In accordance with Section 1833(t)(6)(B) of the Social Security Act, the Hospital Outpatient Prospective Payment System (HOPPS) requires that categories of medical devices be eligible for transitional pass-through payments for a minimum of two years and a maximum of three years. Additionally, Section 1833(t)(6)(B)(ii)(IV) of the Act mandates the creation of new device categories when novel medical technologies are not adequately represented by existing or former device categories.

On March 15, 2025, the President signed into law the Full-Year Continuing Appropriations and Extensions Act of 2025 (H.R.1968) to maintain federal funding and extend temporary Medicare telehealth flexibilities through September 30, 2025, which is the end of the fiscal year (FY). However, this spending package excluded the so-called "doc fix" to reverse the 2.83 percent Medicare pay cut for physicians which was effective January 1, 2025.

There is one denial reason code that consistently ranks among the top denied categories in every organization, yet it is rarely discussed. One payer response that no one wants to see is CO-16. This code requires additional effort on the backend to ensure the claim is fully paid. Sometimes, it can feel like a guessing game when trying to interpret what the payer truly requires with this reason code. To prevent “other documentation” denials, organizations must be proactive in identifying the root cause and implementing workflows for future prevention. 

​On Friday, January 31, 2025, a bipartisan coalition of lawmakers reintroduced a bill aimed at counteracting and surpassing a recent pay reduction for physicians that took effect at the beginning of the year. The Medicare Patient Access and Practice Stabilization Act of 2025, effective April 1, 2025, would continue the 2.83 percent Medicare pay reduction for services provided from January through March. However, starting April 1, 2025, through December 31, 2025, the legislation would implement a 6.62 percent increase, offsetting the previous payment cut and the impact of the first quarter’s reductions while adjusting for inflation. 

​By: ​Ashley Hunter, MBA, CHFP, CRCR, Stevie Zarle, and Briauna Driggers

​When examining the top five denial categories at any organization, authorizations are almost always among them. Obtaining authorization approvals has become significantly more challenging in recent years with frequent changes in payer policies and authorization initiation processes. This poses a significant challenge for healthcare organizations as these denials are often “hard” denials, leading to avoidable revenue loss. The key term here is “avoidable,” as these types of denials can be entirely prevented with the right processes in place. 

​Denials related to surgical services continue to be a major pain point for providers, with payers banking on organizations being too busy to appeal. In our follow-up webinar, we revisited the key issues from the first session, expanding on strategies to effectively address surgical denials and ensure proper reimbursement.

​In 2006, the AMA’s CPT® Editorial Panel established six Category III CPT® codes to describe cardiac computed tomography angiography with contrast materials (cardiac CT services) effective January 1, 2006. In 2010, the six codes were replaced with three Category I CPT® codes, 75572, 75573, and 75574.  The three codes have been paid in alignment with the HOPPS payment rate methodology based on geometric mean cost, ranging from $175-$265 from CY 2015 through CY 2024.

​Magnetic Resonance (MR) safety is a critical concern due to the powerful magnetic fields and radiofrequency energy used in Magnetic Resonance Imaging (MRI) scans. The MR environment has the potential to pose significant risks to patients with implanted medical devices or foreign bodies. These objects may heat up, move, or malfunction, potentially causing harm. Prior to 2025, there was no specific way to report the extra effort involved in assessing and mitigating these risks before an MR exam or procedure. Now, providers can be reimbursed for the essential tasks required to safeguard these patients, including implant or foreign body evaluation, implant positioning or immobilization, safety consultation, and preparation of electronic devices. This change acknowledges the importance of MR safety protocols and supports the necessary steps to protect patients while maintaining imaging quality. 

​On December 21, 2024, the American Relief Act (H.R. 10545) was signed into law. Among the key provisions is the extension of certain Medicare telehealth policy flexibilities for an additional 90 days, now set to expire on March 31, 2025. This extension ensures that Medicare beneficiaries can continue accessing telehealth services without interruption, maintaining the accessibility and convenience that have become essential for many, especially those in rural or underserved areas.