RCM Intelligence Articles

2026 Medicare Advantage Denials for Remote Physiologic Monitoring (CPT 99453‑99458): Navigating CARC 50 Medical Necessity Edits and Prolonged Monitoring Documentation Challenges

Medicare Advantage plans ramp up CARC 50 denials for RPM codes 99453‑99458 in 2026. Learn how to fight back with documentation and modifier logic.

2026 OIG and MAC Audits Target Chronic Pain Management: Defending CPT 64483‑64484 Epidural Injection Claims, Modifier 59 Usage, and Diagnosis Linking Integrity

OIG and MAC audits in 2026 are hammering pain practices over epidural injection claims, modifier 59 use, and ICD-10 linking errors.

2026 Medicare and Commercial Payer Repricing of Infusion Drugs: ASP + 6%, Sequestration Adjustments, and Contract Language That Protects Margin

2026 infusion drug reimbursements are shifting again. Here’s how to protect your ASP + 6% margin against sequestration and payer repricing traps.

2026 OIG and RAC Focus on Telehealth Frequency Audits: Defending Repeated E/M (99213‑99214) and Virtual Check‑In (G2012) Utilization Patterns

OIG and RAC audits in 2026 are targeting telehealth frequency, especially repeated 99213‑99214 and G2012 claims. Here's how to defend legitimate use.

Real‑Time Prior Authorization via FHIR APIs: How 2026 CMS and UHC Rollouts Reshape Radiology and Cardiology Workflow Efficiency

CMS and UHC’s 2026 real-time prior authorization rules force radiology and cardiology groups to rethink workflows or risk denied revenue.

2026 CMS and Commercial Payer Crackdown on Emergency Department E/M (99281‑99285): MDM Level Justification, Time Documentation, and Downcoding Defense Strategies

CMS and major payers are cracking down on 2026 ED E/M (99281‑99285) coding. Here’s how to defend MDM levels and avoid downcoding denials.

Defending Chronic Care Management (CPT 99490, 99439) Under 2026 RAC and Medicare Advantage Audits: Documentation, Time Logs, and Care Plan Integrity

RAC and Medicare Advantage audits are pressing hard on Chronic Care Management in 2026. Here’s how to defend CPT 99490 and 99439.

MDM vs Time-Based Coding for Hospital E/M (99221‑99223): Surviving 2026 Payer Audits on Prolonged and Split/Shared Documentation

Hospitals are getting hammered in 2026 audits over time-based and split/shared E/M coding. Here’s how to stop losing revenue on 99221-99223.

Modifier 25 Under Fire Again: 2026 BCBS and Cigna Policy Changes Denying Same‑Day E/M (99213) with Cryotherapy (17000)

BCBS and Cigna are once again denying same-day E/M 99213 when billed with cryotherapy 17000 using modifier 25 in 2026. Here’s what’s really happening.

TRICARE 2026 Prior Authorization Overhaul: How New Referral and Consult Rules Impact CPT 99244‑99245 Reimbursement and Network Compliance

TRICARE's 2026 prior authorization overhaul rewrites how referrals and consults affect CPT 99244‑99245 claims and network compliance.

Navigating 2026 MAC and UHC Audits on Incident‑to Billing: Defending Split/Shared E/M Claims and APP Supervision Documentation

2026 MAC and UHC audits are hammering practices over incident‑to and split/shared E/M claims. Here’s how to defend your APP supervision files.

Modifier 59 vs X-Modifiers Under Current NCCI Edits: CMS and Payer Divergence on Bundled Joint Injection (20610 + J3301) Claims

CMS says use X-modifiers for joint injections, but in 2026 many payers still reject 20610 + J3301 even with 59. Here’s what’s really going on.

Responding to 2026 CMS Overpayment Demands: Defending Shared‑Care and Transitional Care Management Claims (CPT 99495‑99496) Under the 60‑Day Rule

CMS overpayment letters in 2026 are hitting practices for TCM codes 99495‑99496. Here’s how to defend shared‑care claims under the 60‑day rule.

Anthem/Elevance 2026 cardiology reimbursement shifts: E/M downcoding trends and new global period edits impacting CPT 93000 and 99214 bundling

Anthem/Elevance 2026 cardiology policy updates cut E/M pay and bundle ECGs under new edits. Learn how to defend CPT 93000 and 99214 claims.

UHC and Aetna 2026 postpartum care denials: resolving CARC 50 medical necessity edits for CPT 59430 and global OB package overlap

UHC and Aetna are denying postpartum care claims under CARC 50 for CPT 59430, citing overlap with global OB packages. Here’s how to fix it.

RAC audits target infusion and injection billing: defending CPT 96365‑96367 drug administration documentation under 2026 CMS scrutiny

RAC auditors are hammering practices over infusion CPT 96365‑96367 documentation in 2026. Learn how to defend drug administration claims now.

Defending Orthopedic Injection Claims: 2026 RAC and MAC Audits Targeting CPT 20610 Documentation, NDC Linking, and Medical Necessity Justification

Orthopedic injections are under 2026 RAC scrutiny. Here’s how to defend CPT 20610 with airtight documentation, NDC linking, and medical necessity proof.

Cigna’s 2026 audit surge on modifier 25 usage for minor dermatologic procedures (CPT 11102‑11103): what documentation still holds up

Cigna's 2026 post-pay audits are hammering Modifier 25 claims for CPT 11102‑11103. Here's what documentation still survives and what doesn't.

Centene/Ambetter: Sky-High Denials, Rock-Bottom Appeals, Stop Letting Them Win

Centene/Ambetter leads the ACA marketplace in denial rates and has the worst appeal success. Here’s what RCM pros need to do to stop leaving money on the table.

Prolonged Services 99417: The Documentation Traps Costing You Thousands

Most practices blow 99417 reimbursement by missing these documentation steps, especially with UHC and Medicare. Here’s where your claims fall apart.

Medicaid MCOs: Why Your Same-State Claims Keep Getting Denied for Different Reasons

Why does UnitedHealthcare Community Plan require Modifier 59 for CPT 97530 but Molina doesn’t? Medicaid MCOs rewrite the rules, here’s how to get paid.

Surgical Prior Auth Denials: The Clinical Criteria Payers Actually Use vs What They Publish

Why surgical prior auth denials happen: the real clinical criteria payers use vs what they publish. Examples from UHC, Cigna, and more. Specific CPT codes.

Modifier 26 and TC: The Professional/Technical Split That Bleeds Revenue Every Month

Most radiology and cardiology claims with Modifier 26 or TC lose 15-30% in revenue due to lazy coding or payer-specific traps. Here’s how to stop it.

Telehealth E/M: POS, Modifiers, and the Documentation That Survives Audits

Why your telehealth E/M claims get denied: POS, modifier, and documentation mistakes that cost you thousands. Here’s what really survives audit.

Behavioral Health Billing: The CPT/HCPCS Crosswalk That Saves Practices Thousands

Stop leaving money on the table in behavioral health billing. Use the CPT/HCPCS crosswalk to bill correctly, survive audits, and boost reimbursements.

UnitedHealthcare tightens prior auth for advanced imaging in Q2 2026

OIG adds E/M billing patterns to 2026 Work Plan

Aetna expands outpatient mental health visit limits under parity compliance

BCBS denial rates for knee arthroscopy rise 12% in Q1 2026

CMS updates molecular pathology LCD with stricter ICD-10 requirements