October 2025 Provider Pulse

VA Healthcare Services and Payments Not Affected by the Shutdown

Community providers should continue to see and honor all scheduled Veteran appointments without interruption. VA remains fully funded through advanced appropriations and continues to operate as normal. All VA Medical Centers (VAMCs), outpatient clinics, and Vet Centers are also open as usual. TriWest’s contact center remains open to assist providers in helping ensure continuity of care for Veterans.

CMS Changes to Telehealth Services

Several Medicare telehealth flexibilities have changed as of October 1, 2025:

• Non-behavioral/non-mental telehealth services:
  • Will be limited by geographic and originating site requirements. Patient home will no longer qualify as an originating site.
  • Audio-only coverage ends, except in limited circumstances.
  • Federally qualified health centers and rural health clinics will no longer be authorized to serve as distant site providers for non-behavioral and non-mental telehealth after September 30, 2025.
• Behavioral and mental health services:
  • Will continue to allow the patient’s home as an originating site.
  • Monthly ESRD-related clinical assessments can continue to be performed via telehealth.
  • Audio-only services remain permanently allowed.
  • Federally qualified health centers and rural health clinics may continue to serve as distant site providers for behavioral and mental health telehealth after December 31, 2025.

We encourage you to review the telehealth services you are currently providing. For the current guidance, please refer to the CMS Telehealth and Remove Patient Monitoring booklet or the Department of Health and Human Medicare Payment Policies web page.

Billing Requirements: What to Do When a Sanctioned or Excluded Provider is Involved

A sanctioned or excluded provider is any individual or entity prohibited from participating in federal health care programs. This includes physicians, suppliers, manufacturers, drug plan sponsors, managed care entities, or any party that directly or indirectly furnishes, arranges, or pays for services.

Key Requirements:

• No services can be rendered to a Veteran or federal program beneficiaries by sanctioned providers.
• This restriction applies to all roles: referring, operating, attending, and assisting.
• Any claim billed that includes services from a sanctioned provider will be denied.
• Providers must routinely check the Office of Inspector General (OIG) List of Excluded Individual and Entities (LEIE) and CMS Preclusion List to confirm that staff, contractors, and referring providers are eligible.

To ensure understanding of the requirements and restrictions for billing services when a sanctioned or excluded provider is involved in rendering care to Veterans, please reference the Effect of Exclusion from Participation in Federal Health Care Programs Bulletin. It outlines federal regulations, including CMS and Office of Inspector General (OIG) rules and provides billing guidelines to ensure compliance.

Check Prescription Drug Monitoring Program When Prescribing Opioids to Veterans

As part of our ongoing commitment to ensuring the health and safety of Veterans, TriWest would like to remind all VA CCN providers of the importance of checking your state’s Prescription Drug Monitoring Program (PDMP) before prescribing opioids to Veterans.

Why is this important?

The PDMP is a critical tool in preventing opioid misuse and ensuring that Veterans receive the care they need without unnecessary risks. By reviewing the PDMP, you can:

• Monitor for potential misuse or diversion: Ensure Veterans are not receiving multiple prescriptions from different providers or pharmacies.
• Promote safer prescribing practices: Help reduce the risk of opioid overuse, addiction, or overdose in our Veteran population.
• Collaborate with VA care teams: Gain a more comprehensive view of a Veteran’s overall treatment plan.
• The VA audits opioid prescriptions quarterly: This means a selection of cases will be reviewed, and if PDMP checks are not completed, VA will request medical documentation from the community provider to verify previously prescribed medications.
• OIG oversight: The Office of Inspector General (OIG) has raised concerns regarding the need for better documentation around opioid prescriptions, emphasizing the importance of consistent, complete records.
• Collaboration for improvement: VA is committed to improving the rate at which PDMP checks are conducted and is seeking stronger collaboration with VA CCN providers to meet this goal.

What you need to do:

1. Before prescribing opioids, log into your state's PDMP and check the patient's prescription history.
2. Review the history for any red flags, such as overlapping prescriptions, early refills, or high-dose prescriptions.
3. If you identify any concerns or discrepancies, please coordinate with the VA care team to ensure the best care plan for the patient.
4. Document your review of the PDMP as part of the prescribing process in the patient’s medical record.

For any questions related to prescribing opioids for Veterans or using the PDMP, please contact your State PDMP.

Visit the State PDMP Profiles and Contacts web page to find contacts or learn more about how to access or use the PDMP.

Learn More about VA Clinical Determinations and Indications

VA develops Clinical Determinations and Indications (CDIs) as a reference for CCN providers to use when determining whether a service is considered medically necessary for a Veteran. CDIs define clinical criteria and parameters to determine medical necessity and drive the most appropriate, evidence-based determinations for care.

All current CDIs are available on the CDI library. To submit a question about a published CDI, please use the CDI Question Submission Form and follow the instructions located at the bottom of the the CDI website.

VA published 16 new CDIs since January 2025:

• Routine Colorectal Cancer Screening
• CT Colonography Virtual Colonoscopy
• Metabolic and Bariatric Surgery
• Low-Dose CT Scan for Lung Cancer Screening
• Medical Massage Therapy
• Teprotumumab-trbw (TEPEZZA)
• Percutaneous Coronary Interventions
• Cardiac Stress Tests
• Minimally Invasive and Open Sacroiliac Joint Fusion Stabilization
• Auditory Osseointegrated Implants
• Total/Partial Knee Arthroplasty
• CT Cerebral Perfusion
• Micro-Invasive Glaucoma Surgery
• Implantable Continuous Glucose Monitor
• Prolotherapy
• Functional Endoscopic Sinus Surgery

Additionally, VA updated 4 CDIs:

• Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) Implant System for transfemoral amputations
• Transurethral Waterjet Ablation for benign prostatic hyperplasia
• Ultrasound-Guided Radiofrequency Ablation for symptomatic uterine fibroids
• Eyelid Thermal Evacuation Therapy and Intense Pulsed Light Therapy for meibomian gland dysfunction

For more information on CDIs, please check out the CDI Overview webinar on VHA TRAIN. If you have not already, you will need to create an account to access this webinar.

VA CCN Provider Handbook Updates

An additional section, Billing for Skilled Nursing Facilities, will be added under Billing Requirements for Unlisted and NOC Codes in the VA CCN Provider Handbook:

Billing for Skilled Nursing Facilities

Veterans are eligible for 100 days of Skilled Nursing Facility (SNF) care per calendar year. Separate bills are required when monthly charges overlap calendar years.

Please note that any claims missing required rehabilitation therapy ancillary revenue codes will be returned for correction and resubmission.

Claims Submission

Submit charges monthly, and in order, using a UB-04 claim form, or its electronic equivalent. Claims should also be submitted when the Veteran:

• Transitions out of skilled care
• Upon discharge from skilled care
• When the benefit period ends

Billing Codes

• Type of Bill:
  • Use 21X for SNF inpatient services.
  • Use 18X for hospital swing bed services.
• Occurrence Codes:
  • 70 – Dates of the qualifying hospital stay.
  • 77 – Non-covered days.
  • 50 – For each assessment period represented on the claim with revenue code 0022.
• Revenue Code:
  • Use 0022 to indicate payment under the SNF PPS. This revenue code can appear as often as necessary to indicate different HIPPS Rate Code(s) and assessment periods.
  • Total charges should be zero for revenue code 0022.
  • Ensure the total service units match the number of covered days (excluding non-covered days reported with occurrence code 77).
  • Report 018X (leave of absence) when the patient is on leave of absence and not present during the midnight census.

Billing Reminders

• The HCPCS/Rates field must include a 5-digit HIPPS code. The first 3 digits indicate the RUG group, and the last 2 digits represent the assessment indicator (AI code).
• HIPPS codes require the following:
  • RUAXX, RUBXX, RUCXX, RUIXX: include at least 2 rehabilitation therapy ancillary revenue codes (042X, 043X, 044X).
  • RHAXX, RHBXX, RHCXX, RHLXX, RLAXX, RMAXX, RMBXX, RMCXX, RMLXX, RMXXX, RVAXX, RVBXX, RVCXX, RVLXX and/or RVXXX: include at least one rehabilitation therapy ancillary revenue codes (042X, 043X, 044X).

For more information see Chapter 6 of the Medicare Claims Processing Manual, the Medicare MLN Skilled Nursing Facility Billing Reference or visit VA's Geriatrics and Extended Care web page.