Monthly Newsletter

The critical access hospital (CAH) bills for facility and professional outpatient services only when physicians or practitioners reassign their billing rights to the CAH.   CAHs can prevent Fiscal Intermediary Shared System (FISS) reason codes 31006 and 31007 (indicating that providers don’t have a reassignment on file in PECOS) claim denials:

• CAHs must submit the reassignment application through PECOS or the paper Form CMS-855I
• Starting in January 2026, we’ll deny CAH claims for professional services if a reassignment isn’t in PECOS

Download the Information for Critical Access Hospitals (PDF) booklet and access additional CMS and OIG resources to help your organization stay compliant:

• Editing for Duplicate Processing for Practitioner Professional Services and CAH Professional Services (PDF) Medicare Administrative Contractor instruction
• Medicare Part B Overpaid and Beneficiaries Incurred Cost-Share Overcharges of Over $1 Million for the Same Professional Services Office of the Inspector General report

According to a September 2025 Investigation Report released by the Office of Inspector General (OIG), an audit was conducted to determine if Medicare payments to providers for trauma team activations complied with Federal guidelines.  The report notes “There has also been media attention on the variability of trauma fees among hospitals and how much patients are forced to pay.”

The OIG revealed that approximately 77% of all claims submitted to Medicare with trauma team activations did not comply with Federal requirements.  “Specifically, 107 of 125 sampled claims with trauma team activations did not meet Medicare requirements—100 sampled claims had unallowable trauma team activation charges that totaled $728,468, and 7 sampled claims had coding errors that did not have any impact on payment or charges associated with the trauma team activation.”  Learn more - OIG’s Investigation September 2025 | A-01-23-00500

Over the years, the Centers for Medicare & Medicaid Services (CMS) has posted an Office or Outpatient (O/O) Evaluation and Management (E/M).  Recently CMS posted their updated PDF guide to help providers, coders, CDI professionals, auditors and billers understand basic documentation and coding requirements.  Below is a list of items that have been updated in the September 2025 Guide. 

Office or Outpatient (O/O) Evaluation and Management (E/M) Visits

• CMS added information about using O/O E/M visit add-on HCPCS code G2211 with other services reported by the same practitioner on the same day (page 6)
• Added information about billing intravitreal injections and E/M services using modifier 25 (pages 6–7)

Critical Care Services

• Added examples and scenarios for billing critical care (pages 9–10)
• Added a table for critical care billing situations (page 11)

Hospital Outpatient Clinic Visits

• Added information about billing HCPCS code G0463 (page 15)
• Added information about using modifiers for off-campus provider-based departments (page 15)

Telehealth Services

• 2025 policy updates and changes (page 30)
• Services and codes added to the Medicare Telehealth Services List for 2025 (pages 31–34)

Download the 35-page CMS PDF.  Consider online training from a licensing/certification partner w/CMS to train and become a Certified Medical Documentation Professional.

The Office of Inspector General (OIG) posted information related to the first defendant charged in an Early Intensive Developmental and Behavioral Intervention (“EIDBI”) and Feeding Our Future fraud scheme on September 24, 2025.

28-year-old Asha Farhan Hassan was charged with wire fraud for her role in a $14 million autism fraud scheme. Hassan was also charged with participating in the Feeding Our Future fraud scheme, for which she received $465,000.

“Today’s charges mark the first in the ongoing investigation into fraud in the EIDBI Autism Program,” said Acting U.S. Attorney Joseph H. Thompson. “To be clear, this is not an isolated scheme. From Feeding Our Future to Housing Stabilization Services and now Autism Services, these massive fraud schemes form a web that has stolen billions of dollars in taxpayer money. Each case we bring exposes another strand of this network. The challenge is immense, but our work continues.”