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Today, the Centers for Medicare & Medicaid Services (CMS) updated its Medicare claims hold guidance to Medicare Administrative Contractors, which is copied below. The AMA had been communicating with CMS behind the scenes and urging the agency to clarify its guidance in light of significant confusion about which claims are being paid during the ongoing federal government shutdown.

“CMS instructed all Medicare Administrative Contractors (MACs) to lift the claims hold and process claims with dates of service of October 1, 2025, and later for certain services impacted by select expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025 (Pub. L. 119-4, Mar. 15, 2025). This includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center (FQHC) claims. This includes telehealth claims that CMS can confirm are definitively for behavioral and mental health services. CMS has directed all MACs to continue to temporarily hold claims for other telehealth services (i.e. those that CMS cannot confirm are definitively for behavioral and mental health services) and for acute Hospital Care at Home claims.

Beginning October 1, 2025, for services that are not behavioral health services, 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 include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions can be found here: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are currently not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 (Pub. L. 115-123, Feb. 9, 2018), which added section 1899(l) to the Social Security Act, allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restrictions and in the beneficiary’s home. Separate from requirements to participate in the Medicare Shared Savings Program, there is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers to offer these covered telehealth services. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For clinicians in applicable ACOs, telehealth claims that CMS can confirm are definitively for behavioral and mental health services will be paid. At this time, claims for some telehealth services will continue to be held. For more information, including information on to which ACOs these flexibilities apply: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf (PDF).”

Claims Hold Update

In anticipation of possible Congressional action, CMS has instructed all Medicare Administrative Contractors (MACs) to continue to temporarily hold claims with dates of service of October 1, 2025, and later for services impacted by the expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025. This includes all claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and all Federally Qualified Health Center claims. Providers may continue to submit these claims, but payment will not be released until the hold is lifted.

Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency took effect again for services that are not behavioral health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For more information: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf (PDF).

Claims, Pricers & Codes

NCCI Alert: COVID-19 Vaccine Administration Edit Revision

Some providers may have 90480 claims denied when billed in conjunction with G0008, G0009, or G0010 as a result of a Procedure to Procedure edit released in the 2025 Quarter 4 National Correct Coding Initiative (NCCI) files. On October 14, 2025, CMS issued replacement NCCI files to remove this edit. Medicare Administrative Contractors (MACs) will reprocess claims with dates of service between July 1, 2025, and October 15, 2025, within approximately 30 business days, and Medicare providers don’t need to take any action. Alternatively, a provider may also choose to use the MAC appeals process if they don’t wish to wait for the automatic adjustment to occur, or they can wait to submit impacted claims until after CMS implements the change.

Access the Medicare replacement files.

The full message was posted by CMS here.

But health-care and business groups lobbied against the bill, contending it would drive up malpractice insurance costs and lead to doctors deciding not to practice in Florida. Those groups and DeSantis argued that a repeal of the 1990 law would need to be coupled with broader caps on non-economic damages in malpractice lawsuits. “If you don't have those caps, then you really are incentivizing a lot more litigation to take place in the state of Florida,” DeSantis said. “None of that is free lunch. Somebody will have to pay for it. And unfortunately, I think if this bill became law, I do think the cost would be borne by the physicians, who would potentially flee the state, to people that wouldn't have as much access to care.” Malpractice damage caps have been a political lightning-rod issue for decades, with plaintiffs’ attorneys fighting them. The Senate on May 1 voted 33-4 to pass the bill after narrowly rejecting an amendment to include caps. The House earlier approved the measure in a 104-6 vote.

Under the 1990 law, people who are 25 years old or older cannot seek what are known as “non-economic” damages in medical-malpractice cases involving deaths of their parents. Also, parents cannot seek such damages in malpractice cases involving the deaths of their children who are 25 or older. The bill, which the governor has not received yet, was strongly supported during the 2025 legislative session by people who allege their family members were killed by medical malpractice. Health-care and business groups have lobbied against it. Lawmakers could revisit the issue, as DeSantis suggested putting limits on monetary awards. “What I suggested that was done — I know there was some support for it in the Senate — is that if you had caps on the amount of damages, people could see that and would disincentivize a lot of jackpot justice,” DeSantis said. Damage caps have been a lightning-rod issue for decades, with health-care groups backing such limits and plaintiffs’ attorneys fighting them.

Supporters of the repeal have said the law prevents people from getting justice for deaths caused by medical malpractice. “This is a 35-year-old law that needs to be repealed. … It’s unjust. It shouldn’t be on the books,” Senate bill sponsor Clay Yarborough, R-Jacksonville, said before the Senate voted 33-4 to pass the bill on May 1. The House approved the measure in a 104-6 vote on March 26.

A Senate staff analysis, however, said the state Agency for Health Care Administration, which runs the Medicaid program, thinks the proposed change could affect the program’s budget. “If numerous prescribing physicians elect to prescribe drugs that are not on the PDL (preferred drug list) under the bill, it may lead to an increase in net drug cost in therapeutic classes related to serious mental illness,” the staff analysis said. “The AHCA (Agency for Health Care Administration) estimates a significant overall fiscal increase to the Florida Medicaid program of up to $50 million per year could be possible due to utilization changes and potential loss of supplemental rebates.”

As Congress returns home for the annual August recess, physician advocates have unique opportunities to engage with their members of Congress "back home" in the district.

Find out how you can take advantage of the August recess and tell Congress to Fix Medicare Now!

This summer the American Medical Association's top federal priority remains reforming Medicare's broken physician payment system, and we need your help!

According to an AMA analysis of Medicare Trustees data, Medicare physician payment has been reduced 29% adjusted for inflation from 2001–2024. The Medicare physician payment system lacks an adequate annual physician payment update, unlike those that apply to other Medicare provider payments.

Unfortunately, CMS' recent proposed rule has physicians slated for an additional 2.8 percent Medicare payment reduction on January 1. This latest inexcusable cut looms despite the fact that CMS also projects the increase to the MEI to be 3.6 percent in 2025.

That's why it's so urgent that Congress work with the physician community to develop long-term solutions to the systematic problems with the Medicare physician payment system and preserve patient access to quality care.

Recently, the AMA hosted a webinar featuring Jason Marino, AMA Director of Congressional Affairs, who provided an update on the current state of Medicare physician payment legislation and what lies ahead during the 118th Congress and advocacy expert David Lusk of Key Advocacy who provided best practices for engaging legislators in-district including how to prepare for in-district legislative meetings, host Members of Congress at site visits, and interacting with elected officials online.

To make these interactions with your legislators as impactful as possible, the AMA has developed an online August recess resources site that is your one-stop-shop for toolkits, legislative calls to action, issue briefs, infographics and detailed information on scheduling and preparing for legislative meetings and other in-district opportunities.

Please join us this August recess and let Congress know that it's time to Fix Medicare Now - everyone agrees that the Medicare physician payment system is broken – let's do something about it!