Coding, Billing and Documentation Guidelines

The Clinical Reimbursement Unit (CRU) within the Office of Compliance and Audit Services performs audits, reviews, regulatory research, education and training on clinical documentation, coding and billing issues. The CRU utilizes regulations and guidelines published by the Centers for Medicare and Medicaid Services (CMS) as its authoritative source.  Healthcare providers are compensated by insurers via various payment systems depending on the setting (i.e., hospital inpatient, outpatient, ambulatory surgery, physician office, etc.). Each payment system utilizes diagnostic and service/procedure medical coding systems to determine the ultimate payment for a service/procedure.  Therefore, it is imperative that all medical codes submitted for payment are supported by the documentation in the medical record and that the correct payment system rules have been utilized.

The Centers for Medicare and Medicaid (CMS) Updates for Calendar Year 2025

The following links will be helpful in understanding the changes/updates for CY 2025:

• CMS 2025 Medicare Physician Fee Schedule Summary Final Rule
• CMS 2025 Physician Fee Schedule Final Rule Fact Sheet

What’s new for Telehealth/Telemedicine Evaluation & Management (E&M) Visits for CY 2025

The audio-only (telephone) E&M CPT codes were deleted, and the Centers for Medicare and Medicaid Services (CMS) does not recognize the new telemedicine codes 98000–98015. They will not be eligible for reimbursement.  

A. To bill for a telehealth service, for Medicare Beneficiaries,  including audio-only communication, you must: 

1. Use the standard Evaluation and Management (E/M) codes (e.g., 99202–99215), 
2. Append the appropriate modifier (e.g., 95 for audio-visual, or 93 for audio-only), and, 
3. Append the place of service code to the claim (e.g., POS 2 or 10). 

B. To bill for a telehealth service, for Medicaid Beneficiaries,  including  audio-only communication, you must: 

1. Use the standard Evaluation and Management (E/M) codes (e.g., 99202–99215), 
2. Append the appropriate modifier (e.g., 95 for audio-visual, or 93 for audio-only), and, 
3. Append the place of service code to the claim (e.g., POS 2 or 10). 

Per NYS Medicaid, when a POS is allowable on a claim or encounter, providers should report POS “02” for telehealth provided other than in patient’s home, “10” for telehealth provided in the home of the patient, except in cases where POS “11” is typically submitted (private practice or office setting)- POS “11” providers should continue to report POS “11” and use telehealth modifiers on the claim or encounter to identify it as telehealth. 

https://www.health.ny.gov/health_care/medicaid/redesign/telehealth/docs/provider_manual.pdf - NYS Medicaid Telehealth Policy Manual, 9.6 Telephonic (Audio-Only) Reimbursement Review, page 17 and 18. 

List of Telehealth Services from CMS

C. For Prolonged Services add code G2212 for Medicare and Medicaid Beneficiaries. 

https://www.ngsmedicare.com/web/ngs/search-details?selectedArticleId=4176060&lob=96664&state=97133&rgion=93623 – G2212 Guidance from NGS 

https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf - Section 30.6.7. F – G2212 Guidance- Prolonged Services 

Coding & Billing Resources

• AMA Evaluation and Management Service Guide
• How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211
• G2211 FAQ’s
• Physicians at Teaching Hospitals (PATH) Guidelines
• NPP & Shared Incident To Services Training – Available via Downstate’s Learning Platform, Healthstream.

(Contact Complaince@Downstate.edu to enroll)

Please feel free to contact the Office of Compliance & Audit Services at compliance@downstate.edu with any questions, would like specific training on these topics or if you need any other assistance.