Welcome to “Vital Signs,” your go-to monthly roundup of all things related to RCM tailored for independent practices and medical billers. Access previous editions for top insights and developments.

With the fall season officially upon us, the weather is shifting and so are healthcare regulations. New CPT codes and insurance changes are right around the corner, and the industry continues to await news about telehealth flexibilities currently set to expire on September 30. 

Here’s a roundup of 7 of the most important news stories this month. Take the time to review them and discuss potential impacts on your medical practice or billing company.

The specifics: The American Medical Association (AMA) recently announced its 2026 CPT code update, adding 288 new codes effective January 1, 2026, designating the latest advances in medical, surgical, and diagnostic services available to patients. 

Key updates included in the CPT 2026 code set are new codes for digital health services like remote patient monitoring, medical services involving hearing devices and augmented intelligence, and a comprehensive update of codes for leg revascularization.

Why it matters: The changes emphasize the continued shift toward telehealth, digital care, and data-driven clinical tools, meaning physicians will need to adapt to integrating more technology and software into care delivery.

What’s next: Review these coding changes and consider attending the CPT & RBRVS 2026 Annual Symposium to learn more about how to leverage CPT codes effectively. The virtual symposium is November 19–21, 2025. Also, be sure to purchase the most updated CPT Manual, CPT Professional 2026.

The specifics: The AMA’s work to fight scope creep throughout 2025 led to the defeat of more than 150 bills designed to expand the scope of practice for nurse practitioners, nurse anesthetists, physician assistants, optometrists, pharmacists, psychologists, and others, according to the organization.

Why it matters: Defeating bills that promote scope creep preserves the current guardrails of physician-led care, billing compliance, and liability structures.

What’s next: To avoid triggering scope creep, practices must clearly define roles that align with licensure and payer rules, follow billing rules (e.g., incident-to and split/shared visits), maintain structured oversight (e.g., chart reviews and co-signatures), and embed nonphysician providers into team-based care models where physicians remain the clinical leaders. 

The specifics: A new HHS final rule effective October 1 ensures healthcare providers using certified health IT systems will be able to submit prior authorizations electronically, select drugs consistent with a patient’s insurance coverage, and exchange electronic prescription information with pharmacies and insurance plans.

Why it matters: The rule gives physicians a tool to improve cost transparency and reduce administrative friction.

What’s next: Confirm your EHR vendor is compliant with the new certification requirements (real-time benefit tools, electronic prior authorization integration). Then actively embed cost transparency into your prescribing workflow and train your teams to use the new tools.

The specifics: CMS recently announced it would expand access to catastrophic health insurance plans in the federally facilitated Exchange (and in participating state-based Exchanges), allowing consumers who are ineligible for premium tax credits or cost-sharing reductions (based on their projected incomes) to access catastrophic coverage through a hardship exemption.

Why it matters: Patients who may have previously qualified for premium tax credits or cost-sharing reductions may shift to catastrophic plans with higher deductibles and more out-of-pocket costs. Practices may also see more underinsured patients (i.e., patients who have coverage but still pay a significant amount before benefits kick in). This could lead to increased bad debt or patient responsibility balances. 

What’s next: Consider reinforcing financial counseling, point-of-care estimates, and payment plans to mitigate revenue loss. 

The specifics: According to a new report, 41% of providers now face denial rates of 10% or higher. Also, 54% of providers say claim errors are increasing. The top causes of denials continue to be missing or inaccurate data (50%), authorization issues (35%), and incomplete patient registration information (32%).

Why it matters: When denials occur, providers may face delaying payments, revenue leakage, and increased administrative costs. 

What’s next: Consider ways to modernize denial prevention and claims management using AI and automation. For example, adopting AI-driven eligibility verification, prior auth management, and claims scrubbing can be very helpful. 

The specifics: A recent study found that combining Medicare annual wellness visits (AWV) and problem-based visits with continuity clinicians could improve patient and clinician engagement and increase the percentage of AWVs completed as well as capture of quality measures.

Why it matters: This study suggests that redesigning visit workflows may be a high-yield strategy. In one medical practice, monthly AWV rates rose from ~8.4% to ~50.8% over 9 months. The practice also saw increases in various screenings (e.g., breast cancer, cervical cancer, colorectal cancer, depression, falls, and function), lab tests (i.e., HbA1c and microalbumin), and some vaccinations. 

Combining visits may help better align preventive and disease-management care, reduce fragmentation, and increase convenience for patients and clinicians.

What’s next: Consider combining AWVs and problem-based visits. To do this, add a new scheduling code/visit type in your electronic health record such as ‘AWV + problem visit’ that corresponds to a (longer) 40–60-minute slot. 

Use pre-visit screening to determine whether a patient wants to address active concerns in addition to the AWV, and if so, use the newly created scheduling code. Ensure clear clinical documentation supports both the preventive and problem-based care.

The specifics: A new study found that while Medicare Part D coverage for GLP-1 receptor agonists remains high in 2025, nearly all plans now require prior authorization and patient out-of-pocket costs have risen sharply due to coinsurance, creating significant new barriers to access. 

Why it matters: Physicians now face a sharp increase in administrative workload from nearly universal prior authorization requirements, greater pressure to help patients navigate rising out-of-pocket costs, and more frequent disruptions in treatment plans when patients can’t afford or obtain their prescribed GLP-1 therapy.

What’s next: Prepare to build more efficient workflows for handling prior authorizations, work closely with care teams or technology tools to reduce administrative burden, and proactively counsel patients about coverage and cost expectation.

Tebra's integrated platform can help you navigate CPT code changes, automate eligibility checks and prior authorizations, reduce claim denials through AI-driven claims scrubbing, and streamline billing workflows — all while keeping your practice compliant and getting you paid faster. Book a free, personalized demo today to learn more.