CMS clarifies CAH billing requirements, hints at upcoming OIG audit results

CMS recently revised Chapter 4 of the Medicare Claims Processing Manual to provide Method II critical access hospitals (CAH) with updated billing requirements for professional emergency services performed in the emergency department (ED).

The agency revised the manual in response to ongoing Office of Inspector General (OIG) auditing efforts regarding Medicare payments for ED services provided in non-ED sites of service. The OIG is expected to release the audit findings in fiscal year 2026, but CMS indicated that the investigation revealed patterns of non-compliance.

CMS considers reimbursement of eligible professional ED procedures provided by physicians who reassigned their billing rights to a Method II CAH only when the services are provided in an ED. These facilities must bill professional emergency producers on type of bill 85X with revenue code 0981, as well as Current Procedural Terminology (CPT®) codes 99281–99285.

Revenue integrity professionals can view MLN Matters 14342 for more information. When the OIG releases its audit report later this year, review the findings to ensure your organization is billing compliantly.