Medicare allowing resubmission of some held telehealth claims

After placing most telehealth claims on hold earlier this month, Medicare has adjusted its policy to allow practices to resubmit a subset of the held claims.

After pandemic-era telehealth flexibilities expired on Oct. 1, the Centers for Medicare & Medicaid Services (CMS)  instructed Medicare Administrative Contractors (MACs) to hold all telehealth claims that were not for behavioral and mental health services. To identify claims for behavioral and mental health, MACs used a list of CPT/HCPCS codes or, for claims reported with place of service code 10 (patient’s home), a diagnosis code in the F01.A0-F99 range (mental, behavioral, and neurodevelopmental disorders).

CMS says they now recognize that those methods did not allow MACs to identify all telehealth claims eligible for processing. The agency has since announced that they will return held claims with dates of service between Oct. 1 and Nov. 10 to give practices an opportunity to resubmit them if they fall into the following categories:

• Telehealth services provided by certain accountable care organizations in the Medicare Shared Savings Program,
• Telehealth services for the diagnosis, evaluation, and/or treatment of a behavioral and mental health condition,
• Monthly end stage renal disease-related clinical assessments,
• Telehealth services that meet the originating and geographic site restrictions.

Returned claims will include claim adjustment reason code 16 (Claim/service lacks information or has submission/billing error[s]) and remittance advice remark code M77 (Missing/incomplete/invalid/inappropriate place of service). CMS encourages physicians who are reporting telehealth services for behavioral and mental health conditions using broader CPT codes (e.g., evaluation and management) to include a diagnosis code within the F01.A0-F99 range, when appropriate. But they note that these diagnosis codes are not necessarily required in every case.

For all other telehealth services, practices may continue to hold claims in the event that Congress restores broader telehealth coverage, but retroactive payment is not guaranteed. Practices that hold claims for non-covered telehealth services may want to consider providing patients with an Advance Beneficiary Notice of Noncoverage (ABN). Additional information on ABNs is available here.

Alternatively, practices may continue to submit all telehealth claims, including those that are not currently payable, by including the GY modifier. This alerts CMS that the telehealth service is currently statutorily excluded from payment. These claims will be denied, which provides the practice and patient with the rights of a denied service. CMS will provide additional guidance on whether claims submitted with the GY modifier will need to be resubmitted if Congress restores broader telehealth coverage.

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

Posted on Nov. 10, 2025