Bobbi Buell's Newsletter

Roberta L. Buell is a Principal at onPoint Oncology Inc., specializing in oncology reimbursement. With over 23 years of experience in billing, coding, and drug therapy reimbursement, she's a nationally recognized expert and frequent speaker on regulatory and reimbursement issues. Bobbi has led more than 600 seminars since 1991 and currently serves as content director for focalPoint® and assistPoint®. Learn more about Bobbi here .

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October 2025

Modifier 25 E/M: Ball of Confusion

For the past 20 years, the most asked question from all of my readers is--what documentation do I need to justify a separate visit with drug admin or with a minor procedure? I am not an expert on minor procedures, but with drug admin, the origin of the Modifier 25 requirement was when CMS decided to no longer allow a 99211 to be coded with it. The Medicare national average value of the Work Relative Values in 96365, for example, is $6.79. That does not imply much professional time (or even staff time, for that matter). Still, I have folks saying that all visits are bundled in and that the patients must be seen on a different day. EEEEK! Here are some things to be aware of (denial rates based on our claims data in focalPoint®): Most of the time, large payers DO NOT deny claims for E/M visits on the date of drug admin. Traditional Medicare has a less than 5% denial rate; CVS/AETNA is 5.28%; United is 7.46%; Humana is 9.36%; and CIGNA is 9.92%. The denial average for all drugs in our…

October 2025

Medicare Telehealth On Hold: What You May Bill

Telehealth is defined as real-time audio-visual services. This is like video conferencing with your patients. Some services can be offered VIRTUALLY, meaning your staff and your patients do not have to meet in real time, either via synchronous audiovisual software or in person. As a public service, I want to remind you of services that you probably ignored when telehealth became so popular. Here are some codes that most specialties can bill, and Medicare covers. Care Management (99490, 99439, 99491, 99437, 99487, 99489, 99424-99427, 99495, 99496)--Many of you are already billing these services with success. But if you have been putting off adding these services, now might be a good time to put your toe in the water and try them. RPM/RTM (99453, 99445, 99454, 99470, 99457, 99458, 99091, 98975, 98984, 98976, 98985, 98977, 98986, 98978, 98979, 98980-98981) As we said previously, in 2026, you will not have to do 16 days or more of monitoring to bill these services. Plus, many new devices…

October 2025

CPT Updates (Ho Hum)

The CPT update involves 418 total changes, which include 288 new codes “designating the latest advances in medical, surgical and diagnostic services available to patients,” 84 deletions and 46 revisions, an AMA press release said . For once, there are no E/M changes, except for Remote Physiological Monitoring. There are also no drug administration changes. The changes, effective January 1, 2026, include six new codes created to report remote monitoring services over 2-to-15-day periods (instead of ≥ 16 days) within a 30-day period and two new codes that report remote monitoring of treatment management after 10 minutes of service per calendar month, down from the previous 20-minute threshold. The new codes include the following: 99445: Remote Physiological Monitoring, device supply with daily recording(s) or programmed alerts transmission, 2-15 days in a 30-day period. 99470: Remote Physiological Monitoring, treatment management services, clinical staff/physician/other qualified…

October 2025

TrumpRx: What Are We Talking About Here?

Recently, the Trump administration unveiled a new drug pricing initiative, widely referred to as “TrumpRx.” TrumpRx (reportedly operational in January 2026) is defined by two key aspects: (1) a government-run portal aimed at directing patients to a website to purchase drugs (without going through their insurance) at discounted rates set by the government; and (2) tactics designed to force concessions from drug manufacturers. While the headlines surrounding TrumpRx amplify its hype, the reality is more complex (maybe)—and the expected ramifications will affect pharmacies, plan sponsors, and Pharmacy Benefit Managers (PBMs). This article outlines the administration’s actions towards drug pricing thus far and what TrumpRx could mean for the pharmaceutical marketplace. The Portal As noted, TrumpRx is characterized by: a government-run portal that may send patients to manufacturers’ DTC websites to purchase medications without using their insurance, and trade and pricing tactics that…