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Florida and U.S. Virgin Islands Part B POE-AG minutes – July 24, 2025
Last Modified: 7/30/2025
Location: FL, USVI
Business: Part B
Jurisdiction N
Medicare Part B
July 24, 2025
Janice Mumma, Supervisor, welcomed the members and reviewed current committee guidelines.
Janice advised the purpose of the POE AG is to assist the contactor in the creation, implementation, and review of provider education events. We conduct this meeting to allow provider feedback on training topics, provider education materials, dates, and times of provider education events.
The group discussed the attendance at the prior webinars. The highest and lowest attended prior quarter activities were reviewed, and feedback was requested.
The upcoming activities for the remainder of July 2025 were reviewed. August calendar is in development and will be posted.
Janice reviewed the CMS website, specifically the
Newsroom 
page. The Newsroom page offers the latest information on what is happening in the Medicare world. Please review for the most up to date releases. CMS posted a fact sheet on July 14, 2025, Calendar Year 2026 Medicare Physician Fee Schedule Proposed Rule (CMS-1832-P).
We offer a wide array of educational opportunities. The topics offered in our live webinars are specialty specific and widespread incorporating real-time Medicare requirements, processes, and instructions regarding how to prevent frequent and costly errors.
The StayConnected webinar workshop series consists of topically related events focused on outlining CMS requirements, including coverage, billing, etc. Our Medicare Navigator webinar workshop series consists of events focused on assisting provider navigate to, identify, perform, and submit necessary Medicare tasks. For more information, please visit our
website. The upcoming topics that will be covered were reviewed. Watch our
events calendar for monthly updates.
The 2025 First Coast Virtual Symposium is coming soon. The dates are October 21 - 23, 2025. Our focus will be on Medicare compliance, risk mitigation, program integrity, and fraud prevention. Watch our
website and email communications for updates! Janice asked the group to send in suggestions on how to communicate our educational opportunities to the provider community.
A question was received if we will be doing any in person events this year. Janice advised that the 2025 symposium will all be virtual.
First Coast has a wide array of
on-demand learning resources. These resources are intended for you to participate in Medicare education at your own pace, on your schedule.
First Coast is active in social media. LinkedIn and YouTube are live. Subscribe today and please promote these social media tools to your colleagues.
First Coast is getting a new website! We will be issuing email communications as well as hosting navigation webinars prior to the release this fall.
CMS developed the CERT program to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. We recently revamped the CERT page and have provided a number of new resources. Please visit the
CERT page on our website for more information. Ensure you have the correct mailing address on file so that you can receive Additional Documentation Requests (ADRs) timely. If you do not respond to these ADRs, you will receive claim denials.
The maintenance update of ICD-10 conversions and other coding updates specific to 12 NCDs was released. Key changes in this release with an effective date of April 21, 2025:
• NCD 80.2 Photodynamic Therapy
• NCD 80.2.1 Ocular Photodynamic Therapy
• NCD 80.3 Photosensitive Drugs
• NCD 80.3.1 Verteporfin
• NCD 90.2 Next Generation Sequencing (NGS)
• NCD 100.1 Bariatric Surgery for Treatment of Co-morbid Conditions Related to morbid Obesity
• NCD 110.18 Aprepitant for Chemotherapy-Induced Emesis
• NCD 110.23 Stem Cell Transplantation
• NCD 110.24 CAR-T Therapy
• NCD 250.3 Intravenous Immune Globulin for the Treatment of Auto Immune Mucocutaneous Blistering diseases
• NCD 110.24 CAR-T Cell Therapy
Key changes in this release with an effective date of July 7, 2025:
• NCD 210.3 Colorectal Cancer Screening Tests
• NCD 160.18 Vagus Nerve Stimulation (VNS)
Please review
MM13939
for more information.
Medicare pays practitioners separately for physician services, distinct from payments it makes to inpatient facilities (such as SNFs or hospitals). Practitioners report a 2-digit POS code on Medicare claim lines showing where they provided the service. The Office of Inspector General finds that practitioners don’t always follow CMS regulations and guidance when reporting the appropriate POS code. Use POS 31 for services provided during a patient’s covered Medicare Part A stay and use POS 32 for services provided in nursing facilities and for those provided in skilled nursing facilities when patients have exhausted their Part A coverage. For more information on this topic, please review
MM13767.
CMS developed NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. There are three components for NCCI: Procedure to Procedure (PTP) Edit Pairs, Add-On-Codes (AOC), and Medically Unlikely Edits (MUEs). The PTP, AOC and MUE edits are updated on a quarterly basis To minimize coding and billing errors providers are encouraged to review the updates on the CMS
website .
NCCI PTP edits prevent inappropriate payment of services that should not be reported together. A PTP code pair is subject to automated prepayment edits when two services are performed:
• By the same physician or provider
• For the same beneficiary
• On the same date of service
A modifier is appropriate to use when the modifiers associated with NCCI are allowed with the PTP code pair. Documentation supporting the PTP code pair and the modifier is appropriate when a clinical circumstance justifies the use of a modifier.
First Coast is dedicated to helping our providers with the correct submission of claims. To assist providers, we have developed the
NCCI Procedure to Procedure (PTP) Lookup Tool. This tool will assist with easy identification of proper code pair selection and modifier reporting.
An AOC is a c HCPCS or CPT code that describes a service that, is always performed in conjunction with another primary service. Primary and AOC procedures need to be reported on the same claim. If the primary and AOC are not included on the same claim, the AOC service will deny.
The listings are organized into three separate payment type groups:
• Type I add-on codes are identified in the CPT, HCPCS and other CMS policy which define primary procedures
• Type II add-on-codes don't have a specific list of primary procedure codes
• Type III have add-on codes with the primary procedure codes that are specifically identifiable
A MUE for a HCPCS/CPT code is the maximum units of service a provider will report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have a MUE. Units of service are determined by the MUE Adjudication Indicator (MAI):
• MAI of 1 – MUE based on claim service line
• MAI of 2 or 3 – MUE based on date of service
Do you need a refresher on modifiers? Join us for our Modifier of the Month Series. Visit our
events calendar and register today.
A modifier provides the means to report or indicate that a service that has been performed has been altered by some specific circumstances from the procedure codes definition, however, the definition of the procedure code has not changed.
When submitting claims with modifiers, you will want to report modifiers in Item 24D on CMS-1500 claim form or electronic equivalent. Reimbursement modifiers are indicated in first position on claim, and informational modifiers are indicated in second, third or fourth position on claim.
Medicare pays for a full range of preventive services and screenings: Promoting, providing and educating Medicare patients about potentially life-saving preventive services are essential.
CMS has developed an interactive
Preventive Service Chart to assist the health care community in identifying HCPCS/CPT codes, diagnosis codes, coverage requirements, frequency requirements and beneficiary liability for each Medicare preventive service. When you are using this tool – it will also identify the preventive services eligible for telehealth. Those preventive services will have the “telehealth eligible” icon.
Starting January 1, 2025, CMS expanded hepatitis B vaccination coverage by revising to include patients who haven’t previously received a complete hepatitis B vaccination series or patients with an unknown vaccination history. Prior to this coverage expansion, the hepatitis B vaccine was available to Medicare patients who were at high or intermediate risk of contracting hepatitis B and if ordered by a doctor of medicine or osteopathy.
A doctor’s order will no longer be necessary for the administration of a hepatitis B vaccine under Part B. Therefore, mass immunizers can use the roster billing process to submit Medicare Part B claims for hepatitis B vaccines and their administration. Payment is made for vaccine products at 95 % of the average wholesale price. Payment is made for the vaccine administration based on the national fee schedule. Please refer to
MM13937 
for more information.
Recently CMS updated three publications relating to different topics of mental health:
• Medicare & Mental Health Coverage - Updates include the addition of caregiver training, new coding information and commonly used HCPCS and CPT codes for telehealth services
• Substance Use Screenings & Treatment - Updates include the addition of safety planning intervention, prescribing medications via telehealth, billing information on opioid treatment programs and other payment information
• Screening, Brief Intervention & Referral to Treatment (SBIRT) Services - Updates include telehealth requirements, opioid treatment programs, safety intervention for patient in crisis and medication for opioid use disorder treatment in the emergency department
Recent legislation extended the waiver for geographic restrictions, location restrictions on where you can provide services, and limitations on the scope of practitioners who can provide telehealth services. Medicare patients in non-rural areas and in their homes can continue to receive telehealth services from this extended range of practitioners until September 30, 2025. All providers who are eligible to bill Medicare for professional services can provide distant site telehealth through September 30, 2025. For more information on this topic, please review
MM13887 .
In the CY 2025 PFS final rule, CMS permanently changed the definition of "interactive telecommunications system" to include permitting two-way, real-time audio-only communication technology for any telehealth service furnished to a patient in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system as defined in the previous sentence, but the patient is not capable of, or does not consent to, the use of video technology. For audio only, providers are required to use the 93 and for FQHCs and RHCS uses modifier FQ. Audio-only can be used for both new and established patients.
A distant site is the location where a physician or practitioner provides telehealth. All providers who are eligible to bill Medicare for professional services can provide distant site telehealth through September 30, 2025. CMS will continue to permit distant site practitioners to use their currently enrolled practice locations instead of their home addresses when providing telehealth services from their home through December 31, 2025.
An originating site is the location where a patient is located and receives medical services via telehealth. For dates of service through September 30, 2025, patients can get telehealth wherever they are located with no geographic location restrictions. For dates of service on and after October 1, 2025, the following updates have been made to the originating site:
• Non-behavioral or non-mental telehealth services will have originating site requirements and geographic location restrictions
• Behavioral or mental telehealth services will not have originating site requirements or geographic location restrictions, and patients can receive telehealth wherever they are located
For more information, please refer to the MLN Booklet
MLN901705 .
Beginning October 1, 2025, the originating site must be located in a rural area/Health Professional Shortage Area (HPSA), located in a county that is not included in a Metropolitan Statistical Area (MSA), or an entity participating in a federal telemedicine demonstration project. Use the
Medicare Telehealth Payment Eligibility Analyzer to check to see if a site qualifies for Medicare telehealth reimbursement.
We received claims that were denied for dates of service January 1, 2025 – March 31, 2025, and we found the top claim errors were:
• Duplicate claims
• Eligibility errors
• Non-covered charges
• Non-covered services because this is not deemed a medical necessity by the payer
• The benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated
• Procedure billed exceeds the maximum units of service reported
The most common claim submission errors, descriptions and resolutions can be found under the Top Claims Denials (
JN).
A duplicate denial indicates that more than one claim was submitted for the same:
• Service
• Patient
• Date of service (DOS)
A claim has already been processed or paid and is an exact duplicate of a previously submitted claim. You can prevent duplicate denials by allowing claims to process, checking the status of the claim before rebilling in SPOT or the IVR, or waiting 30 days prior to resubmitting a claim.
An eligibility error denial includes the following:
• Expense incurred prior to coverage -services were prior to the patient’s Medicare’s effective date of coverage
• Claim is not covered by this payer contractor - patient is covered under a Medicare Advantage Plan (MAP) or patient is covered under Hospice and services are related to the Hospice diagnosis
• Record show that Medicare is the patient's secondary payer - this claim must be sent to the patient's primary insurer first
You can prevent eligibility denials by screening your patient's eligibility, verifying Medicare coverage or determining Medicare Secondary Payer (MSP) information.
On the remit, the message 96 will appear. This means a service that is considered non-covered by Medicare is simply one that isn’t ever covered under the Medicare program. Some examples are routine dental care, dentures, cosmetic surgery, or personal comfort items. You can prevent this denial by ensuring the service is covered under Medicare prior to performing or billing a service. Please refer to MLN Booklet MLN906765.
You will see remit message 97 for this denial which means the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This denial may be accompanied by some of the following RARCs:
• M15 (Separately billed services or tests have been bundled, as they are considered components of the same procedure. Separate payment is not allowed)
• M144 (pre-or post-operative care payment is included in allowance for the surgery or procedure)
You can prevent these two specific RARCs by:
• M15 - If the procedure code has a "B" status on the Medicare Physician Fee Schedule (MPFS) database, the service should not be billed to Medicare
• M144 - If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Submit corrected line(s) only. If you resubmit the entire claim, this will cause a duplicate claim denial. In addition, you can request a reopening or appeal request.
On the remit, you will receive message 22 which means this care may be covered by another payer per coordination of benefits. These denials occur when a claim is submitted as primary and CWF indicates other insurance primary to Medicare. You can prevent this denial by verifying eligibility through SPOT, submitting claims to the patient’s primary insurance first and then to Medicare for secondary payment, and submitting timely claims to the appropriate insurance.
Our next POE AG meetings will be November 13, 2025.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
