Medical Tools

Provider Billing Compliance: Is your practice getting it right or wrong?

The original version of this article was written by Stephanie Allard RHIT, CPC, CMPA, and this edited and updated version was posted with permission from Stephanie Allard Consulting, LLC.

A frequently overlooked healthcare billing risk is reporting services under the wrong provider. Even when organizations know claims should name the clinician who delivered the care, many still routinely bill under a physician’s National Provider Identifier (NPI) for work performed by another practitioner. These choices are often driven by reimbursement rather than compliance, increasing exposure to audits and payment recoupments.

This is particularly troubling because the practice can become routine over time. What starts as a short-term workaround or a misread of payer rules can turn into a default process in which most visits are billed under the same supervising provider, regardless of who treated the patient. From CMS and commercial Special Investigations Unit (SIU) viewpoints, these patterns are increasingly easy to spot through analytics, utilization trends, and outlier reviews.

Organizations often confuse credentialling requirements with billing rules such as incident-to. Many assume that employing a physician assistant or nurse practitioner automatically allows the practice to bill that work under the physician’s National Provider Identifier (NPI). In reality, compliance depends on payer enrollment and credentialing policies, state scope-of-practice laws, and supervision requirements. Incident-to billing is also not a stopgap for credentialing delays. Practices sometimes will attempt to bill under a physician’s NPI while waiting for payer enrollment of a new Advanced Practice Provider (APP), but incident-to does not care about incomplete credentialing. When a payer requires individual credentialing and enrollment, organizations cannot bypass that requirement by billing under another physician or another provider. Remember, credentialing is a form of “vetting” that new provider.

It’s important to note that incident-to billing is a CMS construct. It doesn’t automatically apply to commercial insurers just because a practice prefers to use it. Because each payer has its own credentialing and payment policies, organizations should follow payer policy manuals and provider enrollment instructions – not assumptions – before billing under another clinician.

Basics of Incident-To Billing 42 CFR §410.26 – Core Coverage Scope:

  1. Must have been a prior physician service to:
    1. evaluate/address and diagnose the problem &
    2. initiate a management plan/treatment course
  2. “Physician” must be in office suite and immediately available (if you are allowing VDS- you must have a compliance plan outlining your workflow to meet the “immediately available” criteria under incident-to) to provide assistance and direction if needed.
  3. Physician must provide subsequent services of a frequency that reflects the physician’s continuing active participation in/management of course of treatment.
    (While Centers for Medicare & Medicaid Services does not explicitly define a strict “12-month rule,” its guidance does require that the physician’s involvement reflect ongoing, active participation in the patient’s course of treatment.)
    That said, legal and compliance experts consistently caution that if a physician has not personally seen a patient within 12–24 months, billing subsequent non-physician practitioner (NPP) visits as “incident to” may present elevated audit                risk.)
  4. The NPP must represent an expense to the provider (or the entity billing on behalf of the provider) – employee, leased employee, 1099 independent contractor.

To understand payer policies in general, when a physician employs a nurse practitioner, the physician doesn’t get to choose whether claims can be filed under the physician’s NPI (unique provider number). The payer decides if the NP must be separately credentialed and enrolled. More and more commercial insurance payers are requiring individual enrollment for advanced practice providers, questioning the assumption that their services can automatically be billed under the physician.

Organizations also treat incident-to as a reimbursement strategy, but it comes with strict CMS compliance requirements. To bill incident-to under a physician, the physician must first see the patient as a new patient and establish the plan of care or treatment plan. Follow-up visits with the NPP/APP must be consistent with that documented plan. MBPM (Medicare Benefit Policy Manual) Ch.15 § 60.1.B.

 A frequent error happens when an advanced practice provider sees a patient independently, develops a new plan of care and then “discusses” it with the supervising physician. Many practices assume the physician’s agreement in that plan is enough to bill incident-to. It isn’t. Review or concurrence alone does not satisfy incident-to rules. If the visit includes a new workup for a new complaint, a new assessment, or any change to the current physician treatment plan, the physician must personally see the patient and document their own services to bill under the physician’s NPI.

Another major risk is assuming that a collaborative relationship automatically meets incident-to requirements. Many states require supervision and collaboration between physicians and advance practice providers, but those state-law obligations do not, but themselves, satisfy CMS or payer-specific incident-to rules. Practices need to know those are separate payer standards and assess each one independently.

One of the main rules under the incident-to guidelines practices miss is the requirement for ongoing physician involvement in the patient’s care. CMS does not set specific intervals for how often the physician must see the patient, but organizations should be able to show workflows that document continued physician participating in managing treatment. When a patient has been seen by only an APP/NPP for years with no physician contact. Supporting all elements of incident-to billing is very, very difficult.

When a visit is billed under a physician’s NPI, incident-to supervision rules still apply. The supervising physician typically must be in the office suite and immediately available during the encounter. A physician cannot bill incident-to services while away from the office, traveling between sites, on vacation, out of the state or counter, or in the office for administrative purposes only. There is the exception of VDS (Virtual Direct Supervision), but this is an exception to the rule, and practices who choose to use VDS, must be able to demonstrate the ability of the physician to be “immediately available”, and provide proof that the practice internet works 100% of the time, and the platform they are using is HIPAA approved, and not FaceTime or Skype, or a public facing platform. This is a hard policy to perfect and enforce.

For example, let’s say that an established patient is in clinic, and is being seen by the practice NP for her chronic conditions and set treatment plan by the physician. The physician was not in clinic at the time, and the practice needed to locate her. Via text, the physician was alerted that this is an incident-to visit and needed to log into their EPIC telehealth audio and video platform for VDS. The practice does not get confirmation from the physician that she received the contact or that she will be logging in. The patient ended up having dangerously high blood pressure and needed to be sent to the ER for elevated hospital care. The patient visit was completed by the NP, and the patient was sent to the ER. About 10 minutes later, the physician texted that she was available now to log in to the A/V platform, but that her internet was sketchy. She was told that the patient ended up at the hospital for a BP event, and the visit was over. This office visit must be billed direct, under the NP, not the physician. This is also an example of how the VDS can be at issue when it does not work for the current workflow and/or when there is an event with a patient that needs attention.

Terminology Defined

  • Immediately Available: CMS has clarified that “immediately available” means “without delay” so Noridian (Medicare Administrative Contractor) considers “immediately available” to mean the supervising physician is in the office suite or patient’s home, readily available and without delay, to assist and take over the care as necessary.
  • Office Suite: An “office suite” is limited to the dedicated area, or suite, designated by records of ownership, rent or other agreement with the owner, in which the supervising physician or practitioner maintains his/her practice or provides his/her services as part of a multi-specialty clinic.
  • https://med.noridianmedicare.com/web/jeb/topics/incident-to-services

As payer analytics and SIU activity expand, organizations that do not review billing patterns face greater risk. Payers examine utilization trends, provider-to-provider comparisons, credentialing records, and encounter mixes, to flag service that may be billed under the wrong supervising physician. Findings can lead to repayment demands, extrapolated overpayments, audits, corrective action plans, and potential fraud investigations.

Reducing Audit Exposure and Risk

Reducing this risk starts with strong compliance oversight and an honest review of provider workflows. Organizations should routinely audit encounters billed incident-to under supervising practitioners to confirm that documentation supports all of the incident-to requirements, payer rules, physician involvement, and supervision expectations. Also, track credentialing status’ closely along with new hire APP credentials. You can trust, but also verify.

Billing under the wrong provider is not a minor technical error. It is a serious compliance risk that can affect your reimbursement and billing integrity, payer relationships, and audit outcomes. As oversight and analytics with payers has become more sophisticated, organizations cannot rely on assumptions or reimbursement-first decisions when assigning billing providers. Those that build clear workflows, maintain proper credentialing, and follow payer policies are in a far better position than organizations trying to justify improper billing after an audit or investigation has begun.

References

New Medicare ABN 2026

Many of you have asked about the new ABN (Medicare waiver) for 2026. See below for details and effective date.

The Centers for Medicare & Medicaid Services (CMS) periodically releases updated ABN forms. Medical Providers must ensure they are using the currently approved version of Form CMS-R-131, which is valid through March 31, 2029.

The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a written notice from a healthcare provider. It warns Original (Traditional) Medicare patients that Medicare may deny payment for a service, making the patient personally responsible for the full bill. When an ABN is used appropriately, and the patient is alerted prior to the service being performed, the EOMB will transfer responsibility of payment to the patient under the payment code PR (patient responsibility).

When is an ABN issued?

An ABN is issued before a patient receives an item or service, usually under the following circumstances:

  • Not Medically Reasonable and Necessary: The provider believes Medicare will determine the service or item does not meet medical necessity guidelines.
  • Statutory Exclusions: The treatment or item is something Medicare never covers (e.g., most routine dental care, cosmetic surgery).
  • Experimental: The treatment is considered experimental or investigational.

Patient Options Under an ABN

When presented with an ABN, the patient must choose one of three options on the form before receiving the care:

  • They want Medicare billed: This allows the provider to submit a claim to Medicare. If Medicare denies it, the patient will be billed and have pay out-of-pocket, but they may preserve the right to appeal the decision.
  • They want the item/service, but do not want Medicare billed: The patient pays for the service out-of-pocket and cannot appeal to Medicare (this is typically used if the patient does not have Original Medicare or wants to bypass Medicare rules).
  • The patient does not want the item/service: They decline the care, and no one is billed.

Who receives an ABN?

This form is for Original or Traditional Medicare (fee-for-service) beneficiaries only. If a patient is enrolled in a private Medicare Advantage Plan, that insurance plan may use a different process, such as a Hospital-Issued Notice of Non-coverage (HINN)

Instructions to complete the form and copies can be found on the CMS website:

https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn

AI (Artificial Intelligence) in healthcare has both pros and cons

As healthcare organizations move deeper into the adoption of AI tools in 2026, the conversation has shifted from whether to use AI to how responsibly it can be implemented. Coding workflows, billing operations, clinical documentation, and revenue cycle functions are now heavily influenced by AI-driven platforms.

With HHS and CMS expectations around documentation accuracy, heightened scrutiny from commercial payers, and rapid advances in generative AI, organizations must build structured monitoring practices directly into their operational strategy. Implementing AI in 2026 requires more than onboarding technology; it requires adding oversight, validation, and accountability into the development of every AI-supported workflow.

This begins with reinforcing the principle that AI is not a replacement for professional judgment or critical thinking. Even though AI coding instruments and documentation tools are more cutting-edge heading into 2026 than they were just a year or two ago, the potential for misinterpretation, over-coding, and incomplete clinical detail persists. As you consider implementing (or if you already have implemented) AI across medical record documentation, coding, and billing functions, it is imperative that your practices establish a review protocol where a consistent percentage of AI-influenced encounters are examined. Early findings in 2026 will guide how you configure your tools, adjust internal rules and safeguards, and design training that aligns with your organization’s risk profile.

As more practitioners embrace automated chart documentation with functions like ambient scribing in 2026, organizations must ensure that documentation truly reflects the clinical encounter, appropriately supports medical necessity, and avoids artificially inflated complexity. Incorporating AI-specific checks into existing documentation audits ensures that monitoring becomes part of your normal workflow rather than a separate initiative. Reinforce provider accountability and help clinicians understand the risks associated with letting AI fill in gaps that were not part of the actual patient interaction.

Before you dive into AI, here are some “cons” to consider. While this may seem a bit harsh, the reality is that we must be diligent to ensure AI does not take over our physicians’ physical presence and human judgment.

AI in healthcare presents significant cons, including severe data privacy and security risks, potential for algorithmic bias leading to health disparities, and high implementation costs. Key drawbacks also include over-reliance on technology, lack of human empathy, and unclear accountability for errors, which can erode trust in medical systems.

Key Disadvantages of AI in Healthcare:

  • Data Privacy and Security Risks: AI requires massive datasets, creating high-value targets for cyberattacks, data breaches, and misuse of sensitive patient information.
  • Algorithmic Bias and Inequality: Algorithms trained on biased or incomplete data can perpetuate or worsen health disparities among specific demographic groups.
  • Errors and Lack of Accountability: AI systems can make mistakes, such as misdiagnosis or hallucinations (generating false information), with complex, opaque decision-making (“black box”) processes that make it difficult to assign responsibility.
  • High Costs and Implementation Barriers: Adopting and maintaining AI technology is expensive, creating disparities in adoption between large, wealthy institutions and smaller providers.
  • Over-reliance and Reduced Human Interaction: Over-dependence may erode the critical thinking skills of clinicians, and the lack of human empathy and compassion can diminish the patient experience.
  • Workflow Integration Challenges: Interoperability issues with existing, outdated health IT systems can hinder efficient, safe deployment.
  • Job Displacement Fears: Automation of administrative and even some clinical tasks may lead to workforce anxiety and potential job displacement, as we are already seeing.

To mitigate these concerns, here are 5 action items recommended for implementing AI monitoring in 2026:

Establish Governance and Policies

Create an AI oversight committee that includes coding, compliance, HIM, IT, and clinical staff. Develop written policies and SOPs detailing how AI will be used, monitored, verified, and audited, and update them regularly as technology and regulations evolve.

Audit AI-Influenced Workflows

Implement routine reviews of AI-assisted coding and documentation. Verify that all outputs reflect actual patient encounters, support medical necessity, and comply with payer and regulatory requirements. Use findings to refine AI configurations and workflows.

Train Staff and Promote Accountability

Educate coders, auditors, and providers to detect errors, hallucinations, or inferred content in AI-generated outputs. Require provider verification of AI-assisted notes and use audit trails to track decisions, ensuring accountability at every step.

Protect Data Privacy and Security

Confirm that AI vendors comply with HIPAA and other regulatory requirements. Regularly review access permissions, data handling, and vendor security practices to safeguard PHI (protected health information) while maintaining transparency and compliance.

Monitor Performance and Continuously Improve

Track operational and financial metrics such as denial rates, coding accuracy, documentation quality, and productivity. Establish continuous feedback loops with staff and vendors to optimize AI performance, address risks, and ensure ongoing compliance.

References:

Telehealth Flexibilities Extended through 2027

The federal government experienced a brief shutdown from January 20 to February 3, 2026. Upon reopening, Congress extended temporary Medicare telehealth flexibilities until December 31, 2027, and made permanent changes for behavioral and mental health services. These actions solidify telehealth’s role in care delivery but do not lessen compliance requirements for documentation, licensure, or billing.

Temporary telehealth policies now allow eligible Medicare beneficiaries to access non‑behavioral services from any location within the U.S., with geographic restrictions lifted and Federally Qualified Health Centers and Rural Health Clinics serving as providers. Audio‑only telehealth platforms also remain allowable for non‑behavioral and non‑mental health services when clinically appropriate and properly documented.

Permanent telehealth policies for behavioral and mental health eliminate prior site and geographic limitations, though providers must still meet state licensure rules, and in‑person visit requirements persist for some behavioral health care. Federally Qualified Health Centers, Rural Health Clinics, Marriage and Family Therapists, and Mental Health Counselors are now recognized as Medicare telehealth providers.

While these policies are extended for two more years, they remain temporary and subject to future congressional action. Organizations relying on these flexibilities should treat the extension as an opportunity to reinforce compliant workflows rather than assume permanence.

Providers must also continue to comply with state‑level licensure requirements, particularly when delivering services across state lines, as Medicare policy does not override state scope‑of‑practice or licensure laws in individual states. This means the provider MUST be licensed in the state where they are located at the time of the patient encounter and in the state where the patient is located at the time of the encounter.

In addition, Marriage and Family Therapists and Mental Health Counselors are now permanently recognized as Medicare telehealth providers, contingent upon meeting all educational, credentialing, and qualification standards established under Medicare rules.

Despite the significant expansion of permanent telehealth access for behavioral and mental health services, the in‑person visit requirement for behavioral health is part of the COVID‑19 era flexibilities and has not been permanently adopted.

New Telehealth Billing Modifiers

CMS must create new telehealth billing modifiers by January 1, 2027. These will help Medicare determine how telehealth services are delivered—for example, whether a clinician used a telehealth platform owned by another company or whether the service was billed under another provider. For most independent clinicians, this won’t change much beyond adding a few billing steps. Larger health systems, however, may be more affected because they often own telehealth platforms and bill for services provided by supervised staff.

With telehealth policy now stabilized through 2027, providers should take this opportunity to reassess internal policies, enhance compliance, educate staff, and ensure readiness for audits, aligning processes with current telehealth regulations for continued access to care.

Summary

  • H.R. 7148 extends Medicare telehealth flexibilities until December 31, 2027.
  • Keeps home‑based telehealth for beneficiaries.
  • Ends geographic limits on telehealth services.
  • Retains coverage for audio‑only telehealth for certain services under specific rules.
  • Allows RHCs and FQHCs as distant‑site providers.
  • Continues the Acute Hospital Care at Home waiver through 2030.

References

Top 10 Coding and Compliance Q&A for April 2025

Here at Terry Fletcher Consulting, Inc., we get a slew of coding, billing and compliance questions on a daily basis. Our Coding Corner Membership clients send over their challenging questions when working in the Revenue Cycle Management department, and we are here to help. RCM can start at the front desk, to the patient exam room, to the back office, then into the coding and billing office. If we do our job right, we can minimize the claims that end up in the appeals office. Here are the questions and answers for the first quarter of 2025, that I hope may be of interest, and that may assist many of you in your workflows.

Here are our Top Ten Questions:

For ICD-10, intermuscular lipoma on the flank, would you lean to D17.9 for intermuscular or specifically to the site for D17.1?

Answer: I would report D17.1 as it specifies skin and subcutaneous tissue of the trunk. When I search Lipoma –> intramuscular in the ICD-10 index it takes you to D17.9. This is a great way to start your search for specificity. Don’t stop there. Go to the D17.X and then add your details.

I have a client looking to charge patients an annual administrative fee. While, this client is aware they can imposed fees for completion of certain forms including school, work, camp, jury duty, disability forms not connected with the providing of covered services, missed appointment fees, and charges for copies of medical records when the records are being processed for the subscriber or member directly, they are wanting to roll out an annual admin fee to all patients.

Answer: I believe this violates participation agreements with most payors, including CareFirst, UHC and some BC/BS plans. There is a cost of doing business wrapped into the RVU.PE (physician expense) in each CPT® code. This would be inappropriate to try and enforce.

I would like your opinion on the following scenarios of billing imaging during 27245 – Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage.

It is understood that 76000-26 is not billable with 27245 (although we have had instances where it has been paid as 76000.26.59, and I believe we should refund that payment).  NCCI also clearly states that 73503-26 is not allowed. There is discussion whether 73502-26, or 73503-26, are billable if views of the fluoroscopy are taken during the surgery and the interpretations are documented in the operative report. I do not find that the specific codes are disallowed, but the September 2013 CPT® Asst Q&A states that all imaging performed and interpreted during the case is included in the 27245 (see the attachment).  I had another article from CPT® Asst that also confirmed that 73503 was not allowed with 27245, but since CPT® Assistant has been moved to Find-a-Code®, I am having problems finding it other than the below from NCCI edits.

Answer: I do agree that imaging is inclusive. The reason that AMA® has indicated that it is included in the surgical procedure is due to the fact that it is not being done diagnostically. When we look at the category for 73502/73503 they are in the diagnostic radiology section. The descriptions are also “radiologic examination” not fluoroscopy. The documentation of the op report and the performance of the imaging is not for diagnosing the patient; it is checking alignment and placement of hardware; therefore, it is inclusive to the procedure. I have the same issue with cardiologists and IR docs trying to charge for pre- and post-angiography to “set up the procedure or measure the vessel”, and then image post procedure, to “check their work” or stent placement. Again, that is inherent to the procedures, and not diagnostic, and thus not billable in addition to the major procedure.

If a physician sees a patient in the office in the morning for a new condition and again in the afternoon because the condition has worsened, should modifier -25 be appended the afternoon visit?

Answer: No. The physician would be expected to combine the documentation of both encounters and bill one E/M based on the combined documentation. Modifier -25 would not be appropriate for this scenario. Modifier -25 is used to identify a significantly, separately identifiable E/M service performed by a physician on the same date as a procedure or other service. (Novitas. E/M FAQ)

If the same provider (or different providers of the same specialty and subspecialty belonging to the same practice) see a patient more than once on the same date of service in the same setting, CPT® has also clarified in the 2023 E/M update that you’ll submit just one E/M code, using the following criteria:

  • When using medical decision-making (MDM) to select the code, you’ll aggregate all MDM from that date of service together and use that to level your service.
  • When using total time to select the code, you’ll add the times of the two visits together to find the most accurate E/M level.

Can two physicians in the same group practice, who see the same patient on the same day, each bill for an E/M service and receive payment?

Answer: Physicians in the same group practice but who are in different specialties may bill and be paid separately without regard to their membership in the same group.

However, again, physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6.

How is medical necessity considered when scoring medical records?

Answer: All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, “…no payment may be made for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member.” Therefore, medical necessity is the first consideration in reviewing all services.

Is it acceptable to use abbreviations in the patient’s medical record?

Answer: Abbreviations may be used in the patient’s medical record. If your patients’ medical records contain abbreviations not commonly used, and you receive a request for medical records, please provide a key to the abbreviations. Submit the key with the medical records to assist us in the review. (V/U = verbal understanding or P/D = patient discussion are not typical to medical records acronyms). Also remember Googling does not always give you the answers.

MDM Q&A from MAC Novitas provider meeting asked, “If I personally review a film, e.g., x-ray, electrocardiogram in my office, will I receive credit in the amount and complexity of date to be reviewed and analyzed?”

Answer: Credit may be given when a practitioner independently visualizes an image, tracing or specimen previously or subsequently interpreted by another physician. The medical record documentation must clearly indicate that the physician/qualified NPP personally (independently) visualized and performed the interpretation of the image, tracing, or specimen. Credit will not be given if the documentation reveals the practitioner only read/reviewed a report from another physician/qualified NPP.

When a patient presents to an emergency department prior to midnight and the physician sees them after midnight, which date of service do we report?

Answer: The date of service would be the date the physician performs a face-to-face service with the patient. If the service started on one day and carried over continuously through midnight into the next day, the date the service began is the date of service when the face-to-face started. If the physician did not see the patient until after midnight, the date of service is the date of the face-to-face encounter.

Can you help us with MIPS to determine what we need to do?

Answer: No, MIPS (Merit-based Incentive Payment System) quality measures calculations and algorithms are very complicated, and I like to stay in my lane of coding, auditing and education. However, in saying that, you can also go through your EMR vendor (EPIC or NextGen or Cerner, etc) for MIPS. They can run you a report to determine which provider is eligible for MIPS and will also be able to identify what measures need to be performed for that particular specialty.

Since you have to pick certain ones based on the volume of what that individual provider does, then the practice, start there and that should help.

Check back with us quarterly as we will be posting our Top Ten Tuesday podcast sessions as white papers. Don’t forget to listen to and subscribe to our CodeCast Podcast found on all platforms. New episodes drop every Tuesday.

Telehealth 2025: Audio-Only First Quarter

As first published on TerryFletcher.net
This is a revision by the same author, Terry Fletcher CPC, CCC, CEMC, CCS, CCS-P, CMS, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM, PACS.

We have been receiving many inquiries and emails regarding the billing of Audio Only Telehealth for Medicare and Commercially Insured patients starting January 1st, 2025. The published guidance is muddy at best, and a lot has to be “inferred” from the Final Rule, the Federal Register, and the last CR (continuing resolution), to even begin to unfold the direction to our healthcare professions on billing.

First, read the “fine print”. All of the published guidance, states, “…while real-time interactive audio-video remains the generally applicable standard, including for distant site practitioners who wish to furnish these services, there are special considerations for patients when a Medicare telehealth service is delivered in their home. For example, a patient may not have sufficient (or any) access to broadband to support the use of real-time video technology, may not have the technical proficiency or support in place to use video technology, or may have privacy concerns about using video technology for Medicare telehealth services in their home…”

FR in § 410.78(a)(3), page 97761

This language is after every entry relating to audio only telehealth services, meaning that audio only is for “certain circumstances” or “special considerations”, not the norm or for the routine use. Remember, the only reason telehealth audio only was opened up for payment in April of 2020, at the height of the pandemic, is because our older, Medicare population had difficulty connecting to video technology for different reasons and HHS and CMS did not want to limit this population of patients’ access of care.

However, we are now 2-years removed from the end of the PHE (pandemic) as it ended May 2023, so to justify the need or medical necessity of an audio only, that again is “analogous to, and must include the elements of, the in-person service”, is hard to support. As we like to say in the coding and compliance world, “make it make sense”.

The Federal Register is clear that the rules or circumstances for “audio-only” has to “reflect this limited exception to address the unique considerations of patients who may receive Medicare telehealth services in their homes, as stated in the CY 2025 PFS proposed rule, we proposed a policy that would permit a patient driven choice to use audio-only technology to receive a Medicare telehealth service based on their technological capabilities and limitations, and their comfort level with the use of video technology in their home.” FR in § 410.78(a)(3), page 97761, 5th paragraph.

If the criteria or circumstances are met for the audio only telehealth services, we are instructed to use the -93 modifier (although this is not on the Appendix T list as appropriate for office or other patient visits in CPT. This is specific to Medicare), and the place of service below. We would not advocate for audio only for New Patients, as this was ended in 2023.

The Audio and Video Telehealth will continue as it did in 2024, through March 31st, 2025. The POS (Place of Service) options also will continue as stated below.

  • Place of service (POS) codes will continue to have two telehealth designations:
    • 02 Patient not in their home when telehealth services are rendered; or
    • 10 Patient in their home when telehealth services are rendered. POS 10 will continue to be paid at the non-facility rate.
  • CMS will continue to allow physicians to list their practice address, rather than their home address, when performing Medicare services via telehealth from their home, but again, they say this is a rare occurrence.
  • Teaching physicians may continue to have a virtual presence in all teaching settings, but only for Medicare telehealth services. This was only extended 1-year through Dec. 31, 2025.
  • Both patient and any approved Telehealth provider must be in the U.S. (including U.S. territories) when the services are done. The Telehealth provider but be licensed in the state they are in and the state the patient is in at the time the telehealth service is rendered.
  • Out of country (U.S.) medical services are not covered by Medicare via telehealth or otherwise.

Authoritative references are provided in the resources section to allow you to source the information yourself.

Congress Could Change Everything:

We are going to be watching very closely with a new government administration incoming as of January 20th, 2025. We will have a new HHS Secretary, Robert F. Kennedy Jr., along with a new CMS Director, heart surgeon, and former TV personality, Dr. Mehmet Oz M.D.

They may have different ideas for Telehealth and how it is allowed and even reimbursed. So, stay tuned for that possible change.

References and Resources

https://www.federalregister.gov/documents/2024/12/09/2024-25382/medicare-and-medicaid-programs-cy-2025-payment-policies-under-the-physician-fee-schedule-and-other p.97760-97761

https://www.congress.gov/bill/118th-congress/house-bill/10545

Telehealth 2025: The Final Rule

CMS is set to reinstate certain pre-pandemic telehealth policies if Congress doesn’t step in ASAP.

CMS issued the calendar year (CY) 2025 Medicare Physician Fee Schedule (MPFS) final rule on Nov. 1, 2024, publishing guidance that will have providers and coders scrambling to figure out how to handle their Telehealth patients in 2025, unless something is “fixed” or addressed immediately by Congress.

Absent Congressional action, the Final Rule for telehealth services effective Jan. 1, 2025, could leave 85% or more Medicare patients without access to virtual care.

I’ll start with the highlights of telehealth policy changes based in the 2025 MPFS final rule.

Telemedicine Flexibilities

Originating site location telehealth flexibilities that began during the COVID-19 public health emergency and were extended through 2024 by Congress, will end, as required by current law. Starting Jan. 1, 2025, telehealth originating site rules (where the patient is located at the time of service) will limit patient location to certain rural and underserved areas. Several Bills under consideration in Congress would extend or make telehealth flexibilities permanent but those Bills are pending and have not gotten past the Senate or House for approval as of yet.

  • Starting Jan. 1, 2025, two-way, real-time audio-only communication will satisfy the requirement for an interactive telecommunications system under specific circumstances when a patient cannot use or does not consent to using video technology. However, the distant site practitioner must still have audio-video capabilities. (Again, if the geographical site regulation is not changed from the pre-PHE rules by Congress, this is a moot point).
    • Again, pre-pandemic geographic and location restrictions for telehealth (before March 1, 2020) are being reinstated. This means that unless a Medicare patient lives or is located in a health professional shortage area, a rural census track, or a county outside of the metropolitan statistical area, at the time of service, they will not be covered for telehealth services in 2025.
  • Through calendar year 2025, CMS will continue to permit a distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. They will consider this issue further for future rulemaking.
  • CMS acknowledges the CPT® Editorial Panel’s decision to delete audio-only telephone services CPT® codes 99441-99443 for 2025. However, Medicare will not recognize 16 of the 17 telehealth CPT® codes (98000-98016) added for 2025; CPT® codes 98000-98015 will have an “I” Invalid status.
  • Medicare will pay separately for brief virtual check-in encounter CPT® code 98016 in lieu of HCPCS Level II code G2012, which CMS is deleting due to redundancy.
  • Direct supervision through real-time audio and visual interactive telecommunications (not audio only) will continue to be allowed on qualifying services.
  • Certain behavioral and mental health services will be permanently offered under telehealth for Medicare patients beginning Jan. 1, 2025. A link to CMS’s List of Telehealth Services is in the Resources section, which you should reference (once the list is updated on January 1st). (See the CAA – Consolidation Appropriations Act of 2021, Section 123 which outlines the BH permanent benefits under Medicare for 2025).
  • Place of service (POS) codes will continue to have two telehealth designations:
  • 02 Patient not in their home when telehealth services are rendered; or
  • 10 Patient in their home when telehealth services are rendered. POS 10 will continue to be paid at the non-facility rate.
  • CMS will continue to allow physicians to list their practice address, rather than their home address, when performing Medicare services via telehealth from their home.
  • Teaching physicians may continue to have a virtual presence in all teaching settings, but only for Medicare telehealth services. This was only extended 1-year through Dec. 31, 2025.
  • Both patient and any approved Telehealth provider must be in the U.S. (including U.S. territories) when the services are done. Out of country medical services are not covered by Medicare via telehealth or otherwise.

Authoritative references are provided in the resources section to allow you to source the information yourself.

Congress Could Change Everything

We still have until the end of 2024 for Congress to fix the geographical location issue for telehealth. But time is of the essence, or more than 85 percent of Medicare patients’ telehealth encounters occurring after Jan. 1, 2025, could be invalid for payment.

NAMAS urges you to contact your local representative to draw attention to this matter.

References and Resources

As first published on AAPC.com and NAMAS.co
This is a revision by the same author, Terry Fletcher, to this original article.

Complexity Add-on Code G2211

Effective January 1, 2024, complexity add-on code G2211 may be submitted with Evaluation and Management (E/M) office or outpatient (O/O) visits, 99202-99215.

G2211 includes services enabling practitioners to build longitudinal relationships with all patients (not only those patients who have a chronic condition or single, high-risk disease) and to address most patients’ health care needs with consistency and continuity over longer periods of time.

Documentation would support furnishing services to patients on an ongoing basis that results in care personalized to the patient. The services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve the delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader healthcare landscape.

The complexity add-on code would support a long-term patient-provider relationship and would indicate the provider will be managing the patient’s health care over a long period. The provider would build a trusting patient-doctor relationship and be the continuing focal point for all needed health care services related to the ongoing patient’s single, serious condition or complex condition. Every patient would be unique with their health care needs and templated language for the add-on code may not support medical necessity. This is an important caveat as many EMRs have templated drop-down screens that consistently are used for “cut and paste” repeated information visit-to-visit and this is frowned upon to bill the G2211.

The code does not limit the type of provider based on specialties.

Code descriptor

+G2211: Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition, or a complex condition. (add-on code, list separately in addition to office or outpatient E/M visit, new or established)

E/M with Modifier -25

Separately identifiable E/M visits billed with modifier -25 occurring on the same day as a minor procedure, have resources sufficiently distinct from the costs associated with that reimbursement. CMS will not allow payment for the add-on code G2211 when the E/M service is billed with modifier 25.

*There is a 2025 PFS proposed update that would allow G2211 with modifier 25 when an E/M service is done on the day of an annual wellness visit, immunization or other CMS-covered preventive service. This is a proposal, not a final rule yet. (Refer to MLN 13272 in resources.)

Examples included in CR13452

Example 1:

A patient has a primary care practitioner that is the continuing focal point for all health care services, and the patient sees this practitioner to be evaluated for sinus congestion. The inherent complexity that this code (G2211) captures is not in the clinical condition itself – sinus congestion – but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient. There is previously unrecognized but important cognitive effort of utilizing the longitudinal relationship itself in the diagnosis and treatment plan and weighing the factors that affect a longitudinal doctor-patient relationship.

In this example, the primary care practitioner could recommend conservative treatment or prescription of antibiotics. If the practitioner recommends conservative treatment and no new prescriptions, some patients may think that the doctor is not taking the patient’s concerns seriously and it could erode the trust placed in that practitioner. In turn, an eroded primary care practitioner-patient relationship may make it less likely that the patient would follow that practitioner’s advice on a needed vaccination at the next visit.

The primary care practitioner must decide, what course of action and choice of words in the visit itself, would lead to the best health outcome in this single visit, while simultaneously building up an effective, trusting longitudinal relationship with this patient for all their primary health care needs. Weighing these various factors, even for a seemingly simple condition like sinus congestion, makes the entire interaction inherently complex, and it is this complexity in the relationship between the doctor and patient that this code captures.

Example 2:

A patient with HIV has an office visit with their infectious disease physician, who is part of ongoing care. The patient with HIV admits to the infectious disease physician that there have been several missed doses of HIV medication in the last month. The infectious disease physician has to weigh their response during the visit, the intonation in their voice, the choice of words to not only communicate clearly that it is important to not miss doses of HIV medication, but also to create a sense of safety for the patient in sharing information like this in the future. If the interaction goes poorly, it could erode the sense of trust built up over time, and the patient may be less likely to share their medication adherence shortcomings in the future.

If the patient isn’t forthright about their medication adherence, it may lead to the infectious disease physician switching HIV medicines to another with greater side effects, even when there was no issue with the original medication. It is because the infectious disease physician is part of ongoing care, and has to weigh these types of factors, that the E/M visit becomes inherently more complex, and the practitioner bills code G2211. Even though the infectious disease doctor may not be the focal point for all services, such as in the previous example, HIV is a single, serious condition, and/or a complex condition, and so as long as the relationship between the infectious disease physician and patient is ongoing, this E/M visit could be billed with the add-on.

To reiterate, the most important information used to determine whether the add-on code could be billed is the relationship between the practitioner and the patient. If the practitioner is the focal point for all needed services, such as a primary care practitioner, the HCPCS G2211 add-on code could be billed. Or, if the practitioner is part of ongoing care for a single, serious and complex condition (e.g., sickle cell disease), then the add-on code could be billed. The add-on code captures the inherent complexity of the visit that is derived from the longitudinal nature of the practitioner and patient relationship.

An example of when not to use the G2211 with an office visit. Even though this add on code is allowed with a new patient office visit, use with caution, since there has not been that “longitudinal relationship” established yet. Also, if you do not anticipate or expect the patient to return for follow up in the long term, it may also not be an appropriate add on.

If an established patient presents for a recheck appointment with no new problems or concerns to “address” and the chronic condition discussion is not a concern or contributory for this encounter of a simple or low level “recheck” it would be difficult to support the G2211 along with an E/M visit.

CMS also states that not all E/M’s would be eligible. “…E/M visit complexity add-on code would not be appropriately reported, such as when the care furnished during the O/O E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine or time-limited nature…” . They provide specific examples of conditions that would not require the add on complexity code: mole removal, treatment of a simple virus, seasonal allergies, new onset GERD, treatment for a fracture, and/or “when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.” p. 432 Final Rule 2024.

I have heard that many practices have taken some liberties when adding the G2211 to every single E/M when the patient comes in. I will continue to discourage that practice. Above all things, services need to be “medically necessary”, and patients will also have a share of cost attached to this add on. It is being reimbursed around $16.50 on average, but 2nd quarter 2024 already has several commercial plans taking it off their fee schedule. United Healthcare, specifically, put out in their June 2024 policy update newsletter to providers, “Effective with dates of service on or after September 1st, 2024, HCPCS code G2211 will be included within the UHC Commercial Rebundling Policy, Professional Claims: UHC’s reimbursement for the services associated with G2211 is included in its reimbursement for outpatient evaluation and management services and therefore G2211 is not separate reimbursable.”

I would expect more commercial plans to follow with the over-utilization of this code in the first quarter of 2024 after the rollout. Monitor your EOB for possible denials in the future. Also, listen for updates on my CodeCast Podcast, which publishes every Tuesday.

References

Telehealth Fact Sheet and E/M Tips for 2024

As we all know the PHE, public health emergency, ended on May 11th, 2023, but the confusion on how to report Telehealth services continues to live on. When Medicare published its Final Rule last November 2nd, 2023, they did extend many of the original flexibilities through the end of 2024. However, some definite changes will impact all medical practices engaged in using Telehealth for their encounters, and it is imperative to be up on all of the current published guidance.

CPT® has also added their insight on what “qualifies” as Audio-Video and Audio-Only services with the additions of new guidance in CPT® 2024 (page xvii) and Appendix P and Appendix T of the code book.  Remember to check with commercial payers for their specific updates to their telehealth payer policies, so that you are not over or under-reporting your services in 2024.

Here is a checklist and compliance “Tips” for Telehealth services in 2024, primarily for Medicare, that will help you stay compliant:

  • As of 08/09/2023, all Telehealth Platforms must be HIPAA compliant per OCR (Office of Civil Rights). FaceTime, Skype, Google Hangouts, TikTok, and Zoom are non-HIPAA compliant platforms.
  • All audio AND video Telehealth office visits have been extended for coverage through 12/31/2024 per the Consolidated Appropriations Act of 2023, and the 2024 Medicare Final Rule, with some restrictions.
  • Starting January 1st, 2024, CMS has stated that providers will no longer use the “place of service where the patient would have been had they reported in person”.

As of 2024, Medicare has instructed:

POS 02 is to be used when the patient is not in their home, and the reimbursement will be linked to F (facility) rates.

POS 10 is to be used when the patient is in their home, at the time of the telehealth encounter and reimbursement rates will be the same as NF (non-facility) rates.

  • Hospital (POS 02) audio and video Telehealth, if needed, will be reimbursed at the facility rate.
  • Audio-only codes 99441-99443 will continue on payment parity with 99212-99214, respectively. So do not add the modifier -95 in 2024, as it is no longer appropriate, and is not in the CPT® Appendix P. These codes are also not in CPT® Appendix T, so the -93 modifier would also be inappropriate since the code itself states it is audio only. But of note, the documentation of why the patient could not be seen for an audio and video visit or attend an in-person encounter must be entered when using the phone call codes.
  • Audio Only Code(s) (99441-99443) are only for established patients as of 05/11/2023, the end of the PHE, and no longer used for New Patients. The code description in CPT® now has to be followed. Again, the provider must document the time spent on the audio only call, and why the patient couldn’t use audio and video or come into the office for their encounter.
  • AMA/CPT® has created an Appendix P for audio and video services which will require a 95 modifier on the service code along with the appropriate POS (place of service) for payment (see above). CMS agrees.
  • AMA/CPT® has created an Appendix T for audio only eligible services that will require a 93 modifier on the service code along with the appropriate POS (place of service) for payment (see above). CMS agrees.
  • At the height of the pandemic, CMS allowed for both new and established patients to be performed via Audio AND Video platform. As of 2024, the provider must document why a New Patient was not able to be seen in-person versus virtual.
  • Once the PHE ended on May 11th, 2023, CMS stated that providers will have to add their home address to their provider enrollment form, and this could be seen on a public site for all to access. Your deadline to add your additional location to your provider enrollment has been extended through 12/31/2024. We recommend that providers get back to the office to avoid any issues of privacy breaches, from sites, like Care Compare®, that may list the provider’s home address even if the MAC’s (Medicare Administrative Contractors) use the office location address.
  • CMS states they will continue to define direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and video interactive telecommunications through December 31, 2024.
  • Crossing State lines (physician in one state while the patient location is in another state when virtual services are provided) for Telehealth is only allowed if the provider is licensed in the State where the patient is located at the time of the encounter, and if the provider is licensed in the State, they are located at the time they are providing treatment.

For example, if the physician is licensed and resides in Illinois, and the patient resides in Illinois, but the patient is in Florida on vacation and wants a telehealth visit, the physician would have to be licensed in Florida to provide the visit. Or if the physician is licensed in Illinois, but is in California on vacation, he/she would have to be licensed in California to see a patient via Telehealth.

During the PHE, we saw the need for telehealth, and how it allowed for access to medical care when we were told to stay home or to quarantine if COVID-19 symptoms were prevalent, or if you were a high-risk patient. But the payers made it too easy for providers to bill telehealth services, without any guardrails to make sure over-utilization did not occur. Unfortunately, we have seen “bad actors” taking liberties by reporting telehealth visits when not medically necessary or when not appropriate for the patient circumstance. It appears that post PHE, many visits via telehealth are for convenience, and may not be appropriate when the patient is available to come in person.

Many practices have also billed for audio only encounters to give routine test results or to refill prescriptions which is non-compliant. A reminder that if you didn’t charge for incidental and ancillary services prior to the PHE, like giving patient routine test results over the phone, it is not appropriate to report it as a telehealth visit now.

It is important to review the language in CPT® Professional Edition 2024 to know when it is appropriate to report a telehealth visit, and not use that option for incidental or non-medically necessary services. See page xvii in CPT® 2024 to get the information.

Telehealth can be an “invited risk” if not met with compliance. OIG telehealth audits have been ongoing since 2021. Make sure you are spot-checking and internally and externally auditing your telehealth services and practices for compliance to avoid a costly audit in the future.

Also, many commercial plans have changed their telehealth coverage to only cover their “panel physicians” for Telehealth and may not cover the patient’s actual provider for Telehealth services. Check contracts, websites, and policies for post-PHE terms.

Let us know if we can assist with an external audit to keep you compliant in your Telehealth services.

References:

Reporting SDoH G0136 in compliance

(updated 4/6/2024) – This is also posted on the NAMAS.co website

2024 brought new HCPCS codes that Medicare, Medicare Advantage and some 3rd-party Commercial plans that they will now pay for. One of those codes is the G0136; that is the Social Determinate of Health (SDoH) assessment. It is not an add on code, but a stand-alone assessment.

G0136 is defined as “Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.”

G0136 is not a screening tool that should be used on all Medicare patients at office visits or annual wellness visits.

It is an assessment, not a screening. The assessment is performed at a visit after the physician/NPP has seen the patient and decides that it is necessary. And, if problems are found, follow-up is required. See CMS 2024 Final Rule citations below.

From the Final Rule, they do expect that a practitioner who furnishes the risk assessment would “… at a minimum, refer the patient to relevant resources and take into account the results of the assessment in their medical decision making, or diagnosis and treatment plan for the visit.” p.358 Final Rule.

CMS also, was clear that this is not a screening, and it requires physician follow-up.

“We reiterate that the SDoH risk assessment code, HCPCS code G0136, when performed in conjunction with an E/M or behavioral health visit is not designed to be a screening, but rather tied to one or more known or suspected SDoH needs that may interfere with the practitioners’ diagnosis or treatment of the patient.” CMS Final Rule, goes on to say, “An SDOH risk assessment without appropriate follow-up for identified needs would serve little purpose and we continue to believe that follow-up or referral is an important aspect of following up on findings from an SDoH risk assessment.” p.346 Final Rule.

Here is my professional advice on reporting this new code

The only time you would bill Traditional Medicare and/or Medicare Advantage Plans for the SDoH assessment, G1036, is when an SDoH need is suspected, identified, and a plan of care is needed to address these concerns, and at least 5 minutes or greater is documented, as described in the code. Remember, the AWV guidelines were updated this year to include the SDoH considerations, so if there are “unmet needs” that need to be addressed, report it. The appropriate SDoH needs to be identified in the medical record documentation and reported with appropriate diagnosis codes from the ICD-10-CM categories, Z55-Z65. (linking Z13.9 encounter for screening would not be appropriate)

When the patient is presenting for a problem-oriented encounter, this assessment can be done on the day of an E/M service (99202-99215), not including code 99211. Since the patient is there for a problem-oriented visit, I would want to see that there is a reason linked to the problems addressed and the SDoH that needs attention. It would not be reported for every patient, as some just come in for that 3-6 month checkup, or annual medicine reconciliation, etc, and there are no SDoH factors to consider on that DOS. As with all medical services, it has to be medically necessary to capture it.

According to CodingIntel.com, during the Final Rule CY 2024 comment period, CMS was asked about the patient using an on-line portal rather an having the service done on the day of an E/M service and can that be considered the assessment. The short answer is No. Again, CMS believes that this is not a screening, but an assessment, and is to be used when the practitioner believes that the patient has unmet SDoH needs that are interfering with the diagnosis or treatment of an illness, so this needs to be an in-person assessment.

(source: https://codingintel.com/screening-for-social-determinants-of-health-sdoh/ )

CMS did not finalize the requirement that the assessment must be done on the same day as one of these visits, but it seems likely that is when it will be done. They do not believe it will be performed in advance, via a portal, because it is not a screening. It is performed as an assessment based on the practitioner’s evaluation of the patient’s situation.

Also, it is important to remember that G0136 will be subject to cost sharing, (co-pay and deductible) unless it is done at an Annual Wellness Visit (AWV), codes G0438-G0439. The published guidance, when performed on the same date as the AWV, states, that the G0136 will need a -33 modifier to waive the out of pocket for the patient.

Here is the reimbursement breakdown

  • Non-Facility total RVU is 0.57 = $18.39 (office)*
  • Facility total RVU is 0.18 = $5.99 (hospital, SNF, CAH, etc..)*

(* For services after 3/9/2024 the adjusted CY CF is $33.2875)

Some examples of SDoH factors (diagnoses) per NIH.gov

  • Illiteracy and low-level literacy —> Low health literacy may require different or more extensive efforts with patient education (i.e. all verbal instruction because patient can’t read written instructions)
  • Inadequate housing —> Patient may lack refrigeration in their home so can’t be prescribed cold storage medications, so you have to prescribe something else. May have mold infestation so have to intensify management of their asthma.
  • Extreme poverty or Low income —> May not be able to afford medications or other over-the-counter type therapies/devices.
  • Disappearance and death of family member —> May decide to defer addressing some medical issues to prioritize providing emotional support for bereavement.
  • Child in welfare custody. —> May have to spend extra time educating new foster parent on medical management or on how to provide support care for medical condition

Even though CMS does not require a specific form or tool, a link was offered on page 346 of the Final Rule. This link was offered for CMS’ Accountable Health Communities tool and is below in references and resources.

References and Cited Resources