2026-06-25 - CY 2027 End-Stage Renal Disease Prospective Payment System Proposed Rule

REQUIREMENTS: By July 31, 2026: If your practice operates an independent laboratory, physician office laboratory, or hospital outreach laboratory meeting CLFS definition, submit clinical diagnostic laboratory data through the CLFS Data Reporting System, including applicable HCPCS codes, private payor rates, and volume data for January 1 – June 30, 2025. Failure to report may result in non-compliance penalties. Before July 1, 2026: Billing team must update billing software and encounter forms to reflect Hospital Outpatient PPS changes including new COVID-19 monoclonal antibody codes, CPT proprietary laboratory analysis changes, Category III CPT code updates, and device pass-through/offset modifications. Review the July 2026 HOPPS Update document for specific code changes. Immediately: Compliance team must review and implement corrected billing procedures for urinary catheters and tracheostomy supplies using the provider compliance tips to ensure proper billing codes, documentation requirements, and refill protocols are followed. Current improper payment rates (25.6% for tracheostomy supplies) indicate systemic coding errors. Before January 1, 2027: Finance and billing leadership must monitor the final ESRD PPS rule (expected before effective date) to prepare for base rate changes ($299.55 proposed), low-volume payment adjustments, pediatric payment modifications, and updated transitional drug add-on payment adjustment (TDAPA) calculations. Update billing system fee schedules and rate tables accordingly. Authorized officials should request access to the relaunched PEPPER tool to benchmark billing patterns against national data and identify areas requiring correction. By effective date of July 2026 HOPPS: Providers must review updated Part B drug pricing files and revisions with July update; instruct billing staff to use correct average sales price (ASP) and non-otherwise-classified (NOC) pricing files in claim submissions.