Update on Processing of Telehealth and Acute Hospital Care at Home Claims

In the absence of Congressional action, beginning October 1, 2025, many of the statutory limitations on payment for Medicare telehealth services that were, in response to the COVID-19 Public Health Emergency, lifted and subsequently extended through legislation again took effect.  These statutory limitations include restrictions on payment for many telehealth services provided to beneficiaries in their homes and outside of rural areas, and the provision of hospice recertifications that require a face-to-face encounter via telehealth.  These limitations are not applicable to all Medicare telehealth services, such as those for behavioral and mental health services, those for monthly ESRD-related clinical assessments, and those provided by applicable Medicare Shared Savings Program Accountable Care Organizations (ACO) participants.  CMS has been continuously evaluating our operations since October 1, 2025, and taking action when operationally feasible.  To date, to ensure that CMS pays only the telehealth claims consistent with current law, CMS has instructed the Medicare Administrative Contractors (MACs) to pay telehealth claims with dates of service on and after October 1, 2025, when CMS can definitively confirm that the claims are for behavioral and mental health services or otherwise meet the requirements described at Section 1834(m) of the Social Security Act.  CMS has identified these claims using the list of HCPCS codes identified in Table 1.  Additionally, we have instructed the MACs to process Medicare telehealth claims with a place of service code 10 (patient’s home) that contains a diagnosis code in the F01.A0-F99 range if the services were not performed by physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs), or audiologists.  We have further released a small batch of other telehealth claims that we can identify should be permissible to pay under current law.  However, due to systems limitations and recognizing that not all telehealth claims for behavioral and mental health services necessarily include a diagnosis code in the above range — often to further protect the privacy of the patient — we have not been able to identify all claims that are payable under current law.  These limitations have also impacted our ability to identify telehealth services performed by clinicians in applicable Medicare Shared Savings Program ACOs, who may receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restrictions, including in the beneficiary’s home, per section 1899(l) of the Social Security Act as added by the Bipartisan Budget Act of 2018 (Pub. L. 115-123).  To date, this subset of telehealth claims, including those submitted by clinicians in applicable ACOs and those that we’re not able to identify as for behavioral and mental health services, has been held.  To resolve this subset of claims and improve cash flow for practitioners, CMS is taking further action.  For the subset of telehealth claims that are currently being held, and that were submitted on or before November 10, 2025, with dates of service on or after October 1, 2025, CMS will be returning those claims to providers.  For professional claims, claims will be returned with the following messages: CARC 16 and RARC M77.  Practitioners may resubmit returned claims that meet the statutory requirements.  See the spotlight on the All Fee-for-Service Providers webpage for information on statutory requirements and revised instructions for the submission of telehealth claims.