HCC Buddy CMS Watch

CMS WatchSeptember 6, 2026 · 4 min read

CMS opened PY2024 RADV audits built to extrapolate. Records are due February 5, 2027.

CMS released the Payment Year 2024 RADV audit methods on August 28, 2026. The audits are built to calculate extrapolated overpayments, the enrollee data list drops September 11, and medical records are due February 5, 2027.

A spotlight and magnifier over stacked Medicare Advantage medical-record folders beside a calendar, marking the PY2024 RADV audit deadline.

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A printed clinical query practice brief on an outpatient clinic desk beside a laptop and clipboard, the new 2026 ACDIS/AHIMA query standard.

The 2026 ACDIS/AHIMA query standard is final: the outpatient and HCC query rules it sets

September 5, 2026 · 5 min read

A printed Medicare Physician Fee Schedule worksheet highlights the October 2026 MPFSDB CR 14588 status-indicator and HCPCS rows.

CMS October 2026 MPFSDB CR 14588: 10 J-codes not valid for Medicare October 1

September 4, 2026 · 6 min read

A gavel and a stack of Medicare chart folders beside a calculator, the risk-adjustment diagnosis coding at issue in the Monogram Health settlement

Monogram Health to pay $2.4M over four flagged HCCs; malnutrition and stable angina no longer map under V28

September 3, 2026 · 6 min read

A hospice claims worksheet marks HCPCS G0679 for a telehealth face-to-face recertification encounter under revenue code 0657, January 2027.

Hospice G0679: report telehealth F2F recertification on claims from January 1, 2027

September 3, 2026 · 3 min read

Tied stacks of medical file folders with colored page flags and a red pen beside a brass justice scale, evoking The Villages Health Medicare Advantage FCA settlement.

The Villages Health's $541.5M FCA Settlement: What Makes a Record Amendment an Invalid Diagnosis

September 3, 2026 · 4 min read

A claims worksheet highlights CR 14464 October 2026 NCD ICD-10 coding revisions for PET tracers, 0554T-0558T, and 0648U.

CMS October 2026 NCD CR 14464 adds PET tracers, 0554T-0558T, and 0648U

August 31, 2026 · 5 min read

A claims worksheet highlights CPT 0421U ColoSense under NCD 210.3 non-invasive biomarker colorectal screening.

CMS NCD 210.3 adds ColoSense (0421U) for colorectal screening

August 28, 2026 · 4 min read

A SNF billing worksheet marks therapy HCPCS as removed from Part B File #1 and kept on File #4 in the October 2026 SNF CB update.

October 2026 SNF CB update: therapy codes stay on File #4

August 27, 2026 · 4 min read

A lab chargemaster worksheet marks October 2026 CLFS new PLA codes as contractor-priced until nationally priced, effective October 1, 2026.

October 2026 CLFS update: new PLA codes are contractor-priced

August 26, 2026 · 3 min read

A coder's October 2026 HCPCS worksheet adds G0685 for algorithm-based ASD assessment, effective October 1, 2026.

October 2026 HCPCS file adds G0685 for algorithm-based ASD assessment

August 25, 2026 · 3 min read

A coder's FY 2027 ICD-10-PCS worksheet adds XW0U3CC and XW0U4CC from the MS-DRG Version 44 errata, effective October 1, 2026.

CMS FY2027 MS-DRG V44 errata adds 2 ICD-10-PCS codes on October 1

August 24, 2026 · 3 min read

A dictation microphone beside a chart folder with one file card pulled out, showing an ambient AI note that omits a condition.

Ambient AI scribes omit more than they invent, and an omitted chronic condition is a lost HCC

August 21, 2026 · 6 min read

A hospital billing worksheet marks MS-DRGs 210, 211, and 449 as added to the FY 2027 replaced-device credit list effective October 1, 2026.

FY2027 IPPS adds 3 MS-DRGs to the replaced-device credit list on October 1

August 21, 2026 · 3 min read

$Unmarked claim folders and an unlabeled vial on a billing desk, standing in for CMS ASC Encelto J3403 fractionated-billing guidance.$

CMS: ASC Encelto claims use J3403, LU + 76, and 1 unit per eye per day

August 20, 2026 · 3 min read

A coder desk with a codebook, folders, and a highlighter, standing in for the January 2027 NCD ICD-10 coverage-edit update.

CMS January 2027 NCD CRs add FY2027 ICD-10 codes to coverage edits

August 19, 2026 · 4 min read

A coder desk with folders and a printed packet, standing in for the FY 2027 IPPS Table 6 files before October 1.

FY 2027 IPPS Table 6A-6K is posted. Download it before October 1

August 18, 2026 · 5 min read

A coder's CC/NonCC worksheet marks 10 housing-related ICD-10-CM Z codes changing from CC to NonCC on October 1, 2026.

FY2027 IPPS moves 10 housing Z codes from CC to NonCC on October 1

August 14, 2026 · 4 min read

Three labeled sorting trays and an open coding manual, illustrating how CPT Appendix S classifies an AI tool's role before it's coded.

CPT 2027 sharpens the AI taxonomy. How a tool's role is classified decides how it's coded.

August 14, 2026 · 5 min read

A coder's desk calendar marks the August 28 PY2020 RADV medical-record deadline as PY2024 audits start the same month.

PY2020 RADV records are due August 28. PY2024 audits start this month.

August 13, 2026 · 3 min read

A hospital health-information workstation with an abstract coding dashboard, marking Solventum's planned coding and CDI software separation.

Solventum plans to separate its coding and CDI software unit, home to 360 Encompass

August 10, 2026 · 5 min read

A fluoroscopy-guided spinal injection in a pain-management suite, the kind of sacroiliac joint procedure OIG audited for documentation.

OIG: Medicare improperly paid $15.2M for sacroiliac joint injections; 72 of 100 sessions missed the LCD

August 5, 2026 · 5 min read

A signed state legislative bill beside a stack of medical claim forms, marking new 2026 laws that restrict AI-only claim downcoding.

New state laws bar AI-only claim downcoding: Indiana live July 1, Illinois signed July 10

August 5, 2026 · 4 min read

A wooden gavel resting on stacked patient chart folders, the risk-adjustment coding conduct at issue in the Complete Health settlement

Complete Health to pay $14.1M; MSO allegedly prompted doctors to add unsupported HCC diagnoses

August 3, 2026 · 6 min read

An ultrasound machine and eye-exam chair beside a wooden gavel, the diagnostic-test billing at issue in the ophthalmology settlement

Two ophthalmology practices pay $2.3M over allegedly false diagnoses billed for transcranial Dopplers

July 31, 2026 · 4 min read

Rural clinic billing desk with a headset and an October wall calendar, illustrating the RHC and FQHC telehealth switch off code G2025.

CMS retires G2025 for RHC and FQHC telehealth on October 1: bill the individual code plus a modifier

July 31, 2026 · 4 min read

Genetic-testing sample vials and a DNA helix model beside a wooden gavel, the lab billing at issue in the Access DX settlement

Access DX will pay $36.4M over alleged genetic-testing kickbacks and unbundled billing codes

July 31, 2026 · 4 min read

A manual wheelchair and a spinal back brace beside a clipboard and paperwork, illustrating the CMS DMEPOS prior authorization requirement.

CMS adds 8 DMEPOS codes to its prior authorization list and 22 to the face-to-face list, effective October 28

July 30, 2026 · 5 min read

A printed clinical query form and a magnifying glass on a desk beside a laptop, the human review the draft brief requires for an AI-generated query.

Draft ACDIS/AHIMA brief: AI-generated queries must meet the same compliance rules as human queries

July 29, 2026 · 4 min read

A magnifier over billing statements and a calculator, the records behind an OIG audit of Part B payments that exceeded billed charges.

OIG: WPS overpaid providers $140K on 138 Part B lines that paid more than the charge billed

July 28, 2026 · 4 min read

Operative-report folders and a magnifying glass on a desk beside a laptop, illustrating exact-match CPT coding accuracy testing of AI tools

General-purpose AI coded complex surgery at 5% to 12.5% exact-match, a new study reports

July 28, 2026 · 6 min read

Blank lab requisition clipboards beside sealed specimen tubes in a frosted freezer rack, evoking the Magnolia respiratory panel settlement

Magnolia Diagnostics will pay $24M to resolve claims its COVID tests carried unneeded respiratory panels

July 28, 2026 · 4 min read

Exam-room desk with an ambient recording mic beside an open EHR laptop and a chart folder, where AI scribes and prompts surface diagnoses.

OIG's first MA compliance guidance since 1999 names AI EHR prompts: verify every AI-surfaced diagnosis

July 26, 2026 · 4 min read

Editorial photo of a magnifier over stacked claim folders beside a laptop, signaling the rise in payer coding audits and denials.

Coding errors now drive nearly 7 in 10 completed payer-audit denials, MDaudit reports

July 26, 2026 · 4 min read

Printed billing spreadsheet and a records folder under a magnifying glass, the kind of self-audit a PEPPER target area review starts with.

PEPPER relaunch wraps in September, and staff coders can now download the report themselves

July 22, 2026 · 3 min read

A packed card-index drawer with the cards at the back falling into shadow, standing in for the rare-code tail an automated ICD coding system misses.

An ICD coding model scored 0.709 on a 50-code subset and 0.527 across all 15,761 codes

July 22, 2026 · 4 min read

A rack of empty blood collection tubes on a lab counter beside a paper wall calendar, illustrating new payer lab test frequency limits

UnitedHealthcare commercial adds five lab policies September 1, and four cap how often it will pay

July 21, 2026 · 6 min read

A dictation microphone beside a closed patient folder and a red pen, illustrating diagnostic uncertainty lost when AI rewrites a note

AI summaries often drop a note's diagnostic hedges. Outpatient rules make that a coding problem.

July 21, 2026 · 6 min read

Chart folders and a clipboard at a nursing facility nurses station, the kind of records behind an OIG audit of nursing home Part B billing.

OIG: 91 of 150 nursing home Part B patient-months missed Medicare requirements at Novitas

July 21, 2026 · 6 min read

Tabbed medical code books stacked on a desk beside a pencil, illustrating preparation for the AAPC CPC-M master coding credential exam

AAPC's new CPC-M exam puts reviewing AI coding output on the blueprint

July 20, 2026 · 4 min read

A magnifier resting on a printed report beside stacked chart folders, illustrating scrutiny of AI medical coding accuracy

GAO: AI coding tools may capture more diagnoses, and few studies have checked their accuracy

July 20, 2026 · 5 min read

A desk calendar and pen beside stacked chart folders, marking the CY2027 midyear risk adjustment timing shift for coders

CMS delays the audio-only and unlinked CRR exclusions to the CY2027 Midyear model run

July 20, 2026 · 5 min read

An optometric trial lens frame beside a stack of unlabeled record folders and a magnifying glass, for the SMRC nursing facility E/M review.

OIG flagged all 399 sampled optometry E/M lines. The SMRC is now reviewing 99309 and 99310.

July 19, 2026 · 5 min read

Scales of justice beside plain specimen cups on a courthouse bench, the urine drug testing billing at issue in the Labcorp settlement

Labcorp will pay $14.5M after admitting it billed 80307 and G0483 on the same urine sample

July 19, 2026 · 4 min read

A thick printed federal rule beside a September desk calendar and a percentage dial, illustrating the CY2027 Physician Fee Schedule proposed rule and its comment window

CMS's CY2027 PFS would halve the lower-cost same-day E/M or procedure, and turn G2211 into a modifier

July 18, 2026 · 6 min read

A thick unmarked rule document beside a folder of blank draft notes with a red review pen, illustrating CMS's proposed MIPS AI improvement activity and clinician review.

CMS proposes a MIPS activity for AI governance. Its example: AI-generated notes with clinician review.

July 17, 2026 · 5 min read

A thin chart folder flagged with a red tab beside a magnifier and an empty tray, illustrating how documentation gaps drive Medicare denials and paybacks.

Insufficient documentation leads Medicare's $28.8B improper-payment bill. It's the coder's fix.

July 11, 2026 · 5 min read

Labeled sorting bins beside a spilling stack of blank index cards, illustrating the gap between an ICD category and a specific billable code

An AI hit 91% predicting ICD categories. Its scoring counted sepsis for a UTI as correct.

July 10, 2026 · 6 min read

A stack of hospital discharge summaries beside a dark monitor, illustrating AI comorbidity extraction from clinical documentation

A new study graded an AI comorbidity reader against billing codes. Coders get graded against the note.

July 9, 2026 · 6 min read

Paper claim forms flagged with red tabs beside a rubber stamp and a July desk calendar, illustrating NCCI quarterly claim edit denials

CMS's July NCCI update adds 2,199 practitioner edit pairs. No modifier will bypass 424 of them.

July 9, 2026 · 7 min read

A desktop microphone beside a thick stack of paper chart folders and an empty steel tray, depicting AI documentation raising coding intensity without matching treatment

Coding intensity is climbing where AI documentation landed, and payers have started downcoding

July 8, 2026 · 6 min read

Stack of manila claim folders, a rubber stamp and a pen on a wooden desk, depicting WISeR prior authorization review of Medicare services

Medicare's WISeR AI prior-auth model still binds your claims while Congress moves to repeal it

July 8, 2026 · 6 min read

USB flash drive on manila chart folders beside a sealed letter, the Medicare Advantage diagnosis corrections behind the $342M overpayment

Elevance pays CMS $342M to avoid a Medicare Advantage risk-adjustment sanction

June 28, 2026 · 4 min read

Scales of justice beside a stack of closed, unlabeled folders, illustrating the Aetna False Claims Act risk-adjustment settlement.

Aetna pays $117.7M to settle FCA case over one-way chart reviews and unsupported obesity codes

June 6, 2026 · 5 min read

Doctor's bag, blood pressure cuff, and blank assessment forms on a kitchen table, the in-home visits behind the $56.5M FCA settlement

Matrix and HealthFair pay $56.5M over in-home assessment diagnoses the records didn't support

June 6, 2026 · 4 min read

Magnifying glass resting on a stack of medical record documents, depicting the OIG audit of unsupported acute stroke diagnoses

OIG: $462M in Potential MA Overpayments Tied to Unsupported Acute Stroke Codes

June 5, 2026 · 6 min read

A judge's gavel beside a stack of medical file folders, representing the Kaiser Permanente False Claims Act risk-adjustment settlement

Kaiser's $556M FCA Settlement: What the Addenda and Query Allegations Mean for Working Coders

June 5, 2026 · 6 min read

A smartphone face down beside a paper medical chart and stethoscope, depicting audio-only telehealth diagnoses excluded from MA risk scores

CY2027 Rate Announcement: Audio-Only and Unlinked CRR Diagnoses Out of MA Risk Scores

June 5, 2026 · 5 min read

Stacks of tabbed medical record folders piled on a government office desk, representing CMS RADV audits expanding to 550+ MA plans

550 Plans, Quarterly RADV Audits, Five Months to Submit: What the Jan 2026 CMS Memo Means at Your Desk

June 5, 2026 · 5 min read

Risk-adjustment enforcement and policy news for working coders.