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:
For coding advice, seek external sources such as the AMA, AAPC, or specialty societies
Watch our Noridian website for CMS Telehealth updates
Local Coverage Determination (LCD) L35170 "Botox Toxin Injections" updating policy

Pre-Submitted Questions

Q1. Should modifier 93 or 95 be appended to G2211 when a telemedicine visit is billed?
A1. Yes; whichever is appropriate. The place of service provides the information when a telehealth visit is performed. Modifier 93 is only appended when the patient does not consent to a video visit and whenever only an audio visit is performed. Modifier 95 is appended in limited circumstances when the patient is in their home and the provider is at the hospital (POS 19 or 22); or for outpatient therapy performed by a PT, OT, or SLP.

Q2. If the full scope of CPT 64582 (insertion and open implantation of hypoglossal nerve neurostimulator array, etc.), does not include a separate distal respiratory sensor electrode array (e.g., Inspire V); do we append modifier 52 for reduced services?
A2. Append modifier 52 and bill an appropriate reduced rate if the full scope of CPT 64582 is not performed. Do not bill the "standard fee". Note that the code calls for "distal respiratory sensor electrode or electrode array", so either of these would fulfill the requirement and not necessarily an "array".   

Confirm that this follows the Local Coverage Determination (LCD) policy "Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea" or HGNS covered indications, requirements, and limitations. New codes were added April 2026 (effective January 1, 2026):

• C8007 - Open implantation if HGNS array and pulse generator, not requiring insertion of separate distal respiratory sensor electrode or electrode array
• C8008 -  revision or replacement
• C8009 - removal of HGNS
• C8011, C8012 and C8013 - Genio apparatus for placement, revision, and removal introduced

Q3. When comorbidities are omitted from the surgeon's op report, can diagnosis codes be added based on past medical records or should the surgeon be queried for an addendum?
A3. If the surgeon didn't consider the comorbidities for the procedure performed, the addition of the diagnoses would not be appropriate. Only diagnoses that are part of the current procedure or treatment should be included. If the comorbidity is part of the procedure, the surgeon should be queried for an addendum.

Q4. What documentation is required for assistant at surgery (modifier 80 or AS) when procedure has a payment restriction indicator of "0" or "2"?   
A4. Documentation must provide a clinical picture of the patient and include the procedures or services performed to support the use of modifier 80 (physician) or AS (non-physician practitioner). This includes the name of the surgical assistant and evidence the assistant surgeon actively participated in the procedure.

Clearly document the assistant's role during the operative session and that they provided more than ancillary services. If the documentation shows the assistant is acting more as a nursing role rather than surgical assistant and the surgeon could perform the procedure alone, a procedure with indicator zero may not be covered. The primary surgeon's signature is always required on these claims.

Q5. Did our office read previously that Noridian does not cover "Chemotherapy education"? Can an eligible practitioner bill an Evaluation and Management (E/M) for a patient with a treatment plan for newly diagnosed cancer?
A5. Correct; however, Chemotherapy education is bundled into the E/M and not separately billed. This includes the prognosis, expectations, community resources, etc.

Q6. Can or should an "Independent historian" be applied when a parent provides history for a child (e.g., newborn, toddler) who are unable to provide reliable history?
A6. Yes. When a patient is unable to provide a reliable history, the CPT E/M guidelines state a parent, guardian, surrogate, spouse, or witness, may provide medically necessary history. The AMA has some great guidelines for the question under pages 17-42 at this link AMA Evaluation and Management (E/M) Descriptors and Guidelines.pdf. If this is not for a Medicare fee-for-service beneficiary, check with that payer's policy.

Q7. For a bilateral ptosis levator eyelid repair (CPT 67904) performed in an outpatient hospital setting, the facility obtained a Part A prior authorization (PA) for one unit. Since modifiers cannot be included in the Part A PA request, as the physician billing under Part B:
1.  Do we only need one PA (requested by Part A) for both the facility and our physician?
2.  Can we bill CPT code 67904 with modifier 50, even though it doesn't appear on the approval?
A7. Yes, just one PA needed for both facility and provider with the Prior Authorization Coversheet for Blepharoplasty. CPT 67904 must be billed with modifiers RT or LT for one eye or modifier 50 for bilateral. When billed with modifier 50, the payment will be 150% of the fee schedule.

Per the Fee Schedule Indicator List for Column B:
1=150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with "2" in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code.

If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

Q8. Since Medicare did not adopt the AMA telehealth codes (CPTs 98000-98015), if a parent has an "audio only call" with a pediatrician, does the patient need to be present?
A8. Yes; if Medicare is billed. Medicare requires the patient to be present as a condition for payment for telehealth visits. Read Section 190.4 at CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12.pdf. See also the answer provided for A6. If this is not for a Medicare beneficiary, check with that payer's policy.

Q9. Our institutional providers (i.e., hospital-employed clinicians) sometimes provide telehealth services to our patient population. The provider is in Place of Service (POS) 22 and the patient is at home. Please clarify if modifier 95 is needed for audio-visual Evaluation and Management (E/M) services.
A9. Correct. When a provider is in the hospital setting and providing a telehealth visit to a patient who is in their home, modifier 95 would be appended as it indicates synchronous telemedicine service via real-time audio and video telecommunications.

Q10. Is it mandatory to use the official CMS Advance Beneficiary Notice (ABN) form for Medicare non-covered or medically unnecessary Durable Medical Equipment (DME) services? Can providers use an in-house ABN waiver instead if it includes all the required elements?A10. Yes to the first question and no to the second. Providers must use the official CMS ABN form regardless of the reasoning; however, no ABN needs to be provided (unless voluntary), when a procedure or service is statutorily non-covered. New ABN was just released (effective immediately) with updated expiration date 3/31/2029! Providers have a grace period until May 12 of this year (2026) to update and use the new CMS-R-131 form. Read more under CMS Fee-for-Service (FFS) Advance Beneficiary Notice of Noncoverage (ABN).

Q11. Is there a primary CPT
list that add-on CPTs 61781 (stereotactic computer-assisted navigation procedure on skull, brain, or meninges; real time tracking; intradural), 61782 (….; extradural), and 61783 (….; spinal) are billed and allowed?
A11. The only CMS primary code list exists on the Medicare National Correct Coding Initiative (NCCI), Add-on Code Edits list at CMS NCCI Add-On Code Edits. These CPTs have an indicator of "CCCCC", meaning the contractor would determine the primary code.

Q12. If the provider billed an Annual Wellness Visit (AWV) and documentation lacks the required components (e.g., missing visual acuity screening, etc.), is modifier GZ (item or service expected to be denied as not reasonable and necessary) appended to G0438 or G0439 appropriate?
A12. Yes. However, if there had been documentation stating that there was no visual acuity screening because the patient had seen their optometrist, or another appropriate reason the service was not included; then this could be a payable service.

Q13. Would high level risk for Evaluation and Management (E/M) purposes be supported when a provider documents clinical recommendation discussion for cytotoxic chemotherapy that has not been initiated yet?
A13. It will depend on the circumstances and documentation. The assessment of the level of risk is affected by the nature of the event under consideration. The treating provider needs to document the level of risk discussed with the patient in the medical record.

Q14. Why was "Focal Dystonia" taken out of the Noridian Botox Policy and considered "limb spasticity"? Dystonia is dynamic and fluctuating, often triggered by voluntary action or strong emotions.
A14. Some types of dystonia are FDA approved while others are not. This February 2026 updated "Botulinum Toxin Injection (BTI)" policy (L35170) provides coverage for those with FDA approval. For those without FDA approval or who do not contain substantial literature to support, coverage would be denied upon claim submission. However, providers may appeal and submit robust peer-reviewed literature for review.

The management of Focal Hand Dystonia (FHD), BTI is considered reasonable and necessary and consisting of focal injections of the toxin into the muscles responsible for the abnormal postures, and initial BTIs for FHD will be considered reasonable and necessary when the following requirements are met:

• Objective  documentation of the clinical features consistent with the diagnosis of FHD; AND
• Moderate to severe chronic FHDs measured on objective clinical scale*; AND
• The injections are used with guidance either by ultrasound or by electromyography (EMG) with or without electrostimulation.

The objective assessment must be performed and documented at baseline, after each diagnostic procedure, and at each follow-up assessment using the same scale during each assessment. For example, scales that could be used include the Fahn-Marsden rating scale, Unified Dystonia Rating Scale, Arm Dystonia Disability Scale (ADDS); Tubiana-Chamagne Scale; and Writer's Cramp Rating Scale.

Q15. What are examples of recent dementia diagnoses for Fluorodeoxyglucose-Positron Emission Tomography Positron Emission Tomography (FDG-PET) scans?
A15. For advanced imaging coverage such as FDG-PET scans, a ‘recent diagnosis of dementia’ typically means there is physician-documented, with patient's progressive cognitive decline over at least six months, but the exact type of dementia remains uncertain.

Q16. Does CPT 96574 Photodynamic Therapy (PDT) require the provider to apply the medication and turn on the PDT machine, or can a medical assistant perform these tasks and the provider bills?
A16. CPT 96574 debridement requires both the application of the photosensitizing medication and the illumination or activation, using the PDT light source. This is only performed by a physician or other qualified non-physician practitioner professional. Therefore, a medical assistant (MA) is not permitted to perform these components.

Q17. Will Noridian be correcting the Local Coverage Determination (LCD) L40050 titled "Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)" and Billing and Coding Article A59976 for claims with venom-related allergen that are incorrect?
A17. The indications and efficacy for SCIT with aeroallergens (i.e., inhaled allergens, such as pollens, dust mites, animal dander, etc.) are considered in this LCD. SCIT with other allergens, such as venoms, is not considered in this LCD. Therefore, no changes to the current policy (along with the billing and coding article) will be made. The updated proposed policy's comment period ended February 28, 2026.

Q18. When a urinalysis (81003 QW) is provided in the office on the same day (morning) and a telehealth E/M visit (afternoon) with the patient in their home, can we bill on the same claim for two different POS?
A18. No. Bill on separate claims with POS 11 for 81003 QW and another claim for the telehealth E/M with POS 10.

Q19. Per the Botulinum Toxin Injection policy (L35170), what are examples of approved objective assessment scales to use for the Migraine indication? Does it have to be an actual formal scale like the Migraine Disability Assessment (MIDAS) scale?
A19. The LCD policy does not require a specific scale. The provider can use whatever scale they prefer. The results must be documented in the record with the type of scale and score.

Q20. Can providers bill CPTs 27245 (Open treatment of femoral fracture; intramedullary implant) and 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod, or plate]) if the removal requires separate work beyond exposure for new fixation and hardware that has failed or been displaced?
A20. Depends. Per AAPC's Codify page, if the hardware broke away from the fracture site and the surgeon created a separate incision to access, Medicare may reimburse both services. Append modifier 59 (distinct procedural service) to CPT 20680.

Verbal Questions Asked During ACM

Q21. When making the decision for surgery, can we apply chemotherapy that hasn't been initiated yet into high risk?
A21. The decision for chemotherapy is sufficient for the risk categorization and must be documented in the medical record.

Q22. When we have patients who need pain medication following a procedure, in the Ambulatory Surgical Center (ASC), we add the catheter and then attach the external disposable pump (ON-Q*). When the medication in the pump is depleted, we detach and then attach a new pump. Since the C9804 is not refilling the pump, can we bill again for the replacement?
A22. Yes. C9804 is the elastomeric infusion pump (e.g., ON-Q* Pump with Bolus), including catheter and all disposable system components, with non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with Section 4135 of the CAA, 2023) is covered separately for the first time. This is per the “NOPAIN Act” starting January 1, 2025 and continuing through December 31, 2027, as long as it’s provided with a covered surgical service. Per CMS Medicare Prospective Payment Systems-Non-Opioid Treatments and Code of Federal Regulations (CFR) 42 Chapter IV, B, Part 416.174.

Q23. We have a multispecialty group consisting of pain management, neurology, and rheumatology. If the rheumatologist created a care plan consisting of infusions, can another physician in the group from a different specialty be the supervising physician when billing infusions?
A23. The specialties must be within the same scope. The covering physician must be able to self-perform all regularly required services.

Q24. We have HCPCS G2211 add-on code that may be reported with new and established patient office and outpatient evaluation and management (E/M) services. These claims are denying when we are also billing an E/M visit with modifier 25 on a different claim. How do we avoid these denials?
A24. To avoid these denials, the add on code must be billed with the primary code on the same claim. Add on codes are never billed alone.

Q25. We have patients who use a type of Botulinum Toxin Injection (Xeomin) for chronic migraines due to an adverse reaction, but we can't find coverage criteria for this. Is this available?
A25. Although coverage criteria are not available, providers are encouraged to document this in the record and include supporting literature upon appeal. As you are aware, there are three distinct serotype A botulinum toxin therapeutic products, onabotulinumtoxinA (BOTOX®), abobotulinumtoxinA (DYSPORT®) and incobotulinumtoxinA (XEOMIN®); along with the serotype B botulinum toxin product, rimabotulinumtoxinB (MYOBLOC®).

However, these products are not interchangeable, and CMS states it’s the physician's responsibility to select the appropriate product and dose in accordance with FDA-approval indications for use, compendia-supported uses, and supported by peer-reviewed specific scientific literature.

Q26. For patients with dual diagnoses of chronic migraine and cervical dystonia with Botox, we've been told we can't bill CPTs 64615 and 64616 (Under destruction by neurolytic agent procedures on the somatic nerves) together. Are there modifiers that can be used?
A26. Per the National Correct Coding Initiative (NCCI), these two codes cannot be billed together. Refer to the NCCI Policy Manual for proper coding. When a pair of codes have a "zero indicator", no modifier is allowed.

Q27. We are billing CPT 77301 (Intensity Modulated Radiation Therapy or IMRT) planning, not patient-facing. We find out later the patient went on vacation and was hospitalized due to injury. The planning was billed on a date of service that she was in the hospital. When we bill the professional component, which place of service should we use?
A27. Bill CPT 77301 with modifier 26 (professional component) in the office and the technical component split with the facility.