changed

Retroactive — effective Jan 1, 2025

Home Health 2025: Key Changes in HH PPS and IVIG Rates Effective January 1

What Changed

Retroactive — effective Jan 1, 2025

Medicaid Alert: Drug Misclassification Changes — Action Required by November 2024

New Medicaid Drug Rebate Program rules effective November 19, 2024, require compliance with stricter drug classification and documentation.

Retroactive — effective Nov 19, 2024

FY 2025 Hospice Wage Index Update: Key Changes for Skilled Nursing Coders

What Changed

Retroactive — effective Oct 1, 2024

Inpatient Alert: Medicare IRF Payment Changes — Action Required by October 2024

New payment rates for Inpatient Rehabilitation Facilities effective October 1, 2024.

Retroactive — effective Oct 1, 2024

Skilled Nursing Facility Alert: PPS Updates — Action Required by October 1, 2024

Significant updates to the Skilled Nursing Facility PPS effective October 1, 2024, require immediate action.

Retroactive — effective Oct 1, 2024

Medicaid Access Rule 2024: Key Billing Changes Coders Must Implement by July 9

What Changed The Medicaid Access Rule 2024, effective July 9, 2024, introduces significant changes to the Medicaid payment system, focusing on transparency and accountability. This rule aims to improv

Retroactive — effective Jul 9, 2024

Medicaid Alert: New Managed Care Rule — Action Required by July 2024

New Medicaid managed care rule effective July 9, 2024, requires compliance actions.

Retroactive — effective Jul 9, 2024

Decoding 2025 Benefit Parameters: Essential Updates for Multispecialty Coders by June 2024

What Changed The recent update to the Patient Protection and Affordable Care Act's payment parameters, effective June 3, 2024, introduces significant changes to how payments are adjusted and administe

Retroactive — effective Jun 4, 2024

Navigate the 2024 PFS Final Rule: Key Updates for Physician Fee Schedule Coders

What Changed

Retroactive — effective Feb 12, 2024

Understanding the Remedy for 340B-Acquired Drug Payments: Updates for OPPS Coders

What Changed

Retroactive — effective Jan 8, 2024

PFS 2024: Essential Medicare Part B Payment Changes for Coders to Implement

What Changed

Retroactive — effective Jan 1, 2024

Medicaid and CHIP Core Set Reporting: Key Billing Changes Effective January 2024

What Changed The Medicaid and CHIP Core Set Reporting changes, effective January 1, 2024, introduce mandatory annual reporting requirements for state Medicaid and Children's Health Insurance Program (

Retroactive — effective Jan 1, 2024

Navigate 2024 Home Health PPS Updates: Key Changes for Medicare Billing Coders

What Changed

Retroactive — effective Jan 1, 2024

Hospital Outpatient Alert: Medicare Payment Changes — Action Required by January 1, 2024

Significant updates to Medicare OPPS and ASC payment systems effective January 1, 2024.

Retroactive — effective Jan 1, 2024

Medicaid MSP Eligibility Simplified: Key Billing Updates Effective November 17, 2023

Medicaid MSP Eligibility Simplified: Key Billing Updates Effective November 17, 2023

Retroactive — effective Nov 17, 2023

Medicare Hospice Payment Rates Updated for FY 2024: Key Changes for Coders

What Changed

Retroactive — effective Oct 1, 2023

Skilled Nursing Facility Alert: Payment Structure Changes — Action by October 1, 2023

Significant updates to SNF payment structure effective October 1, 2023.

Retroactive — effective Oct 1, 2023

Oncology Alert: Glofitamab Approval — Prepare for Part B Billing Changes

FDA approves Glofitamab; oncology practices should prepare for upcoming billing updates.

Retroactive — effective Jun 15, 2023

Skilled Nursing Facility Alert: Medicare Payment Updates — Action Required

Proposed updates to Medicare payment rates for Skilled Nursing Facilities for FY 2024 require immediate attention.

Physician Fee Schedule Update: Review New Refund Requirements for Compliance

New PFS rules affect billing strategies, effective March 15, 2023.

Retroactive — effective Mar 15, 2023

Oncology Alert: Imfinzi Billing Update — Review Formulary Compliance

New FDA approval for Imfinzi impacts billing practices; update required.

Retroactive — effective May 1, 2017

Oncology Alert: Darzalex J-Code Expected — Prepare for Billing Update

New J-code anticipated for Darzalex; actions needed include formulary updates and reimbursement model adjustments.

Retroactive — effective Nov 16, 2015