DowncodedThe Diff
Every brief we have published, newest first. Rule teardowns, coverage-policy diffs, and the dollar math behind them.
- Sep 134 min read
What Happens When 637 Inpatient Procedures Land on 23 APCs?
CMS proposes taking 637 services off the inpatient-only list on January 1. It published the destination of every one of them, and 566 land on a comprehensive APC, where the whole claim collapses into a single rate and eight groups absorb two-thirds of the volume.
Subscribers - Sep 134 min read
The Committee That Owns Your Taxonomy Code
Eight hundred and eighty-three ten-character codes decide how every NPI in the country gets classified, and a twenty-organization committee has maintained them since 2001. Its July release added no codes, changed eleven rows, and takes effect October 1.
Free - Sep 135 min read
Only 80 of 918 Part B Drug Prices Held Still
Medicare's October drug payment limits posted on a Tuesday with no announcement and no transmittal. We diffed them against July: 799 codes repriced, 38 new, 10 retired, two antivenoms back on the books, and a Notes column that names which codes are priced off AMP instead of ASP.
Subscribers - Sep 124 min read
Who's Left to Run Medicare's Home Infusion Benefit?
CMS proposes to open the DME benefit to infusion pumps a patient cannot run alone, effective April 1, 2027, and the second of the three statutory criteria requires a qualified home infusion therapy supplier. There are 321 of them left in the country, the lowest count on any file CMS still publishes.
Free - Sep 127 min read
How a Rural Add-On Dies in the Provider Specific File
CMS issued the FY 2027 IPPS claims instruction on Friday, and it revises no manual section. It tells every MAC which two PSF fields to blank on January 1, when 589 low-volume hospitals and 81 MDHs lose $352 million between them, and the letters that decide who keeps the money are due before December.
Subscribers - Sep 125 min read
$841 Million Rides on Where the Attending Was Standing
CMS reissued the teaching physician booklet with a line that reads like permanent virtual supervision. The flexibility covers only three-way telehealth visits, and every GC line you bill still attests to where the attending physically stood.
Subscribers - Sep 114 min read
Four MACs Just Closed the Nerve Block List
Thursday's coverage database refresh carried a finished LCD nobody sent you: Peripheral Nerve Injections and Procedures for Chronic Pain, identical across CGS, Palmetto, Wellpoint Federal and WPS, notice opened September 10, paying rules effective October 25. Fourteen codes, 43 covered diagnoses, and anything not on the list is non-covered. Plus six MACs quietly deleting the same sentence, a 115-day retroactive coverage expansion, and 6,687 diagnosis codes that stop supporting an injection.
Subscribers - Sep 114 min read
Eleven Years On, Modifier 59 Is Still Gaining
CMS built four modifiers in 2014 to retire the most abused one in Part B. The CY2025 claims summary says providers went the other way, and that on the same code the swap moves your denial rate by as much as forty points.
Subscribers - Sep 114 min read
California Kept the Notes on 42,749 Denied Appeals
The Department of Managed Health Care has published every independent medical review it has decided since 2001, with the physician reviewer's full written reasoning attached to each one. We pulled all 42,749 rows. The plan lost 72.3% of them last year, 81.7% of the pharmacy cases, and 91.5% of the weight-control drug cases.
Free - Sep 106 min read
Why One Prior Authorization List Got 90 Days and the Other Got 35
Forty orthosis and bone stimulator codes become prior authorization codes on October 15 for any DMEPOS supplier Medicare considers new. The list lives in a four-page PDF, the Federal Register has never printed the words probationary prior authorization, and the regulation CMS cites counts four ways to become new when the announcement names two.
Subscribers - Sep 106 min read
One Price for 283 Telehealth Codes, and an Edit if You Pick Wrong
RHCs and FQHCs stop billing G2025 on October 1 and must report the individual CPT code for every distant site telehealth service. Payment stays a flat $97.53 no matter which of the 283 codes they pick, 162 of the 258 priced ones pay less than that on the fee schedule, and a wrong code now draws IOCE edit 139 and a returned claim.
Subscribers - Sep 103 min read
How the Vaccine Price File Changed Without Changing Its Name
CMS filled in six blank COVID-19 payment limits on September 1 and left the August 27 issue date stamped on the file name. Same URL, same file name, different prices. If you pulled the file the evening it posted, you are still holding the blanks, and the six codes came back 20.5 percent above last season.
Free - Sep 94 min read
Two Fluorouracil Codes, $740 Apart
CMS posted the October preliminary Part B payment limit file Tuesday afternoon. It deletes ten J codes, adds thirty-eight, reprices 799 of the 879 that carry over, and splits three ancient generics into a generic code and a manufacturer-specific one priced up to 380 times higher. Zoledronic acid is up 425.83%. Two antivenoms start paying again and a cyanide antidote stops.
Subscribers - Sep 94 min read
The SNF Exclusion List Has Been Wrong Since January
Forty-four therapy codes sit on the CMS file that tells an outside provider to send the claim to the Part B MAC for a resident in a covered Part A stay. CMS says they never belonged there, pulls them October 5, and will not go looking for the claims that already paid.
Subscribers - Sep 93 min read
CMS Publishes the List of Everyone Allowed to Audit You
The Review Contractor Directory names, for all 56 states and territories, every contractor that can send your practice a records request: the MACs, the Recovery Auditors, the program integrity contractors, with addresses, fax numbers and whether each one takes electronic submission. Ten regional audit territories, seven companies, and three maps that do not line up.
Free - Sep 85 min read
The Sentence Medicare Left Open in 1978
Medicare's national coverage determination on therapeutic embolization is one sentence long and has not been touched since December 1978. UnitedHealthcare just wrote the list that sentence never contained: hemorrhoids and musculoskeletal pain are unproven from December 1, across the commercial, exchange and Medicaid books. The code it lands on pays $6,675 in the office, and 94 cents of every dollar is spent before the claim leaves the building.
Subscribers - Sep 87 min read
The Fee Schedule Arrives the Day It Starts Paying
Aetna is updating its Market Fee Schedule in nine states on October 15 and November 1. The bulletin announcing it went up on August 13. The rates themselves publish on the effective date, which is the one number you need and the one you do not get, and in Maine and Washington the statutes say what you are owed instead.
Subscribers - Sep 83 min read
Louisiana Orders Home Ventilators Seven Times as Often as Utah
E0466 is the fifth largest DMEPOS code in Medicare and the most expensive per patient of the top five, at $9,923 a year. The rental rate barely moves across the country. The ordering rate moves 7.6x, and on October 28 every one of those orders needs a face-to-face encounter on file.
Free - Sep 73 min read
What Is a Perfect MIPS Score Worth?
CMS modeled its own quality program for the 2029 payment year and the ceiling came out at 1.34 percent. The floor is negative 9. The median solo practitioner who submits nothing scores 24.70, which is an 8.05 percent cut on every Part B payment, and comments close September 14.
Subscribers - Sep 74 min read
CMS Wrote the Test Your Price File Has to Pass
The agency maintains an open-source validator for hospital machine-readable files, public domain and free, and shipped seven releases of it this year to keep up with its own new rule. It also publishes every enforcement letter it has sent since 2021, and April 2026 is the biggest month in that file.
Free - Sep 74 min read
42,968 Comments on One Rule and Nine on Another
CMS filed one document with the Federal Register in four days. Meanwhile the CY2027 physician fee schedule docket has taken 42,968 comments, two thirds of everything filed on CMS rulemaking since May, and it shuts Monday. The RAPID device coverage pathway CMS proposed in August has nine, and it stays open until October 13.
Subscribers - Sep 64 min read
Your LCD Feed Fired 406 Times and Meant It 50
Medicare published 406 local coverage determination revisions with a 2026 effective date. We classified every one off the contractor's own revision note, and 50 of them changed coverage, codes or requirements. The other 356 are a corporate rename, a document merge, and a lot of bibliography links.
Free - Sep 67 min read
What Makes an Organ a Medicare Organ?
OIG put $379.9 million on CMS's presumption that any organ a transplant center ships out the door went into a Medicare patient, and said the statute forbids it. Four weeks earlier CMS finalized that same presumption for organ procurement organizations, effective October 2028, and booked $1.28 billion of savings against it.
Subscribers - Sep 66 min read
Medicare Priced Your Remote Monitoring Program Twice
The CY2027 physician fee schedule proposed rule carries a downloads-folder file showing what practice expense RVUs would be with the caps switched off. On 99454 the two numbers are $41.05 and $9.52. Nine thousand of the file's 9,658 lines disagree with Addendum B, and comments close September 14.
Subscribers - Sep 54 min read
Two Curl Commands to the Whole Coverage Database
CMS runs a free API over the Medicare Coverage Database, no key and no registration, and it publishes the declared reason behind every LCD revision. We spent an afternoon in it: of 183 LCD revisions last quarter, 98 declared an administrative reason and 27 declared a change to policy content.
Free - Sep 55 min read
Nobody Told You What Changed in Your Part B Drug Policy
UnitedHealthcare's September Medicare Advantage bulletin lists Medications/Drugs (Outpatient/Part B) as revised effective September 1, then prints the orthopedic change log underneath it: Girdlestone, 27299, 25449, 29840, 27122. Eight CGS coverage determinations took effect the same week with the synopsis field blank. The rest of the radar is the step therapy change that did get written down, Cigna rewriting August on September 4, and Aetna's claim edits landing December 1.
Subscribers - Sep 53 min read
75,001 Exclusions Your NPI Screen Will Never Match
OIG's exclusion file carries an NPI column, and 75,001 of its 83,842 active records leave it blank. Coverage runs 86.8% for physician assistants and 2.6% for nurse aides, which is backwards from where the civil money penalty actually sits. Four entities settled employment-exclusion cases with OIG this year for $406,151, and every one of them self-disclosed.
Subscribers - Sep 46 min read
The Drug Went Over the Counter. The NDC Never Did.
OIG found $587.7 million in Part D payments for five drugs whose brand-name versions went OTC years earlier. We ran the same test against today's NDC Directory: fifteen of those prescription listings are still live, and naloxone has eight more sitting outside the audit window.
Subscribers - Sep 44 min read
How Many Vessels Did Medicare Think You Had?
CPT rebuilt lower-extremity revascularization around 46 codes in January. CMS capped every one of the add-ons at a single unit per day in April, and the October file raises all 24 of them without saying why.
Free - Sep 46 min read
Fourteen Days of Silence Opens a Medicaid Audit
CMS revised nine sections of the Medicaid Program Integrity Manual on Thursday and told its contractors the change does not affect providers. It gives your state Medicaid agency 14 calendar days to answer a UPIC vetting request, opens the investigation if nobody answers, and takes CMS out of reading your response to the findings. Effective October 5.
Subscribers - Sep 35 min read
CMS Reissued Thirteen Pages to Change One Digit
Transmittal 13943 rescinds and replaces the October SNF consolidated billing update CMS published on August 21. A full-text diff of the two versions turns up exactly one substantive change: a year in the policy section, 2025 corrected to 2026. Everything else in this radar is what did not publish, including five straight days with zero coverage-policy changes across all twelve MAC jurisdictions.
Subscribers - Sep 34 min read
California Doubled Its Share of Medicare Home Health
CMS posted the CY2025 home health utilization file on September 1, the same claims year it is using to set CY2027 rates. Across all 55 jurisdictions, California is the only one sending more visits per patient than it did in 2017, and it now books 22.9% of the program on 14.6% of the patients. Here is what the proposed 3% cut takes out of each state.
Subscribers - Sep 27 min read
Who Can Use Medicare's New Hospice Telehealth Code?
CMS reissued its hospice telehealth instruction today, deleting one edit and leaving everything else alone. G0679 goes live January 1 for recertification encounters done by video. The statute the change request cites switches that option off for any patient in an area under a hospice enrollment moratorium, and CMS put the entire country under one on May 13. The instruction does not mention it.
Subscribers - Sep 26 min read
The Fourth Prenatal Visit Is Worth $194
Aetna's August bulletin told practices to bill prenatal visits as E/M for every patient expected to deliver in 2027. The September bulletin adds the condition August left off: only when three or fewer visits land before January 1. The threshold is the AMA's, the instruction took effect Tuesday, and it prices the same eleven-visit pregnancy twelve different ways.
Subscribers - Sep 24 min read
The Benchmark You Are Allowed to Bring to IDR
FAIR Health said in August that its allowed-amount data can be put in front of a certified IDR entity. The federal rule bars the three benchmarks a billing office reaches for first, and the nonprofit's free public site already shows the 20th through 90th percentile of what plans actually pay.
Free - Sep 16 min read
The Downcode Record: Everything Ships in Thirty Days
CMS finalized one payment rule in August and it was the year's largest: FY 2027 hospital rates worth $2.1 billion, plus $779 million in new technology add-ons, all live October 1. Two months of final rules now total $4.75 billion. The proposals that take $5.7 billion back out closed for comment on August 31, and nobody gets to argue about them again.
Subscribers - Sep 13 min read
How Much of Medicare's Revalidation List Is Already Expired?
The September edition of the Revalidation Due Date List posted with 2,943,135 rows, and 277,795 of them carry a real date. Only 44,349 of those dates are still in the future, and 21,885 land before December.
Free - Sep 13 min read
1,539 New Bundles No Modifier Will Open
CMS posted the October correct-coding change lists this morning. The practitioner file adds 4,249 procedure-to-procedure edits and removes 14, and 1,539 of the additions carry modifier indicator 0. The heaviest concentration on any established CPT code lands on percutaneous fistula creation, where a same-session angioplasty worth $4,224 stops being billable at all.
Subscribers - Aug 315 min read
Medicare's Fraud War Room Suspended a Fifth as Much This Year
CMS's Fraud Defense Operations Center suspended more than $1.8 billion in 2025 and $371 million since January, from a larger number of providers. Here is the service-line split behind the drop, what a suspension is now worth, and where the $1.6 billion in lab enforcement CMS announced Friday actually came from.
Subscribers - Aug 315 min read
How a Vaccine Gets an NDC, a Code, and No Price
CMS posted the 2026-2027 seasonal vaccine payment file on Friday evening. Nine influenza codes arrived with a number, every one of them higher than the July quarterly file, and one of them new at $171.21. The six COVID-19 codes arrived with a manufacturer, a national drug code, an August 27 effective date, and the letters TBA where the payment limit goes. Also in this radar: the FY2027 Medicare Code Editor came out of the proposed rule six codes heavier, and the rest of the federal machine published nothing at all.
Subscribers - Aug 314 min read
CMS Already Published the Error Rate on What You Bill
The Medicare Learning Network keeps 57 service-line denial dossiers, each one carrying the 2024 improper payment rate, the projected dollars, and the exact mix of reasons the money failed. Two of them surfaced in MLN Connects this month. The other 55 have been sitting there the whole time.
Free - Aug 303 min read
Why Your October Procedure Codes Expire in March
CMS dates the FY2027 procedure code set October 1 through March 31, not through September. The April 1 mid-year update has grown from 7 codes to 80, it ships its own grouper, and one new cardiac family carries a $10,261 DRG gap.
Subscribers - Aug 306 min read
The Face-to-Face You Have to Produce Five Years Later
CMS wants to stop requiring a new face-to-face encounter for identical DMEPOS replacements, and says the fiscal impact cannot be estimated. On audit you still produce the original encounter, which can be 66 months old, from records nobody has to keep past month 84. Comments close tomorrow.
Subscribers - Aug 303 min read
The 15 Codes That Stay in the Book and Stop Working
The FY2027 diagnosis file adds 190 billable codes, the second-smallest annual haul in six years, and every summary you read this month will lead with that number. The one that reaches your denial queue is 30, and half of those codes never leave the tabular list at all.
Free - Aug 295 min read
What Happens When 66 New Codes Arrive Without a Price?
The October physician fee schedule update went to your MAC on August 21 and to the public on the 27th. Inside: 112 code records, six of them nationally priced, 58 new Category III codes the contractor prices off your operative report, six skin substitutes joining the $127 sheet rate, ten drug codes going invalid with three of their replacements dosed in different units, and one record back-dated to May in a year CMS just told contractors not to reprocess.
Subscribers - Aug 297 min read
The Translator Swap Starts Next Week
CMS is replacing the EDI translator at every A/B MAC with one centralized system, one jurisdiction a week from September 7 through mid-November. The change request that authorizes it lists provider education as None. The same quarter's front-end edit release carries 93 dated rows out of 11,259, and one of them exists because the new gateway was caught rejecting claims it should have passed.
Subscribers - Aug 294 min read
The Oncology LCD Is on Version 220
CMS runs a free, key-free API across the whole Medicare Coverage Database, and it hands back every LCD's version number, revision history and diagnosis code tables as JSON. We pulled all 977 local coverage determinations through it this morning, and the median active policy is on version 22.
Free - Aug 287 min read
Medicare Set Its Screening Floor With a Test It Cannot Cover
NCD 210.3 now pays for any non-invasive colorectal biomarker test clearing one of two sensitivity and specificity pairs, and CMS showed its arithmetic. The lower bound is Freenome's SimpleScreen, which is not FDA market authorized. Coverage backdates to June 8; the edits go live January 4.
Subscribers - Aug 284 min read
How Long Has Medicare Had That Enrollment Application?
CMS publishes the list of initial enrollment applications its contractors have not processed, twice a week, by name. We pulled all 336 archived builds back to June 2023. The July wave drains every autumn like it should, and 1,116 physicians have been on every single build for 1,180 days.
Free - Aug 284 min read
How a Drug Price Drop Lands in Your Clotting Factor Fee
CMS set the 2027 clotting factor furnishing fee at $0.270 per unit yesterday, a 1.89% raise and the third-smallest in twenty-two updates. The fee pays for labor, and it is indexed to a basket where drug prices fell 2.1% this year. Twenty-two years of that blend put it 1.4 cents a unit behind, worth $3.3 million a year across Part B.
Subscribers - Aug 274 min read
The Grouper You Keep Rebuilding Already Exists
CMS quietly maintains a taxonomy that sorts all 17,174 Part B HCPCS codes into clinical service lines, re-argued every year by a panel of clinicians and researchers. The 2026 release posted August 21, it added exactly one new category, and 265 of the codes in it used to be DME.
Free - Aug 276 min read
Seven Devices Medicare Priced Off a Knee Replacement
CMS just posted the payment limitations for the last year of the NOPAIN separate payment, and seven of the twenty products carry the identical cap because the agency has never seen a claim for any of them. Comments close Monday.
Subscribers - Aug 275 min read
How a Code You Never Sent Ends Up on Your Claim
Seven days on the wire: CMS rewrote the list of codes it assigns to your claims for the first time since August 2024, adding 36 contractor bypass modifiers, deleting the incarcerated-beneficiary condition code, and repurposing a value code, all under a change request that says it contains no policy changes. Plus MolDX finalizes one batch and opens another, and CMS points dermatology at an audit it refused to concur with.
Subscribers - Aug 266 min read
Who Reads the CERT Letter at Your Practice?
On Friday CMS deletes the option that let your MAC sit on an unanswered CERT records request, and requires feedback to close at least 30 days before your last chance to send the chart. Unanswered requests already cost Medicare $3.46 billion last year, the only documentation category that rose while the overall improper payment rate fell, and for urological supplies they are 69.4 of the 74.1 percent error rate.
Subscribers - Aug 263 min read
How a Write-Off Turns Back Into a Patient Balance
CMS refreshed the Medicare enrollment file on Monday. Dual eligibles are now the smallest share of Medicare the agency has ever published, and 74% of the twelve-month decline sits in the one dual category that carries no federal bar on billing the patient for the coinsurance.
Free - Aug 264 min read
3,533 Referring NPIs Medicare Lists Both Ways
CMS publishes two files that answer the same question about whether a referral clears the 424.507 edit. On 3,533 opted-out practitioners the files answer it differently, all 3,533 are cleared for DMEPOS in one of them, and the remittance is where you find out which file your MAC read.
Subscribers - Aug 255 min read
Thirty-Nine New Lab Codes, and Not One Has a Price
Seven days on the wire: CMS quietly folded three recurring lab change requests into one, added 39 new laboratory codes effective October 1 with no national payment amount on any of them, deleted three others, and flipped a point-of-care respiratory assay to CLIA-waived retroactive to March. Plus a third state parity audit in eleven days, and an LCD feed that has not refreshed since August 17.
Subscribers - Aug 256 min read
The Sentence Labcorp Asked MolDX to Strike
On August 10 the four MolDX contractors turned on Medicare's first coverage policy for MASH fibrosis blood tests, naming five tests and conditioning every one of them on a FIB-4 result, an elastography lookback and a technical assessment. Seven weeks later Labcorp gets a national code for a sixth test that is on none of the four code lists, and the criterion standing in its way is the one Labcorp asked to have struck.
Subscribers - Aug 254 min read
Ask Your Payer What It Knows About Your Patients
On January 1 every Medicare Advantage organization, state Medicaid program and marketplace issuer has to run an API that hands your practice its record of your patients. The free specification that says how you ask was republished on August 22, and it changed because implementers pointed out that the first version would have shipped entire histories for thousands of attributed members in one request.
Free - Aug 244 min read
Medicare's DME Front Door Reopens Thursday
The nationwide moratorium on new medical supply company enrollments hits its six-month mark on August 27, and CMS has published no extension. The revocation file shows what the screens that come back are actually good at catching.
Free - Aug 246 min read
How the Venom Exception Fell Out of One MAC's Copy
Five Medicare contractors just published the same Allergy Diagnostic Testing LCD, word for word, across 38 states and $45.1 million of Part B testing. CGS's copy is missing two words, and the sentence they came out of is the one that decides whether a serum IgE test and a skin test can both be billed for the same antigen. CGS's own billing article still has them.
Subscribers - Aug 244 min read
How a Therapy Cleanup Stops Paying for Wound Care
CR 14561 calls it an administrative correction of therapy codes. It pulls 45 codes off the only list that makes them separately payable during a covered Part A SNF stay on October 1, and $10.6 million of the $11.2 million riding on those codes is wound care.
Subscribers - Aug 235 min read
Your Primary Payer Now Picks Your Medicare Denial
Seven days on the wire: CMS sorted 129 claim adjustment reason codes into four dispositions for every Medicare Secondary Payer claim at Part A, pulled 45 therapy codes off a skilled nursing facility list they should never have been on, terminated one code effective December 31, 2011, and told ambulatory surgical centers to bill a $261,579 gene therapy across ten claims. Plus a favorable OIG opinion on manufacturer-funded premium assistance.
Subscribers - Aug 234 min read
The Chest Brace That Talked CMS Into a New Code
CMS decided 49 HCPCS Level II applications out of the June public meeting and published every argument on both sides, including the one that moved a chest brace off a non-covered supply code and onto a new L code effective October 1. The record spells out the test. One applicant met it in writing, and another one did not.
Free - Aug 236 min read
Six Timepoints, Then Nothing After Year Five
On August 30 the MolDX allograft rejection LCD is replaced across four jurisdictions. Kidney surveillance went from four covered timepoints to six, the post-year-one allowance doubled, and the billing article quietly reports that no test on the market qualifies past five years.
Subscribers - Aug 227 min read
Your Obesity Code Decides Whether the Liver Test Gets Paid
MolDX switched on coverage for MASLD and MASH fibrosis biomarker testing across seven MAC jurisdictions on August 10, at lab fee schedule rates running from $176.19 to $792.17 for one test per patient per year. The claim needs a diagnosis from each of two lists, and the list that grew from 17 codes to 108 between draft and final still leaves out morbid obesity and metabolic syndrome.
Subscribers - Aug 224 min read
The $572 Million Code Medicare Never Priced
CPT 81479 carries no rate on the clinical laboratory fee schedule. Medicare paid $572.2 million on it in 2024, and the twelve labs that collected 94.6% of that averaged anywhere from $1,661 to $7,099 a test.
Subscribers - Aug 224 min read
How Much Warning Does an LCD Actually Give You?
CMS sets a 45-day floor on LCD notice and lets any MAC ask for more. Across 448 notice periods since the 2019 process reform, 355 ran exactly 45 days, and only ten cleared 52.
Free - Aug 216 min read
The Counter Does Not Care Who Drew the Blood
Five new UnitedHealthcare reimbursement policies take effect September 1 across commercial, the exchanges, and Medicare Advantage. They name 37 lab codes, stop paying 17 of them outright, and run every frequency counter at the member level, so the reference lab's claim spends the same allowance your office draw needs. Seven states are excepted, and they are the same seven that ran 62 to 121 days behind the first tranche.
Subscribers - Aug 214 min read
OIG Will Give You the Software It Extrapolates With
The audit OIG issued on August 3 found $8,112 in improper payments across 100 sacroiliac joint injection sessions and turned it into a $15.2 million finding. The program that does that arithmetic has been a free download on the OIG website since the late 1970s, and the Program Integrity Manual tells contractors to use it by name.
Free - Aug 215 min read
How the Eleventh Reason Code Gets Skipped
A transmittal CMS issued Wednesday says the Fiscal Intermediary Shared System has only ever handed the first ten medical policy reason codes on a Part A claim to the system that adjudicates them, and bypasses the rest. CMS concedes in writing that this lets some claims pay incorrectly. The fix was booked for the October release and just moved to January.
Subscribers - Aug 207 min read
What Nine Contracts Do to the CGM Channel
CMS published its Round 2028 bidder fact sheets this morning. Buried in the rule behind them is a worked example where one unchanged array of bids produces three different Medicare prices, and the only thing that moves is how many contracts CMS decides to hand out.
Subscribers - Aug 204 min read
CMS Wrote 3,646 Warnings to Reach 29 Fines
The Hospital Price Transparency enforcement file is now five and a half years long. Reading it case by case shows almost every warning ends in a Corrective Action Plan, not a check.
Subscribers - Aug 204 min read
$5.18 Million Got Its Own Compliance Tip
MLN Connects published a provider compliance tip this morning telling comprehensive outpatient rehabilitation facilities that their improper payment rate was 45.4 percent on $10.8 million. Both numbers come from the FY 2024 CERT report. The FY 2025 report has been out since November: 20.7 percent, $5.18 million, and the smallest line on the Part A ex-IPPS table.
Free - Aug 195 min read
The Rate Update That Shipped Without the Rates
CMS sent MACs the FY 2027 hospice payment instruction in July with the payment tables missing, and replaced it on August 18 to put them back. Two more transmittals were rewritten the same week under change request numbers that never changed, one of them quietly adding a place-of-service rejection edit to a CR whose summary still says no policy is being changed.
Subscribers - Aug 196 min read
The 16,488 Signatures Medicare Wants Before 2028
Section 6225 of the CAA, 2026 turns a separate NPI and a signed provider-based attestation into conditions of Medicare payment for every off-campus outpatient department on January 1, 2028. CMS had to count the departments to price the paperwork, and the number that fell out is the closest thing to a federal tally anybody has.
Subscribers - Aug 194 min read
How Six Vendor Names Change an Appeal Letter
The free appeal generator your patients use is an open repository, and its logic reads like a compliance document. It scans a denial for six utilization-management vendors, pulls NCD citations from the CMS Coverage API, retrieves prior external review decisions from California and New York, and refuses on purpose to say what any of it means.
Free - Aug 186 min read
Why the Same Square Centimeter Pays $109 in Arkansas
CMS announced one national skin substitute rate of $127.28 per square centimeter and then filed it as 3.81 practice expense RVUs. That makes it two rates before geography and 78 after it, running from $109.31 to $183.51 across the 109 Medicare localities. On a 100 square centimeter application the supply line is 98% of the allowed amount, and CMS has already written down the year that money starts moving everyone else's practice expense RVUs.
Subscribers - Aug 184 min read
The Hip Revision That Loses $13,047 on October 1
A two-page maintenance article pulled eight MS-DRGs off the list where device credits come out of your inpatient payment. They came off because CMS deleted them: hip and knee revision collapses from three severity levels to one weight, cardiac pacemaker work from five to two, and the complicated cases funded both.
Subscribers - Aug 184 min read
Medical Necessity Was Never the Question
OIG pulled 100 denial files at Oregon's largest Medicaid plan and 21 of them failed on process alone. It never sent a single request out for medical review, and the most common defect was that the wrong person made the call.
Free - Aug 177 min read
The $2,672 Observation Payment Now Turns on Six Edits
On October 1 UnitedHealthcare Medicare Advantage adds six claim-line denials to its observation policy, all of them gates around the same comprehensive payment. Medicare pays $2,672.15 for a properly formed observation stay and nothing for the observation code on its own, so each edit is a way to drop a four-figure claim to the price of the visit underneath it.
Subscribers - Aug 174 min read
Sage Transparency Already Has Your Hospital's Number
An employer coalition in Indiana commissioned RAND in 2016 to find out what private plans actually pay hospitals, and has been publishing the answer per facility, for free, ever since. The current edition prices 4,000-plus hospitals against Medicare across 49 states and DC. Enrollment for the next round, built on 2023 through 2025 claims, closes before November.
Free - Aug 175 min read
How a Rate Takes Effect Sixteen Days Before Your MAC Can Pay It
This season's influenza vaccine allowances carry an effective date of August 1 and an implementation date of today, so sixteen days of flu claims priced against last season. The Federal Register published nothing from CMS all weekend, and every change that actually reached a provider came from a contractor: a finalized allergy LCD in Jurisdiction E, a skin substitute billing rule First Coast wrote down 225 days after it started, and an OIG finding that three New York Medicaid plans are still out of parity six years past the deadline.
Subscribers - Aug 164 min read
Where Did the RAC Pipeline Go?
CMS runs two Recovery Audit topic lists: one for what the auditors are cleared to review, one for what they have proposed reviewing next. The proposed list returns "No data available", and the approved list has picked up eight new topic numbers since January 2024 while re-dating sixteen old ones.
Free - Aug 164 min read
CMS Capped the Cut and Published the Destination
A new step 19 in the CY2027 physician fee schedule holds every practice expense RVU to a 5% move per year, so the specialty impact table shows a fraction of what the new methodology does. CMS posted the uncapped file next to it. Priced on CMS's own utilization data, that file parks $3.23 billion of reallocation past 2027: ophthalmology down another 8.3% of its book, private-practice physical therapy up 15.9%.
Subscribers - Aug 166 min read
Cigna Posted 111 Changes and 55 Had Already Taken Effect
Cigna's August policy update went live on the 15th. Half its dated changes were already in force, including both reimbursement policies, and one of them keys your contrast payments to a Medicare indicator that splits the same tracer down the middle.
Subscribers - Aug 154 min read
The Prior Auth Registry Nobody Was Required to Build
CMS-0057-F made 1,378 health plans post their CY2025 prior authorization numbers on their own websites and created nowhere to put them. An independent site has collected 1,276 of those filings, plan by plan, with the source document behind every record. We tested its UnitedHealthcare entries against the filing we parsed ourselves last week.
Free - Aug 156 min read
Nine Overpriced Drug Codes, and CMS Won't Say Which
On August 10 the OIG told CMS that nine Part B drug codes are priced high enough to qualify for a payment cut, then sent the list over by secure file transfer. If one of them is on your buy-and-bill shelf, the payment limit drops at least 7.5% the quarter the substitution lands, and the only public warning is the file itself.
Subscribers - Aug 155 min read
How a Coverage Fix Becomes a Rejection Edit
CMS rescinded and replaced two quarterly NCD change requests on Thursday. One writes a return-as-unprocessable edit into the defibrillator NCD and backdates a place-of-service fix to October 2023, which is two years past the point where you can bill it. The other deletes an eleven-year retroactive payment instruction seven weeks before it was due to install.
Subscribers - Aug 146 min read
Who Decides How Often You Can Bill 77436?
Aetna's August bulletin caps the new superficial radiation planning code at one payment per course starting November 1. The device vendor's own coding desk has been telling practices to bill it every fraction, and Medicare's edits do not stop either reading. On a twenty-fraction course the answer is worth $1,491.
Subscribers - Aug 143 min read
51 Markets Hit the Wage Index Cap, and Everyone Paid
The FY 2027 SNF wage index falls more than 5% in 51 of 468 areas, so Medicare's permanent cap holds every facility in them at exactly a 5% drop. Statute makes that cap budget neutral, which means the rest of the country funds it, and the deferred cut comes back next October.
Free - Aug 134 min read
Who Grades Your Price File Before CMS Does?
CMS publishes the machine-readable file spec and the program that grades it in the same place, under a public domain dedication: npm install -g @cmsgov/hpt-validator-cli, point it at your own file, get the error list before a compliance reviewer does. Ten people have starred it.
Free - Aug 134 min read
Two Codes Carry 95% of Medicare's New Denials
CMS posted the CY2025 Physician/Supplier Procedure Summary on Tuesday. Medicare denied 15.68% of submitted Part B service units last year against 10.89% the year before, and two intermittent-catheter codes account for 94.9% of the increase. The specialty split says whose money it is.
Subscribers - Aug 135 min read
Medicare Will Not Call You About the Last APM Bonus
CMS published the 2026 APM incentive advisory Thursday: the final lump sum in the program's history, 1.88 percent of a qualifying clinician's 2025 professional charges, sitting undisbursed because the agency cannot match a tax ID to the clinician who earned it. Nothing gets mailed, nobody gets called, and on October 13 the claim is forfeited. Four other CMS clocks stop the same day, and the one that matters most closes sooner.
Subscribers - Aug 123 min read
Medicare Has Five Prices for an Hour of Your Time
Fifteen CMS rules published since April all price a manager hour off the same BLS occupation code, 11-9111. They land on five different numbers, from $96.36 to $135.54, and four of the five are exactly the four cells of a two-by-two: May 2024 or May 2025, mean or median.
Free - Aug 126 min read
How CMS Moved Your Recoupment Date Past the Interest Line
On January 4, recoupment on Part A cost report overpayments stops starting on day 16 and starts on day 41. Interest still starts on day 31, at 11.875%. CMS calls it burden relief, and the 25 extra days pay for themselves only if the cash earns 14.4 percent.
Subscribers - Aug 127 min read
280 Hours to Rebuild a Medicaid Benefit in Every State
CMS-2451-F ends federal matching for a defined category of Medicaid and CHIP services on October 13, publishes no code list, and scores the national implementation burden at 280 staff hours and $28,394. Three-quarters of the spending it reaches moves on outpatient pharmacy claims that carry no diagnosis.
Subscribers - Aug 113 min read
The Reassignment Map Medicare Gives Away
CMS publishes the full reassignment graph of Part B once a month, free and without an account: 3,373,759 rows tying 1,692,686 practitioners to 205,490 billing groups, with both revalidation clocks printed next to each other. Half of those groups have exactly one person in them.
Free - Aug 115 min read
How a Maintenance Update Reopens Three Years of Claims
CMS issued two NCD coding change requests on August 7, both stamped effective January 1, 2027. Not one of the fourteen edits inside them takes effect on that date, one reaches back to October 2023, and the two halves give your MAC different orders on whether to fix the claims it already denied.
Subscribers - Aug 113 min read
Home Health's $4.9 Billion Still Has No Due Date
CMS told home health agencies last December it would consider a schedule for collecting the PDGM balance. The CY 2027 proposed rule prices that balance at $4,908,531,936, proposes a second straight year of 3 percent, and says it is not establishing a timeframe. Comments close August 31.
Subscribers - Aug 105 min read
Who Is Paying for the Dialysis Raise?
CMS proposes a $17.84 increase to the ESRD base rate for CY2027. Phosphate binders account for $16.06 of it, and a rebuilt low-volume adjustment charges every facility above 8,000 treatments $3.34 a treatment to fund the ones below. Comments close August 24.
Subscribers - Aug 103 min read
The Contracts That Ask the Most Say No the Least
UnitedHealthcare's first filing under the CMS prior authorization transparency rule covers 8.6 million requests across 63 Medicare Advantage contracts. The blended denial rate is 12.9%. The contract-level rate runs from 1.9% to 23%, and the spread has a mechanism behind it.
Free - Aug 106 min read
Medicare Priced Your Prior Auth at $22.14
CMS wants prior authorization on eight more botulinum toxin codes starting July 1, 2027, and the proposed rule prints its own cost model. Here are the codes, the arithmetic, and the lines the model leaves out.
Subscribers - Aug 94 min read
The Rate Sheet Your Competitor Already Published
Trilliant Health consolidated every hospital machine-readable file it could parse into one free DuckDB lake: 7,698,910,156 negotiated rates this morning, no license and no sales call. Nine of every ten files are on the CMS 3.0 template, which is the version that carries real remittance-derived allowed amounts.
Free - Aug 93 min read
The 24 Percent Margin Medicare Just Gave a Raise
MedPAC voted 17-0 in March to cut base rates for skilled nursing, rehab and hospice. Every one of those settings got 2.3 or 2.4 percent in the FY 2027 final rules that finished landing Tuesday. We price the distance between the votes and the rules at about $4.3 billion for one fiscal year, and show where it sits.
Subscribers - Aug 95 min read
Device Makers Move to the Front of the Coverage Line
CMS filed a new device coverage pathway at 4:15 on Friday afternoon: a proposed national coverage determination the same day FDA authorizes the device, and the two-year-old TCET pathway closed to new candidates. In the same week, its own auditor asked for a national policy on sacroiliac joint injections and CMS said no.
Subscribers - Aug 83 min read
Who Ordered the Catheters?
Urological supplies just became the largest improper payment line in DMEPOS: 74.1% and $885.8 million, more than triple the year before. CMS's own table says the rate turns almost entirely on who is listed as the referring provider, and the compliance page a supplier would go read still quotes last year's number.
Free - Aug 86 min read
How Three Sessions a Quarter Became Three a Year
Novitas and First Coast rewrote their trigger point injection LCDs with identical text, effective September 6. The session count in the policy is unchanged. The window it sits in went from three months to twelve, and four other things stopped being covered on the way.
Subscribers - Aug 85 min read
Anthem Brings the ED Leveler to Ohio Medicaid
Policy G-19002 has run on Anthem's Medicare Advantage book since 2019 with four printed exclusions. The Ohio Medicaid version lands November 1 and prints none of them, and the prudent layperson rule everyone reaches for does not reach a downcode.
Subscribers - Aug 75 min read
Four Error Rates Went Up, and So Did Every Target
HHS's own auditor says Medicare Advantage's improper payment rate rose to 6.09 percent and the RADV audits meant to claw it back have returned nothing yet. Plus two home health survey tags that took effect the day they were written, and the change request that puts Medicare's prior authorization denial reason into the beneficiary APIs.
Subscribers - Aug 74 min read
CMS Just Published Everyone's ABA Rates
The new state toolkit for applied behavior analysis runs 173 pages, and the last appendix is the part to keep: reported 2025 Medicaid fee-for-service rates by state and CPT code, verified against paid claims. The assessment code spans six to one.
Free - Aug 74 min read
8% of Practitioners, 18% of the RVUs
CMS quietly published a spreadsheet showing how the CY 2027 fee schedule lands on individual practitioners rather than on specialty averages. Count practitioners and 8.3% take a cut deeper than 2%. Count RVUs and it is 17.6%, roughly $15 billion of the fee schedule. The specialty average everyone quotes is published as five TIFF images.
Subscribers - Aug 67 min read
What Happens When the Speech Eval Slips Past Noon?
CMS made one word plural in the IRF basis-of-payment regulation and turned a therapy-scheduling detail into a condition of coverage for the entire stay. Two clocks, both effective October 1, both counting from different moments. The only dollar figure the agency ever attached to the package is $399.06 a week.
Subscribers - Aug 66 min read
How One Nursing Home Visit Got Two Medicare Rates
The CY 2026 facility practice expense cut split nine nursing facility E/M codes by the beneficiary's Part A status, so the same visit pays two rates depending on who is covering the bed. We priced the gap at $423 million on CMS's own utilization weights. The CY 2027 proposal closes it for these nine codes and asks, in the same section, whether facility practice expense should go to zero for everyone else.
Subscribers - Aug 64 min read
For the Median Nursing Home, the Quality Bonus Is a 1.4% Cut
FY 2027 SNF VBP score reports hit iQIES this week and the program now runs on eight measures instead of four. The FY 2026 results are public, and they show what the machinery actually pays: 78.6% of 13,900 SNFs got back less than Medicare withheld, and the median multiplier was 0.9864. Corrections close August 30.
Free - Aug 54 min read
What Does the Federal Record Say About Your Doctors?
CMS is running an open FHIR API over the national provider directory at directory.cms.gov, with 35.7 million rows and no login. Fifty-nine percent of it is the affiliation table, every practitioner record carries an HHS exclusion-list flag, and the Medicare Advantage plans feeding it now owe CMS a 30-day refresh clock and an annual accuracy attestation.
Free - Aug 55 min read
The Week CMS Put a Clock on Its Own Contractors
A rewritten provider-audit manual gives MACs 90 days to answer a reopening request and 18 months to settle an unaudited cost report, the first published deadlines that run against the contractor rather than you. Plus a Medicaid ABA toolkit that prices four years of growth at 421 percent and hands states the billing patterns to go looking for.
Subscribers - Aug 54 min read
One in Nine IRFs Would Have Missed the New Deadline
CMS just cut the post-acute quality reporting window from four and a half months to 45 days, in three final rules over five days, and wrote that it creates no additional burden. Its own compliance analysis inside those rules says 11.5 percent of IRFs and 5 percent of SNFs would not have made it. We price what a miss costs: about $388 a discharge.
Subscribers - Aug 46 min read
Medicare Might Not Take the New OB Codes at All
CMS overruled the RUC and added 15 percent to every labor and delivery code, then asked whether it should skip the CPT 2027 maternity restructure entirely and mint fifteen G-codes that keep the global package alive. Comments close September 14.
Subscribers - Aug 44 min read
Medicare Added $39 to the High-Dose Flu Shot
The 2026-2027 Part B vaccine allowances took effect Saturday. Fluzone High-Dose, Flublok and Fluad all went from $83.49 to $122.52 across two seasons, while the manufacturers' own reported contract price sat still at $86.23. Standard dose moved by cents, and all six COVID-19 codes are still blank.
Free - Aug 46 min read
How an MA Readmission Lands on Your Fee-for-Service Check
On October 1, Medicare Advantage patients enter all six readmission measures and the applicable period drops from three years to two. The dollars the penalty gets applied to stay fee-for-service. We price the asymmetry, take apart the new sepsis measure, and map the rest of the measure stack running the same change.
Subscribers - Aug 34 min read
What Happens to the Hospice Cap Money Nobody Collects?
The FY 2027 hospice aggregate cap published this morning at $36,174.75, $35.36 below what CMS proposed in April. MedPAC now puts 28% of hospices over the cap, about $750 million a year in overpayments, and OIG audits of the three MACs that collect it found between 4% and 27% of the money written off as uncollectible.
Subscribers - Aug 35 min read
The Reminder Buried in UnitedHealthcare's August Bulletin
Seven days across the payer bulletins and the CMS manual system: 93 revenue codes become conditional on October 1, the AMA retires the global obstetric package, and nine UnitedHealthcare spine and joint policies land on a single September date. Every change, its effective date, and who it hits.
Subscribers - Aug 34 min read
How a Once-in-a-Lifetime Test Got Billed 520 Times
CMS put its analytics, OIG's exclusion authority and state payment suspensions in the same room in April. Eighty-eight days later it published the scoreboard: 50 providers, $203.3 million, and one lab that billed a once-in-a-lifetime gene test over and over on the same 520 people.
Free - Aug 24 min read
Ten Years of 2016 Lab Prices End on January 1
The Medicare clinical lab fee schedule has been priced off private payor rates collected in the first half of 2016, and hasn't moved a dollar since 2020. The reporting window that resets it closed Friday. Starting January 1, rates can fall 15% a year for three years, and the book of business underneath them looks nothing like it did in 2016.
Free - Aug 27 min read
How a Missing Sign Becomes an Overpayment
CMS wants every Medicare revocation ground to reach back to the day compliance broke, and it wants your last claims filed within 15 days of the letter. The enrollment half of the home health rule applies to every provider type, and comments close August 31.
Subscribers - Aug 26 min read
Half of CJR-X Savings Is a Check You Write
CMS made joint replacement bundles mandatory and national on Friday, starting January 1, 2028. The rule projects $736 million in Medicare savings across five years. Its own table shows participants repaying $1.855 billion and collecting $1.463 billion back, and the sensitivity analysis books savings even if nobody changes anything.
Subscribers - Aug 14 min read
Who Eats the Other 35% of an NTAP Case?
CMS approved 19 technologies for new technology add-on payments in the FY 2027 inpatient final rule, and priced each one. A single drug is $455 million of the $899 million. The add-on tops out at 65% of what that drug costs, which leaves $154,581 a case sitting inside the MS-DRG payment.
Subscribers - Aug 15 min read
The Downcode Record: What July Actually Cost
The record opens here. Four FY 2027 final rules added $2.04 billion to Medicare post-acute payment in the last week of July. The proposals still open take $5.5 billion out in year one, and the Medicaid provider tax rule another $246 billion over a decade. Every change the desk tracked in July, priced, with the date it starts.
Subscribers - Aug 14 min read
How PEPPER Got Rebuilt
The free CMS report that tells a facility where it sits against its peers on the metrics auditors use went dark in 2023. A small Maryland contractor has been putting it back one facility type at a time, and the last of them lands in September.
Free - Jul 314 min read
Why Your IDR Recovery Timeline Is Out of Date
The Departments released the second-half 2025 federal IDR public use files on July 22. The share of payment determinations landing inside 30 business days went from 29% to 62% in a year, the default wins that padded provider win rates are thinning, and the operations rule takes effect August 3.
Free - Jul 316 min read
The 11.6% Inside a 2.4% Outpatient Update
CMS summarized the CY 2027 outpatient proposed rule as a 2.4% update. The conversion factor moves from $91.415 to $102.004, because paying 340B drugs at ASP minus 33.4% pulls $4.85 billion out of drug payment and statute puts it back into everyone's non-drug rates. The agency's own impact model puts 13.4 points between for-profit and major teaching hospitals.
Subscribers - Jul 315 min read
CMS Spent the Week Adding Paperwork
Seven days on the CMS docket: 22 HCPCS codes pick up a face-to-face requirement, eight pick up prior authorization, and the FY2027 SNF and psych final rules landed. Every change, the codes it touches, and the dates that start the clock.
Subscribers - Jul 283 min read
How We Catch the Change Nobody Announced
The policy changes that cost the most rarely come with a press release. The Downcoded method, end to end: where changes surface, how the diff works, and how a diff becomes a dollar figure.
Free - Jul 243 min read
The Senate Wants the Algorithms
Blumenthal and Hawley gave UnitedHealthcare, Humana, and CVS until Monday to hand over their denial-algorithm inventories. We read the record already on the table, and what a revenue-cycle lead should do with it now.
Subscribers - Jul 214 min read
What Happens When Your Hospital Quits Medicare Advantage?
More than 20 health systems have dropped or narrowed MA contracts this year, and insurers pushed 2.9 million members off their plans. We trace what an exit market does to the revenue cycle on both sides of the divorce.
Subscribers - Jul 184 min read
The 56 Cents Coming Out of Every RVU
CMS proposes a $32.84 conversion factor for CY2027, down 1.68%. We price the cut by practice shape, read the specialty impact tables, and set the September 14 comment clock.
Subscribers - Jul 163 min read
Why We Price the Paper Trail
Downcoded machine-reads the documents payers already publish, diffs every one against its prior version, and models what each change costs by specialty. An introduction to the desk and the record it keeps.
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