Medical Review Frequently Asked Questions (FAQs)

Q1. What are the requirements for using Telehealth Services? What has changed about the Place of service indicator (POS) used?
A1: There have been significant updates to the policy change regarding Medicare Part B Telehealth services. Telehealth is a substitute for an in-person visit, and generally involves two-way interactive technology that permits communication between the practitioner and the patient. During the COVID-19 public health emergency (PHE), an emergency waiver was used in conjunction with other regulatory authorities to provide more services to patients via telehealth. Section 4113 of the Consolidated Appropriations Act, 2023 that extended many of these flexibilities through December 31, 2024, and made some of them permanent. For 2023, continue billing telehealth claims with the (Place of Service) POS indicator as it is for an in-person visit. The Modifier 95 must be appended to identify the claim as telehealth through December 31, 2023. After December 31, 2023, use POS 02-Telehealth to indicate you provided the billed service as a professional telehealth service when the originating site is other than the patient’s home. Use POS 10-Telehealth for services when the patient is in their home.

Refer to: MLN901705 - Telehealth Services and CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 26

Q2. What is the difference between CPT® code 97164 for PT Re-evaluation and a Progress Report?
A2. A Progress Report, which must be completed every 10 treatment visits, should include objective measurements of the patient’s progress, the status of progress related to their goals, and the assessment of each goal with plans/modifications for ongoing treatment.

CPT® 97164 for PT Re-Evaluation is different from a progress report and should not be billed as such. CPT® 97164 is only appropriate to be billed if the patient has a significant unanticipated change in condition or unresponsiveness to therapy interventions. It may also be appropriate if a new diagnosis that is related to the original complaint is discovered and requires evaluation.

Refer to: CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220

Q3. What are the coverage indications for CPT® 82607/Vitamin B 12?
A3. Indications for B12 testing:

  • anemia
  • fatigue
  • neurological symptoms
  • h/o vitamin B12 deficiency
  • gastric bypass
  • vegetarian diet

Refer to: CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80

Q4. An Additional Documentation (ADR) request was received by my office. How do I know what documentation to send and how to send the documentation?
A4: Review the following links titled How to Read an ADR and How to Respond to ADR. Also, the ADR letter lists what documentation should be sent. Refer to: How to Read an ADR and How to Respond to ADR

Last Updated Dec 28 , 2023