Updated Guidance on Claims Amid Government Shutdown

The following is an official release from the CMS Medicare Learning Network®:

Claims Hold Update

In anticipation of possible Congressional action, CMS has instructed all Medicare Administrative Contractors (MACs) to continue to temporarily hold claims with dates of service of October 1, 2025, and later for services impacted by the expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025. This includes all claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and all Federally Qualified Health Center claims. Providers may continue to submit these claims, but payment will not be released until the hold is lifted.

Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency took effect again for services that are not behavioral health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For more information: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf (PDF).

Claims, Pricers & Codes

NCCI Alert: COVID-19 Vaccine Administration Edit Revision

Some providers may have 90480 claims denied when billed in conjunction with G0008, G0009, or G0010 as a result of a Procedure to Procedure edit released in the 2025 Quarter 4 National Correct Coding Initiative (NCCI) files. On October 14, 2025, CMS issued replacement NCCI files to remove this edit. Medicare Administrative Contractors (MACs) will reprocess claims with dates of service between July 1, 2025, and October 15, 2025, within approximately 30 business days, and Medicare providers don’t need to take any action. Alternatively, a provider may also choose to use the MAC appeals process if they don’t wish to wait for the automatic adjustment to occur, or they can wait to submit impacted claims until after CMS implements the change.

Access the Medicare replacement files.

The full message was posted by CMS here.