ACM B Questions and Answers - December 3, 2025

The following questions and answers (Q&As) are cumulative from the Part B Ask the Contractor Meeting (ACM). Some questions have been edited for clarity and answers may have been expanded to provide further details. Related questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed this directly with the provider. This session included pre-submitted questions and verbal questions posed during the event. Please note our disclaimer stated that these are accurate as of this publishing and may have future updates.

Updates and Reminders:

  1. For coding advice, seek external sources such as the AMA, AAPC, or specialty societies
  2. Watch our Noridian website for CMS Telehealth updates after January 30, 2026

Pre-Submitted Questions

Q1. Regarding neurobehavioral status exam (CPT code 96116), when a patient is developmentally delayed, nonverbal, or potentially disruptive, is a face-to-face patient evaluation required as part of the clinical assessment?
A1. Yes. The patient's medical record must indicate the presence or symptoms of mental illness and specific psychological tests performed. Also include testing, scoring, and interpretation of test results with the number of hours. This can include Wechsler Memory Scales, Halstead-Reitan Neuro Battery, or Wisconsin Card Sorting.

Q2. When infusion is administered by a nurse in a multi-provider oncology office, and the primary oncologist, is out of the office, can the claim be submitted under the name and National Provider Identifier (NPI) of the supervising physician providing coverage?
A2. Yes. Since this is a group, any physician group member may be present in the office to provide direct supervision. Documentation should clarify the nurse's name and direct supervising physician's name.

Q3. If a patient has Qualified Medicare Beneficiary (QMB) status under Medicare and also has Medi-Cal with a share of monthly cost, are we allowed to collect from the patient?
A3. Medicare providers cannot bill QMB patients for Medicare cost-sharing. This includes deductibles, coinsurance, and copayments. In some cases, a patient may owe a small Medicaid copayment. Medicare and Medicaid payments (if any), and any applicable Medicaid QMB copayment, are considered payment in full.

Providers are subject to sanctions if you bill a QMB above the total Medicare and Medicaid payments (even when Medicaid pays nothing).

Q4. Does CMS require the physician signature on the patient's copy of the Chronic Care Management (CCM) plan?
A4. CMS does not require a physician signature on the CCM care plan for CPT 99490 and add-on CPT 99439.

  • Care team staff may develop and update the care plan while keeping the billing provider involved.
  • Complex CCM care plans never created by clinical staff.

Note: 99491 and add-on 99437 only billed if physician or qualify health practitioner (QHP) are performing the CCM work and NOT clinical staff.

Q5. Does Medicare Part B allow HCPCS J0248 Veklury (remdesivir), and do we need a signed Standard Written Order (SWO) for billing?
A5. Yes. If this antiviral medication is administered in an outpatient setting, it can be billed separately. Document the COVID-19 symptoms, infection severity, and diagnosis.

Q6. If we have a nurse practitioner supervising a licensed acupuncturist for the acupuncture treatment, what documentation and restrictions apply?
A6. The acupuncture restrictions include:

The supervising NP must also meet their "direct supervision" rules, applicable state requirements, and document accordingly.

Q7. Can CPT code 93750 (Left Ventricle Assist Device [LVAD] interrogation) be submitted for interrogation of percutaneous LVADs (Impella), or is the code limited to implanted devices?
A7. CPT code 93750 is limited to implanted devices.

Q8. We're receiving recoupments from Health Maintenance Organization (HMO) and Medicaid plans citing Medicare as primary, but these occur after Medicare's timely filing window (two to three years later) closed. What recourse do we have to file these claims to Noridian Medicare?
A8. If a claim is denied for timely filing, as the result of an administrative error, due to a government agency, such as Medicaid or an HMO recouping money, then due to Medicare entitlement by the patient at the time of the service or an error with the patient's Social Security Administration (SSA) entitlement, the claim(s) may be resubmitted with a comment in Item 19 of the CMS-1500 claim form (or electronic equivalent) that indicates there was an administrative error. Comments in Item 19 for Medicaid recoupments should state, "Medicare Buy Back", "RETRO", or "Took Payment Back".

  • Noridian Medicare website > Browse by Topic > Claims > Timely Filing

Q9. How can we submit a clean claim when an unlisted CPT code is billed in an Ambulatory Surgical Center (ASC) setting? Due to risk factor assessment, the procedure performed does not fully match the CPT expected prior to surgery and no CPT matches the ASC fees. Even appeals are denied.
A9. ASCs cannot bill unlisted codes. For an ASC code to be payable, it must be listed as payable on the ASC addenda files.

Reference CMS Internet Only Manual, Claims Processing Manual, Publication 100-04, Chapter 14, Section 20.2: ", covered surgical procedures do not include those surgical procedures that: (1) generally result in extensive blood loss; (2) require major or prolonged invasion of body cavities; (3) directly involve major blood vessels; (4) are generally emergent or life threatening in nature; (5) commonly require systemic thrombolytic therapy; (6) are designated as requiring inpatient care under § 419.22(n); (7) can only be reported using a CPT unlisted surgical procedure code; or (8) are otherwise excluded under § 411.15."

Q10. Two scenarios include full E/M documentation and separate x-ray interpretation and report:

  • Example A: Patient presents to orthopedic surgeon in office place of service (11). An x-ray is performed using office equipment and read by the orthopedic surgeon. Will both an office visit and global billing of x-ray be covered?
  • Example B: Same situation, with place of service in a hospital outpatient clinic (19 or 22). Will both the office visit and professional component of x-ray be covered?

A10. Medicare will cover medically necessary E/M services and x-rays performed in the locations indicated. In the office setting, the global of an x-ray would be billed. In the outpatient setting, the equipment belongs to the hospital and only the professional component can be billed. When separately billing for x-rays, the data reviewed should not be included when choosing the E/M code.

Q11. Can the required Transitional Care Management (TCM) face-to-face visit be done via telephone if the patient prefers to have a phone visit instead of video or in-person?
A11. TCM CPT codes 99495 and 99496 are allowed through telehealth. CMS has not indicated if an audio only visit would or would not be allowed as the face-to-face visit. If the patient was hospitalized with a condition where it may be necessary to see the patient, the audio-only call should be avoided.

Q12. Can TCM codes 99495 or 99496 be billed on same day as an unrelated E/M service?
A12. Yes, report reasonable and necessary E/M services (except the required face-to-face visit) to manage the patient's clinical issues separately. Check for any National Correct Coding Initiative (NCCI) edits.

Q13. Can critical care be billed for a patient that is being ruled out for stroke? Does the final diagnosis determine critical care?
A13. CMS includes the definition of critical care in Internet Only Manual, Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.12.1. Critical care is direct delivery of medical care for a critically ill or injured patient in which there is acute impairment of one or more vital organ systems, probability of imminent or life-threatening deterioration of the patient's condition.

Suspected stroke as a diagnosis does not meet the full requirement of the definition. The patient would need vital organ or life-saving care. Documentation would support billing of critical care, not the diagnosis.

Q14. Could you provide guidance on the correct Place of Service (POS) and whether a telehealth modifier is required when our physicians perform a post-operative telehealth visit using CPT 99024? If the patient is at home, should we report POS 11 or POS 10, since we've received conflicting instructions? Additionally, if POS 11 is used, should we append modifier 93 or 95?
A14. 99024 is post-op care CPT, which is included in the surgical payment and cannot be billed separately. It is not on the telehealth list of covered services and should not be billed at all.

Please refer to the Medicare Physician Fee Schedule Indicator page for more information. When 99024 is entered, it shows status B; meaning it will always bundle.

  • Noridian Medicare website > Fees and News > Fee Schedules > Medicare Physician Fee Schedules (MPFS) > 2025 MPFS Indicator List and Descriptors

Q15. If a provider documents a discharge note and the patient ends up staying an inpatient, can we code an inpatient E/M visit based on time? Is it acceptable to update the discharge note the following day when the patient is discharged with minimal changes to code 99238 or 99239?
A15. Yes, the documentation could be billed as an inpatient visit based on time if total time is included for the visit. Query the provider to amend the discharge note to an inpatient note.

The discharge documentation needs to support the visit performed on the date the patient is discharged. If a visit was not performed, the discharge could not be billed.

Q16. Regarding the CMS Wasteful and Inappropriate Service Reduction (WISeR) program with skin substitutes, Noridian states (AZ and WA) currently do not have an active Local Coverage Determination (LCD) policy for skin substitutes. How can these states have prior auth without any active LCD policy?
A16. The Local Coverage Determination (LCD) L39760 and Billing and Coding Article A59626 titled "Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers" has been removed from the WISeR program as of 12/31/2025.

Q17. We seek clarification on whether Medicare considers hospital-owned clinics (POS 22 or 19) as facility or office visits for split/shared billing. Guidance appears conflicting on whether split/shared services can be billed for office visits in these settings when reviewing MM13592 and MLN006764.
A17. The CMS Internet Only Manual, Medicare Claims Processing, Publication 100-04, Chapter 12, Section 30.6.18.D provides the clarification. Only visits furnished in hospital and skilled nursing facility settings are billable as split or shared visits. Office visits would not qualify for split or shared visits.

Q18. If the physician performs the initiating Annual Wellness Visit (AWV) HCPCS G0438, can s/he additionally bill for the Advance Primary Care Management (APCM) G0556 on the same day for the same provider?
A18. Yes. Remember that APCM can only be furnished once during a calendar month and must meet Medicare requirements.

Q19. Several Electronic Medical Record systems allow or even suggest the inclusion of CPT codes in operative reports or notes. Is this an acceptable practice?
A19. Neither CMS nor Noridian have a policy in place for reflecting actual CPT codes or even ICD-10 diagnoses in the medical record. Remember that it's NOT appropriate to use the CPT in place of a written and clinical description of the procedure performed.

Q20. Is it allowable for the hospital to bill CPT 86078 on a UB-04 claim form with a technical-only modifier TC?
A20. No. CPT 86078 is a physician-only service. Always check the Noridian Medicare Physician Fee Schedule page under "MPFS Indicator List and Descriptors" to check codes. Under professional/technical (P/T), zero (0) is listed which means "This indicator identifies codes that describe physician services. Examples include visits, consultations, and surgical procedures.

The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifiers -26 and TC cannot be used with these codes."

Q21. Where can we find date of service billing guidance with CPTs 93279 - 93298 for the technical (TC) portion?
A21. This excerpt from Special Edition (SE) 17023 applies to CPT 93279 (in-person programming of a single-lead pacemaker) and 93298 (remote monitoring, etc.):

... the date of service for the technical component would be the date the patient received the service and the date of service for the professional component would be the date the review and interpretation is completed.

Verbal Questions Asked During ACM

Q22. What documentation is needed to support split injection billing for drugs, such as Faslodex or XOLAIR, where the FDA recommends to split these injections into multiple sites for patient safety?
A22. Documentation should include the different sites and times that the injections were administered. Bill Faslodex (J9395) with administration CPT 96402. Bill XOLAIR (J2357) with administration of CPT 96372 (therapeutic, prophylactic, or diagnostic injection).

Q23. If documentation does not support an annual wellness visit (AWV) (e.g., components are missing), can we change coding to an E/M?
A23. If the patient is coming in expecting the AWV with no expenses, changing to an E/M would put the patient responsible for possible unmet deductible and 20% copay. Also, if it doesn't meet the criteria for AWV or an E/M, it cannot be billed. To bill the E/M, illness needs to be addressed as well.

Q24. We are receiving RTP claims stating the code A9616 (Gozellix) is not payable; however, it became effective October 1, 2025. Is the MAC updating the policy since the manufacturer and CMS recently approved?
A24. Noridian shows Fee Schedule pricing under Radiopharmaceutical, HCPCS A9616 (Gallium Ga-68 Gozetotide-Gozellix, diagnostic, 1 millicurie) for men with suspected prostate cancer. Medicare denies claims if no PET scan is billed same day, tracer code is not billed, and/or modifiers are missing.

  • Modifier PI: Positron Emission Tomography (PET) or PET/Computed Tomography (CT) initial tumor treatment that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.
  • Modifier PS: Same as above for subsequent anti-tumor strategy

Q25. Regarding time-based codes, if the practitioner forgot to add the time during the visit, what is the timeframe that a provider can go back to add the time to their documentation?
A25. CMS has indicated that addendums can be made, but must be made as quickly as possible; however, there is no definitive timeframe.

Q26. Regarding callus removal (routine footcare with no systemic diseases), if a service is not payable per the LCD, instead of billing for that procedure, can an E/M be billed?
A26. No. Without the E/M components being met, that cannot be billed. Providers may obtain an Advance Beneficiary Notice of Noncoverage (ABN), letting the beneficiary know this is not going to be covered and it will be patient liability. Append the GA modifier.

Q27. Being a pain management office, when billing E/M services, if medical cannabis is discussed and noted in the chart, could that result in a denied claim? It is not the cause or reason for the visit, but it is discussed and noted.
A27. The cannabis discussion would not deny an E/M visit if other elements were met.

Q28. We collaborate with dentists who provide medical services, such as oral facial pain services which fall under Part B, and suppliers for sleep apnea devices under DME. Some of our providers are enrolled in Part B, some in DME, some in both. For DME suppliers, if they delivered a sleep apnea device to the patient, but they also want to treat them for pain, such as trigger point injection which falls under Part B, can they charge cash because they are not enrolled in Part B?
A28. If the service or procedure can be covered by Medicare and they are seeing a Medicare patient, it must be billed to Medicare due to Mandatory Claim Filing of 1992 under the Social Security Act, Section 1848(g)(4). There is also information found on Noridian's Enrollment icon on either the JE or JF home page.

Q29. I have two vascular surgeons who perform procedures together. Can we use modifier 62 even if they are the same specialty?
A29. This is based on the surgery being performed and if it is allowed. However, there must be a need for both surgeons and documentation showing they performed different services.

Q30. There are new radiation oncology changes for 2026. They are no longer allowing G-codes to be billed and we need to redo our billing system due to this change. Is education to be provided?
A30. Noridian is updating their JE and JF pages under Browse by Specialty, Radiation Oncology with the new codes added for 2026 including CPTs that may be billed global, technical, or professional:

  • 77436 - surface radiation therapy planning for superficial or orthovoltage treatments, including simulation-aided field setting for cutaneous targets (global, TC or 26)
  • 77437 - superficial radiation treatment delivery up to 150 kV per fraction (only global)
  • 77438 - orthovoltage radiation treatment delivery greater than 150 kV and up to 500 kV per fraction (only global)
  • +77439 - add-on code for ultrasound image guidance used to place superficial or orthovoltage treatment fields for cutaneous tumors (global, TC, or 26) and report only once per course with 77437 or 77438
  • Deleted HCPCS G6001-G6017 and CPTs 77014, 77385, 77386, and 77417 as of 12/31/2025
  • Revised radiation treatment delivery CPTs 77402, 77407, and 77412 to levels 1, 2, and 3

Q31. When coding for morbid or class III obesity, does the provider have to explicitly state "due to excess calories", when billed with E66.01? Does documentation support the diagnosis if it states, "continuing with calorie restrictions, increasing exercise weekly, and limiting high fat foods"?
A31. Yes. Since morbid obesity includes class 3, severe and extreme obesity, other diagnoses may be considered as well.

Q32. If a dentist submits Medicare claims for mandibular advancement devices used to treat obstructive sleep apnea, can that same dentist provide non-tooth-related services, such as treatments related to orofacial pain? Can they choose not to submit those claims to Medicare and billing the patient directly instead?
A32. No. Dentists cannot choose electively which services they submit to Medicare for payment. Under the claim submission requirements in Section 1848(g)(4) of the Social Security Act, providers must submit claims for all services that could potentially be covered by Medicare. This means that if a provider charges or attempts to charge a Medicare beneficiary for any service that could fall under Medicare coverage, the provider is obligated to file a claim, even when the provider believes Medicare will not pay for the service. Additionally, if the service provided is potentially non-covered, the beneficiary should be provided with an Advance Beneficiary Notice (ABN), indicating that Medicare may not pay. Prior to providing the service or procedure and submitting the claim with modifier GA, this allows the patient to accept financial responsibility.

Last Updated $dateUtil.getDate( $modifieddate , "MMM dd , yyyy" , $locale , $tzone )