With the increased utilization of both advanced practitioners (i.e., physician assistants [PAs] and nurse practitioners [NPs]) and telehealth, Health Insurance Portability and Accountability Act (HIPAA) covered entities need to stay abreast of the recent changes and the continued implementation of best practices.

On November 1, 2024, the Centers for Medicare and Medicaid (CMS) announced the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule, which finalized changes to the Physician Fee Schedule (PFS). Telehealth was one of the items that received a lot of attention because of its adoption during COVID-19 and the changes that are occurring during 2025.

On the non-surgical PA front, there are also several updates regarding the American Medical Association (AMA) and CMS updates for telehealth services and coding requirements. Importantly, covered entities need to distinguish between what is permissible when treating and coding for a Medicare or Medicaid beneficiary and those individuals covered by a private payor. 

A prudent practice is to update policies and procedures, as well as implement training and evaluate the current settings in electronic health records. 

Analysis

Given the focus on telehealth, let’s begin with the November 1, 2024, CMS interpretation of the PFS and CMS’s “Telehealth FAQ Calendar Year 2025.” While the full PFS telehealth portion appears below, there are three key take-aways from both CMS published items: (1) Through March 31, 2025, Medicare beneficiaries can receive telehealth services in their home and do not need to be in a rural area or a medical facility; (2) Through March 31, 2025, any licensed practitioner who can independently bill Medicare may furnish telehealth services; and (3) “Incident to” codes are updated. 

Importantly, the CMS website links to https://telehealth.hhs.gov/providers/telehealth-policy/telehealth-policy-updates, which indicates that “Medicare patients can receive telehealth services for non-behavioral/mental healthcare in the home through September 30, 2025.” 

The November 1, 2024 excerpt follows:

“Absent Congressional action, beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 PHE will retake effect for most telehealth services. These include geographic and location restrictions on where the services are provided, and limitations on the scope of practitioners who can provide Medicare telehealth services. However, the final rule reflects CMS’s goal to preserve some important, but limited, flexibilities in our authority, and expand the scope of and access to telehealth services where appropriate. 

For CY 2025, we are finalizing our proposal to add several services to the Medicare Telehealth Services List, including caregiver training services on a provisional basis and PrEP counseling and safety planning interventions on a permanent basis. We are finalizing to continue the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations for CY 2025. 

 

We are finalizing that beginning January 1, 2025, an interactive telecommunications system may include two-way, real-time, audio-only communication technology for any Medicare telehealth service furnished to a beneficiary in their home, if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology.

 

We are finalizing that, through CY 2025, we will continue to permit distant site practitioners to use their currently enrolled practice locations instead of their home addresses when providing telehealth services from their home.

 

We are finalizing, for a certain subset of services that are required to be furnished under the direct supervision of a physician or other supervising practitioner, to permanently adopt a definition of direct supervision that allows the supervising physician or practitioner to provide such supervision via a virtual presence through real-time audio and visual interactive telecommunications. We are specifically finalizing to make permanent that the supervising physician or practitioner may provide such virtual direct supervision (1) for services furnished incident to a physician or other practitioner’s professional service, when provided by auxiliary personnel employed by the billing physician or supervising practitioner and working under his or her direct supervision, and for which the underlying HCPCS code has been assigned a PC/TC indicator of ‘5’ and services described by CPT code 99211, and (2) for office or other outpatient visits for the evaluation and management of an established patient who may not require the presence of a physician or other qualified healthcare professional. For all other services furnished incident that require the direct supervision of the physician or other supervising practitioner, we are finalizing to continue to permit direct supervision be provided through real-time audio and visual interactive telecommunications technology only through December 31, 2025.

 

We are finalizing a policy to continue to allow teaching physicians to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings, but only in clinical instances when the service is furnished virtually (for example, a three-way telehealth visit, with the patient, resident, and teaching physician in separate locations) through December 31, 2025. This virtual presence will continue to meet the requirement that the teaching physician be present for the key portion of the service.”

Patient access to and the clinical provision of telehealth services by medical professionals are not the only areas of change. The American Medical Association (AMA) Current Procedural Terminology (CPT) codes also changed. Telemedicine codes experienced an overhaul with 17 new codes being released, which include both audio-visual and audio-only services. 

The breakdown of the new codes follows:

• New CPT Codes: The 2025 CPT Manual includes 17 new codes for telemedicine visits, encompassing both audio-visual and audio-only services for new and established patients. For instance, codes 98000–98003 pertain to new patient visits, while codes 98008–98011 address established patient visits. 
  
  

• Virtual Check-Ins: CPT code 98016 has been introduced to replace the previous virtual check-in code G2012. This service is designed for established patients and must be patient-initiated, involving a 5-10 minute medical discussion unrelated to any evaluation and management (E/M) service in the prior seven days or leading to an E/M service within 24 hours.
  
  

• CMS Policies: Through calendar year 2025, CMS will continue to permit distant-site practitioners to use their currently enrolled practice locations instead of their home addresses when providing services from their home. Additionally, teaching physicians are allowed to have a virtual presence for billing purposes when supervising residents in all teaching settings.  
  
  

Where PAs are utilized, the following codes should be considered:

• Modifier 25 Usage: For most non-surgical procedures, if a physician performs a significant and separately identifiable E/M service beyond the usual pre and post-operative work on the same date, it may be reported by appending modifier 25 to the E/M code. This ensures that the additional E/M service is recognized separately from the procedure performed.  
  
  

• Add-On Code G0559: CMS has introduced HCPCS code G0559 for post-operative care services provided by a practitioner other than the one who performed the surgical procedure (or another practitioner in the same group practice). This code reflects the time and resources involved in post-op visits by practitioners not involved in the original surgery.  
  
  

These updates strive to enhance the flexibility and accuracy of coding for telehealth services and non-surgical situations. Ensuring documentation and coding accuracy is going to be critical for avoiding downstream liability. 

For example, on August 19, 2024, the U.S. Department of Justice announced a False Claims Act settlement with a practice for submitting claims for payment where services were rendered by NPs or PAs not enrolled with Medicare and Medicaid and the physicians had no personal involvement in the supervision of the advanced practitioners (see United States and State of New York ex rel. Nikki Patel v. Orange Medical Care, P.C., et al., 16 Civ. 8589 [PGG] [SDNY Aug. 13, 2024]). 

In sum, providers and facilities are encouraged to review the new requirements, have a third party assess billing and coding practices, identify what should be included in a medical record, and revise policies and procedures to reflect these updates. 

Conclusion

As it is said, “An ounce of prevention is worth a pound of cure.” Distilling private payors’ permitted practices from Medicare permitted practices is going to be critical to avoiding potential False Claims Act liability and the return of overpayments. A proactive approach of having a third-party auditor explain the coding changes and advise on language to include in the medical record, and implementing new policies and procedures while training professionals, especially when advanced practitioners are involved, is crucial to avoiding adverse actions. 

Rachel V. Rose, JD, MBA, advises clients on compliance, transactions, government administrative actions, and litigation involving healthcare, cybersecurity, corporate, and securities law, as well as False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston. Rachel can be reached through her website: www.rvrose.com