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PCP-based behavioral health, teams expand; DMHT stalls

11/17/2025

In two sections of the PFS, CMS adds to its ongoing fusion of primary care and behavioral care codes and expands behavioral health integration (BHI), psychiatric collaborative care model (CoCM), community health integration (CHI) and principal illness navigation (PIN), but fails to add to its digital behavioral health offerings.

Mandatory specialty value-based model approved for 2027

11/17/2025

by: Roy Edroso

CMS’ big bet on a major specialty payment model that mirrors, and in some respect exceeds, other such efforts has been finalized in the final rule, and it will make significant changes to reimbursement metrics for thousands of providers across the country.

MVP still the future of QPP, while QP eligibility metric gets personal

11/17/2025

by: Roy Edroso

CMS continues to push the specialty-specific MIPS Value Pathways (MVP) model to which it hopes to transition the Quality Payment Program (QPP). But there’s still no mandatory adoption date, and the 2026 Merit-based Incentive Payment System (MIPS) and Advanced APM policies are pretty close to the current ones—with a major exception for some Advanced APM providers.

CMS ignores potentially misvalued codes, revalues some codes anyway

11/17/2025

by: Laura Evans, CPC

While CMS declined to consider any codes for revaluation under the agency’s potentially misvalued codes policy for CY 2026, the agency proved responsive to nominators’ requests for certain codes to be valued or revalued.

POS priority: CMS favors non-facility sites of care in 2026 PFS

11/17/2025

by: Richard Scott

Capture a sense of how relative value unit (RVU) fluctuations depending on a provider’s place of service (POS) are expected to impact specialties’ reimbursement in 2026, after CMS finalized several initiatives to modernize its ratesetting mechanisms.

CMS finalizes fee disparity between facility and non-facility, sets two conversion factors

11/10/2025

by: DecisionHealth staff

Your providers will see higher conversion factors (CF) in 2026, with a 3.8% boost to those participating in qualifying alternative payment models (APM) and a 3.3% increase for everyone else. Yet a yawning gap in reimbursement levels will confront practices in 2026, depending on whether your providers deliver care in the non-facility or facility setting.

Medical spa can be a profitable add-on, but take limits seriously

11/10/2025

by: Roy Edroso

Medical spa services are booming and expanding, which may tempt you to establish an adjunct “med spa” office. While that may be an attractive option, remember that even sub-clinical, self-pay procedures are subject to the same standards and scrutiny as medical services — and in some cases even more so.

Tylenol accusations are thin, but be safe and mention to patients anyway

11/10/2025

by: Roy Edroso

Question: Recently HHS made some frightening accusations about Tylenol and pregnant women, and the Texas Attorney General has brought suit against the makers of Tylenol for “deceptively marketing Tylenol to pregnant mothers.” My question is: Can our doctors get into trouble now for recommending or prescribing Tylenol?

Hospital, nursing facility prolonged services saw a denial spike in year two

11/10/2025

by: Julia Kyles, CPC

Refresh your staff on the add-on codes for prolonged E/M encounters in the hospital (G0316), nursing facility (G0317), home or residence (G0318) and office or other outpatient (G2212) settings, with a focus on nursing facility visits.

Can narrative medicine benefit? Proponents see enhanced care, fewer denials.

11/03/2025

by: Roy Edroso

Some newer doctors are coming out of medical school with training in narrative medicine, which uses literary and other artistic techniques in a medical context. While its applications to daily medical practice are limited, you may want to adopt some of its tools to improve documentation and, at least indirectly, patient satisfaction.

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