Net spending on Medicaid outpatient prescription drugs grew substantially in recent years while the number of prescriptions paid by Medicaid only grew slightly, according to a recent issue brief from KFF.
CMS is signaling a clear shift in how it views risk adjustment, quality performance, and documentation integrity. For coding and CDI professionals, this moment represents not a threat, but a critical inflection point.
The phrase “don’t reinvent the wheel” applies well to the development of an outpatient CDI program when a mature inpatient CDI foundation already exists. The challenge is not whether the wheel can be reused, but how to navigate the differences.
Modifier -59 is used to describe a distinct procedural service. It’s appended to codes to identify procedures/services that are not usually payable when reported together. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient presents with acute respiratory failure with hypoxia due to an accidental heroin overdose. What is going to be sequenced first: the acute respiratory failure or the poisoning?
Changes to the Medicare provider-based billing requirements for off-campus outpatient departments are coming with the passage of the Consolidated Appropriations Act last month.
Modifiers -50, -RT, and -LT are laterality modifiers that clarify a CPT code by defining which side of the body the service was performed on. But knowing when to use them is not always immediately clear. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Radiation oncology is a specialty utilizing radioelements either externally or internally to treat medical conditions such as cancer. This article serves as a primer for coding radiation oncology services.
For CPT and ICD-10-CM coding of fracture treatment, coders—particularly those in orthopedic practices—need to identify several vital pieces of information from the physician’s note. This article covers the keys pieces of information and other tips to ensure accurate coding of fracture treatment.
Practitioners work hard, especially when they perform critical care services. Training clinical and coding staff with real-world examples can make sure providers get full credit for their work. Share this case with staff and ask them to decide what services can be reported.
The February 4 issue of CMS’ MLN Matters outlines the January 2026 update to the hospital OPPS, including COVID-19 CPT code changes; new HCPCS codes for drugs, biologicals, and radiopharmaceuticals; and new unlisted skin substitute product HCPCS codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Emergency department visits resulting in outpatient treatment increased sharply, while visits leading to inpatient admission did not—particularly among Medicaid patients—according to research recently published in JAMA Health Forum.
The CPT manual includes many types of biopsies: fine needle aspiration (FNA), core needle, and skin (tangential, punch, and incisional). This article focuses mainly on FNA biopsies and its complicated guidelines, while also touching on core needle biopsies.
A number of Medicare telehealth flexibilities extensions in place until January 30, 2026, lapsed during the partial U.S. government shutdown that began January 31, 2026.
The 2026 Outpatient Prospective Payment System final rule isn’t for the faint of heart. CMS finalized many of the major changes from the proposed rule, although the agency did pull back on certain key areas. With big shifts in compliance and reimbursement taking effect, coders have their work cut out for them.
