Clearing up confusion over Medicare payments

If recent news about Medicare payments has you confused, you’re not alone. The Centers for Medicare & Medicaid Services (CMS) has released several conflicting updates over the last couple of weeks. Here is where things stand, according to their most recent update, which attempted to clear up some of this confusion.

On Oct. 21, CMS instructed all Medicare Administrative Contractors (MACs) to lift the hold on claims with dates of service of Oct. 1 and later for certain services impacted by select expired Medicare legislative payment provisions. Here’s what that means:

• MACs will process claims paid under the Medicare Physician Fee Schedule, as well as ground ambulance transport claims, and Federally Qualified Health Center claims.
• MACs will also process telehealth claims that they can confirm are for behavioral and mental health services.
• MACs will hold claims for telehealth services that CMS cannot confirm are for behavioral and mental health services or for the Acute Hospital Care at Home initiative. (Editor's note: CMS has since announced it will allow practices to resubmit a subset of the held claims). 

What is happening with telehealth?

[Editor's note: See the telehealth update from Nov. 24, 2025.]

COVID-19 pandemic-era telehealth flexibilities expired on Sept. 30. If Congress reinstitutes those flexibilities, CMS may process the held claims. Practices may also choose to hold claims themselves and then submit them if there is congressional action.

Alternatively, practices can provide non-payable telehealth services and bill the patient directly.  If you choose to go this route, you will want to provide patients with an Advance Beneficiary Notice of Noncoverage.

More information about billing for telehealth services can be found on the AAFP's How to Code for Telehealth: Audio-video, Audio-only and Virtual-digital Visits webpage and the CMS Telehealth FAQ.

An erroneous edit caused denials for vaccine codes

Practices may have also experienced claims denials recently when reporting CPT code 90480 for administering a single-dose COVID vaccine in conjunction with HCPCS codes G0008 for administering a flu shot, G0009 for administering a pneumococcal vaccine, and G0010 for administering a hepatitis B vaccine. This was due to an erroneous edit in the 2025 Quarter 4 National Correct Coding Initiative file. CMS has removed this edit, and within approximately 30 business days MACs will automatically reprocess claims with dates of service between July 1, 2025, and Oct. 15, 2025. If you do not wish to wait for the automatic adjustment, you can use the MAC appeals process. 

— Erin Solis, Manager, Practice & Payment at the American Academy of Family Physicians

Posted on Oct. 31, 2025