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December 2025 Monthly Medicare Updates

Published on 

Wednesday, January 14, 2026

 | Case Management 
 | Coding 
 | Documentation 
 | Medicare Coverage 

Medicare Transmittals & MLN Articles

 

November 24, 2025: MLN MM14250: Therapy Code List: 2026 Annual Update

Make sure your billing staff knows about updates effective January 1, 2026, for remote therapeutic monitoring (RTM) services designated as sometimes therapy. https://www.cms.gov/files/document/mm14250-therapy-code-list-2026-annual-update.pdf

 

December 5, 2025: MLN MM14279: Medicare Deductible, Coinsurance & Premium Rates: CY 2026 Update

This article provides information for CY 2026 Medicare Part A and Medicare Part B deductible, coinsurance rates, and premiums. https://www.cms.gov/files/document/mm14279-medicare-deductible-coinsurance-premium-rates-cy-2026-update.pdf

 

December 9, 2025: MLN MM14315: Medicare Physician Fee Schedule Final Rule Summary; CY 2026

Make sure your billing staff knows about updated payment rates and policies for FY 2026. https://www.cms.gov/files/document/mm14315-medicare-physician-fee-schedule-final-rule-summary-cy-2026.pdf

 

December 12, 2025: Inpatient Psychiatric Facilities Prospective Payment System: FY 2026 Updates

Make sure billing staff know about the FY 2026 updates including facility-level adjustment factors, market basket, wage index, quality reporting programs (QRP), and rural adjustment. https://www.cms.gov/files/document/mm14206-inpatient-psychiatric-facilities-prospective-payment-system-fy-2026-updates.pdf

 

December 31, 2025: Transmittal 13570: Implementation of WISeR Model Prior Authorization and Medical Review Process and Establishment of New Quarterly Change Request Process

Transmittal Summary: The purpose of this Change Request (CR) is to implement the Wasteful and Inappropriate Service Reduction (WISeR) Model Prior Authorization and Medical Review Process starting January 1, 2026, and establish a recurring quarterly process to allow for updates to attachment file contents as needed. https://www.cms.gov/files/document/r13570demo.pdf

 

Coverage Updates

December 8, 2025: Anti-Cancer Chemotherapy for Colorectal Proposed Decision Memo (CAG-00179R)

CMS is proposing to remove NCD 110.17 for Anti-cancer Chemotherapy for Colorectal Cancer and notes that “removing this NCD would not end the opportunity for coverage for these agents.” The public comment period is from December 8, 2025 to January 7, 2026. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=320

 

December 11, 2025: MLN MM14263: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2026 Update

CMS advises that you make sure your billing staff know about CPT additions to the NCD: Sacral Nerve Stimulation for Urinary Incontinence (230.18), effective June 17, 2025. https://www.cms.gov/files/document/mm14263-icd-10-other-coding-revisions-national-coverage-determinations-april-2026-update.pdf

 

December 11, 2025: MLN MM14253: Adding Extravascular Defibrillator Codes to National Coverage Determination 20.4: Implantable Cardiac Defibrillators

Make sure your billing staff knows about changes to NCD 20.4 including coverage of additional procedure codes for the Aurora™ extravascular ICD (EV-ICD) system, effective October 20, 2023, and updates to the coding requirements. https://www.cms.gov/files/document/mm14253-adding-extravascular-defibrillator-codes-national-coverage-determination-20-4-implantable.pdf

 

December 12, 2025: MLN MM14204: Chimeric Antigen Receptor T-Cell Therapy Claims: End of Risk Evaluation Mitigation Strategy (REMS) & KX Modifier Requirement

As of June 26, 2025, CMS no longer requires providers to administer CAR T-cell therapy in an FDA REMS approved facility or the KX modifier on Part B claims. https://www.cms.gov/files/document/mm14204-chimeric-antigen-receptor-t-cell-therapy-claims-end-risk-evaluation-mitigation-strategy-kx.pdf

 

December 15, 2025: NDC 20.32: Transcatheter Aortic Valve Replacement (TAVR) National Tracking Analysis

CMS accepted a formal request from Edwards Lifesciences to initiate a reconsideration of this NCD focused on coverage of TAVR for Aortic Stenosis (AS) in symptomatic and asymptomatic patients. The public comment period is from December 15, 2025 to January 14, 2026. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=321

 

December 17, 2025: December 2025 National Coverage Determination (NCD) Dashboard

In this edition of the NCD Dashboard there are 3 open NCDs, 6 NCDs finalized in the past 12 months, 1 pending Transitional Coverage for Emerging Technologies (TCET) topic and 10 accepted NCD requests on the wait list. https://www.cms.gov/files/document/ncddashboard-2025.pdf

 

December 19, 2025: MLN Matters MM14302: National Coverage Determination 20.40 Renal Denervation for Uncontrolled Hypertension

Effective October 28, 2025, CMS covered Renal Denervation (RDN) for treating uncontrolled hypertension under coverage with evidence development (CED). Make sure your staff knows about the NCD criteria, CED study criteria, and claims processing requirements. https://www.cms.gov/files/document/mm14302-national-coverage-determination-20-40-renal-denervation-uncontrolled-hypertension.pdf

 

December 22, 2025: MLN MM14311: Cardiac Contractility Modulation for Heart Failure

Effective October 28, 2025, CMS covers Cardiac Contractility Modulation (CCM) for treating heart failure (HF) under CED according to the coverage criteria in NCD 20.39. Make sure your billing staff knows about the national coverage for CCM including the criteria, CED study criteria, and clams processing requirements. https://www.cms.gov/files/document/mm14311-cardiac-contractility-modulation-heart-failure.pdf

 

December 24, 2025: Final Local Coverage Determinations (LCDs) for Certain Skin Substitutes Withdrawn

CMS published a fact sheet indicating that effective immediately, the A/B MACs are withdrawing the LCDs for skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers that were scheduled to become effective on January 1, 2026. https://www.cms.gov/newsroom/fact-sheets/upcoming-update-final-local-coverage-determinations-lcds-certain-skin-substitutes

 

Compliance Education Updates

 

Medicare Preventive Services – Revised

CMS has made changes to information related to colorectal cancer screening tests, COVID-19 vaccine and administration, PrEP using antiretroviral therapy to prevent HIV infection, and screening pap test and screening pelvic exam. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

 

Medicare Provider Compliance Tips is now a CMS.gov Webpage

CMS has updated several compliance tips based on the improper payment rate and denial reasons for the 2024 reporting period. You can learn more about the services that have been updated and find a link to the new CMS webpage in the Thursday December 18, 2025, edition of CMS’ MLN Connects Newsletter. https://www.cms.gov/training-education/medicare-learning-network/newsletter/mln-connects-newsletter-december-18-2025#_Toc216870507

 

Other Updates

December 4, 2025: Medicare Appeals: Adjustments to the Amount in Controversy Threshold Amounts for CY 2026

CMS published a notice announcing the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. Effective January 1, 2026 the ALJ hearings AIC will increase from $190 in CY 2025 to $200 for CY 2026, and the Federal District Court reviews AIC will increase from $1,900 in CY 2025 to $1,960 for CY 2026. Link to Federal Register announcement: https://www.govinfo.gov/content/pkg/FR-2025-12-04/pdf/2025-21879.pdf

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.