On July 14, the Centers for Medicare & Medicaid Services (CMS) released the 2027 Physician Fee Schedule Proposed Rule, introducing several significant coding and payment changes. One of the biggest updates involves the conversion factor, which last year was divided into two categories: one for Qualifying Alternative Payment Model (QP) participants and another for non-QP participants. While the statute continues to require a 0.75% update for QPs and a 0.25% update for non-QPs, the temporary 2.50% increase established under the Working Family Tax Cut (WFTC) expires at the end of 2026. As a result, the proposed 2027 conversion factor would decrease to $33.17 for QPs (a 1.19% reduction) and $32.84 for non-QPs (a 1.68% reduction).

The Centers for Medicare & Medicaid Services (CMS) released an updated version of the Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, effective March 13, 2026. Providers and suppliers must begin using the revised form no later than May 12, 2026. The ABN is issued to Original Medicare beneficiaries when a provider believes Medicare may deny payment for a service or item that is typically covered, allowing the patient to decide whether to proceed and accept possible financial responsibility.

There has been a significant and sustained increase in medical record requests from Medicare Advantage insurers for risk adjustment, aimed at finding additional diagnoses to reflect higher patient "sickness" scores and maximize payments. This practice, often labeled as "chart review" or "chart harvesting," has led to accusations of artificially inflating risk scores and, consequently, Medicare payments. Ultimately, this is not a provider issue, rather the Med advantage plans working to receive higher pay outs from CMS for the more chronic and sick conditions based on the prior implementation of risk adjustment that they benefit from.

After years of short-term extensions and looming deadlines, Congress has finally delivered a measure of stability for Medicare telehealth. The Consolidated Appropriations Act, 2026 (H.R. 7148), signed into law early February, retroactively extends the Medicare telehealth waivers that briefly expired on January 30, 2026, and continues those flexibilities through December 31, 2027. These waivers, first implemented in 2020 during the COVID-19 public health emergency, have become deeply embedded in how providers deliver care and how patients access it. The nearly two-year extension is significant because it reduces near-term uncertainty and allows providers to maintain current operations.

Significant changes to Medicare Advantage referral requirements are underway, and expectations are not consistent particularly when comparing two major Idaho payors - Blue Cross of Idaho (BCI) and UnitedHealthcare (UHC). Practices can no longer rely on assumptions and must verify the specific insurance product policy before determining whether a referral is required.

On October 21, the Centers for Medicare & Medicaid Services (CMS) released updated guidance to Medicare Administrative Contractors (MACs) regarding the processing of Medicare claims during the ongoing federal government shutdown. The American Medical Association (AMA) has been in active communication with CMS to help clarify previous instructions, as significant confusion had developed among providers about which claims were being processed and paid.

As of October 1, 2025, Medicare telehealth services have reverted to permanent statutory law following the expiration of the temporary waivers first established during the COVID-19 pandemic. Until the shutdown ends, Medicare’s telehealth coverage is again limited to patients located in rural areas and those receiving services in approved medical facilities rather than from home, except in certain limited situations. We highly recommend providers verify location eligibility.

In the CY 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule, CMS introduces a significant update to support the integration of behavioral health services within advanced primary care models. Specifically, the proposal outlines a new suite of G-codes, GPCM1, GPCM2, and GPCM3, intended to function as optional add-on services when billed in conjunction with APCM base codes (HCPCS G0556, G0557, or G0558) by the same practitioner during the same calendar month.

Since the release of visit complexity code, there has been confusion on its use and when it should be reported. HCPCS code G2211 is an add-on code to outpatient evaluation and management services only, CPT code sets 99202-99205 and 99211-99215. Other outpatient services and hospital E/M services are not applicable to the visit complexity add-on code.

Giving back to our GCS clients and community, we are delighted to sponsor this free webinar, Parenting for Resilience, January 16th at 6pm Mountain Standard Time. Join us for a Zoom presentation and discussion with Parent Coach and Therapeutic Consultant, Vashti Summervill.