01/21/2026

ASK MSHO

January 2026 Frequently Asked Questions

Question:

I am wondering if you could direct me to where I can find information on the guidelines for supervising physicians during infusion. We are looking for clarification going into the new year. So far all of the info I have found states that infusions require direct supervision from the provider. My question is, I see that in 2026 they have made audio/video availability to be used as direct supervision. Does this apply to infusion therapies as well, or does the provider need to be onsite and readily available? Another question I have, and I am pretty sure I already know the answer, but I am just looking for some clarification. An APP can be the supervising if there are no physicians in the office that day. Is this a correct statement? We would just be reimbursed at a lower rate?

Answer:

The final rule does allow audio/visual technology to be used to satisfy the direct supervision requirements for infusion.  This means as long as the supervising physician is immediately available via audio/visual technology, you can bill the service under that supervising physician.  

This is the paragraph from the 2026 CMS Final Rule: 

Telehealth Services under the PFS

For CY 2026, we are finalizing to streamline the process for adding services to the Medicare Telehealth Services List. We are simplifying our review process by removing the distinction between provisional and permanent services and limiting our review on whether the service can be furnished using an interactive, two-way audio-video telecommunications system. 

We are finalizing to permanently remove frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations.

We are also finalizing, for services that are required to be performed under the direct supervision of a physician or other supervising practitioner, to permanently adopt a definition of direct supervision that allows the physician or supervising practitioner to provide such supervision through real-time audio and visual interactive telecommunications (excluding audio-only). Except for services that have a global surgery indicator of 010 or 090, we are finalizing that a physician or other supervising practitioner may provide such virtual direct supervision for applicable incident-to services under § 410.26, diagnostic tests under § 410.32, pulmonary rehabilitation services under § 410.47, cardiac rehabilitation and intensive cardiac rehabilitation services under § 410.49. 

We did not propose to extend our current policy to allow teaching physicians to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings, which had been in effect through December 31, 2025. However, in response to public comments highlighting the extent to which this flexibility has been integrated into clinical practice, we are finalizing allowing teaching physicians to have a virtual presence in all teaching settings, only in clinical instances when the service was furnished virtually, on a permanent basis. 

Question:

Our facility is trying to confirm if a JW modifier should be used when waste is created due to an adverse drug reaction.  We are having trouble finding something from Medicare that addresses this.  Would you happen to have any guidance?

Answer:

When chemo infusions are started but stopped prematurely, bill only for the services and the amount of the drug actually provided and use specific modifiers for the wasted drug and discontinued procedure. 

Document the actual time the drug was administered. 

Append a modifier for discontinued procedure (facility -74 and non-facility -52)

Bill for the discarded amount - If the drug came from a single-dose vial and an unused or discarded amount remains that is eligible for separate payment. Report a separate line item for the discarded amount using the same HCPCS code and append modifier JW.  Only indicate the waste on this line on the claim.

Documentation is critical

If the reason is the infusion was discontinued because the patient stopped the infusion and left, that should be documented. 

Indicate the total amount of drug in the vial and the amount administered to the patient.

Start and Stop times of the infusion are very important. 

Type "documentation available upon request" in box 19 of the CMS 1500 form.

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53778

Question:

When is modifier 91 applicable for testing?

Answer:

Modifier 91 is applicable for the repeat of the same test on the same day when performed on a subsequently collected specimen. This modifier is used frequently for billing of repeat chemistry or hematology procedures. However, due to the limitation for use for testing on subsequently collected specimens, this modifier is not typically utilized for billing of histology procedures. Again, it is necessary to first validate the MUE limit for the CPT codes in histology to determine if quantity billing on a single line of the claim is appropriate.

Question:

What are the key differences between white bagging and brown bagging?

Answer:

White bagging refers to a scenario in which the infusion center receives the patient’s medication directly from the specialty pharmacy. Brown bagging refers to instances when the patient obtains the medication directly from the specialty pharmacy or retail pharmacy and then transports the medication to the infusion center. In both scenarios, the physician submits an order to the specialty pharmacy for the specific medication. The pharmacy prepares and packages the medication and then directly bills the patient’s insurance. Payment to the specialty pharmacy is issued through the patient’s pharmacy benefit rather than the medical benefit.