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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November 2025

OPPS Final Rules for 2026

Last week, the Centers for Medicare & Medicaid Services (CMS) released the Final Rule 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: For CY 2026, CMS increased payment rates under the OPPS and the Ambulatory Surgical Center (ASC) Payment System by 2.6%. This increase factor is based on a hospital market basket percentage increase of 3.3%, reduced by a productivity adjustment of 0.7 percentage points. This update is slightly higher than the proposed 2.4% update. Based on the finalized policies, CMS estimates that total payments to OPPS and ASC providers (including beneficiary cost-sharing and estimated changes in enrollment, utilization, and case-mix) for CY 2026 will be approximately $101.0 billion and $9.2…

October 2025

Modifier 25 E/M: Ball of Confusion

For the past 20 years, the most asked question from all of my readers is--what documentation do I need to justify a separate visit with drug admin or with a minor procedure? I am not an expert on minor procedures, but with drug admin, the origin of the Modifier 25 requirement was when CMS decided to no longer allow a 99211 to be coded with it. The Medicare national average value of the Work Relative Values in 96365, for example, is $6.79. That does not imply much professional time (or even staff time, for that matter). Still, I have folks saying that all visits are bundled in and that the patients must be seen on a different day. EEEEK! Here are some things to be aware of (denial rates based on our claims data in focalPoint®): Most of the time, large payers DO NOT deny claims for E/M visits on the date of drug admin. Traditional Medicare has a less than 5% denial rate; CVS/AETNA is 5.28%; United is 7.46%; Humana is 9.36%; and CIGNA is 9.92%. The denial average for all drugs in our…

October 2025

Medicare Telehealth On Hold: What You May Bill

Telehealth is defined as real-time audio-visual services. This is like video conferencing with your patients. Some services can be offered VIRTUALLY, meaning your staff and your patients do not have to meet in real time, either via synchronous audiovisual software or in person. As a public service, I want to remind you of services that you probably ignored when telehealth became so popular. Here are some codes that most specialties can bill, and Medicare covers. Care Management (99490, 99439, 99491, 99437, 99487, 99489, 99424-99427, 99495, 99496)--Many of you are already billing these services with success. But if you have been putting off adding these services, now might be a good time to put your toe in the water and try them. RPM/RTM (99453, 99445, 99454, 99470, 99457, 99458, 99091, 98975, 98984, 98976, 98985, 98977, 98986, 98978, 98979, 98980-98981) As we said previously, in 2026, you will not have to do 16 days or more of monitoring to bill these services. Plus, many new devices…

October 2025

CPT Updates (Ho Hum)

The CPT update involves 418 total changes, which include 288 new codes “designating the latest advances in medical, surgical and diagnostic services available to patients,” 84 deletions and 46 revisions, an AMA press release said . For once, there are no E/M changes, except for Remote Physiological Monitoring. There are also no drug administration changes. The changes, effective January 1, 2026, include six new codes created to report remote monitoring services over 2-to-15-day periods (instead of ≥ 16 days) within a 30-day period and two new codes that report remote monitoring of treatment management after 10 minutes of service per calendar month, down from the previous 20-minute threshold. The new codes include the following: 99445: Remote Physiological Monitoring, device supply with daily recording(s) or programmed alerts transmission, 2-15 days in a 30-day period. 99470: Remote Physiological Monitoring, treatment management services, clinical staff/physician/other qualified…

October 2025

TrumpRx: What Are We Talking About Here?

Recently, the Trump administration unveiled a new drug pricing initiative, widely referred to as “TrumpRx.” TrumpRx (reportedly operational in January 2026) is defined by two key aspects: (1) a government-run portal aimed at directing patients to a website to purchase drugs (without going through their insurance) at discounted rates set by the government; and (2) tactics designed to force concessions from drug manufacturers. While the headlines surrounding TrumpRx amplify its hype, the reality is more complex (maybe)—and the expected ramifications will affect pharmacies, plan sponsors, and Pharmacy Benefit Managers (PBMs). This article outlines the administration’s actions towards drug pricing thus far and what TrumpRx could mean for the pharmaceutical marketplace. The Portal As noted, TrumpRx is characterized by: a government-run portal that may send patients to manufacturers’ DTC websites to purchase medications without using their insurance, and trade and pricing tactics that…

September 2025

Hospital Outpatient Drug Changes Q4

As you are aware, the Hospital Outpatient Fee Schedule changes for a subset of drugs every quarter. For drugs administered on or after October 1, 2025, the changes to the drug listed in Transmittal 13425, Change Request 14223 , are provided below. New COVID Antibody Products and Antibodies Codes Effective August 27, 2025, CMS is retroactively changing the code’s status indicator from E1 (Not Paid) to L (Not paid under OPPS. Paid at reasonable code; not subject to deductible or coinsurance) in the October 2025 Integrated Outpatient Code Editor (I/OCE). M0237-M0238 are status indicator S, meaning not subject to multi-procedure reduction, effective 1/24/25. Q0237 — Injection, tocilizumab-anoh, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg M0237 — Intravenous infusion, tocilizumab-anoh, for hospitalized adult…

September 2025

Older but not Wiser

In June, the Centers for Medicare & Medicaid Services (CMS) announced a new six-year Innovation Center model called the Wasteful and Inappropriate Service Reduction (WISeR) Model . The model establishes new prior authorization or post-payment review requirements for a subset of items and services in Traditional Medicare. Oh joy--this oughta be as much fun as the RACs!!! CMS will partner with companies that have "experience managing prior authorization processes, including utilization management contractors or Medicare Advantage (MA) plans, to apply for model participation". WISeR will run for six performance years from January 1, 2026, to December 31, 2031, in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. The application period opened on June 27, 2025. WISeR will test the use of technologies, including artificial intelligence (AI), for reviews on the designated services, beginning on January 1, 2026. The proposed initiative represents a significant…

September 2025

Trump Talk: A Regulatory Update

While my friends out there know a little about my politics, this article is not a commentary. There are so many things going on right now, I decided to bundle them all into one article. You can also pick and choose which topics interest you the most and ignore the rest. Actually, most of these should be important to most of my readers. A lot is coming down the pike. Here are the highlights of what's currently happening. Shutdown We currently do not have any agreement on a Continuing Resolution. This means that the government could shut down at Midnight on October 1. Last Friday, the House proposed a short CR that would keep everything open until November 21 . The Senate summarily defeated it as negotiations rolled along. Democrats have put forward an alternative that would extend funding through October 31 and add more than $1 trillion to extend Obamacare ("ACA") subsidies that are set to expire at the end of the year and roll back Medicaid and other health program cuts that…

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…