Monthly Provider & Revenue Cycle Brief | October 2026 | Updates reviewed October 5-6, 2026

AM Med Solutions

2026 | Updates reviewed October 5–6, 2026

October brings a new diagnosis code year, important specialty coverage guidance, and payer changes that can affect reimbursement even when a claim is paid. This issue also looks at new federal investments in rural care, medication access, lactation coding, and Medicaid care management across all 50 states.

Provider education and operational planning. Coverage, enrollment, authorization and reimbursement depend on the member, plan, service date and contract. Dated research snapshots are identified throughout.

Federal investment: access closer to home

New Mexico: $74 million for regional care hubs

CMS announced a $74 million investment through the Rural Health Transformation Program. Six Regional Hub Organizations will lead Healthy Horizons, part of New Mexico's five-year strategy to improve access in rural, frontier and tribal communities. The hubs will work with local providers and community partners to identify needs and plan services, including specialty, maternal, behavioral health and chronic disease care.

Practice implication: This is an opportunity to participate in referral networks and regional service planning. It does not itself create a new billable service or guarantee additional reimbursement.

Provider action: Identify potential hub partners and priority patient needs.

AM Med Solutions support: Review enrollment, credentialing, contracting and claims arrangements as partnerships become concrete.

GENEROUS: Medicaid drug payment model

CMS announced that all 50 states, the District of Columbia and Puerto Rico applied to the generating cost reductions for U.S. Medicaid model. At the announcement, 40 states and Puerto Rico had signed participation agreements. CMS estimates $64.3 billion in taxpayer savings over 10 years. These are projected savings, not realized results.

GENEROUS uses negotiated supplemental rebates tied to international net prices for participating drugs. It is intended to reduce Medicaid spending while preserving or improving access and quality. An application is not the same as a signed agreement, and this model is not a universal change to every drug benefit.

AM Med Solutions watch: Track state implementation notices and pharmacy benefit changes. Continue using the applicable formulary, prior authorization and indication criteria until a new policy takes effect.

Obesity care: coverage changes to check now

Obesity treatment includes assessment, nutrition and behavioral services, medication and, where appropriate, surgery. A state's decision about GLP-1 drugs solely for weight loss does not establish coverage of every other obesity service. Use the exact drug indication, age and current clinical criteria.

Obesity coverage changes by state

Program	Verified change or current policy	Operational response
Rhode Island	Certain GLP-1s prescribed solely for weight loss are no longer covered beginning October 1, 2026.	Recheck ongoing authorizations and discuss covered treatment options.
Massachusetts	MassHealth's corrected notice and UHC's June update identify July 3, 2026 for ending drugs used only for obesity/overweight.	Use the corrected notice; distinguish other accepted indications.
Michigan	January 1 restrictions narrow obesity-only access under FY 2026 legislation.	Use current PA criteria; do not rely on a previous approval.
North Carolina	Obesity GLP-1 coverage reinstated effective December 12, 2025.	Apply reinstated criteria and current preferred drug list.
Pennsylvania	GLP-1 overweight/obesity coverage ended January 1, 2026.	Review diagnosis-specific exceptions and pediatric requests individually.
Missouri	Obesity GLP-1 PDL edit updated April 23, 2026.	Use the current clinical edit and product-specific PA.

BALANCE is voluntary; check implementation

CMS allows state Medicaid agencies to join BALANCE from May 2026 through January 1, 2027. Access depends on participating states and manufacturers and negotiated qualifications. It is not an automatic nationwide obesity benefit. CMS's September 29 page also says BALANCE will not launch in Medicare in 2027; the separate Medicare GLP-1 Bridge extends through December 31, 2027.

EPSDT, October edits and pediatric documentation

CMS updated the EPSDT coverage guide in May 2026

EPSDT provides comprehensive prevention, diagnostic and treatment services for Medicaid members under 21. The May guide brings together requirements for informing families, periodic and interperiodic screening, medically necessary treatment, timely access, notices and hearings, and managed care oversight. Necessary services within Social Security Act section 1905(a) must be considered to correct or ameliorate a condition, even when the adult state plan does not otherwise cover them. Separate CHIP programs have different benefit rules.

A utilization limit or an adult benefit exclusion should not substitute for an individualized pediatric medical necessity review. Coverage must still be distinguished from correct claim submission, provider eligibility and applicable authorization procedures.

Quarter 4 Medicaid NCCI edits took effect October 1

CMS posted the October 1, 2026 Medicaid NCCI files on September 1. Review practitioner and outpatient hospital procedure-to-procedure edits and medically unlikely edits for the applicable service date. A code's appearance in an edit file does not establish benefit coverage. Public files are not a substitute for a state's implementation instructions.

The UHC September Community Plan bulletin contains no EPSDT-specific policy row. Its state-specific edits should not be presented as a new nationwide EPSDT rule.

Well visits, screenings and separately identifiable care

Clinical team: Document screening tool, result, interpretation, counseling, abnormal findings and follow-up. When a problem is evaluated at a well visit, distinguish the additional assessment and management from routine preventive work.

AM Med Solutions billing review: Check the state's preventive claim matrix, age limits, screening units, referral indicator, diagnosis requirements and modifiers. Verify whether a screening is separately payable or bundled. Review modifier 25 only when documentation supports a significant, separately identifiable E/M service.

When an EPSDT claim is denied: AM Med Solutions identifies the edit and missing claim elements, obtains the relevant clinical support through the approved secure workflow, and evaluates correction or appeal. Clinical documentation and medical necessity remain the provider's responsibility.

October diagnosis coding

Use FY 2027 ICD-10-CM for October 1, 2026 through September 30, 2027 services. Claims for September care retain the applicable earlier code set, even when submitted in October. Code only the specificity supported by the record.

Undercoding and payer downcoding: protect earned revenue

Physician undercoding: why it matters

Undercoding occurs when the submitted code reports less work or complexity than the documented service supports. Repeated default use of a lower E/M level, missed supported screenings, or omission of a separately identifiable problem visit can leave earned reimbursement uncollected. It also makes claims data less representative of the care delivered.

The answer is accurate coding. For office/outpatient E/M, select the level using qualifying medical decision making or qualifying total time on the service date, as applicable. Diagnosis count, note length or prescribing alone does not automatically establish a level. Avoid both habitual low coding and unsupported increases.

Illustration only: If 100 properly supported claims each miss $30 of contractual reimbursement, the gap is $3,000. This is an example, not a measured client result.

Payer downcoding: a paid claim can still lose revenue

A payer may replace the submitted E/M service with a lower-level code or pay as though a lower level were reported. AMA describes automated reviews that may occur without first requesting records. This can be missed when staff look only for outright denials. Compare the billed code with the adjudicated service and remittance explanation.

A contractual rate difference, bundling edit or percentage reduction is a different payment issue. Identify the actual mechanism before selecting an appeal argument. The UHC Kentucky preventive/modified E/M reduction announced for December is an example of a payment adjustment, not necessarily a change in the submitted E/M level.

1. Detect: Compare billed services, remittances and contracted allowances; flag code substitutions and unexpected payment reductions.
2. Validate: Review the record against the applicable coding rules, policy and service date.
3. Challenge: Build a supported correction or appeal and track its deadline and response.
4. Escalate: Group recurring issues by payer and reason for provider-relations review; involve legal counsel when contractual or legal remedies require it.
5. Prevent: Share focused chart-audit feedback and monitor the recurring pattern.

Provider action: Keep records complete and respond promptly to clinical clarification requests.

AM Med Solutions action: Request the payer's rationale, preserve supporting evidence and pursue supported reimbursement within the practice's service agreement. Recovery cannot be guaranteed.

BCBS settlement watch: identify the right case

The 2007 case: Love v. Blue Cross

The April 27, 2007 settlement addressed physician claims-processing practices and included prospective commitments concerning reimbursement and dispute procedures. It is a different proceeding from the current BCBS provider antitrust settlement. The historical agreement is not evidence that every provision remains enforceable against every plan in October 2026.

No new 2026 claims window or payout update for the 2007 agreement was verified in the sources reviewed. If a practice wants to rely on that agreement for a present downcoding dispute, counsel should check the specific defendant, provision, term and enforcement history.

Current provider antitrust settlement: $2.8 billion

The official provider administrator identifies a class period of July 24, 2008 through October 4, 2024. The claims deadline was July 29, 2025; final approval occurred August 19, 2025 and the settlement became effective September 19, 2025. Claims-review notices began February 16, 2026. The current site lists court status reports and claim-review instructions.

Do not promise a payment date or amount from an unverified news report. Practices with submitted claims should monitor official notices, maintain accurate contact information and follow the administrator's instructions for information requests and any review rights.

Subscriber settlement payments are separate

The BCBS subscriber settlement site states that initial distributions began May 11, 2026. That announcement concerns eligible subscribers and does not establish a payout schedule for physicians in the provider case.

Lactation codes and care management readiness

New lactation services planned for January 2027

CMS's 2027 proposed payment rule describes two new directed lactation care services, including history, assessment, training and a report. The proposal uses the identifiers below; final numeric CPT codes were not verified in the public materials reviewed.

CMS proposed lactation care identifiers

CMS proposal identifier	Service summary
978XX	Initial 30 minutes of directed lactation care
978X1	Each additional 15 minutes

Do not submit these placeholders. Prepare for January 1, 2027 only after confirming the final CPT descriptors, effective date and payer rules. Proposed Medicare payment values are not final coverage decisions for Medicare, Medicaid or commercial plans.

Readiness: Establish time documentation, consultant qualifications, provider direction and reporting. Confirm whether the mother's or infant's benefit applies, rendering/billing enrollment, same-day edits and separate payment. Do not assume that CMS's staffing-cost proxy establishes a mandatory professional credential.

Four programs, four distinct billing checks

Care management program billing checks

Program	What the clinical program needs	What AMMS verifies
CoCM	Treating clinician, behavioral health care manager, psychiatric consultant, registry, measurement-based follow-up and documented qualifying work.	99492–99494/G2214 eligibility, enrollment, consent, plan rules and overlapping services.
CCM	Qualifying chronic conditions, comprehensive care plan, access/coordination and distinct time records.	99490 family payment, provider restrictions, PMPM/sub-capitation and same-month exclusions.
RPM	Ordered monitoring, suitable device, transmitted data, clinical review and qualifying interaction/time.	Covered codes, condition/age limits, data-day threshold, authorization and billing entity.

Continued: obesity program billing checks

Program	What the clinical program needs	What AMMS verifies
Obesity	Documented assessment, counseling, treatment plan, appropriate indication and follow-up.	E/M, nutrition/behavioral services, drug PA, surgery criteria and pediatric exceptions separately.

Medicare requirements are useful for identifying program elements but do not establish Medicaid reimbursement. Never count the same staff work or minutes twice. RPM and remote therapeutic monitoring (RTM) are different services; UHC's laboratory "Routine Test Management" terminology is another use of the RTM abbreviation.

UnitedHealthcare: all four September bulletins

Commercial

Five laboratory policies: allergen testing, hepatic fibrosis, in-vitro chemotherapy assays, testosterone and vitamin B12. Effective September 1; AR/CO/KY/NC/NE/OH/RI start October 1. They introduce indication, frequency or nonreimbursement rules. Review the actual test and diagnosis before ordering. October 1 also adds CPT/HCPCS reporting for 93 outpatient revenue codes on in-network facility UB-04 claims.

Code maintenance: Add-On Codes; Maximum Frequency per Day; medical/surgical MPPR; Outpatient Hospital Add-On Codes; Professional/Technical Component; Supply.

Individual/Family Exchange

The same five laboratory policy topics apply September 1, with CO/NC/NE/OH delayed to October 1. The October 1 outpatient revenue-code requirement also applies. Code maintenance includes Add-On Codes, Clinical Diagnostic Lab, Maximum Frequency per Day, medical/surgical MPPR, Outpatient Hospital Add-On Codes, Professional/Technical Component and Supply.

Medicare Advantage

Code maintenance affects Increased Procedural Service (modifiers 22/63), Add-On Codes and DME Charges in a Skilled Nursing Facility. The bulletin does not announce a separate new implementation date. Check each posted policy's revision history.

AM Med Solutions implementation: Map applicable policy changes to clients, claim types and service dates. Review initial impacted remittances, validate facility code fields and escalate inconsistent policy application with supporting records.

UnitedHealthcare Community Plan: complete change index

2026 dates; repeated radiation row consolidated.

UHC Community Plan change index

Topic	Effective date / states
Drug-testing	7/1 NJ
Iron-homeostasis	9/1 TN
Influenza	10/1 IN, TN
Lyme	10/1 NE; 12/1 ID
Flow-cytometry	10/1 NE; 12/1 WA
Calprotectin / bone-turnover	11/1 ID
Dysbiosis / autoimmune	12/1 ID
Heart-failure	10/1 IN; 11/1 RI
Epithelial-cytology	9/1 RI
Homocysteine	12/1 PA
IBD	9/1 NC
Chemotherapy-assays	10/1 HI, MI, NY; 11/1 CO, FL, MA, NM, VA, WI; 12/1 KY, PA, TN
Testosterone	10/1 CO, MI, NM, NY, PA; 11/1 KS, MA; 12/1 KY
Allergen	10/1 CO, FL, HI, MI, NY, RI; 11/1 ID, KS; 12/1 KY, NM, PA, TN
Hepatic-fibrosis	10/1 CO, FL, HI, MI, NY, RI; 11/1 KS, KY, NM; 12/1 PA, TN
B12	10/1 MI; 12/1 CO, FL, KS, KY, NM, PA, RI, TN, WI
Anatomical-modifiers / anesthesia	10/1 NE (anesthesia DOS from 11/1/2024)
Shoulder-CCI	10/1 IN

UHC Community Plan change index (continued)

Topic	Effective date / states
Excludes1 / home-health / hospital-inclusive / preventive / POS	12/1 KY
Global-days	10/1 CO, MO, PA, TX, DC; 11/1 MA; 12/1 MD
Molecular / radiation / G2211 / G0545 / same-day	10/1 NE
Ultrasound-MPPR	10/1 TX
Vitamin-D	10/1 TN; 11/1 KY

UHC code maintenance and October client priorities

Community Plan code-maintenance topics (September 1)

Age; Ambulance; Autoimmune; B-Bundle; Bilateral; Bone-turnover; Heart-failure; Lab; Devices/skin-substitutes; Diabetes; Influenza; Pancreatitis; Cytology; Calprotectin; Flow; Gender; Global-days; Home-health; Immune-assay; Injection/infusion; Dysbiosis; Micronutrients; Iron; Lyme; Maximum-frequency-CPT; Maximum-frequency-HCPCS; Molecular; Cardiovascular/ophthalmology-MPPR; Facility-covered/noncovered; Professional-covered/noncovered; Nonphysician-E/M; Lifetime; Onychomycosis; Pediatric/neonatal-critical; Preventive; POS; Procedure/modifier; Professional/technical; Same-day; Supply; Telehealth; Time-span; Unlisted.

AM Med Solutions review: Distinguish policy reductions from E/M level changes; validate contracts and supported care.

Carry forward the practical payer checks

• Oscar: Billing taxonomy is required on every claim; rendering taxonomy is required when rendering NPI is reported. New authorizations moved to Availity or delegated vendors September 1. The October 1 laboratory program uses post-billing policies, without PA under that program.
• Ohio CareSource: The August 21 diagnosis-specificity notice concerns inpatient facility claims. Do not extend it to every outpatient pediatric claim. Use documented specificity and review the actual denial.
• Medicare FQHC/RHC: CMS directs individual CPT/HCPCS telehealth coding with modifier 93 or 95 beginning October 1 instead of G2025. Confirm the applicable service pathway; Medicaid PPS and dental rules remain state-specific.

OB/GYN: prepare now for the 2027 maternity overhaul

Effective January 1, 2027: The AMA is replacing traditional global maternity reporting with separate phases of care. Antepartum and postpartum care use appropriate E/M services; labor management and delivery have new codes. The restructuring includes 17 deletions, 12 additions and 6 revisions. These are 2027 changes, not a reason to change coding for October 2026 services.

Selected new codes to build into your 2027 workflow

Code	Brief reporting purpose; consult full CPT instructions
59080 / 59081	Initial-day labor management: straightforward / complex.
59082 / 59083	Subsequent-day labor management: straightforward / complex.
59431 / 59432	Vaginal delivery / vaginal delivery after prior cesarean.
59502 / 59503	Primary / repeat cesarean delivery.
59433 / 59434	Repair of third-degree / fourth-degree obstetric laceration.

Labor complexity depends on documented clinical circumstances, rather than elapsed hours alone. Labor management is reported once per calendar date under the applicable rules. Same-day immediate postpartum work is included in delivery care; later postpartum encounters use appropriate E/M reporting. This table is a planning summary, not the complete code set or a fee schedule.

What your practice should do this month

Map your prenatal, labor, delivery and postpartum documentation to the new structure. Identify pregnancies spanning 2026 and 2027, and request each payer's written transition instructions. Review contracts that refer to global obstetric codes; confirm new-code rates, patient cost sharing and Medicaid requirements before estimating collections. Final Medicare values should be checked after the 2027 final rule is released.

AM Med Solutions support: We can review the affected charge templates, track payer instructions and identify missing documentation before the transition. Ask for an OB/GYN coding-readiness review; do not assume that more claim lines automatically mean higher reimbursement.

FQHCs and RHCs: telehealth and care-management billing

October 1 change: replace G2025 for distant-site telehealth

For Medicare dates of service on or after October 1, 2026, report the individual CPT/HCPCS service code instead of G2025, with the appropriate revenue code and modifier 93 for synchronous audio-only care or 95 for real-time audio/video. Confirm that the service and delivery method qualify for Medicare telehealth.

Non-behavioral distant-site telehealth retains its special payment methodology; the code change does not convert every telehealth claim into an ordinary PFS payment. CMS identifies the 2026 distant-site payment rate as $97.53. Behavioral-health telehealth follows a different payment pathway.

Care coordination: use the individual service codes

G0512 and G0071 are no longer reportable for Medicare dates of service beginning January 1, 2026; G0511 is also terminated. CMS directs clinics to use the individual codes for the underlying CoCM, communication technology and remote-evaluation services. Designated care-management services are paid separately at national non-facility rates under the applicable requirements.

Optional APCM behavioral-health add-ons G0568, G0569 and G0570 are available in 2026. Select the correct pathway and review overlaps rather than billing both the former bundled service and its replacement.

FQHC dental and Medicaid: confirm the payment route

A Medicare telehealth or care-management instruction does not establish Medicaid dental coverage or a separate Medicaid payment. For each state and MCO, obtain the dental benefit rules and encounter instructions: eligible practitioner, CDT reporting, PPS/APM treatment, same-day medical/dental visits and any supplemental or wraparound process. Keep dental procedure reporting distinct from the calculation of a payable encounter.

October claim check: Review the first telehealth remittances for rejected G2025 lines, missing modifiers, revenue-code errors and payment discrepancies. Validate service dates before correcting older claims.

AM Med Solutions support: We can audit sample encounters, update claim mappings and track payer responses. Have your account lead review Medicare and Medicaid workflows separately, including the dental encounter pathway.

Family medicine: capture supported longitudinal care

G2211 now extends to eligible home and residence visits

Medicare expanded G2211 in 2026 to eligible home/residence E/M codes: 99341, 99342, 99344, 99345 and 99347–99350. The add-on recognizes qualifying longitudinal care. It is not automatic because a patient has several diagnoses or because the clinician is a family physician; the documented care relationship must support its use.

Annual wellness visits: distinguish preventive and problem work

A Medicare annual wellness visit is not a routine comprehensive physical. When an AWV includes a significant, separately identifiable medically necessary problem E/M service, review modifier 25 and document the additional work independently. G2211 may be payable with a qualifying office E/M carrying modifier 25 when the same-day service is an AWV, vaccine administration or eligible Part B preventive service; CMS excludes glaucoma screening from this preventive exception.

APCM plus behavioral health: a 2026 billing option

New APCM add-on codes G0568, G0569 and G0570 support complementary BHI/CoCM services. The same practitioner must report the APCM base service in the same month. Verify the selected service's requirements and overlapping care-management restrictions before billing; these Medicare provisions do not establish commercial or Medicaid coverage.

Make the chart audit useful

Review a sample of AWV-plus-problem visits, longitudinal follow-ups and home visits. Look for supported services omitted from charge capture, the wrong preventive visit type, and G2211 denials caused by outdated blanket modifier-25 edits. For chronic-care programs, reconcile enrollment, consent, staff work and the selected billing pathway before submitting monthly charges.

AM Med Solutions support: Our included chart audits can identify missed supported charges and documentation gaps. We can compare payer allowances with actual payments and help correct recurring edits without defaulting every visit to a higher level.

2026 code-set reminder: ADA reports 60 CDT changes, including 31 additions and 14 revisions, effective January 1, 2026. Confirm that your software and templates use the version applicable to the date of service. A valid new code does not guarantee coverage or separate payment.

Selected 2026 CDT additions: brief descriptions

Code	Description
D0426	Point-of-care saliva collection, preparation and analysis.
D0461	Testing for a cracked tooth.
D5877 / D5878	Duplicate complete denture: maxillary / mandibular.
D6049	Nonsurgical scaling/debridement of an implant with peri-implantitis.
D9224 / D9225	General anesthesia with advanced airway: initial / subsequent time increment.

Specific payer example: Delta Dental's published summary treats D0461 as included in definitive treatment and not separately billable to the patient. Its D6049 benefit depends on implant coverage and has frequency and same-day bundling limits. Apply these policies to the applicable Delta product; do not generalize them to every dental plan.

Revised and deleted codes also affect claims

D9230 was clarified for nitrous oxide delivered as a single agent. D1352 was deleted in conjunction with revision of the one-surface composite reporting framework. Update the clinical documentation and code selection together; do not merely substitute a code to overcome a denial.

Medicare-linked dental claims: document the medical connection

Original Medicare generally excludes routine dental care, but some services inextricably linked to covered medical treatment may qualify. Keep evidence of medical/dental coordination and the clinical linkage. CMS instructions allow denial when qualifying claims lack KX and require a valid ICD-10 diagnosis on 837D claims under the July 1, 2025 implementation rules. KX is not a blanket extension of dental benefits.

AM Med Solutions review: Check code version, tooth/arch details, narratives, attachments, frequency limits, authorization and the applicable medical or dental claim route before transferring a balance to the patient.

Cardiology: 2026 procedure coding and September TAVR update

PCI coding changed January 1, 2026

PCI coding changes

Code / change	Documentation and billing focus
92930 (new)	Complex coronary stenting: qualifying multiple distinct lesions/stents across segments, or qualifying bifurcation work in main artery and side branch.
92945 (new)	Chronic total occlusion revascularization using both antegrade and retrograde approaches.
Deleted branch codes	92921, 92925, 92929, 92934, 92938 and 92944: remove from 2026-date charge templates.
Other deletions	Coronary thrombolysis codes 92975 and 92977 were deleted.

Document the artery and branches, distinct lesions, treated segments, devices and intervention approach. The new framework incorporates branch work into revised main-code reporting; do not continue the old branch add-on logic. Lower-extremity revascularization also moved to new codes 37254–37299 with updated territory and complexity rules. Use the complete CPT guidance for the actual procedure.

September 2026: revised TAVR coverage criteria

CMS finalized coverage of TAVR for symptomatic severe aortic stenosis without Coverage with Evidence Development (CED). Asymptomatic severe disease remains subject to CED and an FDA-approved indication. The decision also revises Heart Team, pre-procedure assessment, operator and hospital criteria. Removing CED for symptomatic patients does not remove the other coverage conditions.

ACC reported on September 16 that no CMS-approved CED studies for asymptomatic severe aortic stenosis then existed. Verify the current approved-study status before relying on this pathway, and check MAC claim implementation instructions for the service date.

AM Med Solutions support: We can review cath-lab charge mappings and operative-report detail, check deleted-code denials and compare payments with contracted allowances. For TAVR, confirm coverage documentation with the clinical team before treating a paid authorization as proof that every claim condition is satisfied.

Podiatry: coverage evidence matters as much as the code

Routine foot care: current Medicare coverage checkpoint

Medicare generally excludes routine foot care. Covered exceptions require the applicable medical circumstances and documentation. The current contractor article A57759, revised April 1, 2026, is a useful checkpoint for practices in its listed jurisdictions; it is not a new nationwide benefit or a substitute for your own MAC's policy.

Class-finding modifiers

Modifier	Documented class-finding combination
Q7	One Class A finding.
Q8	Two Class B findings.
Q9	One Class B plus two Class C findings.

Under this article, class-finding modifiers apply to qualifying systemic-condition claims for listed nail/calus services. Neuropathy without vascular impairment follows a different rule. Document the actual examination findings rather than copying a Q modifier from a previous claim. The article generally limits covered routine foot care to once in 60 days; verify the jurisdiction, covered diagnosis and service pathway before applying that interval.

Wound practices: skin-substitute payment changed in 2026

CMS finalized incident-to supply payment for skin-substitute products used in covered applications under the PFS in non-facility settings and under OPPS in hospital outpatient settings. The 2026 policy uses a single payment rate for the specified FDA regulatory categories. Check the actual product classification, code, units and current payment file rather than assuming historical product reimbursement continues.

October billing review for your podiatry team

Separate routine maintenance from medically necessary treatment in the note. Reconcile documented nails, lesions, laterality and performed work with the submitted code. For ulcer care, capture the location and documented severity, and make sure the operative or procedure note supports the work billed. Review any same-day E/M independently; a procedure does not automatically justify an additional office visit charge.

For wound products, compare acquisition cost, covered quantities and payer allowances before building a treatment budget. Payment policy, medical necessity and local coverage are separate checks.

AM Med Solutions support: We can compare recurring denials with the relevant MAC/MCO policy, review charge accuracy and request missing clinical detail. A focused chart audit helps identify both lost supported revenue and claims needing correction.

New York Medicaid: PSP registration requires your action

Required enrollment portal: Beginning September 1, 2026, eMedNY requires PSP submission for initial enrollment, revalidation, reinstatement, changes of ownership and maintenance, including demographic updates. PSP replaces paper enrollment submissions for individual practitioners and organizational providers, including group practices.

An HCS account or NY.gov Business account is required

All NYS Medicaid providers and PSP users need either a Health Commerce System (HCS) account or an NY.gov Business account. A personal NY.gov account is not sufficient for the Business account route. Complete account setup and multi-factor authentication; coordinate with AMMS to confirm access to the correct group and individual records.

What your practice must provide and complete

Practice action	What AMMS needs from you
Confirm account readiness	Tell AM Med Solutions whether the account is active, who manages the provider record and what access problems remain.
Arrange authorized access	Work with our team to establish the permitted access or delegation. Each user should use their own account; do not email passwords or MFA codes.
Supply current information	Provide requested NPIs/Medicaid IDs, practice addresses, contact details, affiliations, ownership disclosures and supporting documents through our approved secure workflow.
Forward enrollment notices	Send AMMS any PSP requests, returned-application notices and revalidation letters promptly so we can track required responses.

Continued: practice actions

Practice action	What AMMS needs from you
Complete final submission	The individual provider must log in, review and submit. For an organization, an owner or duly authorized representative disclosed on the enrollment file/application must complete this step.

AM Med Solutions can prepare and coordinate the application; the required provider or organizational submission remains essential. Contact your credentialing lead to resolve outstanding tasks.

New October 6 alert: duplicate revalidation letters

eMedNY reports that a system error generated duplicate initial revalidation letters for some providers during July–September. When two letters are labeled "initial revalidation notification," the latest-dated letter starts the revalidation period. Send both letters to AMMS so we can verify the applicable date. Begin revalidation when officially notified.

Protecting your practice's future: succession planning

Plan for the next chapter before it becomes urgent

You have spent years building patient relationships, a trusted team and a medical practice. A succession plan helps preserve that work through retirement, reduced hours, a new partner or a sale. It also prepares the practice for unexpected illness, disability or death. Starting early gives you time to prepare a successor.

A medical practice transition affects continuity of care, records, staffing and payer participation. An unclear handoff can leave patients and staff uncertain about what happens next. AMA guidance emphasizes record access and patient communication when a physician leaves, sells a practice, retires or dies.

Your revenue cycle belongs in the succession plan

Unresolved claims, aging receivables, undocumented workflows and enrollment gaps can complicate a transition. Reliable collection reports help a successor assess revenue. Decide who will manage outstanding claims, appeals, refunds and patient balances before the handoff.

Payer arrangements should be reviewed individually rather than assumed to transfer automatically. CMS requires physicians and physician organizations to report Medicare ownership or control changes within 30 days. The transaction structure may also require enrollment or reassignment work; Medicaid and commercial plans have their own requirements.

How AM Med Solutions can guide your preparation

Priority	How we can help
Understand the financial picture	Organize collection trends, payer mix, A/R aging, denial patterns and reimbursement data for your transition advisers.
Prepare payer participation	Inventory contracts and enrollment records; help track required notifications, credentialing, reassignments and approvals.
Keep billing operations moving	Document workflows, responsibilities and secure access; coordinate a handoff plan for claims, payment posting, appeals and patient billing.
Resolve unfinished business	Identify outstanding receivables and underpayments; help establish a follow-up plan and monitor collections through the transition.

We can coordinate billing and enrollment work with your attorney, CPA and valuation adviser. Your advisers should address ownership documents, taxes, buy-sell terms, valuation, insurance and patient-notice or record-retention requirements.

Start the conversation: Ask your AM Med Solutions account lead to discuss succession readiness. We can identify revenue-cycle gaps, assign responsibilities and build a timeline to support your patients, your team and the value you have built. We can even help you put a value to the business and help you find suitable buyers.

50-state Medicaid coverage snapshot: read the key first

The following pages include every state. They are a research and program-planning snapshot, not a complete payer-by-payer coverage determination. A current covered code, an enrolled provider, a qualifying patient and the right payment method must all align before billing.

Column evidence and meaning

Column	Evidence and meaning
CoCM	January 2026 Meadows/Concert original policy research: Y = reported state Medicaid adoption; NR = statewide adoption not reported; MCO = managed-care-only finding. This dated survey is not October confirmation. AL/AR exceptions and TN authority need separate verification.
Obesity	January 2026 KFF survey baseline for FFS GLP-1 obesity-only coverage. Y = reported; NL = not listed as covering. Later verified changes override the baseline. NL does not mean all obesity care is excluded.
CCM	Separate CPT 99490 payment checked where a primary billing source was found. HH = Medicaid health home model on CMS May 2025 map, not proof of CPT CCM payment. V = separate CCM billing not verified.
RPM	Short summary of a state law, provider manual or bulletin. A broad telehealth definition, monitoring device benefit or home-health pathway does not automatically authorize office RPM codes. V marks unresolved coverage.

Every state: Pediatric obesity evaluation and necessary treatment must be assessed under applicable EPSDT rules. Check nutrition/behavioral services, surgery and medication separately. The drug column covers only one slice of obesity care.

Evidence limits: No new policy was verified for every service in every state. Older findings remain dated; unresolved cells are preserved as research gaps. Commercial insurance mandates, state-employee plans, introduced bills and rural-health grants are not treated as Medicaid billing benefits.

Before launch, AMMS confirms: Product and FFS/MCO route; provider type/enrollment; covered codes and modifiers; authorizations; rates/PMPM/PPS; time/data requirements; overlaps and appeals. "Not verified" means further confirmation is needed, not "not covered."

50-state Medicaid coverage snapshot (A–L)

State	CoCM	Obesity GLP-1	CCM	RPM
Alabama	NR; plan exception V	Jan NL; October V	V	In-home RPM pathway; provider/state-share rules.
Alaska	NR	Jan NL; October V	V	V: no specific RPM billing policy confirmed.
Arizona	Y	Jan NL; October V	V	AHCCCS covered-code set; medical necessity.
Arkansas	NR; plan exception V	Jan NL; October V	V	PASSE/mobile monitoring; maternal BP pathway. General RPM V.
California	Y	Ended 1/1/2026	99490/99491 manual: monthly limits.	FFS/MCO RPM established-patient pathway.
Colorado	Y	Jan NL; October V	V	Outpatient RPM from 7/1/2025; condition/provider criteria.
Connecticut	Y	Jan NL; October V	HH; separate CCM V	Statutory definition includes RPM; billable code pathway V.
Delaware	Y	Jan Y; October V	V	Practitioner RPM policy; current manual criteria.
Florida	Y	Jan NL; October V	V	RPM retained; plan-specific and maternal pathways.
Georgia	Y	Jan NL; October V	V	EDWP waiver monitoring; general office RPM V.
Hawaii	Y	Jan NL; October V	99490 listed in 2/28/2025 FFS schedule.	Telehealth statute includes RPM; verify codes/plan.
Idaho	NR	Jan NL; October V	HH; separate CCM V	Established-patient remote monitoring; handbook criteria.
Illinois	Y	Jan NL; October V	V	Home uterine monitoring/CGM are defined benefits; office RPM V.
Indiana	NR	Jan NL; October V	V	RPM covered; 2026 code update also published.
Iowa	Y	Jan NL; October V	HH uses 99490 + tier modifier; not generic CCM.	RPM on permanent telehealth code list (3/26/2026).
Kansas	Y	Jan Y; October V	HH; separate CCM V	Home-health/HCBS monitoring pathway; office RPM V.
Kentucky	Y	Jan NL; October V	V	RPM eligible FFS/MCO; recipient criteria apply.
Louisiana	NR	Jan NL; October V	V	Statutory RPM program; verify operational billing/PA.

50-state Medicaid coverage snapshot (M–W)

State	CoCM	Obesity GLP-1	CCM	RPM
Virginia	Y	Y: restrictive PA/necessity	V	RPM FFS/MCO; high-risk pregnancy clarification 1/2026.
Washington	Y	Jan NL; October V	HH; separate CCM V	Covered RPM codes and medical necessity in July guide.
West Virginia	FFS 99492–99494 not covered	Jan NL; October V	4/2026 FFS file: 99490/99491 not covered.	4/2026 FFS file: 99453/99454 not covered; confirm other routes.
Wisconsin	Y	Jan Y; October V	HH; separate CCM V	Remote physiologic monitoring expanded; criteria apply.
Wyoming	Y	Jan NL; October V	V	V: no current RPM billing pathway confirmed.

Selected state implementation notes

CoCM: adoption does not remove program requirements

• Illinois: HFS publishes CoCM guidelines for FFS and managed care.
• New York: Use the state collaborative-care certification/enrollment pathway; perinatal grants are distinct from claims reimbursement.
• Texas: April 2026 TMHP guidance addresses FQHC/RHC CoCM after G0512 was discontinued.
• Tennessee: The 2026 law permits TennCare/CoverKids coverage when medically necessary. Do not describe it as a Medicaid mandate.
• Oregon: The January survey identifies MCO-only adoption; confirm the CCO agreement.

CCM: avoid confusing alternative payment with CPT payment

• Iowa's Integrated Health Home bills 99490 with a tier modifier and informational codes.
• MassHealth's primary care sub-capitation includes CCM codes; qualifying attributed services are not separately paid FFS.
• A health-home approval elsewhere does not establish a separate office CCM benefit.

RPM: new benefits and specific populations

• Nebraska's July 1 benefit covers defined heart-failure and hypertensive-pregnancy situations, with additional clinical criteria.
• Texas specifically added FQHC/RHC home telemonitoring providers.
• Virginia clarified maternal diabetes and hypertension for high-risk pregnancy.
• General telehealth language alone is insufficient to identify covered office RPM services.