The 2026 Medicare Physician Schedule Final Rule includes several distinct policy changes in which the Centers for Medicare & Medicaid Services (CMS) modifies how it uses or pays for services related to social-risk drivers and the social determinants of health (SDoH), by either eliminating these terms altogether or reframing them under different terminology. Below are the principal changes.
For Community Health Integration (CHI) services listed under HCPCS code G0019, CMS is replacing the descriptor phrase “social determinants of health” with the term “upstream driver(s).” The rule states that this term is “more comprehensive and includes a variety of factors that can impact the health of Medicare beneficiaries, such as smoking, poor nutrition, low physical activity, substance misuse, or potential dietary, behavioral, medical, and environmental drivers.”
In addition, CMS removed the term of an unmet SDoH need from the initiating visit descriptor requirement, to allow for a broader list of eligible initiating services for which CHI can be applied.
In the policies surrounding the Medicare Shared Savings Program (MSSP), CMS finalized the removal of Quality ID 487, “Screening for Social Drivers of Health,” from the APP Plus quality measure set for 2025 and beyond. The ruling explains that MSSP Accountable Care Organizations (ACOs) will no longer report that measure as part of the required quality set.
While strictly speaking of a terminology change for SDoH, the rule removes the health equity adjustment applied to an ACO’s quality score beginning in 2026, and revises related terminology by renaming the benchmark adjustment as the “population adjustment.” This change is described in the rule to be part of a broader recalibration of how CMS handles social risk/health-equity in ACO quality and payment.
In the proposed rule, CMS proposed to delete HCPCS code G0136 – “Administration of a standardized, evidence-based SDOH risk assessment,” on the basis that the resource costs are already captured in existing evaluation and management (E&M) and behavioral health services. However, in the Final Rule, CMS ultimately did not delete G0136, but revised the descriptor instead. The new descriptor shifts the focus from SDoH risk assessment to “administration of a standardized, evidence-based assessment of physical activity and nutrition, 5-15 minutes, not more often than every 6 months.” At the time of this publication, there is no specific recommended screening tool to use in place of the prior Health-Related Social Needs (HRSN) tool.
Entities that had structured workflows around “SDoH risk assessments” should start to revise terminology, documentation templates, care-coordination services, and quality-improvement frameworks to align with “upstream driver(s)” language. Although this is a CMS change in terminology, internal organizational considerations must remain on how populations will be managed, given the known risk factors of housing, transportation, food, and utilities impact, in light of how they are so often felt “upstream” in the health and well-being of our patients.
Healthcare has been transitioning toward a more digital, interconnected ecosystem for many years, but the pace and magnitude of current changes represent a fundamental shift.
H.R. 1 doesn’t directly rewrite ICD-10 or CPT, but it does change the environment in which you’re coding. The impact is mostly indirect – through
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
