CMS Update: Medicare Claims Hold, Telehealth Reversions & Vaccine Billing Fixes

As the healthcare landscape continues to shift, the Centers for Medicare & Medicaid Services (CMS) has issued critical updates that directly impact billing operations. Here’s what medical billing professionals need to know from the latest CMS guidance.

Claims Hold in Effect for Key Medicare Services

CMS has directed all Medicare Administrative Contractors (MACs) to temporarily hold claims with dates of service on or after October 1, 2025, for services affected by expired legislative payment provisions under the Full-Year Continuing Appropriations and Extensions Act, 2025. In light of the continuing government shutdown, CMS will continue to process and pay held claims in a timely manner with the exception of select claims for services impacted by the expired provisions (telehealth claims).

This hold applies to:

• Medicare Physician Fee Schedule (MPFS) claims
• Ground ambulance transport claims
• Federally Qualified Health Center (FQHC) claims

Providers may continue submitting these claims, but payments will not be released until the hold is lifted. This precautionary measure anticipates possible Congressional action that could alter payment structures.

Telehealth Coverage Reverts to Pre-COVID Rules

In the absence of new legislation, pre-pandemic Medicare telehealth restrictions are now reinstated for services not related to behavioral health. Effective October 1, 2025:

• Telehealth services provided in patients’ homes or outside rural areas are no longer covered.
• Hospice recertifications must be conducted in person.

Practitioners offering non-covered telehealth services should consider issuing an Advance Beneficiary Notice of Noncoverage (ABN) to inform patients of potential out-of-pocket costs. CMS provides ABN forms and instructions here.

Providers may also choose to hold telehealth claims that are not payable under current rules while monitoring Congressional developments. For more details, visit the CMS telehealth coverage page.

ACOs Retain Telehealth Flexibility

Clinicians participating in Medicare Shared Savings Program Accountable Care Organizations (ACOs) can continue furnishing and billing for covered telehealth services without geographic restrictions, including services delivered in the patient’s home. No special application is required to access these flexibilities. Learn more in the ACO Telehealth Fact Sheet.

NCCI Edit Revision: COVID-19 Vaccine Billing Correction

CMS has resolved a billing issue that caused denials of CPT code 90480 when submitted with G0008, G0009, or G0010. The error stemmed from a Procedure-to-Procedure edit in the 2025 Q4 National Correct Coding Initiative (NCCI) files.

On October 14, 2025, CMS released updated NCCI files to remove the problematic edit. MACs will automatically reprocess affected claims with service dates between July 1 and October 15, 2025, within approximately 30 business days. Providers do not need to take action unless they prefer to:

• Use the MAC appeals process, or
• Wait to submit impacted claims until after the correction is fully implemented.

Takeaway for Billing Teams

Stay alert to these changes and adjust claim submission strategies accordingly. Whether it’s holding claims, issuing ABNs, or tracking vaccine billing corrections, proactive steps now can prevent payment delays and compliance issues later.

Contact Yeo & Yeo Medical Billing & Consulting for assistance.