The Medicare system can be daunting at first. However, once you master the enrollment process and billing requirements, you’ll find it manageable. This step-by-step guide helps you learn how to bill Medicare as a provider, from Medicare claim submission to getting paid.

Many new providers struggle with Medicare’s documentation requirements and coding standards. Others face delays because they miss enrollment deadlines or submit incomplete applications. Let us share practical steps to avoid these common pitfalls while maximizing your reimbursements.

How to Bill Medicare as a Provider (Complete Guide)

Medicare billing process for providers requires three essentials:

• Proper enrollment to Medicare
• Accurate claim submission
• And ongoing compliance.

To bill Medicare as a provider, you must obtain an NPI number and enroll through the Provider Enrollment, Chain, and Ownership System (PECOS). Next, you’ll verify patient eligibility and gather required documentation before submitting claims to your Medicare Administrative Contractor (MAC). Finally, you must maintain accurate records and update your enrollment information as needed.

The entire process follows a structured workflow designed to protect both providers and beneficiaries. Medicare uses standardized systems like the resource-based relative value scale (RBRVS) to determine payments. Your MAC processes claims and handles communications throughout the billing cycle. Success depends on understanding each step and following established guidelines consistently.

What is Medicare? And What Does Medicare Billing Mean for Providers?

Medicare serves as America’s federal health insurance program for adults aged 65 and older. The program also covers younger individuals with specific disabilities or permanent kidney failure. The Centers for Medicare and Medicaid Services (CMS) manages this vast system that processes billions of claims annually.

Medicare program divides into three main parts that affect your Medical billing strategy.

For providers, Medicare billing means following federal regulations while serving eligible beneficiaries. You must determine which Medicare part covers each service you provide. Some patients only qualify for certain coverage types, which affects your billing strategy.

Medicare may act as a secondary payer when patients have other insurance coverage.

Understanding Medicare’s structure helps you navigate billing requirements more effectively. Each part has different rules, payment schedules, and documentation needs. Your billing staff must recognize these differences to submit accurate claims and avoid denials.

How to Bill Medicare as a Provider (Step-by-Step)

Successfully billing Medicare requires following a systematic approach from enrollment through payment reconciliation. The process involves multiple steps that build upon each other to ensure compliance and maximize Medicare reimbursement.

Here are the nine essential steps every provider must master:

1. Obtain an NPI Number
2. Enroll in Medicare
3. Verify Enrollment and Maintain Compliance
4. Verify Patient Eligibility and Coverage 
5. Gather Required Documentation
6. Submit Claims to Medicare
7. Respond to MAC Communications and Track Claims
8. Receive Payment and Reconcile Accounts
9. Maintain Records and Compliance

Let us dive a little deeper into these steps to billing Medicare as a healthcare provider.

1. Obtain an NPI Number

Your National Provider Identifier (NPI) serves as your unique healthcare identifier across all transactions. This 10-digit number links all your Medicare billing activities to your practice or facility. Without an NPI, you cannot submit claims or receive payments from Medicare.

Apply for your NPI through the National Plan and Provider Enumeration System (NPPES) website. The application process requires basic information about your practice, including your name, address, and taxonomy code.

Note: Individual providers and healthcare organizations each need separate NPI numbers.

The NPPES system typically processes applications within 10 business days. You’ll receive your NPI via email once approved. Keep this number confidential and use it consistently across all Medicare transactions. Never share your NPI with unauthorized individuals or organizations.

Some providers already have NPI numbers from other insurance billing. You can use the same NPI for Medicare if it’s still active and accurate. Verify your existing NPI information through the NPPES registry before proceeding to Medicare enrollment.

2. Enroll in Medicare

Medicare enrollment establishes your eligibility to bill the program for covered services. The process varies depending on whether you’re an individual provider or institutional facility. Individual physicians typically complete the CMS-855I form, while groups use CMS-855B forms.

Access the enrollment system through PECOS, Medicare’s online platform for provider registration. Create your account using your NPI number and basic practice information. The system guides you through each section of the enrollment application.

Institutional providers face additional requirements during enrollment. Hospitals, skilled nursing facilities, and similar organizations must pay application fees. These fees vary by provider type and are updated annually on the PECOS website.

Prepare supporting documentation before starting your application. You’ll need copies of your professional license, malpractice insurance, and curriculum vitae. Some provider types require additional certifications or accreditations. Having these documents ready speeds up the enrollment process.

3. Verify Enrollment and Maintain Compliance

Your Medicare Administrative Contractor (MAC) reviews your enrollment application and may request additional information. Respond promptly to any MAC communications to avoid processing delays. The review process can take several weeks depending on your provider type and application completeness.

Once enrolled, you must keep your information current in the PECOS system. Report ownership changes, legal actions, or address updates within 30 days. Other enrollment changes must be reported within 90 days. Failure to maintain current information can result in payment delays or enrollment termination.

Institutional providers may undergo site visits or surveys during the enrollment process. Your CMS Location and State Agency coordinates these evaluations. Prepare your facility for inspection and ensure all required documentation is readily available.

Monitor your enrollment status regularly through PECOS. The system shows your current status and any pending actions. Address any issues immediately to maintain uninterrupted billing privileges. Set calendar reminders for important deadlines and renewal dates.

4. Verify Patient Eligibility and Coverage

Patient eligibility verification prevents claim denials and ensures proper billing. Check each patient’s Medicare status before providing services. Use your MAC’s portal or eligibility verification tools to confirm coverage details.

Determine whether Medicare serves as the primary or secondary payer for each patient. Other insurance coverage may take precedence over Medicare in certain situations. Workers’ compensation, employer group health plans, and auto insurance often pay before Medicare.

Collect comprehensive insurance information from every patient. Use the CMS Questionnaire or similar forms to gather employment and coverage details. Ask about spouse’s insurance, recent accidents, and work-related injuries. This information helps identify other potential payers.

Document your eligibility verification efforts in the patient’s record. Note the date, method, and results of your verification. This documentation supports your billing decisions and helps during audits or appeals. Update eligibility information if the patient’s circumstances change.

5. Gather Required Documentation

Accurate documentation forms the foundation of successful Medicare billing. Collect all necessary information before submitting claims to avoid delays or rejections. Your documentation must support the medical necessity of services provided.

Start with basic patient demographics including name, date of birth, and Medicare Beneficiary Identifier (MBI). Verify the patient’s address and contact information. Ensure the MBI matches exactly with Medicare’s records to prevent processing errors.

Select appropriate diagnosis codes using the current ICD-10 system. Choose codes that accurately reflect the patient’s condition and support the services provided. Use the most specific code available and include secondary diagnoses when relevant.

Identify correct procedure codes using CPT or HCPCS Level II codes. Match procedures to appropriate diagnosis codes to demonstrate medical necessity. Apply modifiers when required to clarify services or indicate special circumstances. Review coding guidelines regularly!

6. Submit Claims to Medicare

Electronic claim submission offers the fastest and most reliable method for Medicare billing. Use HIPAA-compliant systems that meet federal privacy requirements. Most practice management systems include Medicare billing capabilities.

Submit claims through your MAC using approved Electronic Data Interchange (EDI) formats. The standard format for professional claims is the 837P transaction. Institutional claims use the 837I format. Ensure your medical billing system supports these formats.

Paper claims serve as a backup option when electronic submission isn’t possible. Use the CMS-1500 form for professional services or the UB-04 form for institutional services. Complete all required fields and include supporting documentation when necessary.

Medicare Advantage patients require different claim submission procedures. Send these claims directly to the patient’s specific plan administrator, not to traditional Medicare. Each Medicare Advantage plan has its own submission requirements and contact information.

7. Respond to MAC Communications and Track Claims

Your MAC processes all Medicare claims and manages communications throughout the billing cycle. Monitor your submissions regularly and respond promptly to any requests for additional information. Delays in responding can result in claim denials.

Track claim status through your MAC’s provider portal or electronic systems. Claims typically process within 14-30 days depending on complexity. Follow up on any claims that exceed normal processing times.

Address claim rejections immediately by reviewing error messages and correcting problems. Common rejection reasons include invalid patient information, coding errors, or missing documentation. Resubmit corrected claims as soon as possible.

Appeal denied claims when you believe Medicare’s decision is incorrect. Submit additional documentation or clarification to support your position. Follow the appeals process outlined by your MAC and meet all required deadlines.

8. Receive Payment and Reconcile Accounts

Medicare payments arrive via electronic funds transfer to your designated bank account. Payment amounts reflect the Medicare fee schedule minus any applicable deductibles or coinsurance. Reconcile payments against your submitted claims to identify any discrepancies.

Review your Medicare Summary Notice (MSN) or Electronic Remittance Advice (ERA) for payment details. These documents explain what Medicare paid, what the patient owes, and any claim adjustments. Use this information to bill patients for their portion of costs.

Handle patient billing carefully to comply with Medicare regulations. You cannot bill patients for services that Medicare doesn’t cover unless you provide proper advance notice. Use Advance Beneficiary Notices (ABNs) when services may not be covered.

Track your accounts receivable to ensure timely payment collection. Follow up on unpaid claims and patient balances according to your practice’s policies. Maintain detailed records of all collection efforts for audit purposes.

Tip: Some visits can be billed incident-to and pay the full doctor rate even if a nurse practitioner saw the patient. Learn the rules here → [Medicare incident-to billing guide]

9. Maintain Records and Compliance

Medicare requires providers to maintain comprehensive records for audit and compliance purposes. Keep all billing documentation, patient records, and correspondence for at least five years. Some states have longer retention requirements.

Update your PECOS enrollment information whenever changes occur. Report new locations, ownership changes, or changes in services provided. Keep your contact information current to ensure you receive important Medicare communications.

Participate in Medicare audit requests promptly and thoroughly. Provide requested documentation within specified timeframes. Maintain organized records that allow quick retrieval of information during audits.

Stay informed about Medicare policy changes and updates. Subscribe to your MAC’s newsletters and attend provider education sessions. Changes in coverage, coding, or billing requirements can affect your reimbursement if not implemented properly.

Medicare Provider Billing Guidelines

Medicare billing guidelines are a set of rules that providers must follow when submitting claims for reimbursement. Following these guidelines helps providers submit claims accurately. This also protects healthcare providers and beneficiaries.

Key Medicare provider billing guidelines include:

• Document medical necessity for all services in patient records
• Use accurate CPT, HCPCS, and ICD-10 codes for all procedures and diagnoses
• Apply modifiers correctly to indicate service variations or special circumstances
• Submit claims within 12 months of service date
• Determine primary vs. secondary payer status for each patient
• Bundle services appropriately and avoid improper unbundling
• Accept Medicare’s approved amounts when participating in the program
• Maintain accurate patient insurance and employment information
• Coordinate benefits with other insurance carriers when applicable
• Respond promptly to MAC requests for additional information
• Keep detailed records for audit and compliance purposes
• Update enrollment information within required timeframes
• Follow appeals procedures for denied claims
• Bill patients appropriately for non-covered services with proper notices
• Use electronic submission methods when possible
• Protect patient information according to HIPAA requirements

Common Medicare Medical Billing Questions

Let us answer some of the most common Medicare billing questions for providers.

1. What is the Medicare billing process?

The Medicare billing process involves submitting claims electronically to your assigned Medicare Administrative Contractor (MAC) for covered services. You must first enroll in Medicare, obtain an NPI number, and verify patient eligibility before providing services.

After treatment, you code the services using appropriate CPT and ICD-10 codes and submit the claim within one year. Your MAC reviews the claim for accuracy and compliance with Medicare guidelines. They may request additional documentation or clarification before processing payment. Once approved, Medicare pays 80% of the approved amount for Part B services. Patients remain responsible for deductibles and coinsurance.

2. What providers can bill Medicare?

Medicare accepts claims from a wide range of healthcare providers including physicians, nurse practitioners, physician assistants, and clinical specialists. Hospitals, skilled nursing facilities, home health agencies, and hospice organizations also qualify for Medicare billing.

Other eligible providers include physical therapists, occupational therapists, speech-language pathologists, and clinical social workers.

Suppliers such as ambulance services, durable medical equipment companies, and independent diagnostic testing facilities can also bill Medicare. Healthcare providers must enroll in the Medicare program and meet requirements established by CMS. Enrollment requirements vary by provider type and may include licensing, accreditation, or certification standards.

3. Is provider based billing only for Medicare?

Provider-based billing extends beyond Medicare to include Medicaid and some Medicare Advantage plans. This billing method separates professional and facility charges for services provided in hospital-based outpatient clinics or departments. CMS requires this approach for government programs. But some insurance companies also use provider-based billing models.

The requirement affects facilities that have relationships with hospitals and bills under the hospital’s NPI number. Private insurance plans may combine professional and facility charges into single bills, but Medicare and Medicaid maintain separate billing requirements.

4. Are providers required to bill Medicare?

Most providers must submit claims to Medicare for covered services provided to Medicare beneficiaries, regardless of their participation status. Participating providers agree to accept Medicare’s approved amounts and must file claims for all covered services. Non-participating providers can accept assignments on a case-by-case basis but must still submit claims.

Providers can opt out of Medicare entirely by entering into private contracts with patients. In this arrangement, providers cannot bill Medicare and patients pay entirely out-of-pocket. Certain exceptions exist for small providers, roster billing, and demonstration projects. But the general rule requires claim submission for covered services.

5. How to Bill Medicare Electronically?

Electronic Medicare billing uses HIPAA-compliant systems to submit claims through Electronic Data Interchange (EDI) transactions. Providers transmit claims to their MAC using direct data entry screens or practice management software. The system automatically checks claims for errors and returns rejected submissions for correction before final processing.

Most healthcare facilities use clearinghouses or billing services that handle electronic transmission. These intermediaries convert claims into proper EDI formats and manage the submission process. Electronic billing reduces processing time, minimizes errors, and provides faster payment compared to paper submissions.

6. What Payment Will I Receive From Medicare?

Medicare payments follow the resource-based relative value scale (RBRVS) system that calculates reimbursement based on resources required for specific services. Payment amounts vary by geographic location, provider specialty, and service complexity. The Medicare Physician Fee Schedule provides specific payment rates updated annually.

Medicare pays 80% of approved amounts for Part B services, with patients responsible for remaining costs. Part A payments vary by service type and may include deductibles or coinsurance. Providers who accept assignments agree to Medicare’s approved amounts as full payment. Non-participating providers can charge limited additional amounts above Medicare’s rates.

The Office of Inspector General (OIG) has updated its 2025 Work Plan and is focusing on reviewing postoperative services that are part of the global surgery period. With the recent changes in the global surgery coding system for 2025, it’s essential for healthcare professionals to stay up-to-date.

The OIG (Office of Inspector General) is examining how these postoperative services are being provided and billed during the global surgery period. This could involve checking for compliance, accuracy in billing, or identifying issues like overbilling or lack of quality of care.

For healthcare providers, it is important to understand the 2025 global surgery updates as it could impact their practices of documenting the surgery procedures and billing for services. However, for patients it is also vital as it lets them receive proper care during the recovery period and improve transparency.

This guide will help you walk through the new coding requirements, postoperative services, and how to comply with Medicare regulations. But, first let’s discuss the global surgical period.

What Is a Global Surgery Package?

A Global Surgery Package, also known as global surgery or the global period is a Medicare concept where payment for a surgical procedure includes the surgery itself and related services provided before, during, and after the surgical procedure. These services are bundled into a single payment, covering preoperative visits, the surgical procedure, and postoperative care (follow-up visits) within a specified time frame usually ranging from the day of surgery to 10 or 90 days after the surgery.

If providers in the same group and specialty are involved in the surgical procedure, they must submit their bills and accept payment as if they’re one provider. This keeps billing simple and avoids double charges.

Global Surgery Package Duration and Procedure Types

CMS Guidelines for Global Surgery Period—What Is Included in The Global Surgery Package?

For Medicare claims, CMS (Centers for Medicare & Medicaid Services) includes the following services in the global surgery payment:

• Preoperative Visits
• Intraoperative Services
• Other Medical or Surgical Services in the Postoperative Period
• Postoperative Follow-Up Visits
• Post-Surgical Pain Management
• Supplies
• Miscellaneous Services

Preoperative Visits

These are visits that happen after the decision to operate has been made during the evaluation and management process (E/M). This includes minor surgeries or endoscopy procedures performed by the same provider on the same day as the surgery.

Intraoperative Services

These are services provided during the actual surgery, including everything necessary to perform the surgical procedure.

Other Medical or Surgical Services in the Postoperative Period

All other medical or surgical services after the surgical procedure include any additional medical or surgical care that the surgeon provides to the patient during the designated recovery time after the surgery.

Postoperative Follow-Up Visits

These are check-ups or follow-up appointments to monitor the patient’s recovery during the postoperative period. Usually the code 99024 is used to track the follow-up visits. 

Post-Surgical Pain Management

Post-Surgical Pain Management includes care provided to help the patient manage pain after the surgery, such as medication or therapy.

Supplies

These are materials used during the surgery and recovery period, except for certain excluded items. For example, bandages or surgical tools.

Miscellaneous Services

These are smaller, routine tasks related to surgery, such as bandage changing, local incision care, operative pack removal, cutaneous sutures and staples removal, etc.

CMS guidelines for global surgery Period— What Isn’t Included in the Global Surgical Package?

Here are certain services that CMS does not include in the global surgical package, and what providers can bill separately and get paid.

• Initial Evaluation for Surgery
• Services by Other Providers
• Unrelated Visits
• Treatment for Separate Health Conditions
• Diagnostic Tests
• Additional Surgeries
• Complication Treatment in OR (Operating Room)
• Failed Minor Procedure Leading to Major Surgery
• Organ Transplant Medications
• Critical Care Services

Initial Evaluation for Surgery

The surgeon’s decision on the first visit to evaluate if major surgery is needed is not part of the global surgical package. The evaluation visit (E/M) can be billed separately using modifier 57.

Services by Other Providers

If other providers (not the surgeon) perform surgery-related services, these are excluded from the package unless there’s an agreement to transfer care between the surgeon and other providers. This agreement must be documented in the patient’s medical records.

Unrelated Visits

Follow-up visits for conditions unrelated to the surgery or its diagnosis are not included in the global surgery package, except when visits are due to surgery complications.

Treatment for Separate Health Conditions

If a patient needs treatment for an underlying or unrelated health condition, or begins a new treatment unrelated to surgery recovery, it’s billed separately.

Diagnostic Tests

Tests or procedures to diagnose issues (like X-rays or other scans) are not included in the package and require separate billing.

Additional Surgeries

Surgeries performed during the recovery period that are not part of the original surgery or related to surgery complications are excluded from the Medicare global surgery package. 

Complication Treatment in OR (Operating Room)

If the patient needs to return to the OR for postoperative complications, the treatment is billed separately.

Failed Minor Procedure Leading to Major Surgery

When a less serious surgery doesn’t work and a major surgery is needed, Medicare covers the major surgery separately.

Organ Transplant Medications

Medications used to manage the immune system after an organ transplant are not part of the global surgical package.

Critical Care Services

Critical care provided (CPT codes 99291 and 99292) after surgery for issues unrelated to the surgical procedure is excluded. These services should be billed separately using modifier FT.

2025 Global Surgery Updates

The 2025 global surgery package updates bring key changes, including the introduction of HCPCS code G0559, which is used for postoperative follow-up visits provided by a different healthcare professional who didn’t perform the surgery, within the 90-day global period, and without a formal transfer of care.

Modifiers 54, 55, and 56 are now more strictly required for managing preoperative, surgical, and postoperative care within 90-day global packages, with modifier 56 now requiring formal documentation for preoperative care transfers.

The updates also focus on the Office of Inspector General’s (OIG) review of postoperative services, ensuring proper reporting and preventing overreporting of services during the global period. These updates aim to improve billing practices and ensure accurate Medicare reimbursement for global surgeries.

The Role of the OIG and CMS in Global Surgery Coding 2025

The Office of Inspector General (OIG) is investigating how well postoperative services are reported under Medicare’s global surgery payment system. Since July 1, 2017, Medicare requires healthcare providers to report follow-up visits after surgery using a specific code, CPT code 99024. This code is for postoperative visits where the doctor checks the patient’s recovery after surgery.  Although these visits are part of the global period and aren’t paid separately during the global period, reporting them helps Medicare track how often patients need follow-ups after surgery.

Here is when providers have to report postoperative visits using code 99024 under specific conditions:

• Practitioners in certain states (like Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, Rhode Island) who work in groups with 10 or more practitioners.
• Providers in those states need to check a list from Medicare each year to see if their surgeries are on the list of surgeries that need the code.
• This code applies only to specific types of surgeries or procedures. These procedures are selected by Medicare because they are either very common (performed over 10,000 times a year) or very expensive (with charges over $10 million a year).

The OIG (Office of Inspector General) is monitoring that doctors are reporting these follow-up visits correctly. They will look at a sample of global surgeries, compare the number of follow-up visits in the CMS records with what doctors reported to Medicare, and verify if the payments made for the surgeries match the actual care provided to Medicare beneficiaries. If doctors don’t report this information properly, it could lead to Medicare paying less for those surgeries. If providers don’t report this information properly, it could lead to devaluation of the Medicare global surgery payment.

Basically, Medicare wants to check the follow-up visits after surgery are being properly tracked, and if doctors aren’t reporting them correctly, it might affect their payment.

Importance of Using Modifiers During Global Surgery Period 

Sometimes, a patient may need other procedures that aren’t related to the surgery they just had, but these procedures still happen during the global period. The usage of global surgery modifiers (24, 25, 54, 55, 57, 58, 78, 79, FT) facilitate healthcare providers to get paid for these services. These modifiers are used to separate unrelated procedures from the global surgery, so they can be paid for separately, even if they happen during the global period.

In the Medicare Physician Fee Schedule (MPFS), there are certain payment policy indicators that show which services are billable (can be paid for) and whether a modifier is needed.

Some examples of global modifiers include:

• Modifier 24: Used for services unrelated to the surgery but happening during the global period.
• Modifier 25: Used for an unrelated service provided on the same day as the surgery.
• Modifiers 54, 55, 57, 58, 78, 79: Indicate different situations where services are not included in the global period.
• Modifier FT: Used for specific cases defined by Medicare.

➜ Modifiers 24

Modifier 24 is used when a doctor or healthcare provider performs unrelated evaluation and management (E/M) service. These services must be after the procedure but within the global period and are unrelated to the original surgical procedure.

For example:

On March 10, a patient visits their orthopedic surgeon for a knee arthroscopy (CPT 29881), which has a 90-day global period. On March 15, the patient returns to the same surgeon, complaining of new back pain unrelated to the knee surgery. The surgeon evaluates the patient’s back condition and recommends physical therapy for the back pain. Since this visit is not related to the knee arthroscopy, the surgeon will code the appropriate office visit E/M code with modifier 24. This allows the surgeon to be separately paid for the back-pain evaluation, even though it falls within the global period for the knee surgery.

➜ Modifier 25

This modifier is used when the same physician or other qualified healthcare professional performs a significant, separately identifiable evaluation and management (E/M) service on the same day as a procedure or other service.

For example:

A patient arrives at the doctor’s office on the same day they are scheduled for gallbladder removal surgery (CPT 47562 – Laparoscopic Cholecystectomy). During the pre-surgery evaluation, the doctor notices that the patient has significantly high blood pressure. The doctor spends extra time assessing the patient’s blood pressure, determining the cause, and prescribing immediate medication to stabilize the patient before proceeding with surgery.

In this case, the additional evaluation and management (E/M) service for high blood pressure is beyond the usual preoperative care related to the gallbladder surgery. The doctor can use Modifier 25 to bill separately for the extra E/M service.

➜ Modifier 57

Use of Modifier 57 indicates that a decision for surgery was made during an evaluation and management (E/M) service, and that the decision occurred on the same day as the E/M service. This modifier tells the payer that the E/M visit led to a decision for surgery, and because the decision was made during the same visit, the surgery is being reported separately from the usual preoperative care.

For example:

A patient arrives at the emergency room (ER) after experiencing severe abdominal pain. The ER physician performs an evaluation and determines that the patient may have acute appendicitis. After a thorough examination and some tests, the physician discusses the situation with the patient and recommends immediate surgery to remove the appendix.

The decision for surgery is made during the evaluation and management (E/M) service in the ER. The patient is then taken to the OR on the same day for an appendectomy (removal of the appendix).

Since the decision for surgery was made during the E/M service on the same day, the ER physician uses Modifier 57 when reporting the E/M code. This modifier indicates that the E/M visit led directly to the decision for surgery, which occurred on the same day.

➜ Modifier FT

Using Modifier FT indicates an unrelated evaluation and management (E/M) visit during a postoperative period or on the same day as a procedure or another E/M visit. The key aspect here is that the E/M service is unrelated to the procedure that was performed or is planned, and it may be billed separately. This modifier applies when an E/M service is provided that is unrelated to the surgery or procedure performed on the same day or within the global surgical period. It is particularly relevant when a patient requires critical care during the postoperative period, which is unrelated to the surgery.

For example:

A patient undergoes gallbladder surgery (CPT® 47562) on March 10. On the same day, the patient develops a severe allergic reaction unrelated to the surgery, requiring urgent treatment and evaluation. The physician uses Modifier FT to report the E/M service provided on March 10 for the allergic reaction as unrelated to the gallbladder surgery. This ensures the physician gets reimbursed for both the surgery and the unrelated E/M service provided on the same day.

Procedural Modifiers 54, 55, 56

Modifiers 54, 55, and 56 are used to split reimbursement between two different healthcare providers when the surgical procedure and preoperative/postoperative care are managed by separate physicians. This is often referred to as a “transfer of care” and helps ensure that both the surgeon and the other providers (such as a primary care physician) are appropriately reimbursed for their role in the patient’s care.

• Modifier 54 (Surgical Care Only)

Modifier 54 is used by the surgeon who performs the surgery but does not provide preoperative or postoperative care.

• Modifier 55 (Post-Operative Management Only)

Modifier 55 is used by the physician or provider who takes over post-operative care after the surgery is completed. It applies when the provider does not perform the surgery but manages the recovery phase instead. After a surgery is performed in one hospital, the patient may be transferred to a different location, and a different physician will provide follow-up care for the post-operative recovery period.

• Modifier 56 (Pre-Operative Management Only)

This modifier is used when the physician or provider who manages the preoperative care of the patient. It applies when the provider does not perform the surgery but is responsible for preparing the patient before the surgery, such as clearing them for anesthesia or managing their health conditions. For example, a primary care provider may ensure the patient is ready for surgery, while a different physician performs the procedure.

These modifiers are used when two different healthcare providers (such as a surgeon and a hospitalist or a primary care physician) are involved in a patient’s surgical care, especially when the care is split between preoperative, surgical, and postoperative periods.

According to 2025 global surgery updates, CMS will require these modifiers for all 10 to 90-day global surgical packages, ensuring accurate reimbursement for each phase of surgical procedure.

For example:

A patient comes to the ER with a dislocated shoulder. The ED physician performs a closed reduction and reports the procedure with Modifier 54 for surgical care only. The patient is then referred to an orthopedic specialist for postoperative care, and the orthopedic doctor reports the same procedure code with Modifier 55. If the patient had seen a primary care provider (PCP) before the surgery for preoperative management, the PCP would have reported their care with Modifier 56 for preoperative care only. All providers use the same date for the procedure on their claims.

➜ Modifier 58

Adding modifier 58 indicates that a staged or related procedure was performed by the same physician (or other qualified healthcare professional) during the post-operative period of a previous procedure. This modifier specifies that the new procedure or service is planned, expected, or necessary due to the patient’s condition and is related to the initial surgery. Modifier 58 resets the global period, starting a new one for the next procedure.

For example:

A patient undergoes a knee replacement surgery. As part of the surgical plan, the surgeon schedules a follow-up arthroscopic procedure to inspect and adjust the placement of the knee prosthesis after the initial healing phase. This follow-up procedure is planned in advance and is related to the initial surgery. When the patient returns during the global period of the knee replacement for the planned arthroscopic procedure, the surgeon reports the follow-up procedure with Modifier 58 to indicate that it is a staged and related procedure.

➜ Modifier 78

Modifier 78 is used for an unplanned return to the operating room when a patient requires a related procedure during the postoperative period due to complications from the initial surgery, such as infection or bleeding. This modifier indicates that the same physician, or a healthcare professional from the same specialty group, performs the second procedure to address the issue. The second procedure is considered part of the original surgery and does not start a new global period. For repeat procedures, Modifier 76 should be used. 

For example:

During the global period of a surgery, the patient experiences excessive bleeding, requiring the surgeon to return to the operating room to control it. This procedure is reported with Modifier 78 to indicate it is an unplanned related procedure performed during the postoperative period.

➜ Modifier 79

Modifier 79 is used when a physician performs an unrelated procedure or service during the postoperative period of a prior surgery. This procedure is not related to the initial surgery and must be billed separately, as it is not covered by the original surgery’s global package. If a procedure is repeated on the same day, Modifier 76 should be used.

For example:

On March 5, a patient undergoes knee replacement surgery on the right leg. On April 5, the patient undergoes the same surgery on the left leg. Even though it’s the same procedure for the same diagnosis, the surgeries are performed on two different surgical sites, making them unrelated. Modifier 79 is appended to the medical code for the surgery on April 5 to indicate it is a separate, unrelated procedure performed during the postoperative period of the first surgery.

Best Practices for Global Surgery Coding Compliance

By following these best practices, healthcare providers can stay compliant with global surgery coding requirements:

Use Proper Documentation

• Keep complete and accurate documentation for all care services provided before, during, and after the surgical procedure.
• Maintain clear records for transfer of care, especially when other providers are involved in preoperative, surgical, or postoperative care.

Know the Global Surgery Period

• Understand the global surgery period for each surgical procedure and apply it correctly. For example, some procedures may have a 10-day, 90-day, or 0-day global period as explained in the table above.
• Review the global surgery indicators assigned to each procedure (e.g., 000, 010, 090) to confirm the global period for billing purposes.

Use Proper Modifiers

• Use the correct modifiers when services are provided that are outside the scope of the global surgery package.

Properly Apply HCPCS Code G0559

• According to the 2025 global surgery period, use HCPCS code G0559 for post-operative follow-up visits by a healthcare provider who did not perform the surgery, and there was no formal transfer of care.

Review Medicare Physician Fee Schedule (MPFS)

• Check the MPFS for global surgery package indicators (e.g., 000, 010, 090) and understand the rules for each CPT code.

Comply with OIG Guidelines

• Adhere to Office of Inspector General (OIG) requirements for reporting postoperative services, especially for evaluation and management (E/M) services.
• Use CPT code 99024 for postoperative E/M visits where required, particularly in states that require reporting for global surgeries.

Accurate Reporting of Postoperative Care

• Report only care services that are directly related to the original surgical procedure. Do not report services outside of the global package unless they are unrelated or involve complications.
• If a procedure or service is unrelated to the original surgery, apply the correct modifier (e.g., modifier 79).

Provide Transfer of Care Documentation

• Document formal transfers of care when the patient’s care is transferred between providers, especially for preoperative and postoperative care.
• Use modifier 56 for preoperative services and modifier 55 for postoperative services when the care is performed by different providers.

Stay Updated on CMS and OIG Changes

• Regularly review updates from CMS and the OIG to stay compliant with new coding guidelines or updates as they released global surgery period 2025 updates, such as the use of HCPCS code G0559 for postoperative follow-up visits.

FAQs

Physicians usually avoid providing health care services to Medicare patients—those of 65 years or older and some younger people with disabilities. Because Medicare offers low reimbursement rates.

The Medicare reimbursements are even insufficient to cover practice costs. As a result, the doctors lose money on Medicare patients.

Furthermore, it also causes a decrease in revenue for healthcare practices as they likely treat fewer patients because of low Medicare reimbursement rates for physicians.

However, while some doctors do not lose money on Medicare patients, they often face challenges affecting their performance of practice sustainability, and they face financial strains.

Here, we discuss the reasons why doctors lose money on Medicare patients and are reluctant to provide services to Medicare patients.

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Why Do Doctors Lose Money on Medicare Patients?

Physicians often face financial challenges and lose money for several reasons when providing care services to Medicare patients:

1⃣ Low Reimbursement Rates

Medicare typically reimburses healthcare providers at lower rates than private insurance companies. This means that the payments physicians receive for healthcare services provided to Medicare patients may not cover the full cost of care, or sometimes, doctors face deficits while managing their practices’ expenses. However, Medicare offers low reimbursements but provides stability and predictability in payments.

Payment rates under the Physician Fee Schedule dropped down by 2.93% in 2025, which went into effect on January 1, compared to 2024 rates. As a result, the conversion factor will decrease from $33.29 in 2024 to $32.35 in 2025, a reduction of $0.94 (2.83%).

In addition, one reason for avoiding treating Medicare patients is affordable care. CMS Administrator Chiquita Brooks-LaSure said, “CMS remains committed to delivering affordable, high-quality care to all Americans while continually driving innovation to help better meet the individual needs of every person with Medicare.” As a result, physicians should expect less from CMS to pay for services provided to Medicare Patients.

2⃣ High Practice Costs Compared to Reimbursements

The physician practice costs portion of the current MEI includes components for non-physician compensation (including fringe benefits), medical supplies, professional liability insurance, and other expenses (including other professional services, salaries for staff, and overhead expenses). They have been increasing. These rising costs can make it difficult for physicians to break even or profit when providing healthcare services to Medicare-covered patients.

CMS acknowledged that the costs incurred by physicians to deliver healthcare went up by 3.5% in 2025, as determined by the Medicare Economic Index (MEI). However, as CMS finalized the 2025 Medicare physician pay schedule, there will also be a 2.85% cut in pay. This proportion of pay cuts and cost rise can significantly impact practice revenue. Therefore, physicians are less likely to accept Medicare patients.

Increasing costs make it harder for physician practices running on small margins to acquire new equipment, retain staff members, and keep doors open for new Medicare patients. If the gap between what Medicare pays physicians and what it costs to provide high-quality care continues to grow, it will limit access to healthcare for senior Americans and persons with disabilities.

3⃣ Administrative Burden

Dealing with Medicare claims and paperwork can be time-consuming and costly. Physicians often need additional staff to handle the administrative workload, which adds to their practice expenses. Furthermore, physicians spend considerable time on administrative tasks such as filling out forms, managing electronic health records (EHRs), and complying with regulatory requirements. This time away from patient care means fewer billable hours, directly impacting their income.

Many practices need to hire additional staff, such as medical billers, coders, and administrative assistants, to handle the administrative workload. These additional salaries and benefits add to the practice’s overall operating costs.

4⃣ Payment Cuts and Inflation

Over the years, multiple cuts to Medicare reimbursement rates have been made, further reducing physicians’ income from treating Medicare patients. For example, in the last twenty years, from 2021 to 2025, Medicare payments to healthcare providers have dropped by 33% after accounting for rising costs, making it harder for doctors to care for their Medicare-covered patients.

“This actual dollar amount is something that physicians have to sort of fight for year after year. It’s a constant issue with reimbursement. If you look at how physicians have been reimbursed since 2001, once you’ve adjusted for inflation, there’s been a 30 percent decrease in physician reimbursement for Medicare patients,” Dr. Chang.

The table below shows the comprehensive details of practice cost inflation according to MEI and physician payments according to the Physician Fee Schedule (PFS).

Medicare Updates Compared to Inflation in Practice Costs (2001 to 2025)

Moreover, here we mention some crucial reasons physicians are less likely to accept Medicare patients:

• Medicare pays doctors about 80% of the “reasonable charge” for services it covers. At the same time, private insurance companies pay almost twice what Medicare pays for hospital services.
• CMS releases the Physician Fee Schedule each year. Medicare physicians must be participating providers by agreeing to the PFS and not charging more than the amount. However, non-participating providers can charge up to 15% more. Participating providers accept Medicare’s approved amount as full payment and bill Medicare directly. In contrast, non-participating providers can charge up to 15% more than the agreed amount and require patients to pay upfront.
• It can often take months for physicians to receive their payments. However, sometimes, they can receive payment within 14 days after electronic claim filing and within 28 days after paper filing.
• The estimated loss of Medicare claims due to billing problems is 7.3%. The loss is reduced to an estimated 4.8% with private insurers.

Do Physicians Really Lose Money on Medicare Patients?

According to the NYT, it is not always correct that doctors lose money on Medicare patients. Many physicians claim that insurance companies are not paying enough for doctors for care services they provide to seniors or disabled residents—Medicare-covered patients. As Dr. Barbara L. McAneny claims, “Insurers in the New Mexico exchange reimburse doctors at Medicare levels, which were ‘often below our cost of doing business, and definitely below commercial reimbursement rates.”

However, this claim seems doubtful since many doctors accept Medicare patients. Doctors earn over $200,000 annually, putting them in the top 1% of earners. Because they make so much money and work hard to keep out competition, it is hard to believe that many doctors would want to lose money by treating Medicare patients.

However, doctors receive less than expected pay when they provide healthcare services to Medicare patients. It is baseless to say that they completely lose money.

When Doctors Avoid Medicare Patients: The Impact on Access & Care Quality

When doctors avoid accepting Medicare patients due to financial constraints, it can have significant impacts on both patient access and care quality.

Reduced Access to Care

Many Medicare patients, especially those in rural or underserved areas, may find it challenging to find physicians willing to accept them. This can lead to longer wait times for appointments and increased travel distances to see a doctor.

Quality of Care

With fewer doctors available to treat Medicare patients, the quality of care may suffer. Physicians may have less time to spend with each patient, potentially leading to rushed appointments and less personalized care.

Health Outcomes

Limited access to care can result in delayed diagnoses and treatment, which can worsen health outcomes for Medicare patients. Chronic conditions may go unmanaged, leading to more severe health conditions over time.

Financial Strain on Practices

Physicians who continue to accept Medicare patients may face financial strain due to lower reimbursement rates, which can impact their ability to invest in new technologies and maintain high-quality care standards.

Overall, the avoidance of Medicare patients by doctors can create a ripple effect, impacting not only individual patients but also the broader healthcare system. It’s a complex issue that requires thoughtful solutions to ensure that all patients receive the care they need.

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AMA Smoothen Ways for Physicians—Policy and Solutions

Since January 1, doctors have been paid 2.83% less than in 2024 for treating Medicare patients. This is the fifth year in a row that Medicare has cut payments for doctors. Along with not adjusting for rising costs, this is making it very hard, or even impossible, for some doctors to keep their practices running and care for aged patients.

During a webinar, Todd Askew, the senior vice president of AMA advocacy, mentioned that in 2025, the American Medical Association is working toward reversing the 2.83% cut that took effect on January 1 and is aiming for an annual increase tied to inflation. He emphasized the need for bipartisan support in a closely divided Congress, where Republicans have a narrow majority, to achieve these goals and address the key issues faced by patients and physicians.

Further, he explained that their advocacy has consistently prioritized bipartisanship. He noted that nearly every piece of legislation they have supported in the last several Congresses has been bipartisan, as they aim to build support from the center outward.

A bipartisan group of 10 House members introduced a bill in late January to prevent a 2.83% cut in Medicare payments to doctors this year and to give a 2% payment increase. The American Medical Association (AMA) fully supports this bill and will help include it in future laws to fund the government before the March 14 deadline.

Furthermore, Greg Murphy, MD (R-N.C.), and Jimmy Panetta (D-Calif.), along with eight other House members, introduced a bill called H.R. 879, the Medicare Patient Access and Practice Stabilization Act. This bill, starting on April 1, would cancel the 2.83% cut that began on January 1. Similar bills had support from both parties, but Congress did not deal with this issue during the last session.

AMA’s Reforms

In addition, The American Medical Association (AMA) has been advocating for reforms to the Merit-based Incentive Payment System (MIPS) as AMA proposes a new Data-Driven Performance Payment System that aims to:

• Lower the maximum penalty from -9% to -0.5% of a physician’s annual payment update.
• Streamline reporting requirements and recognize quality efforts across performance categories.
• Provide more flexibility and support for small, rural, and safety-net practices.
• Adjust payments based on inflation rates to ensure that physicians are compensated fairly as the cost of living rises.
• Ensure that physicians’ income keeps pace with inflation, preventing a decrease in real income over time.
• Provide a more predictable and stable revenue stream for physicians, which can help them manage financial risks better.

Telehealth Flexibilities and Equity Initiatives

Telehealth has become a crucial tool, especially during the COVID-19 pandemic. The AMA has outlined several steps to ensure equitable access to telehealth services, including:

• Providing internet-connected devices and broadband access to underserved communities.
• Ensuring telehealth solutions are user-friendly and accessible to people with varying levels of digital literacy.

These initiatives aim to address the financial challenges faced by physicians while ensuring that patients continue to receive high-quality care.

Final Words

Doctors treating Medicare patients often face tough financial challenges. While some wonder if they lose money, many say low payments and high costs make it hard to keep up. This leaves some patients struggling to find care. We looked at both sides of this issue and offered solutions to help both doctors and patients.

As 2025 unfolds, healthcare providers are struggling with a rising wave of claim denials for Durable Medical Equipment (DME). The culprit? Medicare’s opaque frequency limits that dictate DME replacement periods. For providers, this translates to clogged operations and patients left waiting.

But there’s hope on the horizon. Developing expertise in Medicare’s frequency limit nuances is the antidote providers need. With this knowledge, they can comply with requirements, streamline DME delivery, and slash denials.

This blog offers providers a detailed decode of Medicare’s complex frequency rules. Consider it your insider’s guide to seamlessly supplying DME on time, without getting ensnared in Medicare’s red tape. Armed with these insights, providers can meet patient needs promptly and painlessly while keeping denials at bay.

What is meant by Medicare’s “DME Frequency Limits?

Medicare DME frequency limits refer to guidelines determining how often Medicare will cover replacement durable medical equipment (DME) for a beneficiary.

For example, Medicare may allow a new wheelchair every 5 years, a new walker every 3 years, or new diabetic test strips every month. These limits enable Medicare to manage costs and prevent overutilization of equipment.

However, the frequency limits also ensure beneficiaries have access to essential DME on a reasonable replacement schedule. With frequency limits, patients can receive new DME when truly needed, while Medicare can control excessive spending.

Understanding Medicare DME Frequency Limits

➜ Medicare has limits on how often it will cover the replacement of Durable Medical Equipment (DME) such as wheelchairs, walkers, and hospital beds.

➜ These limits are based on the equipment’s Reasonable Useful Lifetime (RUL). The RUL is the expected lifespan of the equipment, calculated from the date it was issued to the beneficiary, not the manufacturing date.

➜ Medicare will typically cover a replacement after the RUL has expired or if the equipment is lost, stolen, or damaged beyond repair.

➜ Your healthcare provider can guide you through the process of obtaining necessary authorizations if your situation warrants an exception to the standard frequency limits.

The following is a table of the specific Medicare frequency limits that have been established for a variety of durable medical equipment (DME). We have grouped the frequency limits based on how long they last. For instance, some items can only be replaced once a month, while others can be replaced only once every few years.

How are the limits for Medicare DME set?

Medicare DME has rules about how often you can get things. These rules help make sure patients get what they need and that costs stay manageable. There are a few things that help decide these limits. Let’s look at each one that helps Medicare figure out the DME frequencies:

Assessing Patient Needs and Equipment Usage

Medicare sets frequency limits for DME by closely analyzing patient needs and equipment usage. This process involves reviewing medical records and claims data to understand how often equipment requires replacement for different conditions. Medicare examines factors like expected equipment life spans, how deterioration occurs with use, and the level of support needed by patients over time.

By gathering data on real-world equipment use, Medicare can establish reasonable limits on replacement frequency. This makes sure patients get the DME they need, without getting too much and wasting it.

Conducting Cost-Effectiveness Analysis

Medicare carefully checks how much things cost to keep the program running with financial stability. These analyses give Medicare a comprehensive understanding of the costs of providing and replacing Durable Medical Equipment (DME) versus the benefits this equipment provides to patients.

The analyses look at factors like how much it costs to buy and take care of equipment over time and how much better it makes people’s health. They also consider if less expensive alternatives could provide similar benefits.

By weighing all these factors, Medicare looks at all these things to make sure it saves money while still helping patients with their health needs.

Engaging with Key Stakeholders

Medicare recognizes the importance of a collaborative approach when setting DME frequency limits. Therefore, Medicare engages with different stakeholders to make sure the rules are easy to follow, make sense for health care, and fit what everyone needs.

To do this, Medicare talks with doctors, medical equipment makers, and patient advocacy groups. Doctors and nurses know a lot about taking care of patients. They understand what is needed for medical equipment to help people feel better. Manufacturers, on the other hand, contribute their expertise on the latest advancements in DME technology, ensuring that the limits are compatible with the available products and innovations.

Crucially, Medicare also seeks input from patient advocacy groups, ensuring that the patient’s perspective is at the forefront of the decision-making process. These groups share important stories about what patients go through. They help create rules that focus on keeping patients happy and healthy.

By encouraging this collaborative atmosphere, Medicare may strike a balance between cost-effectiveness and patient care, ensuring that frequency limits are neither overly strict nor unnecessarily lenient.

Adherence to Regulatory Standards

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administering the Medicare program, works closely with various regulatory bodies, including the Food and Drug Administration (FDA), to ensure that the DME frequency limits are aligned with the latest medical practices, technological advancements, and safety protocols.

By staying up-to-date with regulatory standards, Medicare can make informed choices when setting or revising the frequency limits for different types of DME. This process looks at scientific facts, clinical studies, and expert advice to figure out how often DME should be replaced or restocked.

Following the rules helps Medicare stay legal and makes sure that the equipment given to people is safe and good quality. Following the rules helps keep everyone safe, makes sure Medicare spends money wisely on the right medical equipment, and leads to better health for the people who need it.

Also, by keeping the DME frequency limits up to date with new rules, Medicare shows it cares about giving people the best and newest medical technology and treatment choices. This active way helps patients on Medicare get the best care and support for their health needs, making them feel better and live happier lives.

Why Medicare DME frequency limits matter?

Medicare Durable Medical Equipment (DME) limits help keep healthcare affordable. Here’s why they matter:

Cost Control

Limits stop waste so Medicare can use funds well. Without them, a patient could get multiple wheelchairs in a short time when not needed. Limits let Medicare spend wisely.

Prevents Budget Overruns

Medicare could run out of money fast if no limits existed. For example, if folks got unlimited replacements of expensive items, Medicare funds would dry up quick. Less would be on hand when truly needed.

Prevents Overuse

Limits prevent folks from overusing medical gear. This way, only needed, required items get provided. It avoids waste. Limits and management keep use of resources proper.

Prevents Excess Requests

With no limits, some may ask for new oxygen machines more than required. This can lead to waste and higher costs. For instance, if a patient asks monthly but only needs yearly. Too many requests can limit resources.

Standardizes Care

Limits give all patients the same care. This makes treatment fair and steady. It highlights the importance of evenly sharing resources.

Prevents Unequal Care

With no standard care, some patients may get more equipment based on their provider. For example, one area may get new walkers yearly while another gets them every 5 years. This can cause unfair differences.

Reduces Fraud

Clear limits make fraud and abuse less likely. Defining necessity helps Medicare spot and stop fraudulent billing easier. Limits and compliance keep the system working properly.

Prevents False Billing

Without fraud oversight, providers could falsely bill Medicare multiple times for the same item. For instance, billing for many oxygen machines with no patient need causes big financial losses.

While Alaska and parts of California still pay more than other states, they’ll also see smaller decreases. Big cities like Chicago, Miami, and Houston, which typically have higher payment rates, will also face Medicare cuts in 2025 of more than 16%. 

Before we jump on the table for details by state, let us quickly share some factors affecting Medicare payment for mental health therapy in 2025. 

Factors Influencing the Medicare Reimbursement Rates for MHT in 2025

Medicare reimbursement rates for mental health therapy services in 2025 are shaped by a variety of factors, from legislative actions to economic conditions. 

Here are the key elements influencing these rates:

1. Conversion Factor Adjustments
2. Legislative Actions
3. Economic Factors
4. Medicare Advantage (MA) Plans
5. Quality Payment Program (QPP)
6. Inflationary Pressures
7. Other factors

Let’s have a quick look at these factors now.

1. Conversion Factor Adjustments

The conversion factor, a key component in Medicare’s payment system, has decreased by 2.83% for 2025, down to $32.3465. This marks the fifth consecutive year of reductions. The decrease is due to the expiration of a temporary adjustment and a 0% baseline update, which does not account for inflation in practice costs.

2. Legislative Actions

Congress plays an important role in determining Medicare’s payment rates. If lawmakers fail to intervene, providers, including mental health therapists, may face further payment cuts. Legislative action helps stabilize and increase reimbursement rates for mental health services.

3. Economic Factors

The Medicare Economic Index (MEI) predicts a 3.5% increase in the cost of providing services in 2025. However, due to budget neutrality rules, this increase does not result in higher reimbursement rates, leading to a financial strain for providers.

4. Medicare Advantage (MA) Plans

Medicare Advantage plans are seeing an average reimbursement increase of 3.7% for 2025. In contrast, traditional fee-for-service Medicare is experiencing cuts. This difference underscores a growing trend toward shifting reimbursements from traditional Medicare to MA plans.

5. Quality Payment Program (QPP)

The QPP continues to shape reimbursements by rewarding physicians who meet performance metrics. Those involved in Advanced Alternative Payment Models (APMs) may see higher payments compared to providers under the standard fee-for-service model. This shows a shift toward value-based care in 2025. 

6. Inflationary Pressures

The absence of an inflation adjustment within the current reimbursement framework puts pressure on healthcare providers. Consequently, as costs rise, many mental health therapy practices face financial challenges in delivering care.

7. Other Factors (Not Entirely Applicable in 2025)

Geographic reimbursement variations, impact of fee schedule area, differences in CPT codes can affect reimbursements. But mental health therapy reimbursement rates will drop in 2025 mainly because of new laws, economic challenges, and the reasons mentioned earlier.

Medicare Reimbursement Rates for Mental Health Therapy by State and Areas in 2025

The table outlines the reimbursement rates for CPT Code 90791 (Mental Health Therapy) across various states and counties in the US. It shows the percentage change in reimbursement rates for 2024 and 2025.

But first, let us share the key observations across states:

• The national reimbursement rate for CPT Code 90791 drops from $195.46 in 2024 to $166.91 in 2025, showing a -14.63% decrease.
• This national decline is consistent across most states, with the exception of a few where local factors might affect reimbursement.
• While most states see a similar decline, some regions, such as Alaska and certain counties in California, experience slightly higher reimbursements for mental health therapy relative to the national rate but still face similar percentage declines.
• Major urban areas like Chicago, Miami, and Houston tend to have higher rates, but also see large reductions in reimbursement rates, often surpassing 16% in decline.

Jump on the table below for more details by state:

Mental health therapy payment rates are dropping across the US from 2024 to 2025. This could be happening because of budget cuts, new healthcare rules, or rising costs of mental health care. While some areas still pay more than others, payments are going down almost everywhere in the country.

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However, securing Medicare coverage for insulin and related supplies, like needles and syringes, can be difficult for healthcare providers.

Medicare covers insulin and related supplies under specific conditions that healthcare providers must understand. These complexities can lead to confusion and unexpected patient costs if not handled correctly.

If you’re unsure whether Medicare covers insulin needles, you’re in the right place. In this blog, we will clarify whether Medicare covers insulin needles.

Medicare Insurance Plans

Before determining whether Medicare covers insulin needles, healthcare providers must understand the insurance plans offered by Medicare.

Medicare, the federal health insurance program primarily for individuals aged 65 or older, is divided into different parts, each covering various healthcare services:

• Medicare Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
• Medicare Part B (Medical Insurance): Covers outpatient care, doctor services, and certain preventive services.
• Medicare Part C (Medicare Advantage Plans): Offered by private companies approved by Medicare, these plans include Part A, Part B, and sometimes Part D.
• Medicare Part D (Prescription Drug Coverage): Helps cover the cost of prescription drugs.

Coverage becomes more nuanced when it comes to insulin and related supplies, like insulin needles. Providers need to understand the specifics of both Part B and Part D for proper coverage. Many providers remain confused about whether insulin needles are covered, so it’s crucial to understand how Medicare addresses this.

Does Medicare Cover Insulin Needles?

Yes, Medicare covers insulin, but it depends on how you administer it.

Let’s break this down:

➜ Medicare Part B covers insulin if you use an insulin pump, which is considered durable medical equipment. However, it does not cover insulin pens or supplies like syringes, needles, alcohol swabs, or gauze.

➜ Medicare Part D covers insulin that is not used with a traditional insulin pump, along with certain medical supplies needed to inject insulin, such as syringes and needles. The cost for a one-month supply of each covered insulin product is capped at $352.

➜ Medicare Part D covers insulin needles, Medicare Part B does not. However, if you have a Medicare supplement insurance plan that covers your Part B coinsurance, it may help pay for insulin under Part B.

When covering insulin and related supplies, understanding the distinctions between Part B and Part D is crucial for providers.

Now, let’s explore these differences in more detail:

When a Patient Has a Medicare Part B Plan

Medicare Part B is a component of Medicare that covers medical services and supplies necessary for treating or managing health conditions.

Medicare Part B covers a variety of services and supplies, such as:

• Blood glucose testing supplies (e.g., blood glucose monitors, test strips, and lancets)
• Certain preventive services, including diabetes self-management training and nutritional therapy
• Durable medical equipment, such as insulin pumps
• Therapeutic shoes or inserts

However, Medicare Part B does not cover the following diabetes-related supplies:

• Insulin pens
• Syringes
• Needles
• Gauze
• Alcohol swabs

So, to answer your question: Medicare does not cover insulin needles under Part B.

It’s important to remember that Medicare Part B covers insulin when administered via an insulin pump that qualifies as durable medical equipment (DME). This coverage can be a significant benefit for patients who need continuous insulin infusion through a pump, as both the pump and the insulin used in it may be covered.

However, while Part B covers the insulin and the pump, it generally does not cover needles or syringes for manual insulin administration.

Under the Part B plan, patients are responsible for paying 20% of the cost in 2024, while Medicare covers the remaining 80%. These costs are in addition to other out-of-pocket payments for Part B, including the monthly premium, yearly deductible, and copayments.

When the Patient Has a Medicare Part D Plan

Medicare Part D is the prescription drug plan that covers medications and certain medical supplies needed to administer them.

Patients need a Part D plan for insulin and related supplies, such as needles and syringes. Here’s what Part D covers:

• Insulin that isn’t used with an insulin pump
• Medical supplies used to inject insulin, like syringes and needles

Part D plans also cover a one-month supply of each covered insulin product, with a capped cost of $35.

Medicare Part D, which provides prescription drug coverage, typically includes the cost of insulin and the supplies needed to inject it—such as needles, syringes, alcohol swabs, and gauze. This is especially important for patients who self-administer insulin, as it ensures they have access to both the medication and the necessary tools to use it effectively.

When your patient has a standalone Part D plan or a Medicare Advantage plan that includes drug coverage, you must verify that their specific plan covers these supplies. Each Part D plan has a formulary—a list of covered drugs and supplies—which can vary by plan.

As a provider, it’s essential to confirm the coverage beforehand to avoid surprises at the pharmacy, where patients may otherwise face unexpected out-of-pocket costs.

Before proceeding with billing and claim submission, make sure that the pharmacy providing these drugs and supplies is in-network.

The Medicare Pricing Plan for Diabetes

As a healthcare provider, you must be aware of the costs of insulin that Medicare charges. Below is the breakdown of three plans for Medicare insulin costs.

FAQs

1). Are pen needles covered by Medicare?

Yes, Medicare covers pen needles. Providers are reimbursed for the pen needles under the Medicare Part D plan. Pen needles are used by providers to treat asthma attacks and severe allergic reactions. Pen needles from various brands covered by Medicare include:

• Auvi-Q
• EpiPen
• EpiPen 2-Pak
• EPIsnap
• Adyphren
• EpinephrineSnap-V
• Bronchial Mist Refill
• Adyphren II, Adyphren Amp II
• Adyphren Amp

2). What insulin is covered by Medicare?

Medicare covers insulin used with a disposable or non-traditional insulin pump, not an insulin pump itself. Medical supplies used to inject insulin include syringes, gauze, and alcohol swabs.

3). What insulin is covered by Medicare Part B?

Medicare Part B covers insulin used with an insulin pump, as part of the durable medical equipment benefit. Remember, Part B does not cover insulin pens or insulin-related supplies like syringes.

4). What insulin is covered by Medicare Part D?

Medicare Part D (also called the Drug Coverage Plan) covers insulin used with injectables like syringes or pens. However, it does not cover insulin used with a disposable or non-traditional insulin pump.

Final Thoughts

Medicare Part D typically covers the supplies needed to inject insulin, including needles, syringes, alcohol swabs, and gauze. However, Part B can come into play when insulin is administered through an insulin pump.

In conclusion, we can say that Medicare covers the Insulin needles but only under its Part D plan.

So, to successfully reimburse the treatments given to your patient with diabetes, confirm that they have a Medicare Part D Plan.

One in seven medical claims are denied, leading to approximately 200 million rejections daily. Of these, a significant 27% are due to issues with patient registration and Verify Medicare Coverage thing for the medical claim.

On average, denial management costs at least $25 per claim denial, resulting in cash flow issues for healthcare practices’ Revenue Cycle Management (RCM).

When the Verify Medicare Coverage part is not done correctly, it not only drives up billing costs but also delays revenue collection, causing disruptions throughout the revenue cycle.

Implementing a reliable insurance verification process helps mitigate claim denials, streamlining medical billing and ultimately improving the practice’s financial health.

This document offers a detailed guide on how to Verify Medicare Coverage, eligibility, and benefits for providers using various methods.

What is Medicare Coverage Verification for Providers?

Medicare coverage verification is the process of checking that a healthcare service or item will be paid for by Medicare before it is provided.

Medicare is a federal health insurance program that covers certain medical costs for people aged 65 and over. While Medicare pays for things like doctor visits, hospital stays, lab tests, and prescriptions, it does not cover all health expenses. Medicare coverage verification allows healthcare providers and patients to confirm in advance that a proposed treatment or service will be covered and reimbursed by Medicare.

For example, before scheduling an MRI, a doctor’s office may contact Medicare to verify that the scan will be covered for that patient. This prevents unexpected costs and ensures the patient and provider are aware of any potential out-of-pocket expenses ahead of time.

“Medicare coverage verification refers to checking in advance whether something will be covered under Medicare for a particular patient. This prevents the patient or healthcare provider from assuming something is covered, only to find out later that Medicare denied the claim.”

Wyatt Butler, Medical Biller & RCM Expert

Why Do Providers Need to Verify Medicare Coverage?

Medicare Coverage Verification is essential for providers as it optimizes the revenue cycle and streamlines the collection process.

According to CompuGroup Medical, manual verification causes providers to lose the average visit cost of two patients per day, which amounts to $6000 annually. Therefore, staying electronic with verification saves you time, money, and effort.

Healthcare providers must verify their patient’s Medicare eligibility coverage due to the following reasons:

➜ Upfront eligibility verification improves your first-pass rate while reducing A/R days, meaning you’ll get paid faster without any delays.

➜ Checking Medicare eligibility before providing services gives you a better understanding of your patients’ co-pay amounts, co-insurance, deductibles, and out-of-pocket costs, allowing you to collect Medicare payments in a timely manner.

➜ Prior eligibility verification allows you to educate your patients ahead of time about the billing process with their insurance plan, co-pays, and deductibles. This leads to enhanced patient satisfaction and fewer contested bills.

➜ Lastly, it improves cash flow, as you collect your revenue upfront without any delays.

List of Things You Need to Verify Medicare Coverage of a Patient

• National Provider Identifier (NPI)
• Provider Transaction Access Number (PTAN)
• Tax Identification Number (TIN)
• Beneficiary Medicare ID
• Beneficiary name
• Beneficiary date of birth
• Date of service (if applicable)

How to Check Your Patient’s Medicare Eligibility Status?

Checking your patient’s Medicare eligibility is key to avoiding billing problems and getting paid on time. There are different ways to verify Medicare coverage, from online tools to phone calls. Here are the most common methods to help you confirm your patient’s Medicare eligibility.

Method #1 – BellMedEx Medicare Coverage Verification Tool

BellMedEx is a medical billing company that has its own comprehensive Medicare verification system. The company takes over a provider’s non-clinical burdens and simplifies the Medicare coverage verification process. This enables providers to focus on their core tasks, such as delivering care.

To verify Medicare insurance eligibility via BellMedEx, follow these simple steps: 

1). Visit BellMedEx’s Medicare Coverage & Patient Eligibility Checker Tool online.

2). Fill in the form – enter your name, email, and phone number – and click on “Book a Free Consultation”.

3). BellMedEx’s support representative will immediately contact you and help you with confirming your patient’s Medicare coverage.

4). Likewise, you can also contact BellMedEx at 888-987-6250 to receive Medicare coverage verification support and verify if a patient qualifies for Medicare or not.

Method #2 – Confirm Medicare Coverage Online via Secure Provider Online Tool (SPOT)

SPOT, as known as Secure Provider Online Tool, gives you the ability to view claims status and confirm patient’s Medicare eligibility status online. SPOT also offers the opportunity to search for a Medicare Beneficiary Identifier (MBI) through the Medicare MBI lookup tool.

The eligibility information through SPOT is accessible 24/7, and the providers can check Part A and Part B eligibility status, as well benefit eligibility for preventive services, deductibles, therapy caps, inpatient care, hospice, home health, Medicare secondary payer (MSP), plan coverage data categories, and claim status up to twelve months from the date of the inquiry.

Here’s how you can verify Medicare eligibility for your patients via SPOT:

1). Select Eligibility from the top drop down menu.

2). A pop up will appear, asking for the following details:

• Beneficiary Last Name
• Medicare Beneficiary ID
• Beneficiary First Name 
• Beneficiary Date of Birth
• Date(s) of Service

Note: (You may limit your query to the date(s) the service will be furnished to the patient, or you may specify any time up to four months in the future and 24 months in the past).

3). Click Search to view Eligibility status.

4). The Eligibility results will include complete eligibility information of the beneficiary, including part A and part B eligibility statuses, with effective and termination dates.

Method #3 – Using IVR to Verify Medicare Part A and Part B Eligibility

The Interactive Voice Response (IVR) system allows a provider to verify Medicare eligibility for free by phone. You can access primary insurance info, confirm pre-authorization, and check claim status.

Contact the following numbers for Medicare Part A verification:

• 1-888-664-4112 (Toll-free telephone number)
• 1-877-660-1759 (For speech and hearing impaired)

Contact the following numbers for Medicare Part B verification:

• 1-866-454-9007 (Toll-free telephone number)
• 1-877-660-1759 (speech and hearing impaired)

Providers can access Medicare Part A and Part B eligibility information via IVR during the following times (excluding holidays):

• Monday-Friday 7am to 7pm, ET
• Saturday 6am to 3pm, ET

IVR’s CSR service is also available in case a complexity arises about insurance plans, coverage, and benefits that you need to navigate through. Customer service representatives are available during the following times, excluding holiday closings:

• 8am to 4pm Monday through Friday, ET and CT for providers in Florida.
• 8am to 4pm Monday through Friday, ET for providers in the U.S. Virgin Islands.

Method #4 – Confirming Medicare Benefits via MAC Online Provider Portal

Medicare Administrative Contractors (MACs) process claims and Medicare eligibility verification for fee-for-service (FFS). These contractors offer an online provider portal for registered providers.

Not registered with MAC?

A supplier can register with its MAC’s provider portal by contacting its MAC or by finding its MAC provider portal online. Once registered, the supplier can use the portal to search a Medicare beneficiary’s eligibility. The supplier can access its MAC’s provider portal at any time and look up a beneficiary’s verification.

Here’s how you can verify Medicare coverage of your patient with MAC provider portal:

1. Enter the beneficiary’s Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI)
2. Beneficiary’s first and last name
3. Beneficiary’s date of birth
4. Upon entering the above information you can check the status.

However, the process is self-service, meaning you are responsible for entering the information to check the status.

Method #5 – Phone Number to Verify Medicare Eligibility and Benefits

Using Medicare Administrative Contractor (MAC) Phone Verification

Medicare Administrative Contractors offer a phone verification system as well that Medicare suppliers can contact to access beneficiary eligibility information. The appropriate phone number of a MAC can be found from its website by state. Or you can simply dial 1-800-MEDICARE (800-633-4227) to get your state’s phone number.

To perform the eligibility verification, the authentication should be done through the phone system by entering:

• National Provider Identifier (NPI), 
• Provider Transaction Access Number (PTAN), and 
• Tax Identification Number 

This information is needed by Medicare to accurately perform the eligibility query and provider authentication. Once the provider has confirmed its authentication, the provider can now enter the following details to confirm the patient’s Medicare eligibility.

• The beneficiary’s HICN or MBI, 
• The beneficiary’s first and last name, and 
• The beneficiary’s date of birth 

This option is self-service and available around the clock, 24/7.

Method #6 – Validate Medicare Coverage via HIPAA Eligibility Transaction System (HETS)

HETS (HIPAA Eligibility Transaction System) allows providers and suppliers to verify and check Medicare eligibility status using a HIPAA compliant transaction. You can get eligibility information by submitting a HETS 270 request. To check eligibility status in HETS, you must have the following information:

• MBI
• First and last name
• Date of birth (MM/DD/YYYY)

If a patient is eligible, you will get a 271 response with information like Part A entitlement, Part B entitlement, Part D, Hospital lifetime reserve days remaining, skilled nursing facility remaining benefit days, and more.

Note: To verify your patients’ Medicare eligibility via Health Eligibility Transaction System, your medical billing software must connect with it. This integration permits creating, sending, and getting the transactions. HETS benefits large healthcare facilities with the resources to build their own programs. This makes it a good choice if you want to avoid third parties and keep things quick and secure.

Conclusion

Now that you know how to verify Medicare eligibility and verify Medicare benefits across multiple methods—whether through IVR, MACs, or online platforms like SPOT—you can streamline your verification process. This will help reduce denials, improve patient billing accuracy, and increase your cash flow. Efficient Medicare verification for providers is key to ensuring your practice operates smoothly, so make sure to verify Medicare eligibility as soon as possible to avoid delays in claims processing.