Tag: CodingIntel-Betsy Nicoletti
The Definition of G0136 is Changing
Another Great Article from CodingIntel
November 2025
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Government Shutdown Changes
What has changed due to the Government Shutdown?
It’s pandemic-era flexibilities that will come to an end:
- Geographic restrictions that only permitted telehealth in medically underserved areas
- Requiring the patient to go to an originating site (a health care facility) instead of being in their homes
- Allowing therapists (PTs, OTs, SLPS, audiologists) to perform services via telehealth
Behavioral health via telehealth will still be allowed after September 30th, because Congress passed a law allowing it permanently. It won’t be affected by a government shutdown, if one occurs. The Social Security Act references “mental health” as opposed to “behavioral”.
Quoting the MLN Matters Article on E/M services
MLN006764 September 2025
Telehealth Services
Section 2207 of the Full-Year Continuing Appropriations and Extensions Act, 2025, extended many of these flexibilities through September 30th, 2025. Starting October 1, 2025, the statutory limitations that were in place for Medicare telehealth services before the COVID-19 public health emergency (PHE) will retake effect for most telehealth services.
These include:
- Geographic restrictions
- Location restrictions on where you can provide services
- Limitations on the scope of practitioners who can provide telehealth services
That is, telehealth as we know it to anywhere in the country, in the patient’s home ends. How do you know if you are in an underserved area, and can continue to do telehealth? Quick and easy: could your practice do telehealth before the pandemic? Yes: in all likelihood, you can continue, but remember the patient must go to an originating site, not their homes. Are you in an underserved area? Check here.
At CodingIntel, we have a copy of the CMS telehealth fact sheet from prior to the pandemic. It isn’t up-to-date with the list below, but it will tell you the rules for most practices in the country if a shutdown occurs.
Still allowed are services that weren’t implemented as a result of the pandemic.
eCFR :: 42 CFR 410.78 — Telehealth services.
(iv) The geographic requirements specified in paragraph (b)(4) of this section do not apply to the following telehealth services:
(A) Home dialysis monthly ESRD-related clinical assessment services furnished on or after January 1st, 2019, at an originating site described in paragraphs (b)(3)(vi), (ix), or (x) of this section, in accordance with section 1881(b)(3)(B) of the Act; and
(B) Services furnished on or after January 1st, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
(C) Services furnished on or after July 1st, 2019, to an individual with a substance use disorder diagnosis, for purposes of treatment of a substance use disorder or a co-occurring mental health disorder.
(D) Services furnished on or after January 1st, 2025, for the purposes of diagnosis, evaluation, and/or treatment of a mental health disorder. Payment will not be made for a telehealth service furnished under this paragraph unless the physician or practitioner has furnished an item or service in person, without the use of telehealth, for which Medicare payment was made (or would have been made if the patient were entitled to, or enrolled for, Medicare benefits at the time the item or service is furnished) within 6 months prior to the initial telehealth service and within 6 months of any subsequent telehealth service.
Betsy
Telehealth Breaking News
The below information was received today 12/26/2024, from Betsy Nicoletti
Medicare practitioners and patients can continue to perform/receive telehealth services as they have since the start of the pandemic for the next three months.
The first keep-the-government-open bill from Dec. 20 extended Medicare telehealth for two years. It didn’t pass. The bill that passed and was signed into law extends telehealth for Medicare patients as we know it now until March 31, 2025. Then, Congress must ACT again or we have the return to the pre-pandemic rules
Does this mean we can use the new CPT telehealth codes 98000-98015?
NOT FOR MEDICARE PATIENTS
98000-98015 have a status indicator of INVALID
Continue to use office visit codes with POS 02 or POS 10
And Other Payers?
Sadly, each payer can make their own telehealth rules.
Good News, Bad News in Medicare 2025
A first look at the 2025 Physician Fee Schedule
The 2025 Physician Fee Schedule proposed rule is a study in contrasts. If you’re the kind of person who can see both sides of an issue, this rule is for you.
Good News
Bad News
Practitioners doing telehealth from their home can continue to use the practice address instead of their home address on claims for 2025
Without an act of Congress, for real time audio/visual visits on 1/1/2025 patients can no longer receive these services in their homes in all geographic areas. Patients must be in an underserved area and go to a facility setting for telehealth. (Unless Congress changes this in their end of year Consolidated Appropriations Act.)
16 new telehealth codes that can be selected based on Medical Decision Making (MDM) or time.
Medicare has given them a status indicator of invalid.
New HCPCS code for GIDXX for visit complexity inherent to in patient and observation services associated with a confirmed or inspected infectious disease. (GIDXX is a placeholder code, not a final code.)
Limiting use. “We anticipate the HCPCS code GIDXX would be reported by physicians with special infectious disease training”
Can use G2211 when you use modifier 25 for an E/M and wellness visit on the same day, immunizations, and other preventive medicine services.
That’s the only exception.
Code Selection and Level of Service Training
“CodingIntel” is launching new courses, and the first is E/M Expertise: Go Beyond the Basics!
“We’ve developed a four-module course intended for those with a strong E/M knowledge base. The content is supported by CMS and CPT citations. When the citations are definitive, you’ll have a definitive answer. When they aren’t, you’ll be able to explain the gray areas clearly.”
This isn’t an introductory course. Knowledge and experience in E/M codes and selection is a prerequisite for this course.
This course has 3.5 AAPC CEUs for those who view the entire course and have at least a 70% score on the post-test.
The 1st course will drop March 4, 2024. POET will post the link as soon as we get it.
How’d You Score?
Did you take Betsy Nicoletti’s Quiz on Modifier 25?
Let’s Explore the Facts or Rules Behind the Answers.
#1. The definition and rules for modifier 25 did not change in 2023. “In the March edition of the CPT Assistant it says that while the rules weren’t changed in the 2023 code set “confusion exists regarding its appropriate use.”
#2. What does a modifier added to a CPT or HCPCS code do? The answer is b) Indicates the service or procedure was altered by specific circumstances.
Some modifiers affect payment (like modifier 25) and some are informational only (those appended to teaching physician services). CPT modifiers may be used on HCPCS codes and HCPCS modifiers on CPT codes. A modifier doesn’t change the definition of the code, but indicates that the service or procedure was altered in some way.
#3. When using modifier 25 when reporting an E/M services and a minor procedure, do you need a different diagnosis for the E/M and the Procedure? The answer is NO.
“As such, different diagnoses are not required for reporting of the E/M services on the same date”. CMS says, “If a significant separately identifiable evaluation and management service is performed, the appropriate E&M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or nonchemotherapy injection and infusion service. For an evaluation and Management service provided on the same day, a different diagnosis is not required.” Medicare Claims Processing Manual, CH. 12 30.5.C
#4. When performing a minor procedure, usual preoperative and postoperative activities are included i in the work of the procedure and should not be reported with an E/M service. Which of these activities are considered usual preoperative and postoperative activities? (List may not be complete). Answer is d) All of the above.
The March 2023 CPT Assistant lists the services that are considered part of the procedure—paid for within the fee for the procedure—and should not be counted as a separate E/M.
Pre- and post-operative services typically associated with a procedure include the following and cannot be reported with a separate E/M services code:
• Review of patient’s relevant past medical history,
• Assessment of the problem area to be treated by surgical or other service,
• Formulation and explanation of the clinical diagnosis,
• Review and explanation of the procedure to the patient, family, or caregiver,
• Discussion of alternative treatments or diagnostic options,
• Obtaining informed consent,
• Providing postoperative care instructions,
• Discussion of any further treatment and follow up after the procedure
5) When performing a preventive medicine service or wellness visit, the practitioner also assesses and manages the patient’s chronic conditions, reviews labs, and renews multiple prescriptions. How is this billed? The Answer is b) Preventive medicine or wellness visit and a problem-oriented visit, with modifier 25 on the problem-oriented visit
Medicare Claims Processing Manual, Ch 12. 30.6.1.1.2.H
“When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier -25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).”CPT Professional Ed., 2023, page 32
Cheers to knowledge
Check Your Modifier 25 Knowledge
Our Friend Betsy Nicoletti founder of CodingIntel, says “It’s hard for me to think of a topic that invites so much disagreement between coders and auditors, between practices and payers and with our practitioners.”
She has put together a short little quiz on the topic (below). Tell us how you did.
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