Preparing for 2025- How New Regulations Impact Credentialing
                     PREPARING FOR 2025: HOW NEW REGULATIONS IMPACT CREDENTIALING
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PREPARING FOR 2025: HOW NEW REGULATIONS IMPACT CREDENTIALING
New regulations from the Centers for Medicare & Medicaid Services (CMS) continue to 
shape medical billing practices, with notable implications for healthcare providers’ 
credentialing. Credentialing is a foundational component of the medical billing process, 
ensuring that providers meet the necessary standards to participate in Medicare and 
Medicaid programs and are eligible for reimbursement.
With recent regulatory shifts impacting telehealth, primary care, cardiovascular care, and 
other service areas, healthcare providers must stay updated on evolving credentialing 
requirements to remain compliant and avoid potential billing issues. This analysis 
examines how these regulatory changes affect credentialing.
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ow-new-regulations-impact-credentialing
 
Impact of 2025 Regulations on Credentialing
1. Telehealth Policies
Telehealth has become an essential mode of healthcare delivery, and new CMS policies for 
2025 reflect continued flexibility while tightening standards for telehealth credentialing. 
Effective January 1, 2025, Medicare telehealth services can be provided via audio-only 
technology when patients are unable or unwilling to use video technology. Credentialing 
for telehealth providers now must ensure they are equipped with necessary capabilities, 
including interactive telecommunications technology. Providers must document technical 
abilities for telehealth, especially if serving Medicare beneficiaries who require real-time, 
audio-only services. HTTPS://WWW.247MEDICALBILLINGSERVICES.COM/ 
PREPARING FOR 2025: HOW NEW REGULATIONS IMPACT CREDENTIALING
Another change extends permission through 2025 for practitioners to list practice 
addresses on telehealth claims instead of their home addresses when providing services 
from home. Credentialing departments must verify providers' compliance with these 
location requirements. This shift requires documentation that telehealth practitioners 
are enrolled at a valid practice location and capable of fulfilling these Medicare 
standards.
Virtual supervision, another aspect of the CMS telehealth rule, affects credentialing for 
supervisory roles, allowing supervising physicians to be present virtually via real-time 
video and audio in specific situations. Credentialing departments must ensure that 
supervising practitioners meet the virtual presence criteria and document the approved 
settings for such supervision, particularly for outpatient services requiring oversight.
2. Advanced Primary Care Management Services (APCM)
The CMS’s establishment of new Advanced Primary Care Management (APCM) codes 
(G0556, G0557, and G0558) to support primary care transformation also has 
credentialing implications. These codes are structured around the complexity of 
patients’ conditions and allow providers to bill for comprehensive primary care without 
time-based requirements, simplifying administrative tasks. However, providers utilizing 
these APCM codes must meet specific qualifications and service standards, including 
24/7 access and continuity of care, comprehensive care planning, and care 
coordination.
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PREPARING FOR 2025: HOW NEW REGULATIONS IMPACT CREDENTIALING
Credentialing must verify that providers meet these new requirements and possess the 
competencies to deliver such comprehensive care. This involves ensuring that providers 
have training in managing chronic conditions, coordinating care transitions, and 
maintaining care continuity. Credentialing for APCM is further complicated by the 
integration of the Merit-Based Incentive Payment System (MIPS), wherein providers must 
meet primary care quality measures to bill for APCM services. MIPS eligibility criteria 
now factor into credentialing for providers delivering these advanced services, requiring 
verification of past performance metrics and enrollment in an advanced care model to 
bill these codes effectively.
3. Cardiovascular Risk Assessment and Management Services
In response to the success of the Million Hearts® Model, CMS finalized coding for 
cardiovascular risk assessment and management, which adds another layer to 
credentialing. The assessment codes are designed for patients at risk of cardiovascular 
disease (CVD) but without a formal diagnosis, necessitating standardized risk 
assessments that consider demographic data, modifiable risk factors, and laboratory 
data. Credentialing teams must now confirm that healthcare providers are trained in 
CVD risk assessment and management and that they have the clinical competencies to 
conduct evidence-based evaluations.
Providers must also follow protocols for risk management services, which include 
strategies for aspirin use, blood pressure management, cholesterol management, and 
smoking cessation. Credentialing will need to ensure providers are credentialed in using 
the ASCVD risk assessment tool and proficient in the management of intermediate and 
high-risk patients. This policy emphasizes preventive care for CVD, and credentialing 
must align with the qualifications HnTTePcSe://WssWaWr.2y47 MtoED ImCAeLBeILtL INCGMSESRV’sIC ErSi.sCkOM r/ eduction standards.
PREPARING FOR 2025: HOW NEW REGULATIONS IMPACT CREDENTIALING
4. Therapy Services
Regulatory changes also impact credentialing for physical, occupational, 
and speech therapy services. CMS’s recent rule allows therapists to bypass 
physician signatures on treatment plans when certain conditions are met, 
such as having a documented physician order on file. This change requires 
credentialing departments to confirm therapists’ documentation skills and 
ensure adherence to policy regarding timely transmission of treatment 
plans to supervising physicians.
Therapists’ credentialing must now account for their ability to manage 
treatment plans independently under certain conditions, meaning 
credentialing processes should include training and assessment of 
documentation capabilities, communication with physicians, and 
adherence to updated regulatory guidelines. Additionally, credentialing 
departments may need to clarify roles when new patients initiate therapy 
and ensure compliance with Medicare’s initial certification and 
documentation standards.
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PREPARING FOR 2025: HOW NEW REGULATIONS IMPACT CREDENTIALING
5. New Dental and Oral Health Service Policies
CMS’s decision to cover dental and oral health services tied to specific medical conditions, such 
as end-stage renal disease, further influences credentialing. Effective July 1, 2025, Medicare will 
require the KX modifier on claims for covered dental services. This update means dental 
providers billing Medicare must credential to ensure eligibility and training to meet CMS’s specific 
coding and modifier requirements. Credentialing teams must now evaluate dental providers’ 
familiarity with the 837D dental claims format, knowledge of diagnosis coding, and correct use of 
the KX modifier, especially in cases of medically necessary services linked to covered conditions.
Credentialing for these dental providers must include verification of expertise in treating medical 
conditions related to dialysis, as well as understanding of the link between oral health and 
chronic disease management. This shift emphasizes that providers delivering multidisciplinary 
care need credentials supporting complex patient care models, aligning oral and general 
healthcare to Medicare’s standards.
Looking for Expert Advice?
Outsourcing to 24/7 Medical Billing Services (MBS) can be invaluable for healthcare providers 
dealing with these complex regulatory updates. With a deep understanding of CMS guidelines, 
24/7 MBS provides tailored support to ensure providers remain compliant with new credentialing 
requirements, especially those impacting telehealth, advanced primary care, cardiovascular 
services, and more. Their team offers expert guidance on implementing updated protocols, 
handling compliance documentation, and managing billing nuances like the correct application of 
modifiers for drugs and services.
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PREPARING FOR 2025: HOW NEW REGULATIONS IMPACT CREDENTIALING
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