BlueSpeak Provider Newsletter — August 2026

REQUIREMENTS: By September 1, 2026: (1) Billing team must update system documentation to reflect that observation services (G0378, G0379) are NOT separately reimbursable when integral to standing orders following outpatient surgery, extended observation following procedures, services concurrent with chemotherapy, inpatient-to-outpatient observation transitions, blood administration, routine diagnostic prep/recovery, or awaiting facility transfer. Update claim scrubbing logic to deny these combinations. (2) Coding and billing staff must train on MOHs micrographic surgery (CPT 58674) — procedures performed in same operative session may now be submitted on separate claims instead of consolidated to single claim. Update billing software to allow separate claim submission for MOHs procedures. By October 1, 2026: Prior authorization requirements take effect for CPT 58674 (laparoscopic ablation of uterine fibroids) in ACA plans (already required in Commercial). Update prior auth matrix and encounter forms to require authorization before service delivery. By November 1, 2026: (1) Billing team must update readmission logic in billing system. When a patient is readmitted to the same health system within 15 calendar days (changed from 30 days) for related conditions, combine admissions into single payment per contractual agreement instead of separate reimbursement. Related readmissions include same/closely related diagnosis, infections/complications from original stay, failed interventions, acute exacerbations of chronic conditions, and clinical instability at discharge. (2) Revenue cycle team must prepare for Post-Payment Clinical Claim Validation reviews by Cotiviti. Establish process to respond to medical record requests from Cotiviti within required timeframe. Cotiviti reviews will examine coding accuracy and documentation; failure to provide records may result in claim payment recoupment or denial. ConsEQUENCES: Claims submitted without prior authorization for CPT 58674 will be denied. Observation services billed as separate line items when integral to covered procedures will be denied. Readmissions within 15 days billed separately will be combined retroactively and reimbursement adjusted. Failure to provide medical records for post-payment validation may result in claim adjustments or denials.