Payment in 2026 Necessitates Being Proactive

HEALTHCARE FACILITIES are facing multiple financial challenges with changes, including regulatory mandates, margin erosion and compression in payer rates. Optimizing payment will depend on data and revenue integrity, as well as understanding the three pillars of payment: payer requirements, health system adherence/governance and infrastructure data and support.

At a time when this scenario is squeezing healthcare revenue, are you in one of the many systems relying on reactive reimbursement strategies or leaving millions on the table because you are not proactive in seeking out leaks? Here’s where you can find some meaningful remedies for 2026.

Capturing Revenue: Codes Submitted on the Claim

Capturing revenue begins with the charge description master (CDM) and its link to the pharmacy drug master (PDM). If a product is being used in the facility, it must have an assigned CDM number and be linked to its PDM description to be entered into the electronic health record (EHR) and subsequently sent to the payer. Make it your goal to add a drug before the first dose is administered.

• What is included in the CDM description? At a minimum: either the long or short description of drug name and strength (dependent on system number of characters) from the healthcare common procedure coding system (HCPCS) tables, HCPCS code, billing unit, national drug code (NDC) number, dosage form and perhaps other terms depending on system space limitations.
• Why is this important? Because it is the only information on the electronic claim sent to the payer to describe the drug and amount administered to the patient! A mismatch in any of the components of the CDM description or billing unit calculation results in payment denial or payment inaccuracy.
• Where can I start looking for issues? Although your CDM is likely thousands of lines long, use a data sorting tool even as simple as Excel to sort on the HCPCS code. Hone in on J9999, C9399, J3490 and J3590: These codes may have been used while awaiting a permanent HCPCS code. Payment is denied if one has been assigned and you are still using these codes.¹
• However, if there is an actual need for use, you must identify the drug by including its NDC code and dose administered, as it is the only way the payer will be able to reimburse for the cost of the product rather than a standard reimbursement amount that is usually less than $50.

Billing Unit Assignment and Calculation

Years ago, the Centers for Medicare and Medicaid Services (CMS) ceased paying for entire vials, amps or containers of injectable products and instituted payment only for the actual dose of the drug administered. Since doses vary due to weight, illness, severity, etc., each HCPCS code has its own assigned billing unit to calculate the appropriate reimbursed payment. Although a commercially available crosswalk usually determines this entry into your system, errors associated with new or facility-built entities are often the culprits. Billing unit assignment could change, or the original entry could be incorrect with a decimal place error.

Current Procedural Terminology (CPT)

The American Medical Association released 2026 changes, including 288 new codes, 84 deletions and 46 revisions. New codes are those for shorter duration remote patient monitoring, augmentative and assistive AI services, hearing device services, as well as revision for leg revascularization. Updated appendices P and T list services provided via audio-video or audio-only technologies recognized by the CPT Editorial Panel as correlating to in-person services. These additions increase flexibility in how behavioral health services are delivered, helping to overcome access barriers, especially in rural, underserved and vulnerable communities. As you develop and expand the clinical services your facility will be offering in the new payment year, connecting them to the appropriate CPT codes is the backbone of payment. Additionally, three new codes cover immunization counseling when an immunization is not administered to the patient on the same date.²

The Rural Health Transformation Fund

The Rural Health Transformation Fund is a $50 billion funding pool set aside in the new tax law that was designed to help rural providers weather healthcare cuts. The fund is divided into two parts:

$25 billion will be evenly distributed to states with approved plans, and $25 million will be awarded “based on individual state metrics and applications that reflect the greatest potential for and scale of impact on the health of rural communities,” according to CMS. Rural hospitals, critical access hospitals, safety-net hospitals, sole community hospitals, Medicare-dependent hospitals and low-volume hospitals are eligible to receive funding support, as well as federally qualified health centers, rural health clinics and community mental health centers.

Specifics apply to how states can use the funding: at least three of a prescribed set of activities, such as recruiting staff, setting up new technologies, paying providers, developing value-based care initiatives and supporting access to substance use disorder treatments, among others. Not more than 10 percent of funds can be used for state administrative expenses.³

NCD and ICD-10 Revisions

Both international classification of disease (ICD)-10 code sets and national coverage determinations (NCDs) also can change. Your financial team receives automatic downloads of these, but those affecting your practice may not reach the pharmacy department. A simple Internet search of any NCD will provide the details of what it entails, which gives you the basics of what documentation must be in the EHR to substantiate payment.

Evaluation and Management (E/M) Services Coding

In September 2025, CMS published a revised 35-page Medicare Learning Network (MLN) booklet that clinical staff should use to learn details of billing for clinical services. Highlights relevant to your practice include general principles of E/M documentation, and common sets of codes used to bill for E/M services, chronic pain management and telehealth services.⁴

Internet-Only Manual (IOM) Update: Addition of Section 70.2 to Publication 100-04, Chapter 17 – Billing Zero Charges for Drug Line Items Provided at No Cost

CMS updated the IOM to provide billing instructions for the submission of zero-charge line items for drugs provided at no cost. “According to the Social Security Act (SSA) Section 1861(v)(1) (A), the reasonable cost of any service is the cost actually incurred, excluding any part of an incurred cost found to be unnecessary in the efficient delivery of needed health services. If a provider does not purchase a drug, but provides the administration service, the physician cannot bill Medicare for the drug. However, the administration of the drug, regardless of the source, is a service that represents an expense to the physician. Therefore, administration of the drug is payable if the drug would have been covered when purchased by the physician. Under such circumstances, to avoid drug administration code denials, a drug code must be present on the same or prior claim and $0 should be entered for the billed amount of the drug.”⁵

From the perspective of the provider, there are at least three opportunities for using “$0 priced drugs”: white bagging, patient assistance drugs and sample drugs, as well as study drugs. As healthcare is on the cusp of dramatic change with many new regulations dictating eligibility, coverage and payments, it behooves providers to establish a mechanism for efficiently and effectively handling these. Basically, all require the same steps: knowing the payer requirements, establishing procedures for handling and storage, and adjusting the PDM/CDM to accommodate EHR records/claims submission for a $0 priced drug.

Be Proactive to Stay Financially Sound

Understand that payer-mandated acquisition in some format is here to stay. Can you afford to ignore it and do your own thing?