Bobbi Buell's Newsletter

Roberta L. Buell is a Principal at onPoint Oncology Inc., specializing in oncology reimbursement. With over 23 years of experience in billing, coding, and drug therapy reimbursement, she's a nationally recognized expert and frequent speaker on regulatory and reimbursement issues. Bobbi has led more than 600 seminars since 1991 and currently serves as content director for focalPoint® and assistPoint®. Learn more about Bobbi here .

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July 2025

OPPS Proposal for 2026

Last week, the Centers for Medicare & Medicaid Services (CMS) released its proposal for The Hospital Outpatient Prospective Payment System (OPPS) for calendar year 2026. The proposed rule includes several proposals that would reduce Medicare funding for some services provided by hospital outpatient departments. The following paragraphs summarize the "highlights" of this proposal. Conversion Factor: There is a 2.4 percent payment rate increase for hospital outpatient departments and ASCs. The payment update includes a 3.2 percent increase in the hospital market basket percentage, along with a 0.8 percentage point productivity adjustment. This payment update is slightly smaller than the 2.9 percent increase for 2025. Site-Neutral Payment for Drug Administration Services: CMS is proposing to extend site-neutral policies to drug administration services in hospital provider-based departments (PBDs), previously referred to as off-campus provider-based departments. CMS proposes to…

July 2025

The Proposed Medicare Part B Rules 2026

On July 14, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2026 Medicare Physician Fee Schedule (PFS) proposed rule . This release represents the Trump administration’s first opportunity to enact Medicare payment policies that directly impact hundreds of thousands of physicians and other clinicians. CMS presented the reading public with 1800 pages of information--but there are a few themes to watch--reduction of the site of service differential between offices and hospitals, trashing of anything related to the social and financial disparities in healthcare, and insertion of 'health and wellness' into quality programs. Here is a summary of the proposal's key points. The conversion factor update: The conversion factor (CF) is the standardized dollar amount used to convert relative value units (RVUs) into allowed payment rates. Despite rising practice costs and inflation, the CF has been reduced over the last five years due to policy and budgetary…

July 2025

2026 Code Changes to Remote Monitoring

Have you been wanting to do Remote Patient monitoring but the 16-day rule is way too much?? Take heart, here come some changes you just might love. On October 18, 2024, the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Editorial Panel released a Summary of Panel Actions from its September 2024 Panel Meeting, which includes six new remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) codes in addition to revisions to the existing codes. Effective January 2026, these changes include removing the current requirement for healthcare providers to receive 16 days’ worth of data to bill RPM codes. The AMA CPT Editorial Panel likely made these updates in response to stakeholder feedback that the 16-day billing threshold was not necessary in certain clinical use cases. Additionally, two new codes will reimburse providers for 10-19 minutes of managing RPM or RTM data in a month. Over the past few years, there is data indicating that…

July 2025

Hospital Outpatient Drug Changes Q3

As you know, the Hospital Outpatient Fee Schedule changes for a subset of drugs each quarter. For drugs given on or after July 7, 2025 (accounts for the holiday), the drug changes documented in Change Request Transmittal 13258, Change Request 14091 , are listed below. Just a note--many COVID vaccines and antibodies have been removed from OPPS. New HCPCS Codes Gaining Pass-Through Status C9174 Injection, datopotamab deruxtecan-dlnk, 1 mg C9175 Injection, treosulfan, 50 mg J9174 Injection, docetaxel (beizray), 1 mg J9220 Injection, indigotindisulfonate sodium, 1 mg J9289 Injection, nivolumab, 2 mg and hyaluronidase-nvhy J9382 Injection, zenocutuzumab-zbco, 1 mg Q5100 Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg Existing HCPCS Codes Gaining Pass-Through Status J9038 Injection, axatilimab-csfr, 0.1 mg J9249 Injection, melphalan (apotex), 1 mg Q5152 Injection, eculizumab-aeeb (bkemv), biosimilar, 2 mg HCPCS Codes Losing Pass-Through Status A9596 Gallium ga-68 gozetotide…

July 2025

Payers Say They'll Reform Prior Auth

On June 23, health insurance plans announced a series of alleged commitments to streamline, simplify, and reduce the burdens imposed by prior authorization . Responding to complaints and extensive surveys by the American Medical Association, these new actions aim to get patients to treatment more quickly while reducing the paperwork and appeals that weigh heavily on providers. Before you believe any of what we outline below, consider the source. These supposed 'commitments' are being implemented across insurance segments, including Commercial, Medicare Advantage, and Medicaid Managed Care, while maintaining compliance with state and federal regulations, and will reportedly benefit 257 million Americans..” Participating health plans say they are going to: Standardizing Electronic Prior Authorization. Participating health plans will collaborate to implement standardized, transparent submissions for electronic prior authorization. This includes the development of standardized data and…

July 2025

Bodacious B. S. Bill: Signed by the Senate

I have held off on publishing this new information until the Final bill is signed, but there is no June newsletter without this update. So, this is the latest update to the UNSIGNED bill. This is excerpted from the Senate Version of the Bill, which is expected to go to the House on July 2. There may be more changes, but we are not expecting big ones. The Congressional Budget Office projects that nearly 12 million people would end up uninsured if the Senate bill becomes law. This is somewhat deceptive because some of the changes below do not take effect for several years; nonetheless, between Medicaid and the ACA changes, the current bill will leave a lasting mark on our healthcare system. And that doesn't take into account what will happen if PAYGO kicks in and we get more sequestration. That is up to Congress. Here are some of the changes in the Senate bill as recorded by the Kaiser Family Foundation . There may be more changes in the House, so stay tuned. Medicaid Changes Medicaid…