CMS 2026 Billing Updates: What Your Practice Needs to Know
What’s Changing
New RPM / RTM CodesCMS finalized updates to its Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) code families.Specifically, two new CPT codes (99445 and 99470) address “less-than-full” data transmission cycles, reflecting more realistic patient adherence patterns.Code descriptors for existing codes like 99454 have also been clarified, especially around the required number of data transmission days in a billing period.Implication: If your RPM/RTM workflows don’t align with these usage patterns, claims could be at risk of denial or underpayment.ICD-10-PCS UpdateThe ICD-10 Coordination & Maintenance Committee’s Fall 2025 update proposes new and revised PCS procedure codes, potentially effective in April or October 2026.Action Item: Review these changes now to ensure your documentation and coding teams are ready — this could impact how procedures are reported and reimbursed.Prior Authorization EnhancementsStarting January 1, 2026, affected payers must adhere to strict timelines on prior authorization decisions: 7 calendar days for standard reviews, 72 hours for expedited cases.For denied authorizations, payers must provide specific reasons for denial, not just generic “insufficient documentation.”Why this matters: Ensuring clean, complete documentation before submission could drastically reduce denials and appeals.Quality Reporting & Practice Model AdjustmentsCMS is updating Promoting Interoperability (PI) measures and adding a new bonus measure around public health reporting via TEFCA.Six new MIPS Value Pathways (MVPs) are being introduced for 2026: Diagnostic Radiology, Interventional Radiology, Neuropsychology, Pathology, Podiatry, and Vascular Surgery.Impact: These changes will shift how quality is measured and could influence risk- or value-based payments.
Why Your Team Must Act Now
Coding & Billing Readiness: Update your code sets and train your billing team on the new RPM/RTM codes and PCS changes — misunderstandings could lead to under-coding or misbilling.Clinical Documentation: Revise your documentation templates to capture the right details (e.g., usage days, interactive communication) so claims are solid on submission.Pre-Authorization Processes: Review your prior authorization workflows to ensure documentation is robust and meets the new specificity requirements.Quality Strategy: Align your quality reporting and care models with the new MVPs and PI measures — this could affect both compliance and financial outcomes.
Bottom line: These coding and documentation updates aren’t just technical tweaks, they’re levers that will directly influence which claims get approved and how efficiently they flow through your revenue cycle. Reach out to D'Souza & Associates to prepare as the time is now!
