Suppose a cardiology practice performs a transthoracic echocardiogram. The technician performed it, while the physician interpreted it and created the report. Everything went as it should. However, when the billing department files an insurance claim for it, it gets rejected. Why? An outdated CPT code. This is not just a hypothetical scenario; it happens in real clinical settings more often than you think.
The only solution is to keep your billing staff updated with the latest changes in the cardiology billing guidelines and tools. That’s why we have created this guide especially for cardiology billers. We will discuss the latest changes in regulations and other essential things that you need to follow in 2026.
So, let’s start.
Cardiology CMS Billing Guidelines
Here are some things to keep in mind for 2026 cardiology billing and coding:
2026 Medicare Physician Fee Schedule Changes
Centers for Medicare & Medicaid Services (CMS) finalized the CY 2026 Physician Fee Schedule (PFS) on October 31, 2025. Like all other medical specialties, CMS raised the conversion factor from $32.3465 to $33.5675 for qualifying alternative payment model participants. The conversion factor for non-qualifying participants has also increased and now stands at $33.4009. This is a big increase.
For cardiology services, the reimbursement is expected to rise by about 1% on average. However, this impact is uneven. For instance, CMS has cut the indirect practice expense allocation for hospital-based services by 50%. This translates to a reduction of about 10% for facility-based services like pacemaker implants, TAVR, and PCI.
To summarize all this, we can state that in 2026, reimbursement for facility-based cardiology services is expected to drop by 7% on average. On the other hand, non-facility cardiology reimbursements are projected to rise 5%.
Status of the Appropriate Use Criteria Program
This is not a recent highlight, as it was rolled out in the 2024 PFS and implemented in 2025. However, due to its importance, we have mentioned it here. CMS has paused the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging.
In 2026, the pause is still ongoing. So, no AUC reporting requirement applies in 2026.
Percutaneous Coronary Intervention (PCI) Changes
Some major changes were made to the Percutaneous Coronary Intervention (PCI) coding in 2026. Here is the summary of the key changes:
- All work performed in one major coronary artery, including its branches, is now reported with a single base code instead of separate branch-level codes.
- Codes 92921, 92925, 92929, 92934, 92938, and 92944 are no longer valid in 2026.
- Codes 92975 and 92977 (intracoronary and intravenous infusion thrombolysis) were also deleted in January 2026.
- CPT code 92928 has also been altered. As per the new guidelines of 92928, a single lesion in one major artery and/or its branches, regardless of stent count or number of segments involved. So, multiple stents in one lesion no longer require multiple codes.
- Codes 92973, 93571, and 93572 received small wording revisions without changes to their core reporting rules.
Common Challenges in Cardiology Billing
The table below summarizes the most common challenges in cardiology medical billing:
| Challenge | What It Means in Practice |
|---|---|
| Regulatory Changes | Cardiology billing rules are revised frequently, and falling behind on the latest guidelines increases the risk of audits and fines. |
| Pre-authorization Delays | Procedures such as nuclear stress tests and laser ablations require payer pre-approval, and delays in securing that authorization can postpone patient care. |
| Complex Coding | With over 300 cardiology CPT codes, each one must be paired with the correct ICD-10 diagnosis code, making coding accuracy difficult to maintain. |
| Documentation Gaps | Incomplete or hastily prepared records often fail to support the medical necessity of a service, leading to denials. |
| Staff Shortages | A lack of trained cardiology billing and coding staff results in late or erroneous claim filings. |
| Frequent Denials | Cardiology carries one of the highest claim denial rates of any specialty, at around 15%. |
Best Practices to Streamline Cardiology Billing & Coding
Now that we have discussed the latest changes in cardiology medical billing and the challenges that billers face most, here are some best practices that you can implement to counter them:
- Verify eligibility and obtain prior authorization before scheduling any test or procedure on a payer’s pre-certification list. As we mentioned in the previous section, prior authorization is one of the biggest challenges and a cause of most of the denials. Paying attention to it should be your priority.
- Build NCCI, MUE, and PC/TC edit checks directly into the claim scrubbing process.
- Cardiology billing faces frequent changes in its billing guidelines. We gave an example of PCI changes for 2026. So, you should train your staff every quarter on the latest changes. If you cannot manage quarterly training, then at least do it once a year.
- Conduct quarterly internal coding audits on high-dollar services such as catheterization, ablation, and device implantation.
- Separate aged accounts receivable recovery from current claims follow-up.
- Compare payer remittances against contracted fee schedules on a routine basis to catch underpayments that would otherwise go unnoticed.
- Lastly, make sure your documentation is perfect. Detailed documentation is the only thing that can save your claims from a denial. If there is any error or mistake in the reports, claims will not hold up. So, to counter this issue, create a standardized documentation process and templates for your practice.
Final Thoughts
In this guide, we tried to summarize the recent changes in cardiology billing rules and regulations. We also highlighted some key challenges that billers face while creating cardiology claims and some best practices that can help them overcome these challenges.
However, even with all the guidelines, specialty-specific billing and coding can be frustrating for in-house teams. That’s why many practices now prefer to get professional cardiology billing services from companies like NeuraBill. You, too, can hop on the bandwagon and notice the difference.
