Select the title to see a summary and a link to the full article.
October 15th, 2021
Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 15th, 2021 - Last Review/Update October 19th, 2021
Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?
By Wyn Staheli, Director of Research | Published October 4th, 2021
New ICD Codes for: Low Back Pain, Cervicogenic Headache, Non-Radiographic Axial Spondyloarthritis (nr-axSpA), and Social Determinations of Health (SDOH). These codes became effective on October 1, 2021.
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.”
So what are those requirements?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
Understanding hospital pricing can get complicated, so we have broken it down according to CMS and the acute Inpatient Prospective Payment System, also known as IPPS. Find-A-Code uses IPPS for inpatient pricing with our MS-DRG grouper. The following information comes from CMS.gov and answers the most common questions regarding DRGs ...
Final Rule on Communications Technology and 2021 Physicians Fee Schedule
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...
Medicare Improper Payment Report for Chiropractic (2019)
By Jared Staheli | Published October 12th, 2020
CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report by specialty, chiropractic has the highest Part B improper payment ...
Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately
By Aimee Wilcox | Published July 21st, 2020
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
By Wyn Staheli, Director of Research | Published July 7th, 2020 - Last Review/Update July 8th, 2020
The anticipated changes to the Advanced Beneficiary Notice of Non-coverage (ABN) Form (CMS-R-131) have arrived. This important form is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied.
You can begin using the new ABN immediately if you so wish. However, it becomes mandatory on August 31, 2020.
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 10th, 2020
There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE). The updated files included;
291,902 Deleted Procedure to Procedure (PTP) edits
197 Deleted Medically Unlikely ...
The Centers for Medicare & Medicaid Services finalized several changes in Medicare Advantage and Part D on Friday.
The Trump administration has finalized several changes in Medicare Advantage (MA) and Part D in anticipation of bid submissions on June 1.
The Centers for Medicare & Medicaid Services (CMS) released Friday that includes ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 20th, 2020
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.
The use of Modifier 25 is one example ...
By Wyn Staheli, Director of Research | Published May 4th, 2020
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
By Wyn Staheli, Director of Research | Published April 13th, 2020
COVID-19 Chiropractic Resources contains current, updated information regarding COVID-19. Included are lists of webinars, articles, websites and links pertaining to the ongoing changes.
By Wyn Staheli, Director of Research | Published April 2nd, 2020
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information
Medicare Announces Coverage of Acupuncture Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 30th, 2020
On January 21, 2020, a CMS Newsroom press-release read,
This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...
CMS and HHS Tighten Enrollment Rules and Increase Penalties
By Wyn Staheli, Director of Research | Published September 30th, 2019
This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019.
There have been known problems ...
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
The OIG Work Plan: What Is It and Why Should I Care?
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
By Namas | Published August 2nd, 2019 - Last Review/Update August 8th, 2019
Who knew that when Jack & Jill when up the hill to fetch a pail of water, they would have to ensure that in order to keep the level of water the same on the way back down, they would need to both support the pail.
Many of you in this industry are ...
Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?
By Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA | Published July 22nd, 2019
Question:
What type of documentation is required for a Medicare patient with degenerative joint disease who get adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms.
Answer:
There is no question that these adjustments would be considered ...
Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain
By Wyn Staheli, Director of Research | Published July 17th, 2019
Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.
Helping Others Understand How to Apply Incident to Guidelines
By Namas | Published July 5th, 2019 - Last Review/Update July 16th, 2019
Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...
By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019
A United Approach
As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
By Wyn Staheli, Director of Research | Published April 29th, 2019
On April 12, 2019, Medicare announced that there will be some changes to their appeals process effective June 13, 2019. According to the MLN Matters release (see References), the following policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 are taking place:
The policy on use of electronic signatures
Timing ...
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
By Wyn Staheli, Director of Research | Published April 8th, 2019
Question: What do I do when a Medicare patient refuses to sign an ABN?
Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...
Clearing Up Some Medicare Participation Misunderstandings
By Wyn Staheli, Director of Research | Published March 25th, 2019 - Last Review/Update April 2nd, 2019
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...
The Impact of Medical Necessity on High Level E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019
I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"
The quick answer is, "it depends."
Code 99233 has the following minimal component requirement:
Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
By Wyn Staheli, Director of Research | Published March 18th, 2019
Although it has been quite some time since ChiroCode published an article about the revised instructions for non-participating providers who use the ABN, there are still some outstanding questions about this change. So far, Medicare has not provided additional guidance about this question despite requests by us for clarification.
Medicare now requires non-participating providers to include the ...
Q/A: Can you Help me Understand the New Medicare Insurance Cards?
By Wyn Staheli, Director of Research | Published March 7th, 2019
As many of you are aware, CMS began issuing new Medicare identification cards last year which required the replacement of social security numbers with a new Medicare Beneficiary Identifier (MBI). All cards have now been mailed out and patient's should have the new cards when they come in. Currently, we are in the transition period until January 2020.
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
Medicare Supplemental Policies (MediGap) and Extremity Adjustments
By Wyn Staheli, Director of Research | Published February 25th, 2019
The nice thing about MediGap policies is that they pay for some of the healthcare costs that an original Medicare plan (Part B) does not cover. So when a patient has Medicare and a Medicare supplement (MediGap) and their condition is related to an extremity (a noncovered service), Medicare must ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019
The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward.
Purpose
An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
Charging Missed Appointment Fees for Medicare Patients
By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
Attestations Teaching Physicians vs Split Shared Visits
By BC Advantage | Published February 1st, 2019 - Last Review/Update February 7th, 2019
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
By Find-A-Code | Published January 28th, 2019 - Last Review/Update January 29th, 2019
BLOG: CMS announced a NEWS release today making it easier to help Medicare Beneficiaries access cost and quality information. CMS announced, "Today, the Centers for Medicare & Medicaid Services (CMS) launched a new app that gives consumers a modernized Medicare experience with direct access on a mobile device to some of ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ...
By Wyn Staheli, Director of Research | Published January 3rd, 2019
Back in August of 2018, as part of the Medicare Shared Savings Program (Shared Savings Program), CMS proposed some sweeping changes for Accountable Care Organizations (ACOs). There has been some controversy over these changes which require ACOs to move to two-sided models. In this Final Rule which was scheduled to be published in the Federal Register ...
Medicare Advantage Providers are not Required to be Enrolled in Medicare
By Wyn Staheli, Director of Research | Published December 18th, 2018
There was a ruling that was requiring providers to be enrolled in Medicare in order to provide services for Part C (Medicare Advantage (MA)) and/or Part D. However, on April 2, 2018, CMS released the 2019 Final Rules for MA and Part D which changed this previous ruling. According to ...
Errors Billing Outpatient Services When Patient is also Inpatient
By Wyn Staheli, Director of Research | Published November 29th, 2018
The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance:
Medicare Inappropriately Paid Acute-Care Hospitals for ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 26th, 2018
Immunotherapy (Allergy Shots) is a medical treatment to used to treat and prevent reactions or desensitize the immune system to specific allergens that trigger allergy symptoms. Payers have specific coverage guidance and rules for reporting injections, the specific type of antigen(s) provided and how they should be reported.
Below are the coding guidelines from ...
Reciprocal Billing and Locum Tenens Arrangements Changes
By Wyn Staheli, Director of Research | Published November 26th, 2018
CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate.
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
CMS: Medicare Diabetes Prevention Program Expanded Model
By Find-A-Code | Published November 1st, 2018
CMS announces the Medicare Diabetes prevention program is now a new covered service. Per a recent MLN news release. Medicare Beneficiaries will be notified in 2019 in a Medicare handout. Diabetes affects more than 25 percent of Americans aged 65 or older, and its prevalence is projected to increase approximately...
By Noridian Medicare | Published August 30th, 2018
There are many factors that can contribute to your success in filing claims and getting reimbursed. The information below is from the CMS website.
Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim
A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on ...
By Wyn Staheli, Director of Research | Published August 20th, 2018
Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?
By Wyn Staheli, Director of Research | Published August 16th, 2018
Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time.
It should be noted that while ...
On July 16th 2018, anyone subscribed to the CMS Quality Payment Program received an e-mail containing a letter to doctors from Seem Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS). There are some widespread changes proposed in this letter of which you need to be aware.
Where ...
CMS Proposes Changes to Evaluation & Management Requirements
By Wyn Staheli, Director of Research | Published July 25th, 2018
It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of ...
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
By | Published July 18th, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed.
For ...
By Wyn Staheli, Director of Research | Published July 12th, 2018
It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):
A state plan must provide ...
ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2018
Medicare sent out a news release to inform of incorrect reimbursement and correction.
"End Stage Renal Disease (ESRD) claims are incorrectly reimbursed if they:
Are eligible for Transitional Drug Adjustment Add-On Payment Adjustment and
Contain non-covered charges
After we fix the system on January 1, 2019, your Medicare Administrative Contractor will mass adjust claims ...
Q/A: Can a PT Assistant Perform Physical Therapy Modalities?
By Wyn Staheli, Director of Research | Published June 18th, 2018 - Last Review/Update January 30th, 2019
Whether or not a physical therapy assistant (PTA) may perform physical therapy modalities depends on two factors: state law and payer policies. Read here for more.
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
Will Medicare's Proposed Reformations Affect Your Practice?
By Wyn Staheli, Director of Research | Published June 12th, 2018
Recently, Medicare's Innovation Center released an informal Request for Information (RFI) seeking input on several different system reformation proposals. As the market moves towards more value based payment systems, innovation and new models are being sought to both reduce costs and increase quality. This article outlines the ideas presented in the ...
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns ...
Indications for Serotypes A and B Botulinum Toxins
By Find-A-Code | Published April 16th, 2018
According to Novitas LCD L27476, the following indications apply:
1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
Medicare Using Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting January 2018
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 6th, 2018
On June 17, 2016, CMS announced the release of its final rule implementing section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA). This final rule requires reporting entities to report private payor rates paid to laboratories for lab tests, which will be used to calculate Medicare payment ...
By Wyn Staheli, Director of Research | Published February 1st, 2018
On January 16, 2018, the OIG released a report of their findings on claims data for Medicare Advantage plans. While it appears that there were not significant issues, they did find that:
"Types of potential errors included inactive or invalid billing provider identifiers; duplicated service lines; missing required data; inconsistent dates; ...
By Wyn Staheli, Director of Research | Published January 25th, 2018
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of ...
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
By Wyn Staheli, Director of Research | Published January 15th, 2018 - Last Review/Update January 30th, 2019
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
By Wyn Staheli, Director of Research | Published January 2nd, 2018 - Last Review/Update January 30th, 2019
I checked the government website to see if I am an eligible clinician and it says that I am not. I just don't want to get blindsided with a letter saying I will be penalized. Is there anything you would suggest or recommend that I do now to protect myself from future penalties. Thank you
AT and GA Modifiers When Billing CMT and Non-covered Codes to Medicare
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published December 13th, 2017 - Last Review/Update February 5th, 2019
Questions regarding using modifiers when billing CMT and non-covered codes to Medicare. We have used AT (Active) and GA (signed ABN) when billing active care for CMT codes 98940-98942 (e.g., 98941-ATGA) in the past. Currently we are told not to bill GA with AT. How do we bill?
Medicare Diabetes Prevention Program (MDPP) Expanded Model Information
By Jared Staheli | Published December 12th, 2017
Diabetes treatment places an ever-increasing strain on the resources of the U.S. healthcare system. CMS estimated that in 2016 alone, Medicare incurred an additional $42 billion in costs due to the number of beneficiaries with diabetes. The best way to keep these costs down in the future is by preventing ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 22nd, 2017
ASCs (Ambulatory Surgical Centers) have a separate fee schedule with a base allowed amount that is adjusted for each state using Core Based Statistical Areas (CBSA). Under the ASC payment system, Medicare pays facilities for specific ASC covered surgical procedures, however, there are only certain types of procedures that are eligible for payment ...
By David Klein CPC, CPMA, CHC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 13th, 2017 - Last Review/Update February 5th, 2019
Chiropractors cannot opt-opt of Medicare. Does that only refer to chiropractors that see Medicare patients? Do all Florida chiropractors have to complete Medicare enrollment/credentialing? Bottom line- do ALL chiropractors, no matter where or who, have to complete Medicare enrollment since they cannot Opt-out?
By ChiroCode | Published September 25th, 2017 - Last Review/Update February 5th, 2019
MIPS is a program that allows Medicare to collect data from providers about high quality low cost care that uses technology effectively. There are four categories and providers need to learn about the available measures so that they can pick the ones that make them look the best.
Medicare Improper Payment Report for Chiropractic (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
Medicare Improper Payment Report for Behavioral Health Services (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
By Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC | Published August 25th, 2017 - Last Review/Update January 31st, 2018
On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule."
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
We can look forward to a few prospective payments for Skilled Nursing Facilities, Hospice and Inpatient Rehab; CMS released their final rule and reported on key highlights of the new FY 2018 Medicare payment rules.
CMS States, “The 2018 Skilled Nursing Facility (SNF) Prospective Payment System Final Rule increases Medicare payment rates ...
By Wyn Staheli | Published August 4th, 2017 - Last Review/Update October 4th, 2017
Medicare has proposed making some changes to policies regarding telehealth services. They are adding some new codes to their covered list of telehealth services and propose eliminating the requirement to use the GT modifier. Since many payers adopt similar policies, watch for further announcements from other third-party payers.
Proposed Codes
HCPCS code G0296 ...
By Dr. Mario Fucinari, Author & Member of the Carrier Advisory Committee for Medicare | Published June 28th, 2017 - Last Review/Update February 8th, 2019
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published May 2nd, 2017 - Last Review/Update January 31st, 2019
Watch Another quick tip from the ChiroCode HelpDesk - Plain Film Xray Penalty 2017. Even though this news comes from Medicare, who does not reimburse chiropractic physicians for x-rays, private payers nearly always follow their example. This represents the trend of X-ray reimbursement for all of healthcare.
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 24th, 2017
Medicare has given the option for participation in the Quality Payment Program offering two tracks you can choose from as well as the option to pick your pace. You can choose to start anytime between January 1 and October 2, 2017:
Advanced Alternative Payment Models (APMs) or
The Merit-based Incentive Payment System ...
By ChiroCode | Published February 27th, 2017 - Last Review/Update February 8th, 2019
Question: Is it true that I can opt out of MIPS & MACRA if my part B charges are less than or equal to $30,000? If so, are the charges based on covered Medicare charges (98940, 98941, 98942) or all charges sent to Medicare? Some patients want non-covered charges sent to Medicare too.
By Wyn Staheli, Director of Research | Published February 8th, 2017
In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...
By Wyn Staheli, Director of Research | Published February 6th, 2017
On January 17, 2017, a Final Rule was published in the Federal Register outlining changes to the Medicare Appeals process in an order to streamline procedures and reduce the current backlog of appeals at the third and fourth levels of appeal. This new policy takes effect on March 20, 3017. ...
Code Sets - Health Care Provider Taxonomy Code Set Link
By Raquel Shumway | Published January 24th, 2017
Every Provider needs to know their Health Care Provider Taxonomy Codes. The Taxonomy Codes define the provider type, classification, and area of specialization. We have provided a link and instructions to help you locate your code.
By Wyn Staheli, Director of Research | Published January 23rd, 2017
During the comment period of the MIPS Proposed Rule (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models), there were some concerns about NPI and TIN usage for MIPS reporting for smaller organizations.
The following statements are from the MIPS Final ...
Alternative Payment Models (APMs) and Advanced APMs
By Wyn Staheli, Director of Research | Published January 16th, 2017
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?
According to a fact sheet ...
Medicare’s Quality Payment Program: Getting Paid for Value Instead of Volume
By ChiroCode | Published December 28th, 2016 - Last Review/Update February 8th, 2019
The government has become increasingly concerned with how they spend money in the healthcare sector. As part of the latest proposal to fix this, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015. This law changes reimbursement to remunerate providers more when they provide high quality care rather than just more care. It rewards value over volume. It also ends the flawed Sustainable Growth Rate (SGR) formula that had been in use to determine Medicare payment for many years. And, it combines three other quality-based programs into one. It’s biggest and lasting impact may be how it influences the way that patients select the provider they choose to see.
VACCINE AND VACCINE ADMINISTRATION PAYMENTS UNDER MEDICARE PART D
By Brittney Murdock, QCC, CMCS, CPC | Published December 16th, 2016
Please note: The information in this publication applies only to Medicare Part D; the Prescription Drug Benefit.
Except for vaccines covered under Medicare Part B, Medicare Part D plans cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness.
Health care professionals (sometimes known as ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 22nd, 2016
If you are a part of the team of Medicare’s Part B clinicians, Medicare is providing you with a new quality payment program. You will get to chose from Advanced Alternative Payment Models (APMs or Merit-Based incentive Payment system (MIPS). The MIPS is a new program that combines parts of ...
By ChiroCode | Published November 19th, 2016 - Last Review/Update March 5th, 2019
(from page 210 in chapter 3.5 of the 2017 DeskBook) One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record.
Here are some specific situations as they may ...
CMS Finalizes the New Medicare Quality Payment Program
By ChiroCode | Published October 17th, 2016 - Last Review/Update March 5th, 2019
On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program.
By Wyn Staheli, Director of Research | Published September 17th, 2016
The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:
Medicare
Federal Workers’ Compensation
Military and Veterans
Medicaid
Federal ...
CMS offering options for MACRA Participation. You Choose - Be prepared!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2016
The most recent Blog Post from CMS has given a new update on The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS states they will allow providers four options of reporting for the first year of the program stating they can pick their pace of participation for the ...
Mastering Medicare: When Opting Out is not an Option
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Unlike MDs and DOs, chiropractors may not opt out of Medicare.
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t.
The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US do you really want to limit your patient base?
The Health Insurance Portability and Accountability Act (HIPAA) has been around for quite some time. There are many misconceptions about HIPAA compliance that our office still gets calls about. This page is to help clear up some of these misconceptions.
Skilled nursing facilities paid for participating in new program, starting the summer of 2016
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 19th, 2016
Medicare plans to start a Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP), beginning fiscal year 2019. This program will be used to promote better clinical outcomes for skilled nursing facility patients and improve care during their stay at a skilled nursing facility. Skilled nursing facilities will be paid for participating. ...
CMS Publishes Final Rule on Fire Safety Requirements for Certain Health Care Facilities
By Brittney Murdock, QCC, CMCS, CPC | Published May 3rd, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule (https://www.federalregister.gov/public-inspection) to update health care facilities’ fire protection guidelines to improve protections for all Medicare beneficiaries in facilities from fire.
The new guidelines apply to hospitals; long term care (LTC) facilities; critical access hospitals (CAHs); inpatient hospice facilities; ...
CMS Finalizes its Quality Measure Development Plan
By Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS | Published May 3rd, 2016
On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals ...
Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.
By Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
Formats for Submitting Claims to Medicare - Electronic Submission Requirements
By Find-A-Code | Published July 20th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
The Administrative Simplification Compliance Act (ASCA) requires that claims be submitted to Medicare electronically unless certain exceptions are met. In addition, the Health Insurance ...
Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04)
By Jared Staheli | Published July 10th, 2015
Carriers shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the carrier record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90 modifier. If the laboratory test billed is not a reference laboratory ...
In addition to the amounts provided under the fee schedules, the Secretary shall provide for and establish a nominal fee to cover the appropriate costs of collecting the sample on which a clinical laboratory test was performed and for which payment is made with respect to samples collected in the ...
Medicare allows separate charges made by laboratories for drawing or collecting specimens whether or not the specimens are referred to hospitals or independent laboratories. The laboratory does not bill for routine handling charges where a specimen is referred by one laboratory to another.
Medicare allows payment for a specimen collection fee ...
Specimen Drawing for Dialysis Patients (Rev. 3056, 12-01-14)
By Jared Staheli | Published July 10th, 2015
See the Medicare Benefit Policy Manual, Chapter 11, for a description of laboratory services included in the composite rate. With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base ...
Clinical laboratory tests are covered under Medicare if they are reasonable and necessary for the diagnosis or treatment of an illness or injury. Because of the numerous technological advances and innovations in the clinical laboratory field and the increased availability of automated testing equipment, no distinction is generally made in ...
Profiles are specific groupings of blood chemistries that enable physicians to more accurately diagnose their patients’ medical problems. While the component tests in automated profiles may vary somewhat from one laboratory to another, or from one physician’s office or clinic to another, in order to develop appropriate payment amounts, contractors ...
When displaying claims payment for each CPT code in history, contractors apply the following rules:
1. If all component tests of any panel are allowed because the individual line item comparison is less than the fee (as determined in item C above), record the panel codes as determined on the line-by-line ...
The Competitive Acquisition Program (CAP) for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
Section 303 (d) of the Medicare Prescription Improvement and Modernization Act (MMA) of 2003 requires the implementation of a competitive acquisition program (CAP) for Medicare Part B drugs and biologicals not paid on a cost or prospective payment system basis. Beginning with drugs administered on or after July 1, 2006, ...
Application of Local Medical Review Policies (Rev. 866, 07-03-06) - Competitive Acquisition Program
By Jared Staheli | Published July 9th, 2015
Carriers and/or Program Safeguard Contractors shall apply all Local Coverage Determination (LCD) policies and National Coverage Determination (NCD) policies to the administration and no-pay drug code lines on the CAP claims.
Should it be determined that a drug administration or drug code service line does not meet the requirements of the ...
Creation of Internal Vendor Provider Files (Rev. 866, 07-03-06) - Competitive Acquisition Program
By Jared Staheli | Published July 9th, 2015
The designated carrier shall create an internal provider file for each vendor which includes the names, addresses, and UPINs, (NPI when effective), of those physicians who have elected that vendor.
The designated carrier shall edit incoming vendor claims to verify that the UPIN number on the claim for the ordering physician ...
Diagnostic X-ray, laboratory, and other diagnostic tests, including materials and the services of technicians, are covered under the Medicare program. Some clinical laboratory procedures or tests require Food and Drug Administration (FDA) approval before coverage is provided.
A diagnostic laboratory test is considered a laboratory service for billing purposes, regardless of ...
“Independent Laboratory” - An independent laboratory is one that is independent both of an attending or consulting physician’s office and of a hospital that meets at least the requirements to qualify as an emergency hospital as defined in §1861(e) of the Social Security Act (the Act.) (See the Medicare Benefits ...
General Explanation of Payment (Rev. 2581, 04-01-13) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
Outpatient laboratory services can be paid in different ways:
• Physician Fee Schedule;
• 101 percent of reasonable cost (critical access hospitals (CAH) only);
NOTE: When the CAH bills a 14X bill type for a non-patient laboratory specimen, the CAH is paid under the fee schedule.
• Laboratory Fee Schedule;
• Outpatient Prospective Payment System, ...
Calculation of Payment Rates - Clinical Laboratory Test Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Under Part B, for services rendered on or after July 1, 1984, clinical laboratory tests performed in a physician’s office, by an independent laboratory, or by a hospital laboratory for its outpatients are reimbursed on the basis of fee schedules. Current exceptions to this rule are CAH laboratory services as ...
Initial Development of Laboratory Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Initially, each carrier established the fee schedules on a carrier-wide basis (not to exceed a statewide basis). If a carrier’s area includes more than one State, the carrier established a separate fee schedule for each State. The carrier determined the fee schedule amount based on prevailing charges for laboratory billings ...
The CMS adjusts the fee schedule amounts annually to reflect changes in the Consumer Price Index for all urban consumers (CPI-U) (U.S. city average) and the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity, unless alternative updates are specified by legislation. The CMS communicates this ...
Mandatory Assignment for Laboratory Tests (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Unless a laboratory, physician, or medical group accepts assignment, the carrier makes no Part B payment for laboratory tests paid on the laboratory fee schedule. Laboratories, physicians, or medical groups that have entered into a participation agreement must accept assignment. Sanctions of double the violation charges, civil money penalties (up ...
Rural Health Clinics (Rev. 1, 10-01-03) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
Rural Health Clinics (RHCs) must furnish the following laboratory services to be approved as an RHC. However, these and other laboratory services that may be furnished are not included in the encounter rate and must be billed separately:
• Chemical examinations of urine by stick or tablet method or both;
• Hemoglobin ...
Deductible and Coinsurance Application for Laboratory Tests (Rev. 2581, 04-01-13)
By Jared Staheli | Published July 9th, 2015
Neither the annual cash deductible nor the 20 percent coinsurance apply to:
• Clinical laboratory tests performed by a physician, laboratory, or other entity paid on an assigned basis;
• Specimen collection fees; or
• Travel allowance related to laboratory tests (e.g., collecting specimen).
Codes on the physician fee schedule are generally subject to ...
Method of Payment for Clinical Laboratory Tests - Place of Service Variation (Rev. 2971, 07-07-14)
By Jared Staheli | Published July 9th, 2015
The following apply in determining the amount of Part B payment for clinical laboratory tests:
Laboratory tests not payable on the Clinical Diagnostic Laboratory Fee Schedule (CLFS) will be based on OPPS (for hospitals subject to OPPS) and current methodology for hospitals not subject to OPPS.
Independent laboratory or a physician or ...
Payment for Review of Laboratory Test Results by Physician (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Reviewing results of laboratory tests, phoning results to patients, filing such results, etc., are Medicare covered services. Payment is included in the physician fee schedule payment for the evaluation and management (E and M) services to the patient. Visit services entail a wide range of components and activities that may ...
Which Contractor to Bill for Laboratory Services Furnished to a Medicare Beneficiary in a Skilled Nursing Facility (SNF) (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Inpatient Part A beneficiary - SNF bills the FI under Part A. The service is included in SNF PPS payment.
Inpatient Part B beneficiary (benefits exhausted or no Part A entitlement) - SNFs may provide the service and bill the FI, may obtain the service under arrangement and bill the ...
Date of Service (DOS) for Clinical Laboratory and Pathology Specimens (Rev. 1515, 01-05-09)
By Jared Staheli | Published July 9th, 2015
The DOS policy for either a clinical laboratory test or the technical component of physician pathology service is as follows:
General Rule: The DOS of the test/service must be the date the specimen was collected.
Variation: If a specimen is collected over a period that spans two calendar days, then the DOS ...
The Medicare Modernization Act section 303(e)(1) added section 1842(o)(5)(C) of the Social Security Act which requires that, beginning January 1, 2005, a furnishing fee will be paid for items and services associated with clotting factor.
Beginning January 1, 2005, a clotting factor furnishing fee is separately payable to entities that furnish ...
Intravenous Immune Globulin (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
Beginning for dates of service on or after January 1, 2004, Medicare pays for intravenous immune globulin administered in the home. (See the Medicare Benefit Policy Manual, Chapter 15 for coverage requirements.) Contractors pay for the drug, but not the items or services related to the administration of the drug ...
Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs) (Rev. 1212; 06-29-07)
By Jared Staheli | Published July 9th, 2015
Patients with end stage renal disease (ESRD) receiving administrations of erythropoiesis stimulating agents (ESA), such as epoetin alfa (EPO) and Darbepoetin alfa (Aranesp) for the treatment of anemia may receive intravenous administration or subcutaneous administrations of the ESA.
Effective for claims submitted on or after February 1, 2007 with dates of ...
Exceptions to Average Sales Price (ASP) Payment Methodology (Rev. 2437, 01-01-13) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 8th, 2015
The payment allowance limits for blood and blood products (other than blood clotting factors) that are not paid on a reasonable charge or prospective payment basis, are determined in the same manner the payment allowance limits were determined on October 1, 2003. Specifically, the payment allowance limits for blood and ...
Calculation of the AWP (Rev. 397, 01-03-05) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 8th, 2015
See Business Requirements and Excel Spreadsheets at http://www.medicaid.com/manuals/pm_trans/R54CP.pdf http://www.medicaid.com/manuals/pm_trans/R55CP.pdf
Carriers must ensure that if any NDCs are added or deleted, the formulae are applied appropriately.
A separate AWP is calculated for each drug as defined by a HCPCS code. Within each HCPCS code there may be a single source or there may ...
Carrier Distribution of Limit Amounts (Rev. 1, 10-01-03) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 8th, 2015
The FIs get drug prices from the carrier for drugs not listed on the SDP.
Carriers prepare a list of the drug payment allowance limits updates (or new file depending upon local requirements) to the claims system.
Carriers distribute, free of charge, the updated limits in an agreed upon format directly to ...
Discarded Drugs and Biologicals (Rev. 1962, 07-30-10)
By Jared Staheli | Published July 8th, 2015
The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.
When a physician, hospital or other provider or supplier must discard the remainder of a single ...
Discarded Erythropoietin Stimulating Agents for Home Dialysis (Rev. 1581; 12-01-08)
By Jared Staheli | Published July 8th, 2015
Multiuse vials are not subject to payment for discarded amounts of drug or biological, with the exception of self administered erythropoietin stimulating agents (ESAs) by Method I home dialysis patients. The renal facility must bill the program using the modifier JW for the amount of ESAs appropriately discarded if the ...
Assignment Required for Drugs and Biologicals (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
A. Local Carriers
Under §114 of the Benefits Improvement Act of 2000, effective for claims with dates of service on or after February 1, 2001, payment for any drug or biological covered under Part B of Medicare may be made only on an assignment-related basis. Therefore, no charge or bill may ...
DMEPOS Suppliers Require a License to Dispense Drugs (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Regulations at 42 CFR 424.57(b)(4) (supplier standards) state that a “supplier that furnishes a drug used as a Medicare-covered supply with durable medical equipment or prosthetic devices must be licensed by the State to dispense drugs. (A supplier of drugs must bill and receive payment for the drug in its ...
Prescription Drugs Billed by Suppliers Not Licensed to Dispense Them (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Medicare does not cover a drug used as a supply with DME or a prosthetic device if the drug is dispensed by an entity that is not licensed to dispense the drug. The drug is not considered to be reasonable and necessary because CMS cannot be assured of its safety ...
Reporting Modifiers in the Compound Drug Segment (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Certain informational modifiers are required on compound ingredients. The NCPDP format does not currently support reporting modifiers in the compound segment. Therefore, the narrative portion in the prior authorization segment must be used to report these modifiers. The following must be entered in positions 001-003 of the narrative (Example, MMN ...
Oral Anti-Emetic Drugs Used as Full Replacement for Intravenous Anti-Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
See the Medicare Benefit Policy Manual, Chapter 15, and the National Coverage Determination (NCD) Manual, Section 110.18, for detailed coverage requirements.
Effective for dates of service on or after January 1, 1998, Medicare Part B (including (institutional claims processed by Part A Medicare Administrative Contractors (MACs) and physician/supplier claims processed by ...
Screening for Depression in Adults (Rev. 2431,10-14-11)
By Jared Staheli | Published July 7th, 2015
A. Coverage Requirements
Effective October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual screening up to 15 minutes for Medicare beneficiaries in primary care settings that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up. Various screening tools are ...
Intensive Behavioral Therapy for Obesity (Effective November 29, 2011) (Rev. 2421, 11-29-11)
By Jared Staheli | Published July 7th, 2015
The United States Preventive Services Task Force (USPSTF) found good evidence that body mass index (BMI) is a reliable and valid indicator for identifying adults at increased risk for mortality and morbidity due to overweight and obesity. It also good evidence that high intensity counseling combined with behavioral interventions in ...
Payment Rules for Drugs and Biologicals (Rev. 2437, 01-01-13)
By Jared Staheli | Published July 7th, 2015
Drugs for inpatient hospital and inpatient skilled nursing facility (SNF) beneficiaries are included in the respective prospective payment system (PPS) rates, except for hemophilia clotting factors for hospital inpatients under Part A.
All hospital outpatient drugs are excluded from SDP because the payment allowance for such drugs is determined by a ...
MMA Drug Pricing – Average Sales Price (Rev. 1513, 06-23-08)
By Jared Staheli | Published July 7th, 2015
In general, CMS establishes a single, national payment limit for FI, carrier, DME MAC, and A/B MAC payment for each Medicare-covered drug whose payment is determined based on the methodology described above. Drugs billed to DME MACs are still priced locally, albeit under the new statutory formula, as applicable. The ...
Average Sales Price (ASP) Payment Methodology (Rev. 1513, 06-23-08) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 7th, 2015
Section 303(c) of the Medicare Modernization Act of 2003 (MMA) revised the payment methodology for Part B covered drugs and biologicals that are not priced on a cost or prospective payment basis. Per the MMA, beginning January 1, 2005, the vast majority of drugs and biologicals not priced on a ...
A/B MAC and Fiscal Intermediary (FI) Billing Requirements for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Contractors will pay for IPPE or EKG only when the services are submitted on one of the following TOBs: 12X, 13X, 22X, 71X, 73X and 85X.
Type of facility and setting determines the basis of payment:
• For the IPPE or the screening EKG tracing only performed on a 12X and 13X ...
Remittance Advice Remark Codes for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
Contractors shall use the appropriate claim Remittance Advice Remark code, such as N117 (This service is paid only once in a patient’s lifetime) when denying additional claims for an IPPE and/or a screening EKG.
...
Claims Adjustment Reason Codes for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
Contractors shall use the appropriate Claim Adjustment Reason code, such as 149 (Lifetime benefit maximum has been reached for this service/benefit category) when denying additional claims for an IPPE and/or a screening EKG.
...
Advanced Beneficiary Notice (ABN) as Applied to the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
If a second IPPE is billed for the same beneficiary, it would be denied based on Section 1861(s)(2) of the Act, since the IPPE is a one-time benefit, and an ABN would not be required in order to hold the beneficiary liable for the cost of the second IPPE. However, ...
Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 6th, 2015
Section 1861(s)(2)(AA) and 1861(bbb) of the Social Security Act and implementing regulations at 42 CFR 410.19 authorize coverage under Medicare Part B for a one-time ultrasound screening for abdominal aortic aneurysm (AAA), effective January 1, 2007.
...
Definitions for Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 6th, 2015
The term “ultrasound screening for abdominal aortic aneurysm” means the following services furnished to an asymptomatic individual for the early detection of an abdominal aortic aneurysm—
(1) a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of Health ...
Coverage for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 6th, 2015
Payment may be made for a one-time ultrasound screening for AAA for beneficiaries who meet the following criteria:
(i) receives a referral for such an ultrasound screening from the beneficiary’s attending physician, physician assistant, nurse practitioner or clinical nurse specialist;
(ii) receives such ultrasound screening from a provider or supplier who is ...
Payment for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 1113, 01-02-07)
By Jared Staheli | Published July 6th, 2015
If the screening is provided in a physician office, the service is billed to the carrier using the HCPCS code identified in section 110.3.2 below. Payment is under the Medicare Physicians Fee Schedule (MPFS).
Fiscal Intermediaries (FIs) shall pay for the AAA screening only when the services are performed in a ...
Payment Method for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Payment for HIV screening is under the Medicare Clinical Laboratory Fee Schedule for TOBs 12X, 13X, 14X, 22X, and 23X beginning January 1, 2011. For TOB 85X payment is based on reasonable cost. Deductible and coinsurance do not apply. Between December 8, 2009, and April 4, 2010, these services can ...
Pursuant to section 4103 of the Affordable Care Act of 2010, the Centers for Medicare & Medicaid Services (CMS) amended section 411.15(a)(1) and 411.15(k)(15) of 42 CFR (list of examples of routine physical examinations excluded from coverage) effective for services furnished on or after January 1, 2011. This expanded coverage ...
Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after August 25, 2010, the Centers for Medicare & Medicaid Services (CMS) will cover counseling to prevent tobacco use services for outpatient and hospitalized Medicare beneficiaries:
1. Who use tobacco, regardless of whether they have signs or symptoms of tobaccorelated disease;
2. Who ...
For services furnished on or after November 8, 2011, the Centers for Medicare & Medicaid Services (CMS) covers intensive behavioral therapy (IBT) for cardiovascular disease (CVD). See National Coverage Determinations (NCD) Manual (Pub. 100-03) §210.11 for complete coverage guidelines.
...
Specialty Codes and Place of Service (POS) for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Medicare provides coverage for screening for chlamydia, gonorrhea, syphilis, and/or hepatitis B and HIBC to prevent STIs only when ordered by a primary care practitioner (physician or non-physician) with any of the following specialty codes:
• 01 – General Practice
• 08 – Family Practice
• 11 – Internal Medicine
• 16 – Obstetrics/Gynecology
• ...
MSN Messages for Prostate Cancer Screening Tests and Procedures (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
If a claim for screening prostate specific antigen test or a screening digital rectal examination is being denied because of the age of the beneficiary, FIs use MSN message 18.13:
This service is not covered for patients under 50 years of age.
The Spanish version of this MSN message should read:
Este servicio ...
See the Medicare Benefit Policy Manual, Chapter 1, for Medicare Part B coverage and effective dates of colorectal rectal screening services.
Effective for services furnished on or after January 1, 1998, payment may be made for colorectal cancer screening for the early detection of cancer. For screening colonoscopy services (one of ...
Determining Frequency Standards for Colorectal Cancer Screening (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
To determine the 11, 23, 47, and 119 month periods, start counts beginning with the month after the month in which a previous test/procedure was performed.
EXAMPLE: The beneficiary received a fecal-occult blood test in January 2000. Start counts beginning with February 2000. The beneficiary is eligible to receive another blood ...
Claims Submission Requirements and Applicable HCPCS Codes for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
Claims for screening for glaucoma should be submitted on Form CMS-1500 to carriers and Form CMS-1450 to FIs or their electronic equivalents. Claims must be prepared and submitted by physicians and providers to the carrier in accordance with the general instructions in Chapter 26. Claims submitted to FIs must be ...
Additional Coding Applicable to Claims Submitted to FIs for Glaucoma Screening Services (Rev. 371, 04-04-05)
By Jared Staheli | Published July 5th, 2015
A. Type of Bill The applicable FI claim bill types for screening glaucoma services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X. (See instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs).)
B. Revenue Coding The following revenue codes should be reported when billing for screening ...
Special Billing Instructions for RHCs and FQHCs for Glaucoma Screening Services (Rev. 371, 04-04-05)
By Jared Staheli | Published July 5th, 2015
Screening glaucoma services are considered RHC/FQHC services. For claims with dates of service before April 1, 2005, RHCs and FQHCs bill the FI under bill type 71X or 73X along with revenue code 0770 and HCPCS codes G0117 or G0118 and RHC/FQHC revenue code 0520 or 0521 to report the ...
Payment Methodology for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
Carriers pay for glaucoma screening based on the Medicare Physician Fee Schedule. Deductible and coinsurance apply. Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge, which means they cannot charge the beneficiary more than 115 percent of the allowed amount.
FI pay ...
Determining the 11-Month Period for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed. To determine the 11- month period, start counts beginning with the month after the month in which the previous covered screening procedure was performed.
...
Remittance Advice Notices for Glaucoma Screening Services (Rev. 895, 04-03-06)
By Jared Staheli | Published July 5th, 2015
Appropriate remittance advice(s) must be used by fiscal intermediaries and carriers when denying payment for glaucoma screening. The following messages are used where applicable:
• If the services were furnished before January 1, 2002, use existing ANSI X12N 835 remittance advice claim adjustment reason code 26 “Expenses incurred prior to coverage” ...
MSN Messages for Glaucoma Screening Services (Rev. 895, 04-03-06)
By Jared Staheli | Published July 5th, 2015
The following MSN messages where appropriate must be used.
If a claim for a screening for glaucoma is being denied because the service was performed prior to January 1, 2002, use the MSN message:
MSN Message 16.54:
This service is not covered prior to January 1, 2002.
The Spanish version of the MSN message ...
(NOTE: For billing and payment requirements for the Annual Wellness Visit, see chapter 18, section 140, of this chapter.)
Background: Sections 1861(s)(2)(w) and 1861(ww) of the Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11)) authorize coverage under Part B for a one-time initial preventive physical examination ...
MSN Messages for Screening Pap Smears (Rev. 1, 10-01-03)
By Jared Staheli | Published June 29th, 2015
If there are no high risk factors, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed use MSN 18.17:
Medicare pays for a screening Pap smear and/or screening pelvic examination only once every (2, 3) years unless high risk ...
If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ANSI X12N 835:
• Claim adjustment reason code 119 - “Benefit maximum for this time period has been reached” at the ...
Section 4102 of the BBA of 1997 (P.L. 105-33) amended §1861(nn) of the Act (42 USC 1395X(nn)) to include Medicare Part B coverage of screening pelvic examinations (including a clinical breast examination) for all female beneficiaries for services provided January 1, 1998 and later. Effective July 1, 2001, the Consolidated ...
MSN Messages for Screening Pelvic Examinations (Rev. 440, 07-05-05)
By Jared Staheli | Published June 29th, 2015
If there are no high risk factors, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, contractors use MSN 18-17:
• Medicare pays for a screening Pap smear and/or screening pelvic examination only once every (2, 3) years unless ...
Remittance Advice Codes for Screening Pelvic Examinations (Rev. 440, 07-05-05)
By Jared Staheli | Published June 29th, 2015
If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ANSI X12N 835:
• Claim adjustment reason code 119 - “Benefit maximum for this time period has been reached” at the ...
The following messages are used on the MSN.
If the claim is denied because the beneficiary is under 35 years of age, use the following MSN:
MSN 18.3:
Screening mammography is not covered for women under 35 years of age.
The Spanish version of this MSN message should read:
Las pruebas de mamografía para mujeres ...
If the claim is denied because the beneficiary is under 35 years of age, contractors must use existing ASC X12N 835 claim adjustment reason code/message 6, “The procedure/revenue code is inconsistent with the patient’s age” along with the remark code M37 (at the line item level), “Service is not covered ...
Effective January 1, 1998, §1861(nn) of the Act (42 USC 1395x(nn)) provides Medicare Part B coverage for a screening Pap smear for women under certain conditions. See the Medicare Benefit Policy Manual, Chapter 15, for coverage of screening PAP smears.
To be covered screening Pap smears must be ordered and collected ...
Pap Smears On and After July 1, 2001 (Rev. 1, 10-01-03)
By Jared Staheli | Published June 26th, 2015
The following requirements must be met.
1. The beneficiary has not had a screening Pap smear test during the preceding three years (i.e., 35 months have passed following the month that the woman had the last covered Pap smear. Use one of the following ICD-9-CM codes V76.2, V76.47, or V76.49; or
2. ...
Payment Method for RHCs and FQHCs for Screening Pap Smears (Rev. 795, 04-03-06)
By Jared Staheli | Published June 26th, 2015
The professional component of a screening Pap smear furnished within an RHC/FQHC by a physician or non physician is considered an RHC/FQHC service. RHCs and FQHCs bill the FI under bill type 71X or 73X for the professional component along with revenue code 052X. See Chapter 9, for RHC and ...
FI – Telehealth Originating Site Facility Fee – Medicare Part B – Payment Policy for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2009, IHS providers, including CAHs are paid separately from the AIR for the Telehealth Originating Site Facility Fee. HCPCS code Q3014 (“telehealth originating site facility fee”) is a Part B benefit. The fee is updated each calendar year by the Medicare Economic Index announced in the annual ...
FI – Telehealth Originating Site Facility Fee – Medicare Part B – Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
The Telehealth Originating Site Facility Fee is reported on TOB 12X, 13X or 85X along with the revenue code 0780 and HCPCS code Q3014 as described in Chapter 12, Section 190 of Pub. 100-04, Medicare Claims Processing Manual.
No clinic visit shall be billed if this is the only service received. ...
FI -- Payment for Distant Site Practitioner Services for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
Distant site services are listed in §190.3 in Chapter 12 of this manual. These services are payable only by the FI to a Method II CAH. Payment is based on 80 percent of the MPFS. Deductible and coinsurance apply, but are waived by IHS.
The MSN is suppressed.
...
All IHS hospitals that convert to CAH status are subject to audit by the FI. CMS’ audit policy can be found in Chapter 8, Contractor Procedures for Provider Audit, of Pub. 100- 06, Medicare Financial Management Manual.
The CAHs are reimbursed under the Medicare Principles of Reasonable Costs. These principles are ...
Method E Cost Reports for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS has used the Method E cost report since it began filing cost reports with CMS in 1998. Method E is the method of cost apportionment which is used to calculate the all inclusive outpatient per visit rate and the all inclusive inpatient ancillary per diem rate. Both of ...
Critical Access Hospitals for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All IHS hospitals that elect CAH status, and are certified as such, are reimbursed under the reasonable cost method of reimbursement. The all inclusive inpatient per diem rate, the all inclusive outpatient per visit rate, and the all inclusive inpatient ancillary per diem rate are calculated based upon the individual ...
Payment to Non-Indian Health Service Physicians by Indian Health Service (IHS) Providers for Teleradiology Interpretations (Rev. 1643, 03-09-09)
By Jared Staheli | Published June 25th, 2015
The IHS providers may choose to purchase or otherwise contract for teleradiology interpretation from non-IHS practitioners. Two options are available for payment for these services.
(1) Contractual Reassignment – Under this provision, non-IHS physicians can reassign their benefits to the IHS hospital where the technical component is performed. Non-IHS practitioners providing ...
Medicare Preventive and Screening Services (Rev. 2233, 06-28-11)
By Jared Staheli | Published June 25th, 2015
The Patient Protection and Affordable Care Act (ACA) amended the definition of “Preventive Services” available in Medicare and included two additional preventive physical examination services: the initial preventive physical examination (IPPE) and the annual wellness visit (AWV).
The definition of preventive services and the corresponding table of services are reflective of ...
Definition of Preventive Services (Rev. 2233, 06-28-11)
By Jared Staheli | Published June 25th, 2015
Section 4104 of the ACA revised section 1861(ddd) of the Social Security Act (the Act) to add subsection (3), which defines the term “preventive services” as follows:
• The specific services currently listed in section 1861(ww)(2) of the Act with the explicit exclusion of electrocardiograms (as specified in section 1861(ww)(2)(M) of ...
Waiver of Cost Sharing Requirements of Coinsurance, Copayment and Deductible for Furnished Preventive Services Available in Medicare (Rev. 2233, 06-28-11)
By Jared Staheli | Published June 25th, 2015
Section 4104(b)(4) of the ACA, amends section 1833(a)(1) of the Act, by requiring 100 percent payment for the IPPE, AWV and for those preventive services recommended by the United States Preventive Services Task Force (USPSTF) with a grade of A or B for any indication or population and that are ...
Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
For Carriers/AB MACs, Part B of Medicare pays 100 percent of the Medicare allowed amount for pneumococcal vaccines and influenza virus vaccines and their administration.
Part B deductible and coinsurance do not apply for pneumococcal and influenza virus vaccine.
Part B of Medicare also covers the hepatitis B vaccine and its administration. ...
Pneumococcal vaccine, influenza virus vaccine, and hepatitis B vaccine and their administration are covered only under Medicare Part B, regardless of the setting in which they are furnished, even when provided to an inpatient during a hospital stay covered under Part A.
See Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, ...
Section 1861(s)(10)(A) of the Social Security Act and regulations at 42 CFR 410.57 authorize Medicare coverage under Part B for pneumococcal vaccine and its administration. Medicare does not require for coverage purposes, that a doctor of medicine or osteopathy order the pneumococcal vaccine and its administration. Therefore, the beneficiary may ...
Effective for services furnished on or after May 1, 1993, the influenza virus vaccine and its administration is covered when furnished in compliance with any applicable State law. Typically, this vaccine is administered once a flu season. Medicare does not require for coverage purposes that a doctor of medicine or ...
Effective for services furnished on or after September 1, 1984, the hepatitis B vaccine and its administration is covered if it is ordered by a doctor of medicine or osteopathy and is available to Medicare beneficiaries who are at high or intermediate risk of contracting hepatitis B, e.g., exposed to ...
A. Edits Not Applicable to Pneumococcal or Influenza Virus Vaccine Bills and Their Administration
The Common Working File (CWF) and shared systems bypass all Medicare Secondary Payer (MSP) utilization edits in CWF on all claims when the only service provided is pneumococcal or influenza virus vaccine and/or their administration. This ...
Bills Submitted to FIs/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The applicable types of bills acceptable when billing for influenza virus and pneumococcal vaccines are 12X, 13X, 22X, 23X, 34X, 72X, 75X, 83X and 85X.
The following revenue codes are used for reporting vaccines and administration of the vaccines for all providers except RHCs and FQHCs. Independent and provider based RHCs ...
FI/AB MAC Payment for Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus Vaccines and Their Administration (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Payment for Vaccines
Payment for all of these vaccines is on a reasonable cost basis for hospitals, home health agencies (HHAs), skilled nursing facilities (SNFs), critical access hospitals (CAHs), and hospital-based renal dialysis facilities (RDFs). Payment for comprehensive outpatient rehabilitation facilities (CORFs), Indian Health Service hospitals (IHS), IHS CAHs and ...
Special Instructions for Independent and Provider-Based Rural Health Clinics/Federally Qualified Health Center (RHCs/FQHCs) (Rev. 1586,10-06-08)
By Jared Staheli | Published June 25th, 2015
Independent and provider-based RHCs and FQHCs do not include charges for influenza virus and pneumococcal vaccines on Form CMS-1450. Administration of these vaccines does not count as a visit when the only service involved is the administration of influenza virus and/or pneumococcal vaccine(s). If there was another reason for the ...
Bills Submitted to Regional Home Health Intermediaries (RHHIs) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The following provides billing instructions for Home Health Agency (HHAs) in various situations:
• Where the sole purpose for an HHA visit is to administer a vaccine (influenza virus, pneumococcal, or hepatitis B), Medicare will not pay for a skilled nursing visit by an HHA nurse under the HHA benefit. However, ...
Bills Submitted by Hospices and Payment Procedures for Renal Dialysis Facilities (RDF) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Hospices can provide the influenza virus, pneumococcal, and hepatitis B vaccines to those beneficiaries who request them including those who have elected the hospice benefit. These services may be covered when furnished by the hospice. Services for the vaccines should be billed to the local carrier/AB MAC on the Form ...
Hepatitis B Vaccine Furnished to ESRD Patients (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Hepatitis B vaccine and its administration (including staff time and supplies such as syringes) are paid to ESRD facilities in addition to, and separately from, the dialysis composite rate payment.
Payment for the hepatitis B vaccine for ESRD patients follows the same general principles that are applicable to any injectable drug ...
Claims Submitted to Carriers/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Medicare does not require that the influenza virus vaccine be administered under a physician’s order or supervision. Effective for claims with dates of service on or after July 1, 2000, Medicare does not require that pneumococcal vaccinations be administered under a physician’s order or supervision. Medicare still requires that the ...
Carrier/AB MAC Indicators for the Common Working File (CWF) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The carrier/AB MAC record submitted to CWF must contain the following indicators:
Description
Payment Indicator
Payment
Deductible Indicator
Deductible
Type of Service
Pneumococcal
“1”
100 percent
“1”
Zero deductible
“V”
Influenza
“1”
100 percent
“1”
Zero deductible
“V”
Hepatitis B
“0”
80 percent
“0”
Deductible applies
"1"
A payment indicator of “1” represents 100 percent payment. A deductible indicator of “1” represents a zero deductible. A payment indicator of “0” represents 80 percent payment. A ...
Carrier/AB MAC Payment Requirements (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Payment for pneumococcal, influenza virus, and hepatitis B vaccines follows the same standard rules that are applicable to any injectable drug or biological. (See chapter 17 for procedures for determining the payment rates for pneumococcal and influenza virus vaccines.)
Effective for claims with dates of service on or after February 1, ...
Simplified Roster Claims for Mass Immunizers (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass pneumococcal and influenza virus vaccination programs offered by PHCs and other individuals and entities that give the vaccine to a group of beneficiaries, e.g. at PHCs, shopping malls, grocery stores, senior citizen homes, and health ...
Roster Claims Submitted to AB MACs for Mass Immunization (Rev. 3159, 02-02-15)
By Jared Staheli | Published June 25th, 2015
If the PHC or other individual or entity qualifies to submit roster claims, it may use a preprinted Form CMS-1500 that contains standardized information about the entity and the benefit. Key information from the beneficiary roster list and the abbreviated Form CMS-1500 is used to process pneumococcal and influenza virus ...
Centralized Billing for Influenza Virus and Pneumococcal Vaccines to Medicare Carriers/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The CMS currently authorizes a limited number of providers to centrally bill for influenza virus and pneumococcal immunization claims. Centralized billing is an optional program available to providers who qualify to enroll with Medicare as the provider type “Mass Immunization Roster Biller,” as well as to other individuals and entities ...
Claims Submitted to FIs/AB MACs for Mass Immunizations of Influenza Virus and Pneumococcal Vaccinations (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Some potential "mass immunizers," such as hospital outpatient departments and HHAs, have expressed concern about the complexity of billing for the influenza virus vaccine and its administration. Consequently, to increase the number of beneficiaries who obtain needed preventive immunizations, simplified (roster) billing procedures are available to mass immunizers. The simplified ...
Simplified Billing for Influenza Virus and Pneumococcal Vaccine Services by HHAs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The following billing instructions apply to HHAs that roster bill for influenza virus and pneumococcal vaccines.
• When an HHA provides the influenza virus vaccine or the pneumococcal vaccine in a mass immunization setting, it does not have the option to pick and choose whom to bill for this service. If ...
In order to prevent duplicate payments for influenza virus and pneumococcal vaccination claims by the local contractor/AB MAC and the centralized billing contractor, effective for claims received on or after July 1, 2002, CWF has implemented a number of edits.
NOTE: 90659 was discontinued December 31, 2003.
CWF returns information in Trailer ...
CWF Edits on Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
In order to prevent duplicate payment by the same carrier/AB MAC, CWF will edit by line item on the carrier/AB MAC number, the HIC number, the date of service, the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, or 90688; the ...
CWF A/B Crossover Edits for FI/AB MAC and Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
When CWF receives a claim from the carrier/AB MAC, it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted.
CWF will edit on the beneficiary HIC number; the date of service; the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, ...
Contractors must generate a Medicare Summary Notice (MSN) for the pneumococcal, influenza virus, hepatitis B vaccines, and their administration.
For vaccines rendered to beneficiaries other than pneumococcal, influenza virus or hepatitis B, which are not covered by Medicare, they must send the following MSN message.
MSN: 18.2:
This immunization and/or preventive care is ...
The FDA furnishes data to CMS on a weekly basis, which specify the certification of facilities under the MQSA. This data are contained in a “MQSA file.”
Prior to April 1, 2003, the MQSA file showed all facilities that are certified to perform film screening and diagnostic mammograms. After April 1, ...
Mammography Services (Screening and Diagnostic) Payment (Rev. 1931, 06-14-10)
By Jared Staheli | Published June 25th, 2015
There is no Part B deductible for screening mammographies, however, coinsurance is applicable. The anti-markup payment limitation on physician billing for diagnostic tests does not apply to these services. Following are three categories of billing for mammography services:
• Professional component of mammography services (that is the physician’s interpretation of the ...
Payment for Screening Mammography Services Provided On and After January 1, 2002 (Rev. 1070, 01-02-07)
By Jared Staheli | Published June 25th, 2015
The payment limitation methodology does not apply to claims with dates of service on or after January 1, 2002.
FI Claims
For claims with dates of service on or after January 1, 2002, §104 of the Benefits Improvement and Protection Act (BIPA) 2000, provides for payment of screening mammography under the ...
Durable Medical Equipment Medicare Administrative Contractors (DME MAC) Designation for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
There are four DME MACs assigned to geographical regions. Jurisdiction for DME claims is based upon the permanent residence of the beneficiary, regardless of the location of the supplier submitting the claim. The IHS facilities shall enroll with the National Supplier Clearinghouse (NSC) to obtain a supplier number for billing ...
Overview of Medicare Part B Services for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Section 630 of the MMA, indefinitely extended by §2902 of the ACA, extended to IHS providers, suppliers, physicians and practitioners, independent ambulance suppliers, hospital based ambulance providers and clinical laboratory service suppliers the ability to bill for all Medicare Part B covered services and items which were not covered under ...
Medicare Part B Services for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2001, §432 BIPA extended payment for the services of physician and non-physician practitioners furnished in hospitals and ambulatory care clinics (services paid under the MPFS, §1848 of the Act). Clinics associated with hospitals or which are freestanding that are owned and operated by IHS or tribally owned ...
Provider Enrollment with Carrier for Indian Health Services (Rev. 1027, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The designated carrier shall designate a consistent method of labeling all IHS-related enrollment applications. For Form CMS-855B (11/01) submission, under item 2.A.1 Supplier Identification, check the “Other” box and manually indicate IHS, tribes or tribal organization on the line provided.
The designated carrier shall follow these enrollment requirements:
• All applications are ...
Entities Enrollment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In order to enroll IHS clinics that are currently provider-based (and use the hospital’s tax identification number (TIN)) and that wish to bill the designated Medicare Part B carrier, the hospital must complete a Form CMS-855B and enroll as a “group”. Each clinic would be reflected on the Form CMS-855 ...
Individual Practitioners Enrollment for Indian Health Services (Rev. 1643, 03-09-09)
By Jared Staheli | Published June 25th, 2015
For those eligible practitioners already working in or for hospitals or freestanding ambulatory care clinics, whether operated by the Indian Health Service (IHS) or by an Indian tribe or tribal organization, enroll and process requests for reassignment of benefits following the current individual practitioner enrollment and verification instructions. For practitioners ...
Multiple Sites Enrollment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Multiple clinics utilizing the same TIN can be enrolled as practice locations under the “owner” of the TIN (i.e., the hospital). Each clinic will be assigned a separate PIN. If the clinic has a separate TIN, then the clinic would have to enroll separately. Payment is made to the name ...
Reassignment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
For those individual practitioners who are employees of the IHS, tribe or tribal facility that provides offsite care to the IHS, tribe or tribal Medicare Part B beneficiary, the facility can bill under reassignment from the employee. With regard to contract practitioners, the IHS, tribe, or tribal facility can accept ...
Mobile Units for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The entity providing the service must bill for the service unless the service is provided under contractual arrangements. If the contracted entity performs services on space that the IHS facility owns or leases, the IHS facility can bill under arrangements.
In order to purchase a professional test interpretation, the IHS physician ...
Mobile Mammography Units for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
With respect to mobile mammography units, the law provides specific standards regarding those qualified to perform mammograms and how they should be certified. The Mammography Quality Standards Act (MQSA) requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards. Effective October 1, 1994, all ...
Clinical Laboratory, Ambulance and Medicare Part B Drugs for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Enrollment of IHS, tribe and tribal organization facilities providing clinical laboratory, ambulance services and Medicare Part B drugs must be provided through the designated carrier. These IHS, tribe and tribal organization facilities must meet all the usual enrollment requirements for the designated carrier. The designated carrier started accepting enrollment applications ...
Provider Enrollment with FI for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
New IHS providers, including Critical Access Hospitals (CAHs) follow the same application process as any other provider enrolling in Medicare with the designated FI. Instructions for completing the Form CMS-855A, Application for Health Care Providers that will bill Medicare FIs are found in Pub. 100-08, Medicare Program Integrity Manual, Chapter ...
Provider Enrollment with FI - Ambulatory Surgical Services for Indian Health Services(Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
For dates of service prior to January 1, 2008, IHS providers that want to bill for surgeries on the ambulatory surgical center (ASC) list and receive the ASC rate must contact their designated FI. IHS providers are certified by one of several national accrediting organizations recognized by the Centers for ...
Provider Enrollment with FI - Services Under Arrangements for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
If an IHS provider is unable to provide all the services a beneficiary that is a registered outpatient of the provider needs, the provider may provide those services “under arrangements”, via a contract with another entity. Section 1862(a)(14) of the Social Security Act prohibits payment for nonphysician services furnished to ...
Provider Enrollment with DME MAC for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All IHS providers and suppliers that do not currently have a supplier number and want to bill for DMEPOS items must enroll with the NSC.
Beginning July 1, 2005, IHS providers (including CAHs) and pharmacies were eligible to begin billing for DME. The NSC must accept enrollment applications from IHS and ...
NSC Supplier Number for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
To enable direct billing of DMEPOS, an IHS supplier must enroll with the NSC as a “DME Supplier”, secure a Medicare supplier billing number and comply with the supplier standards specified in 42 CFR §424.57, and submit all DME claims to the appropriate DME MAC based on current DME jurisdiction ...
Reporting Requirements and Specifications for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In order to facilitate report generation and data collection regarding IHS physicians, practitioners and services, the designated carrier shall assign PINs to each IHS physician and practitioner in a manner that will allow the designated carrier to ascertain which facilities are IHS, Indian tribe or tribal organization. For example, the ...
Incentive Payments for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In accordance with §1833(m) of the Act, IHS physicians who provide covered professional services in any rural or urban health professional shortage area (HPSA) are entitled to an incentive payment. IHS physicians providing services in either a rural or urban HPSA are eligible for a 10 percent incentive payment. It ...
Covered Medicare Part B Services That May Be Paid to IHS Providers, Physicians and Practitioners (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medicare Part B covers medically necessary expenses incurred for the following medical and other health services:
• Diagnostic x-ray tests, and other diagnostic tests;
• Physician services;
• Anesthesia services (anesthesiologist, certified registered nurse anesthetist);
• Practitioner services (clinical nurse specialist, clinical psychologist, clinical social worker, nurse mid-wife, nurse practitioner, physician assistant);
• Drugs and ...
Carrier - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, §432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.
The services that may be paid ...
Carrier - Claims Processing Requirements for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
1. Claims will be submitted by IHS physicians and practitioners using either the American National Standards Institute Accredited Standards Committee (ANSI ASC) 837P or Form CMS-1500.
2. The designated carrier shall supply IHS physicians and practitioners with any billing software that would normally be given to physician and non-physician practitioners.
3. The ...
Carrier - Ambulance Services - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2005, Medicare Part B payment may be made to IHS independent ambulance suppliers that furnish ambulance services. IHS independent ambulance suppliers bill the designated carrier for services.
Payment for independent ambulance supplier claims shall be based on the ambulance fee schedule and processed based on point of pickup ...
Medically necessary ambulances provided by an IHS ambulance supplier are paid based upon Chapter 15 of Pub. 100-04, Medicare Claims Processing Manual. Suppliers must report an origin and destination code for each ambulance service billed.
Modifier Reporting –
Origin and destination modifiers used for ambulance services are created by combining two alpha ...
Carrier - Vaccines and Vaccine Administration - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medicare Part B payment may be made to IHS physicians and practitioners that furnish vaccines including pneumococcal pneumonia virus (PPV), influenza virus and hepatitis B virus. Medicare Part B payment may be made to IHS physicians and practitioners for the administration of these vaccines. Payment for the administration of the ...
Carrier - Vaccines and Vaccine Administration - Coverage Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Pneumococcal Pneumonia Vaccinations
The Medicare Part B program covers PPV and its administration when furnished in compliance with any applicable State law by any provider of services or any entity or individual with a supplier number. This includes revaccination of patients at highest risk of pneumococcal infection. Typically, these vaccines ...
Carrier - Screening and Preventive Services for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Medicare Part B makes payment for the following screening and preventive services:
• Pelvic exam;
• Glaucoma screening;
• Bone mass measurements;
• Prostate cancer screening;
• Colorectal cancer screening;
• Screening pap smear;
• Screening mammography;
• Cardiovascular screening blood tests;
• Diabetes screening tests;
• DSMT;
• Influenza virus vaccine and its administration, pneumococcal vaccine and its administration; hepatitis ...
Carrier - Clinical Laboratory Services - Payment Policy for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Medicare Part B payment may be made to freestanding facilities for covered clinical laboratory tests. Freestanding facilities are paid for clinical laboratory tests covered as a result of §630 MMA, indefinitely extended by §2902 of the ACA, based on the clinical laboratory fee schedule.
...
Carrier - Clinical Laboratory Services - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Some clinical laboratory procedures or tests require FDA approval before coverage is provided. Laboratory services furnished by a freestanding facility are covered under Medicare Part B if the laboratory is an approved independent clinical laboratory. However, as is the case of all diagnostic services, in order to be covered these ...
Carrier – Medical Nutrition Therapy (MNT) - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Section 105 of BIPA permits Medicare coverage of MNT when furnished by a registered dietician (RD) meeting certain requirements. See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims Processing Manual, for more information on these requirements.
Medical nutrition therapy services rendered by an RD who is an individual practitioner ...
Carrier – MNT - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
If the RD providing the services is an employee of an independent or free standing clinic and the services are provided in the clinic, the services are billed to the designated carrier.
See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims Processing Manual, for more information on the Healthcare ...
Dual Eligibility for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The Omnibus Budget Reconciliation Act of 1989 requires mandatory assignment of claims for physician services furnished to individuals who are eligible for Medicaid, including those individuals eligible as qualified Medicare beneficiaries. Therefore, claims for services to dual eligibles are paid as assigned claims.
...
Carrier Claims Processing and Payment Policy for ASC Claims for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Effective for services on or after January 1, 2008, the designated IHS carrier shall accept and pay for claims submitted by IHS and tribal hospitals that elect to enroll as ASC facilities. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 14, for information on ASC claims processing. See Pub. 100-02, ...
DME General Information for Indian Health Services (Rev.2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
The DME MACs process claims for items of DMEPOS for use in the beneficiary’s home. Beginning January 1, 2005, Medicare Part B makes payment for medically necessary items of DME, prosthetics, orthotics, and supplies to IHS suppliers that furnish DME for use in the beneficiary’s home. See Pub. 100-02, Medicare ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Payment Policy for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Section 630 of the MMA, indefinitely extended by §2902 of the ACA, permits IHS suppliers to directly bill for itemized DMEPOS with dates of service (DOS) on or after January 1, 2005. Previously IHS suppliers could not directly bill Medicare for DMEPOS.
...
Licensure to Dispense Drugs for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In order to bill drugs to the DME MACs, the supplier must be a pharmacy. States may not regulate the qualifications of Federal employees who are carrying out their authorized Federal activities within the scope of their employment. However, IHS employees are not subject to state licensure laws and IHS ...
Payment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Surgical dressings, splints, casts, DME and other devices used for reductions of fractures and dislocations are paid based on the DMEPOS fee schedule. Claims will be priced using the appropriate DMEPOS fee schedule based on the beneficiary’s address.
Payment for DME MAC-covered drug claims shall be based on the ASP fee ...
Services Billed to the DME MAC for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2005, IHS suppliers and IHS providers (including CAHs) shall bill the appropriate DME MAC for DME.
Although, parenteral and enteral nutrients, equipment, and supplies meet the definition of the prosthetic benefit, they are separately billable to the DME MAC for home use. Ostomy, tracheostomy, and urological supplies meet ...
Prosthetics, Orthotics and Supplies Billed to the A/B MAC for Indian Health Services (Rev. 1957; 10- 04-10)
By Jared Staheli | Published June 25th, 2015
Effective for dates of service on or after July 1, 2005, IHS providers, including CAHs shall bill the designated A/B MAC for prosthetics and orthotics under revenue code 0274 (prosthetic/orthotic devices) on type of bill (TOB) 12X (hospital inpatient part B), 13X (hospital outpatient) or 85X (Critical Access Hospital (CAH). ...
General Claims Processing Rules for DMEPOS for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The DME MACs may only be billed for surgical dressings, splints, casts and for prosthetics and orthotics by IHS suppliers, not by IHS providers. The Region D DME MAC shall accept all DMEPOS claims submitted by IHS suppliers and shall forward electronic media claims to the appropriate DME MAC for ...
A/B MAC (A) Payment Policy and Claims Processing for Indian Health Services (Rev. 3049, 09-23-14)
By Jared Staheli | Published June 25th, 2015
Bills are submitted to the A/B MAC (A) by IHS providers (including CAHs) using the ASC-X12 837 institutional claim format. In exceptional circumstances, a hardcopy Form CMS-1450 may be accepted by the designated A/B MAC (A).
The IHS providers are identified by Provider Type 08 in the Provider Specific File in ...
FI - Medicare Part B Services Paid Under Various Fee Schedules for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
The legislative change in MMA §630 of 2003, which was effective January 1, 2005, and indefinitely extended by §2902 of the ACA, allows IHS providers to bill for other Medicare Part B services, not covered under §1848 of the Act. In an effort to clarify that these charges are not ...
FI - Medicare Part B Services Included in the All Inclusive Rate (AIR) for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Unless otherwise specified in this chapter, payment to IHS providers is made based on the AIR. To understand how payment is made for IHS services, it is recommended that Chapter 19 be reviewed in its entirety. Services provided in IHS providers that are considered part of the AIR include:
• Diagnostic ...
FI - Inpatient Acute Care - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medicare Part A provides payment to IHS providers for up to 90 days of covered inpatient hospital services in a benefit period. These services are subject to Medicare Part A inpatient deductible and coinsurance. Each beneficiary also has 60 lifetime reserve days (LTR) of inpatient hospital services to draw upon ...
A/B MAC (A) - Inpatient Acute Care - Medicare Part A - Claims Processing for Indian Health Services (Rev. 3049, 09-23-14)
By Jared Staheli | Published June 25th, 2015
All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on type of bill (TOB) 11X (hospital inpatient). Inpatient services are billed from admission through discharge. Interim billing is not allowed.
See Chapter 1, §50.2 of Pub. 100-04, Medicare Claims Processing Manual, for more information ...
FI - Physician Acknowledgement Statement for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Section 42 CFR 412.46 requires hospitals to obtain only one signed acknowledgment from physicians who are being granted admitting privileges at a particular IHS provider. The physician must complete the acknowledgment at the time that he/she is granted admitting privileges at the hospital or before, or at the time the ...
FI - Social Admissions for Indian Health Services (Rev. 1446, 07-07-08)
By Jared Staheli | Published June 25th, 2015
Social admissions for patient and family convenience are not covered by Medicare. They are not billable to Medicare by IHS providers (including CAHs) on either TOB 11X (hospital inpatient) or 12X (hospital inpatient Part B). For admissions before surgery, only the scheduled surgery and related services may be billed on ...
FI - Inpatient Ancillary Services - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1511; 06-23-08)
By Jared Staheli | Published June 25th, 2015
Certain inpatient hospital ancillary services are covered under Medicare Part B when coverage is no longer provided under Medicare Part A due to benefits exhausted, the beneficiary is determined to be receiving a non-covered level of care, or is not eligible for Medicare Part A benefits. Chapter 4, §240 of ...
FI - Inpatient Ancillary Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (allinclusive ancillary) on TOB 12X (hospital inpatient Part B). Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but ...
FI - Swing-bed for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Under §1880 of the Act, Medicare Part A provides payment for hospitalization and post hospitalization extended care in SNFs, including swing-bed SNFs.
A beneficiary is entitled to 100 days of skilled nursing care in a SNF or the swing-bed unit of an acute care hospital or CAH during each benefit period. ...
Swing-bed – Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 2002, IHS hospital swing-bed services began being paid according to the SNF prospective payment system (PPS) payment methodology. See Chapter 6, §30.6 in Pub. 100-04, Medicare Claims Processing Manual for information on SNF PPS payment methodology.
Medicare Part A coinsurance is applied to IHS swing-bed inpatient bills, but is ...
Swing-bed – Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Revenue code 0022 (special charges) and the Health Insurance Prospective Payment System (HIPPS) codes are reported on the bill along with the accommodation revenue codes. Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing bed). Medicare swing-bed bill processing instructions ...
FI - Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1511; 06- 23-08)
By Jared Staheli | Published June 25th, 2015
The IHS providers are paid for covered inpatient Medicare Part B ancillary services based upon an all inclusive inpatient ancillary per diem rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost reports prepared by IHS’s contractor. Upon completion of the review, IHS ...
FI - Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS hospital swing-bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills and are submitted under the regular hospital (or CAH) provider number (not the swing-bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is ...
FI - Outpatient - Medicare Part B - Payment Policy for Indian Claims Processing (Rev. 1511; 06-23-08)
By Jared Staheli | Published June 25th, 2015
The IHS providers are paid for covered outpatient services based upon an all inclusive outpatient per visit rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost reports prepared by IHS’s contractor. Upon completion of the review, IHS submits the agreed upon rate ...
FI - Outpatient - Medicare Part B - Claims Processing for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).
Regardless of the number of times a patient is seen in a given day at ...
FI - Ambulatory Surgical Center (ASC) - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Qualified IHS providers are reimbursed at the ASC rates published in the Federal Register. Medicare Part B deductible and coinsurance amounts apply to ASC services, but are waived by the IHS.
See §40.2.1 of this chapter for information on enrolling with the designated FI to receive payment for ASC services based ...
FI - ASC - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Charges are reported under revenue code 0360 (operating room services) or 0490 (ambulatory surgical care) on TOB 83X (ambulatory surgical center). ASC surgeries are identified with CPT codes 10000-69979 only. One bill is required for all services provided on the day a surgical procedure is performed.
*Exception: Revenue code 0276 (intraocular ...
FI - Critical Access Hospital (CAH) Inpatient - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS CAHs are paid 101 percent of the all inclusive facility specific per diem rate established on a yearly basis from the most recently filed cost report information for covered inpatient services (on and after January 1, 2004). An average of 96 hours of acute inpatient care in a ...
FI - CAH Inpatient - Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on TOB 11X (hospital inpatient). Inpatient services are billed from admission through discharge.
The MSN is suppressed.
...
FI - CAH Ancillary Services -Medicare Part B - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Certain inpatient CAH ancillary services are covered under Medicare Part B when coverage is no longer provided under Medicare Part A due to benefits exhausted, the beneficiary is determined to be receiving a non-covered level of care, or is not eligible for Medicare Part A benefits. Chapter 4, §240 of ...
FI - CAH Ancillary Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (allinclusive ancillary) on TOB 12X (hospital inpatient Part B). The MSN is suppressed.
See §§100.10 and 100.11 of this chapter, for more information on the payment of ...
FI - CAH Swing-bed - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
The IHS CAH swing-bed services are paid 101 per cent of an all inclusive facility specific per diem rate. Medicare Part A coinsurance is applied to IHS CAH swing-bed inpatient bills, but is waived by the IHS.
...
FI - CAH Swing-bed - Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing-bed). Technical criteria for swing-bed admissions apply (i.e., 3 day qualifying hospital stay, 30 day transfer requirements, etc.) but CAH swing-bed providers are not required to report revenue code 0022 or HIPPS ...
FI - CAH Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
The IHS CAHs are paid for covered inpatient Medicare Part B ancillary services based upon 101 percent of an all inclusive facility specific per diem rate that is established on a yearly basis from prior year cost report information. Medicare Part B deductible and coinsurance amounts are applied to inpatient ...
FI - CAH Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS CAH swing-bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills and are submitted under the regular hospital (or CAH) provider number (not the swing-bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is ...
FI - CAH Outpatient - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS CAHs are paid for covered outpatient services based on 101 percent of an all inclusive facility specific per visit rate that is established on a yearly basis from prior year cost report information for both facilities electing Standard Method I and Optional Method II billing.
For services provided in ...
FI - CAH Outpatient - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine, and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 85X (CAH).
Non-patient lab specimens are billed on TOB 14X (hospital other).
The MSN is suppressed.
See Chapter18, §10 of Pub. ...
CAH Election of Method I or Method II for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
See Chapter 4, §250 of Pub. 100-04, Medicare Claims Processing Manual, for information on the election of Standard Method I or Optional Method II IHS CAH billing for professional services.
...
FI - Vaccines and Vaccine Administration - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2006, IHS providers, including CAHs are paid separately from the AIR for certain vaccines and their administration. See Chapter 18 of Pub. 100-04, Medicare Claims Processing Manual for more information on the payment of PPV, influenza virus, and hepatitis B vaccines. The administration of vaccines is paid ...
FI - Vaccines and Vaccine Administration - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
These vaccines are reported on TOB 12X, 13X, 83X, or 85X along with the appropriate revenue codes and HCPCS codes as found in billing instructions in Chapter 18, §10.2 of Pub. 100-04, Medicare Claims Processing Manual.
No clinic visit shall be billed if vaccine and its administration are the only service ...
FI - Physical Therapy, Occupational Therapy, SpeechLanguage Pathology and Diagnostic Audiology Services - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2006, IHS providers are paid separately from the AIR for physical therapy, OT, speech-language pathology and diagnostic audiology services. Payment for services to IHS providers on TOB 12X, 13X or 83X is made based on the MPFS. Payment for services to IHS CAHs on TOB 85X is ...
FI - Physical Therapy, Occupational Therapy, SpeechLanguage Pathology and Diagnostic Audiology Services - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Therapy services and diagnostic audiology services are reported on TOB 12X, 13X, 83X or 85X using the appropriate revenue code and HCPCS codes.
No clinic visit shall be billed if a therapy service or a diagnostic audiology service is the only service received. These services may be billed with or without ...
A/B MAC - Ambulance Services for Indian Health Services (Rev. 2102, 04-04-11)
By Jared Staheli | Published June 25th, 2015
Section 630 of the MMA allows for the reimbursement of ambulance services provided by IHS hospital-based ambulance providers, CAHs, and entities owned and operated by a CAH, for the 5 year period beginning January 1, 2005. Section 2902 of the Affordable Care Act indefinitely extends Section 630 of the MMA, ...
FI - Outpatient Hospital-Based Ambulance Services - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medically necessary ambulance services submitted by hospital-based ambulance providers are reimbursed based on the ambulance fee schedule.
The Medicare Part B deductible and coinsurance apply to ambulance services, but are waived by the IHS.
See Chapter 15, §30.2.4 of Pub. 100-04, Medicare Claims Processing Manual, for more information on the payment of ...
FI - Outpatient Hospital-Based Ambulance Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Outpatient ambulance bills from hospital-based ambulance providers are submitted with revenue code 054X (ambulance) with charges for ambulance, as well as the appropriate ambulance HCPCS codes on TOB 12X or 13X.
If an outpatient encounter occurs at the same time a covered ambulance service is provided, the hospital-based ambulance providers may ...
A/B MAC - CAH Ambulance Services - Medicare Part B - Payment Policy for Indian Health Services (Rev. 2102, 04-04-11)
By Jared Staheli | Published June 25th, 2015
For dates of service on or after December 21, 2000 and prior to January 1, 2004, medically necessary ambulance services provided by an IHS CAH or an entity that is owned and operated by the IHS CAH are paid based on 100 percent of the reasonable cost if the 35 ...
FI - CAH Ambulance Services - Medicare Part B -Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medically necessary ambulance services originating out of an IHS CAH with a hospitalbased ambulance service are submitted with revenue code 054X (ambulance) with charges for ambulance, as well as the appropriate ambulance HCPCS codes on TOB 85X. IHS CAHs that meet the 35 mile rule for cost based payment shall ...
FI - Ambulance Services - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
If an inpatient is transferred to another hospital for services under arrangement, the ambulance services are not billable to Medicare. Reimbursement for such services is part of the inpatient stay and payment is included in the IPPS payment based on the DRG.
...
FI - Other Screening and Preventive Services - Payment Policy for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2005, payment is made by the FI based on the AIR to IHS providers, excluding CAHs, for screening and preventive services covered under §630 of the MMA, indefinitely extended by §2902 of the ACA. Payment is made to CAHs based on cost. Screening and preventive services covered ...
FI - Other Screening and Preventive Services - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The screening and preventive services listed in §100.13 of this chapter are reported on TOB 12X, 13X, or 85X with revenue code 0510 (clinic visit).
Services for screening pap smears are only payable by the FI when billed with a pelvic exam. Prostate cancer screening, cardiovascular screening blood tests and screening ...
FI - MNT - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Section 105 of BIPA permits Medicare coverage of MNT when furnished by a RD meeting certain requirements. See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims Processing Manual, for more information on these requirements.
If the RD providing the services is either an IHS hospital employee or has contracted ...
FI - MNT - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The MNT services provided under the auspices of the hospital are reported to the designated FI under revenue code 0510 (clinic visit). The current MNT HCPCS codes are required for the both the assessment and reassessment. The MSN is suppressed.
See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims ...
FI - Laboratory Services for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
• Laboratory services furnished to IHS provider inpatients are combined with other inpatient services furnished and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on TOB 11X. Payment is made for inpatient laboratory services under the PPS based upon DRGs.
• Inpatient hospital laboratory ancillary services are covered ...
FI - Drugs for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS providers, including CAHs, are paid by the FI for covered drugs and biologicals provided during a covered inpatient hospital stay. All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on TOB 11X.
Payment is made to IHS/tribal hospitals under IPPS. IHS CAHs ...
FI--Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
For background on the telehealth benefit, see Chapter 12, §190.1 in this manual. For more information on the payment of Telehealth services, see Chapter 15 of the Benefit Policy Manual. Telehealth services fall into two categories: an originating site facility service in which the beneficiary is presented to the distant ...
The Indian Health Service (IHS) is the primary health care provider to the American Indian/Alaska Native (AI/AN) Medicare population. The Indian health care system, consisting of tribal, urban, and federally operated IHS health programs, delivers a spectrum of clinical and preventive health services to its beneficiaries, via a network of ...
Carrier and FI Designation for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 24th, 2015
The designated carrier and FI enroll IHS operated facilities, process IHS institutional claims, IHS physician and practitioner claims for IHS or tribally owned facilities and hospitals. The designated carrier may also enroll tribally operated facilities and process the practitioner claims for these facilities, if the tribally operated facility chooses. All ...
A. Notice Title
This section names the notice, specifies the function of the notice and the Medicare program under which the notice’s claims are paid, and identifies the Federal agencies responsible for generating the notice.
GLOBAL SPECIFICATIONS
POSITION
This subsection contains information of a fixed size. It does not vary in ...
MSN - Specifications for Header for Other Pages (Rev. 2522, 01-03-13(Final Implementation)
By Jared Staheli | Published June 22nd, 2015
This element repeats at the top of every page of the MSN, except for the first page. It contains the beneficiary’s name, a notification, and page numbering.
POSITION
This subsection is of a fixed size. It does not vary in overall width or length.
It begins (0˝, 0˝) and is full-page or 540 ...
MSN - Specifications for Section 2: Making the Most of Your Medicare (Page 2) (Rev. 3210, 04-16-15)
By Jared Staheli | Published June 22nd, 2015
A. Section Title
POSITION
This subsection contains information of a fixed size. It does not vary in overall width or length.
The content area begins (0˝, 5˝), 7 points from the baseline of the Headers for Other Pages subsection. It is full-page or 540 points in width and 24 points in height.
CONTENT
Making ...
Format Conventions for the MSN (Rev. 3210, 04-16-15)
By Jared Staheli | Published June 19th, 2015
This information describes the overall format conventions for the MSN.
MSNs are a combination of fixed and variable length sections, using a range of different typefaces and type styles, as well as a number of static graphic elements. For discussion of the display in specific areas of the notice, see the ...
General Medicare Summary Notices (MSN) Requirements (Rev. 955, September 1, 2006)
By Jared Staheli | Published June 18th, 2015
Effective July 1, 2002, the MSN is used by all carriers and intermediaries.
The MSN is the primary vehicle by which beneficiaries are notified of decisions on their claims for Medicare benefits. The intermediary or carrier mails a single MSN at the end of the month to each beneficiary for whom ...
General Requirements for the MSN (Rev. 1491, 05-12-08)
By Jared Staheli | Published June 18th, 2015
A. Intermediary/RHHI MSN
The MSN is used to notify Medicare beneficiaries of action taken on intermediary processed claims. MSNs are not used by RHHIs for RAPs, and RAP data are not included on the monthly MSN.
The MSN provides the beneficiary with a record of services received and the status of ...
Correction/Reissuance of Faulty MSNs (Rev. 159, 04-30-04)
By Jared Staheli | Published June 18th, 2015
Occasionally programming errors will occur which cause inaccuracies on MSNs that do not materially affect benefits. An example of a potential programming error could be one data column writing in another data column. So long as the claims are correctly paid and the notice is intelligible, it is not necessary ...
Basic Concepts and Approaches (Rev. 3210, 04-16-15)
By Jared Staheli | Published June 18th, 2015
A. Overview
The Medicare Summary Notice (MSN) is a printed notification, sent to Medicare beneficiaries enrolled in Original Medicare, that displays data for claims processed during a given reporting period. The MSN lists claim information in a summarized format. It also contains other helpful information for beneficiaries. Each MSN consists of ...
Where to Bill DMEPOS and PEN Items and Services (Rev. 1603, 10-27-08)
By Jared Staheli | Published June 17th, 2015
Skilled Nursing Facilities, CORFs, OPTs, and hospitals bill the FI for prosthetic/orthotic devices, supplies, and covered outpatient DME and oxygen (refer to §40). The HHAs may bill Durable Medical Equipment (DME) to the RHHI, or may meet the requirements of a DME supplier and bill the DME MAC. This is ...
Durable Medical Equipment (DME) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
DME is covered under Part B as a medical or other health service (§1861(s)(6) of the Social Security Act [the Act]) and is equipment that:
a. Can withstand repeated use;
b. Is primarily and customarily used to serve a medical purpose;
c. Generally is not useful to a person in the absence of ...
Prosthetic devices (other than dental) are covered under Part B as a medical or other health service (§1861(s)(8) of the Act) and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body ...
Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
These appliances are covered under Part B as a medical or other health service (§1861(s)(9) of the Act) when furnished incident to physicians' services or on a physician's order. A brace includes rigid and semi-rigid devices that are used for the purpose of supporting a weak or deformed body member ...
Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
When a beneficiary who was previously enrolled in a Medicare HMO/Managed Care program returns to traditional FFS, he or she is subject to all benefits, rules, requirements and coverage criteria as a beneficiary who has always been enrolled in FFS. When a beneficiary returns to FFS, it is as though ...
Scenario: How Medicare Pays For Electric Wheelchairs (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
If you need an electric wheelchair prescribed by your doctor, you may already know that Medicare can help pay for it. Medicare requires (specify name of supplier) to give you the option of either renting or purchasing it. If you decide that purchase is more economical, for example, because you ...
Medicare Updates Preventive Exam and Wellness Visit Information
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update June 9th, 2016
Medicare has updated their provider educational tools for the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV). These tools were designed to help providers gain a greater understanding of these services. Learn what the required elements for these services as well as important coverage and coding information.
CLICK ...
By Wyn Staheli, Director of Research | Published March 27th, 2015 - Last Review/Update June 9th, 2016
It appears that the repeal of the Sustainable Growth Rate formula (SGR) could finally be a real possibility. On Thursday, March 26, The U.S. House of Representatives overwhelmingly passed H.R 2, The Medicare Access and CHIP Reauthorization Act which includes both repeal and replace the flawed SGR formula that has ...
By | Published February 27th, 2015 - Last Review/Update June 9th, 2016
Originally, for providers to Attest EHR/Meaningful Use for the 2014 reporting period, the attestation deadline was February 28, 2015. However, to encourage providers to start attesting for the 2014 reporting year, CMS has extended the attestation deadline for eligible professionals to March 20, 2015. CMS indicates this has been done, ...
By | Published February 26th, 2015 - Last Review/Update January 27th, 2017
Recently, the U.S. Department of Health and Human Services Office of Inspector General updated their booklet, “Avoiding Medicare and Medicaid Fraud and Abuse.”
In this publication, the Government agencies, including the Department of Justice, the Department of Health and Human Services office of Inspector General, and the Centers for Medicare and ...
By | Published February 23rd, 2015 - Last Review/Update March 9th, 2016
Q: We have recently enrolled with Medicare and treat only a few patients. However, those claims are being denied. Can you help me to understand why this might be happening?
A: First, I would recommend you carefully review your Medicare Remittance Advice as that will identify the reason Medicare is denying your ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update March 1st, 2016
Lots of information on government regulations pertaining to Medicare is listed here:
The Electronic Code of Federal Regulations (e-CFR) is a regularly updated, unofficial editorial compilation of CFR material and Federal Register amendments produced by the National Archives and Records Administration's Office of the Federal Register (OFR) and the Government Publishing Office.
...
By | Published February 10th, 2015 - Last Review/Update February 18th, 2016
The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MAC) to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Even though ...
By | Published February 3rd, 2015 - Last Review/Update June 9th, 2016
The following information (emphasis added) is from: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html
Provider Non-Discrimination PHS Act section 2706(a), as added by the Affordable Care Act, states that a “group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against ...
CMS Announces New HCPCS Modifiers to be Implemented January 2015
By | Published December 23rd, 2014 - Last Review/Update January 30th, 2017
Beginning January 5, 2015 CMS (Centers for Medicare and Medicaid Services) requires new HCPCS modifiers to be used in place of modifier 59 for all Medicare claims.
These new subset modifiers are known as -X{ESPU} and are defined as follows:• XE - separate encounter, a service that is distinct because it ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
What are NCDs and LCDs?
NCD — NATIONAL COVERAGE DETERMINATIONS
Medicare specific coverage on the national level. All Medicare carriers are required to follow the NCDs. The NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an ...
Q & A: Establishing a Multi-Disciplinary Practice and Being Legal
By | Published December 1st, 2014 - Last Review/Update January 30th, 2017
Q: How do you add another provider type such as a Nurse Practitioner to your practice to provide additional services to patients and legally bill for those services under their license?
A: Multi-disciplinary practices are under scrutiny at the moment by ZPIC, CMS and State Boards. For your reference, just below, there ...
Have you checked your QRUR to find out if you qualify for a CMS bonus (or penalty)?
By | Published November 25th, 2014 - Last Review/Update January 30th, 2017
What? You've never heard of a QRUR?
You have probably heard about Meaningful Use (MU) and penalties that kick in for those who did not attest. And the Physician Quality Reporting System (PQRS) with penalties for those who did not successfully report on at least one patient. The new one ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
Local Medical Review Policies (LMRPs) were converted to LCDs. This was done as a result of the Benefits Improvement and Protection Act of 2000 (BIPA 2000). The difference between LCDs and previously written LMRPs is that LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) ...
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contain information about each zone as well as activity and updates in those regions.
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  RAC began in 2005 as a three-year demonstration project consisting ...
Medicare's Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
By Wyn Staheli, Director of Research | Published November 17th, 2014 - Last Review/Update January 6th, 2017
Medicare understands that there are individuals who may not meet the diagnostic criteria for substance abuse, but who are still at risk. To help identify these individuals and take steps to keep them from reaching the level of abuse, Medicare has established a program called the Screening, Brief Intervention, and ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update January 23rd, 2017
In October of 2000 in the Federal Register the Office of the Inspector General (who investigates fraud against the federal government on behalf of the Department of Health and Human Services) offered general guidelines for health care facilities to set up a “Compliance Program”. This advice has long been pushed ...
The Role of Statistical Analysis in Fighting Fraud
By Jared Staheli | Published October 16th, 2014 - Last Review/Update January 30th, 2017
It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. New developments in statistical analysis helps to combat this.
By | Published October 16th, 2014 - Last Review/Update November 29th, 2017
What is the ABN form used for?
The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due ...
By | Published October 15th, 2014 - Last Review/Update January 30th, 2017
In February, 2014, CMS announced the "pausing" of the RAC (Recovery Audit Contractors) program to allow current RAC contractors to complete remaining claim audits and related duties before CMS begins the process of reviewing RAC program contracts as well as allowing time for CMS to make improvements in the RAC program itself. ...
By | Published October 9th, 2014 - Last Review/Update January 30th, 2017
As of May 14, 2012, the billing effective date can be made retroactive as far back as 30 calendar days from the date the application was received in Medicare's office.
Provider offices must submit the CMS 855 form as soon as the provider begins seeing Medicare patients to ensure their services will be ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 18th, 2014 - Last Review/Update January 30th, 2017
The CMS Physician Quality Reporting System (PQRS) Program: "What Medicare Eligible Professionals Need to Know in 2014” Web-Based Training Course — Released
“The CMS Physician Quality Reporting System (PQRS) Program: What Medicare Eligible Professionals Need to Know in 2014” Web-Based Training (WBT) Course was released and is now available. This WBT ...
By Wyn Staheli, Director of Research | Published September 15th, 2014 - Last Review/Update July 12th, 2016
Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. Medicare Claims Processing Manual, Chapter 5 clarification included here.
By | Published August 27th, 2014 - Last Review/Update January 30th, 2017
PQRS FAQs: How do I report for the 2014 PQRS? What is the MAV and when does it apply? What happens if we report less than 9 measures across 3 domains? How does CMS apply the MAV Clinical Relation/Domain test for PQRS?
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
By | Published July 24th, 2014 - Last Review/Update January 29th, 2016
Are Medicare fees going up? Or down? Results for the following:
Sequestration
Chiropractic Demonstration Project
Electronic Health Record/Meaningful Use
Physician Quality Reporting System - PQRS
Value-Based Modifier
Will mandatory Medicare payment cuts (due to the SGR) get repealed?
By | Published March 2nd, 2014 - Last Review/Update January 27th, 2017
Since 2003, healthcare providers have been dealing with the the short term patches to the Medicare payment system. After all this time, it now appears that Congress is making a move to address the ongoing issues with the Sustainable Growth Rate (SGR). This is the formula that has caused the payment problems with Medicare. Many professional organizations are endorsing the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015, S. 2000) and encouraging providers to contact their congressional leaders and lend their support for this legislation. If you wish to join those lending their support CLICK HERE for a helpful tool to contact YOUR congressional leaders.
Read More
By | Published February 12th, 2014 - Last Review/Update January 27th, 2017
The following information is from the Centers for Medicare & Medicaid Services (CMS) regarding the Electronic Health Records (EHR) payment reduction hardship exemption.
How do I know which ICD-10 codes payers are going to like?
By | Published November 26th, 2013 - Last Review/Update January 27th, 2017
One of the biggest questions doctors have is “Which codes will I actually use when ICD-10 kicks in on October 1, 2014?” This is the great mystery. Fortunately we have access to the same code set that payers will be using as they determine which codes they like to see. ...
ICD-10 Coding Possibilities for Chiropractic Physicians
By Evan M Wsilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA | Published September 11th, 2013 - Last Review/Update January 27th, 2017
Right now, it’s hard to say which ICD-10 codes third-party payers will select as medically necessary, but we can make an educated guess based on information from a few sources. More detail is expected from Medicare before the end of 2013. For doctors of chiropractic (DCs), the natural place to start is with the relatively short list of frequently used ICD-9-CM codes for submitting claims. We’ll investigate a handful of diagnosis codes that Medicare recognizes as medically necessary and explore ICD-10-CM code possibilities.
By | Published July 15th, 2013 - Last Review/Update January 27th, 2017
Recently Medicare issued a press release about their updated Medicare Summary Notice. The Obama Administration has made the elimination of fraud, waste, and abuse a top priority and the number of providers thrown out of Medicare programs has more than doubled in the last few years. The newly designed Medicare ...
Inappropriate Medicare Payments for Chiropractic Services
By | Published August 30th, 2012 - Last Review/Update January 27th, 2017
OIG released two reports critical of the way chiropractic handled documentation and coding. Their findings are included in this article. Read further to see what documentation is needed for proper payment.
As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
Medicare Fee Alert-June 21, 2010, by Dr. Ron Short
By | Published June 21st, 2010 - Last Review/Update January 27th, 2017
Congress continues to debate the elimination of the negative update that took effect June 1, 2010. The CMS is hopeful that Congressional action will be taken to avert the negative update.
April 30, 2015 - "Accreditation for Ventilators" MLN Matters® Article - Released - MLN Matters® Special Edition Article #SE1513, "Accreditation for Ventilators" has been released and is now available in downloadable format. This article is designed to provide education on accreditation requirements for ventilators to ensure that frequent and substantial servicing is provided to Medicare beneficiaries. It includes background information and key points.
April 23, 2015 - "Vaccine and Vaccine Administration Payments under Medicare Part D" Fact Sheet - Revised - The "Vaccine and Vaccine Administration Payments under Medicare Part D" Fact Sheet (ICN 908764) was revised and is now available in downloadable format. This fact sheet is designed to provide education on vaccine payments under Medicare Part D. It includes information on the difference between Part B and Part D vaccine coverage, what Part D covers, and additional information on vaccine coverage under Part D plans.
April 23, 2015 - "Home Health Prospective Payment System" Fact Sheet - Revised - The "Home Health Prospective Payment System" Fact Sheet (ICN 006816) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Home Health Prospective Payment System (HH PPS). It includes the following information: background, consolidated billing requirements, criteria that must be met to qualify for home health services, therapy services, elements of the HH PPS, updates to the HH PPS, billing and payment for home health services, and Home Health Quality Reporting Program.
April 9, 2015 - "Discontinued Coverage of Vacuum Erection Systems (VES) Prosthetic Devices in Accordance with the Achieving a Better Life Experience Act of 2014" MLN Matters® Article - Released - MLN Matters® Special Edition Article #SE1511, "Discontinued Coverage of Vacuum Erection Systems (VES) Prosthetic Devices in Accordance with the Achieving a Better Life Experience Act of 2014" has been released and is now available in downloadable format. This article is designed to provide education on the changes made to the July Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule related to VES devices and prohibits payment on claims for VES prosthetic devices for dates of service on or after July 1, 2015. It includes background information.
April 9, 2015 - "Medicare Information for Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants" Booklet - Revised - The "Medicare Information for Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants" Booklet (ICN 901623) was revised and is now available in downloadable format. This booklet is designed to provide education on Medicare services furnished by certified registered nurse anesthetists, anesthesiologist assistants, nurse practitioners, certified nurse-midwives, clinical nurse specialists, and physician assistants. It includes the required qualifications, coverage criteria, billing, and payment for these provider types.
April 9, 2015 - "The ABCs of the Initial Preventive Physical Examination (IPPE)" Educational Tool - Revised - "The ABCs of the Initial Preventive Physical Examination (IPPE)" Educational Tool (ICN 006904) was revised and is now available in downloadable format. This educational tool is designed to provide education on IPPE. It includes a list of elements that must be included in the IPPE, as well as coverage and coding information.
April 9, 2015 - "The ABCs of the Annual Wellness Visit (AWV)" Educational Tool - Revised - "The ABCs of the Annual Wellness Visit (AWV)" Educational Tool (ICN 905706) was revised and is now available in downloadable format. This educational tool is designed to provide education on the AWV. It includes a list of the required elements in the initial and subsequent AWVs, as well as coverage and coding information.
April 2, 2015 - "Preventive Services" Educational Tool - Revised - The "Preventive Services" Educational Tool (ICN 006559) was revised and is now available in an interactive format. This educational tool is designed to provide education on Medicare-covered preventive services. It includes coverage, coding, and payment information.
April 2, 2015 - "Long Term Care Hospital Prospective Payment System" Fact Sheet - Revised - The "Long Term Care Hospital Prospective Payment System" Fact Sheet (ICN 006956) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Long Term Care Hospital (LTCH) Prospective Payment System. It includes the following information: LTCH certification, Medicare Severity Long Term Care Diagnosis-Related Groups patient classification, payment policy adjustments, payment updates, and LTCH Quality Reporting Program.
April 2, 2015 - "Clinical Laboratory Fee Schedule" Fact Sheet - Revised - The "Clinical Laboratory Fee Schedule" Fact Sheet (ICN 006818) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Clinical Laboratory Fee Schedule (CLFS). It includes the following information: background, coverage of clinical laboratory services, how payment rates are set, and updates to the CLFS.
April 2, 2015 - "Medicare Appeals Process" Fact Sheet - Reminder - The "Medicare Appeals Process" Fact Sheet (ICN 006562) is available in downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in Original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers in addition to including information on available appeals-related resources.
April 2, 2015 - "Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians" Fact Sheet - Reminder - The "Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians" Fact Sheet (ICN 905645) is available in downloadable format. This fact sheet is designed to provide education for physicians on understanding how to comply with Federal laws that combat fraud and abuse and ensure appropriate quality medical care. It includes information on identifying "red flags" that could lead to potential liability in law enforcement and administrative actions.
March 12, 2015 - "Global Surgery" Fact Sheet - Revised - The "Global Surgery" Fact Sheet (ICN 907166) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the components of a global surgery package. It includes information about billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians.
March 12, 2015 - "Guidelines for Teaching Physicians, Interns, and Residents" Fact Sheet - Revised - The "Guidelines for Teaching Physicians, Interns, and Residents" Fact Sheet (ICN 006347) was revised and is now available in downloadable format. This fact sheet is designed to provide education on physician services in teaching settings. It includes information on payment for physician services in teaching settings, general documentation guidelines, evaluation and management (E/M) documentation guidelines, and exception for E/M services furnished in certain primary care centers. It also includes resources and a glossary.
March 12, 2015 - "Mental Health Services" Booklet - Revised - The "Mental Health Services" Booklet (ICN 903195) was revised and is now available in downloadable format. This booklet is designed to provide education on mental health services. It includes the following information: covered and non-covered mental health services, eligible professionals, supplier charts, assignment, outpatient and inpatient psychiatric hospital services, same day billing guidelines, and National Correct Coding Initiative.
March 12, 2015 - "Medicare Vision Services" Fact Sheet - Reminder - The "Medicare Vision Services" Fact Sheet (ICN 907165) is available in a downloadable format. This fact sheet is designed to provide education on Medicare coverage and billing information for vision services. It includes specific information concerning coding requirements and an overview of coverage guidelines and exclusions.
March 12, 2015 - "HIPAA Privacy and Security Basics for Providers" Fact Sheet - Reminder - The "HIPAA Privacy and Security Basics for Providers" Fact Sheet (ICN 909001) is available in a downloadable format. This fact sheet is designed to provide education on basic HIPAA privacy and basic HIPAA security information for providers. It includes information on covered entities, business associates, and the disposal of private health information.
March 5, 2015 - "Physician Feedback, Quality and Resource Use Reports (QRURs) and Value-Based Modifier Program – Overview & Implementation" MLN Matters® Article - Released - MLN Matters® Special Edition Article #SE1507, "Physician Feedback, Quality and Resource Use Reports (QRURs) and Value-Based Modifier Program – Overview & Implementation" has been released and is now available in downloadable format. This article is designed to provide education on the Physician Feedback/Value-Based Payment Modifier Program that will provide comparative performance information to individual physicians and groups, as part of Medicare's efforts to improve the quality and efficiency of medical care.
March 5, 2015 - "Diagnosis Coding: Using the ICD-10-CM" Web-Based Training Course - Released - The "Diagnosis Coding: Using the ICD-10-CM" Web-Based Training Course (WBT) was released and is now available. This WBT is designed to provide education on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). It includes ICD-10-CM/PCS implementation guidance, information on the new ICD-10-CM classification system, and coding examples. Continuing education credits are available to learners who successfully complete this course. See course description for more information. To access the WBT, go to Medicare Learning Network® Products (use the link above), scroll to "Related Links" at the bottom of the web page, and click on "Web-Based Training Courses."
March 5, 2015 - "Medicare Physician Fee Schedule" Fact Sheet - Revised - The "Medicare Physician Fee Schedule" Fact Sheet (ICN 006814) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Medicare Physician Fee Schedule (PFS). It includes the following information: physician services, Medicare PFS payment rates, and resources.
March 5, 2015 - "Medicare Enrollment Guidelines for Ordering/Referring Providers" Fact Sheet - Reminder - The "Medicare Enrollment Guidelines for Ordering/Referring Providers" Fact Sheet (ICN 906223) is available in downloadable format. This fact sheet is designed to provide education on the Medicare enrollment requirements for eligible ordering/referring providers. It includes information on the three basic requirements for ordering and referring, and who may order and refer for Medicare Part A Home Health Agency, Part B, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) beneficiary services.
March 5, 2015 - "Medicare Fraud & Abuse: Prevention, Detection, and Reporting" Fact Sheet - Reminder - The "Medicare Fraud & Abuse: Prevention, Detection, and Reporting" Fact Sheet (ICN 006827) is available in downloadable format. This fact sheet is designed to provide education on preventing, detecting, and reporting Medicare fraud and abuse. It includes fraud and abuse definitions, as well as an overview of the laws used to fight fraud and abuse; descriptions of the government partnerships engaged in preventing, detecting, and fighting fraud and abuse; and resources on how providers can report suspected fraud and abuse.
February 26, 2015 - "Medicare Basics Commonly Used Acronyms" Educational Tool - Released - The "Medicare Basics Commonly Used Acronyms" Educational Tool (ICN 908999) was released and is now available in downloadable format. This interactive educational tool is designed to give you a list of acronyms you commonly see in Medicare publications. It includes a clickable list of alphabetized acronyms, with additional definitions and information on certain acronyms.
February 26, 2015 - "Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) – A Re-Issue of MM7492" MLN Matters® Article - Revised - MLN Matters® Article #SE1408, "Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) – A Re-Issue of MM7492" was revised and is now available in downloadable format. This article is designed to provide education on the required use of the ICD-10 code sets for dates of service on and after October 1, 2015. It includes tables for providers regarding claims that span the periods where ICD-9 and ICD-10 codes may both be applicable. This article updates MLN Matters® Article #MM7492 to reflect the October 1, 2015, implementation date. This article was revised to add a question and answer at the bottom of page 2 regarding dual processing of ICD-9 and ICD-10 codes.
February 19, 2015 - "Independent Diagnostic Testing Facility (IDTF)" Fact Sheet - Released - "Independent Diagnostic Testing Facility (IDTF)" Fact Sheet (ICN 909060) was released and is now available in downloadable format. This fact sheet is designed to provide education on requirements for the IDTF. It includes information on enrollment; the effective date of billing privileges; billing issues; ordering of tests; place of service issues; and requirements for multi-state IDTFs, physicians, and technicians.
February 19, 2015 - "Chronic Care Management Services" Fact Sheet - Released - "Chronic Care Management Services" Fact Sheet (ICN 909188) was released and is now available in downloadable format. This fact sheet is designed to provide background on the separately payable Chronic Care Management (CCM) services for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions. It includes information on eligible providers and patients, Physician Fee Schedule billing requirements, and a table aligning the CCM Scope of Service Elements and billing requirements with the Certified Electronic Health Record or other electronic technology requirements.
February 19, 2015 - "Provider Compliance Tips for Spinal Orthoses" Fact Sheet - Released - "Provider Compliance Tips for Spinal Orthoses" Fact Sheet (ICN 909187) was released and is now available in downloadable format. This fact sheet is designed to provide education on spinal orthoses. It includes helpful tips on how to prevent claim denials, as well as documentation needed to submit a claim for spinal orthoses.
February 19, 2015 - "Provider Compliance Tips for Enteral Nutrition Pumps" Fact Sheet - Released - "Provider Compliance Tips for Enteral Nutrition Pumps" Fact Sheet (ICN 909186) was released and is now available in downloadable format. This fact sheet is designed to provide education on enteral nutrition pumps. It includes helpful tips on how to prevent claim denials, as well as documentation needed to submit a claim for enteral nutrition pumps.
February 19, 2015 - "Provider Compliance Tips for Diabetic Test Strips" Fact Sheet - Released - "Provider Compliance Tips for Diabetic Test Strips" Fact Sheet (ICN 909185) was released and is now available in downloadable format. This fact sheet is designed to provide education on diabetic test strips. It includes helpful tips on how to prevent claim denials, as well as documentation needed to submit a claim for diabetic testing supplies.
February 12, 2015 - "Hospital Outpatient Prospective Payment System" Fact Sheet - Revised - Released - The "Hospital Outpatient Prospective Payment System" Fact Sheet (ICN 006820) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Hospital Outpatient Prospective Payment System. It includes the following information: background, ambulatory payment classifications, how payment rates are set, payment rates, and Hospital Outpatient Quality Reporting Program.
February 12, 2015 - "DMEPOS Quality Standards" Booklet - Reminder - Released - The "DMEPOS Quality Standards" Booklet (ICN 905709) is available in downloadable format. This booklet is designed to provide education on Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). It includes DMEPOS quality standards as well as information on Medicare deemed Accreditation Organizations (AOs) for DMEPOS suppliers.
February 12, 2015 - "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies" Fact Sheet - Reminder - Released - The "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Information for Pharmacies" Fact Sheet (ICN 905711) is available in downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by a CMS-approved independent national Accreditation Organization (AO) as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements.
February 12, 2015 - "Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services" Fact Sheet - Reminder - Released - The "Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services" Fact Sheet (ICN 904084) is available in downloadable format. This fact sheet is designed to provide education on SBIRT services. It includes an early intervention approach that targets those with nondependent substance use to provide effective strategies for intervention prior to the need for more extensive or specialized treatment.
February 5, 2015 - "Payment Codes on Home Health Claims Will Be Matched Against Patient Assessments" MLN Matters® Article - Released - MLN Matters® Special Edition Article #SE1504, "Payment Codes on Home Health Claims Will Be Matched Against Patient Assessments" was released and is now available in downloadable format. This article is designed to provide education on a system change that will compare the Health Insurance Prospective Payment System (HIPPS) code on a Medicare home health claim to the HIPPS code generated by the corresponding Outcomes and Assessment Information Set (OASIS) assessment before the claim is paid. It includes information on how this change will be implemented and how it will impact home health agencies.
February 5, 2015 - "Extension of Provider Enrollment Moratoria for Home Health Agencies and Part B Ambulance Suppliers" MLN Matters® Article - Revised - MLN Matters® Special Edition Article #SE1425, "Extension of Provider Enrollment Moratoria for Home Health Agencies and Part B Ambulance Suppliers" was revised and is now available in downloadable format. This article is designed to provide education on the extension of the temporary moratoria for an additional 6 months in certain geographic locations. It includes background information and tables. This article was revised to reflect an extension of the moratoria for an additional 6 months.
January 29, 2015 - "Continued Use of Modifier 59 after January 1, 2015" MLN Matters® Article - Released - MLN Matters® Article #SE1503, "Continued Use of Modifier 59 after January 1, 2015" was released and is now available in downloadable format. This article is designed to provide education on continued use of the new –X {EPSU} modifiers, as outlined in Change Request 8863. It includes information to remind providers that they may continue using the -59 modifier after January 1, 2015, in any instance in which it was correctly used prior to January 1, 2015.
January 29, 2015 - "Telehealth Services" Fact Sheet - Revised - The "Telehealth Services" Fact Sheet (ICN 901705) was revised and is now available in downloadable format. This fact sheet is designed to provide education on services furnished to eligible Medicare beneficiaries via a telecommunications system. It includes information about originating sites, distant site practitioners, telehealth services, billing and payment for professional services furnished via telehealth, billing and payment for the originating site facility fee, resources, and lists of helpful websites and Regional Office Rural Health Coordinators.
January 29, 2015 - "Medicare Part B Immunization Billing" Educational Tool - Revised - The "Medicare Part B Immunization Billing" Educational Tool (ICN 006799) has been revised and is now available in downloadable format. This educational tool is designed to provide education on Medicare-covered preventive immunizations. It includes coverage, coding, and billing information on the influenza, pneumococcal, and Hepatitis B vaccines and their administration.
January 22, 2015 - "Opting out of Medicare and/or Electing to Order and Certify Items and Services to Medicare Beneficiaries" MLN Matters® Article - Revised - MLN Matters® Special Edition Article #SE1311, "Opting out of Medicare and/or Electing to Order and Certify Items and Services to Medicare Beneficiaries" was revised and is now available in downloadable format. This article is designed to provide education on the necessity to file an affidavit with Medicare to opt-out of Medicare. It also clarifies the difference between providers who are permitted to opt-out and providers who opt-out and elect to order and refer services. This article was revised to add clarifying language on the opt-out process and requirements, especially with regard to the definition of "opt-out."
January 15, 2015 - "Ambulance Fee Schedule" Fact Sheet - Revised - The "Ambulance Fee Schedule" Fact Sheet (ICN 006835) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Ambulance Fee Schedule. It includes the following information: background, the Medicare ambulance transport benefit, ambulance providers and suppliers, Advance Beneficiary Notice of Noncoverage, payments, how payment rates are set, and updates to the fee schedule.
January 15, 2015 - "Medicare Secondary Payer for Providers, Physicians, Other Suppliers, and Billing Staff" Fact Sheet - Revised The "Medicare Secondary Payer for Providers, Physicians, Other Suppliers, and Billing Staff" Fact Sheet (ICN 006903) was revised and is now available in a downloadable format. This fact sheet is designed to provide education on the Medicare Secondary Payer (MSP) provisions. It includes information on MSP basics, common situations when Medicare may pay first or second, Medicare conditional payments, the Coordination of Benefits rules, and role the Benefits Coordination & Recovery Center.
January 8, 2015 - "Certifying Patients for the Medicare Home Health Benefit" MLN Matters® Article - Released - MLN Matters® Article #SE1436, "Certifying Patients for the Medicare Home Health Benefit" was released and is now available in downloadable format. This article is designed to provide education on the Medicare home health services benefit, including patient eligibility requirements and certification/recertification requirements of covered Medicare home health services. It includes an overview of the Medicare home health services benefits and a list of eligibility and certification requirements.
January 8, 2015 - "Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations" MLN Matters® Article - Released - MLN Matters® Article #MM9051, "Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations" was released and is now available in downloadable format. This article is designed to provide education on updates to the Medicare pneumococcal vaccine coverage requirements, as outlined in Change Request 9051. It includes information on new Advisory Committee on Immunization Practices (ACIP) recommendations for administering two different pneumococcal vaccinations.
January 8, 2015 - "Discharge Planning" Booklet - Revised - The "Discharge Planning" Booklet (ICN 908184) was revised and is now available in downloadable format. This booklet is designed to provide education on Medicare discharge planning. It includes discharge planning information for Acute Care Hospitals, Inpatient Rehabilitation Facilities, and Long Term Care Hospitals; Home Health Agencies; Hospices; Inpatient Psychiatric Facilities; Long Term Care Facilities; and Swing Beds.
January 8, 2015 - "The Basics of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Accreditation" Fact Sheet - Reminder - "The Basics of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Accreditation" Fact Sheet (ICN 905710) is available in downloadable format. This fact sheet is designed to provide education on DMEPOS. It includes information so suppliers can meet DMEPOS quality standards established by CMS and become accredited by a CMS-approved independent national Accreditation Organization (AO). There is also information on the types of providers who are exempt.
December 18, 2014 - "Medical Privacy of Protected Health Information" Fact Sheet - Revised - The "Medical Privacy of Protected Health Information" Fact Sheet (ICN 006942) was revised and is now available in a downloadable format with a print ready feature. This fact sheet is designed to provide education on resources and information regarding the HIPAA Privacy Rule and how this rule applies to customary health care practices. It includes information on accessing the HHS HIPAA web page resources.
December 11, 2014 - "Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs" MLN Matters® Article - Revised - MLN Matters® Special Edition Article #SE1434, "Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs" was revised and is now available in a downloadable format. This article is designed to provide education on writing prescriptions for Medicare beneficiaries for Medicare Part D drugs. It includes background information and examples. The article was revised to emphasize that form CMS-855O is appropriate for use by prescribers.
December 11, 2014 - "Skilled Nursing Facility Billing Reference" Fact Sheet - Revised - "Skilled Nursing Facility (SNF) Billing Reference" Fact Sheet (ICN 006846) was revised and is now available in downloadable format. This fact sheet is designed to provide education on Medicare Part A which covers skilled nursing and rehabilitation care in a SNF under certain conditions for a limited time. It includes information for SNF providers about SNF coverage, SNF payment, and SNF billing.
December 11, 2014 - "The Basics of Internet-based PECOS for DMEPOS Suppliers" Fact Sheet - Reminder - "The Basics of Internet-based PECOS for DMEPOS Suppliers" Fact Sheet (ICN 904283) is available in downloadable format. This fact sheet is designed to provide education on how Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers should enroll in the Medicare Program and maintain their enrollment information on Internet-based Provider Enrollment, Chain, and Ownership System (PECOS). It includes information on how to complete an enrollment application using Internet-based PECOS and a list of frequently asked questions and resources.
November 20, 2014 - "Complying With Medical Record Documentation Requirements" Fact Sheet - Released - The "Complying With Medical Record Documentation Requirements" Fact Sheet (ICN 909160) was released and is now available in downloadable format. This fact sheet is designed to provide education on proper medical record documentation requirements. It includes information and resources to help Medicare providers understand how to provide accurate and supportive medical record documentation. This Medicare Learning Network® publication was developed in conjunction with the Comprehensive Error Rate Testing (CERT) Part A and Part B and Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Outreach & Education Task Forces in an effort to provide nationally-consistent education on topics of interest to health care professionals.
November 20, 2014 - "Hospital Reclassifications" Fact Sheet - Revised - The "Hospital Reclassifications" Fact Sheet (ICN 907243) was revised and is now available in downloadable format. This fact sheet is designed to provide education on hospital reclassifications. It includes the following information: urban to rural reclassification, geographic reclassification, Rural Referral Center status, Sole Community Hospital status, and Critical Access Hospital status.
November 20, 2014 - "Revised Centers for Medicare & Medicaid Services (CMS) 855R Application – Reassignment of Medicare Benefits" MLN Matters® Article - Released" - MLN Matters® Article #SE1432, "Revised Centers for Medicare & Medicaid Services (CMS) 855R Application – Reassignment of Medicare Benefits" was released and is now available in downloadable format. This article is designed to provide education on the revised CMS 855R application, which physicians, non-physician practitioners, providers, and suppliers must begin using on June 1, 2015. It includes information on how the form has changed and when it will be available for use on the CMS website.
November 20, 2014 - "Medicare Billing: 837I and Form CMS-1450" Fact Sheet - Revised" - The "Medicare Billing: 837I and Form CMS-1450" Fact Sheet (ICN 006926) was revised and is now available in downloadable format. This fact sheet is designed to provide education on electronic and paper claims for institutional providers as well as other health care professionals and suppliers. It includes information about Medicare claims submissions, coding, submitting accurate claims, when Medicare will accept a hard copy claim form, and timely filing.
November 20, 2014 - "Medicare Billing: 837P and Form CMS-1500" Fact Sheet - Revised" - The "Medicare Billing: 837P and Form CMS-1500" Fact Sheet (ICN 006976) was revised and is now available in downloadable format. This fact sheet is designed to provide education on electronic and paper claims for health care professionals and suppliers. It includes information about Medicare claims submissions, coding, submitting accurate claims, when Medicare will accept a hard copy claim form, timely filing, and where to submit Fee-For-Service (FFS) claims.
November 20, 2014 - "Evaluation and Management Services Guide" Educational Tool-Revised" - The "Evaluation and Management Services Guide" Educational Tool (ICN 006764) was revised and is now available in downloadable format. This guide is designed to provide education on evaluation and management services. It includes the following information: medical record documentation, evaluation and management billing and coding considerations, the "1995 Documentation Guidelines for Evaluation and Management Services," and the "1997 Documentation Guidelines for Evaluation and Management Services." Re-updated in August of 2017.
November 6, 2014 - "Skilled Nursing Facility Prospective Payment System" Fact Sheet - Revised - The "Skilled Nursing Facility Prospective Payment System" Fact Sheet (ICN 006821) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Skilled Nursing Facility Prospective Payment System (SNF PPS). It includes the following information: background and elements of the SNF PPS.
November 6, 2014 - "Inpatient Rehabilitation Facility Prospective Payment System" Fact Sheet - Revised - The "Inpatient Rehabilitation Facility Prospective Payment System" Fact Sheet (ICN 006847) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS). It includes the following information: background, elements of the IRF PPS, payment updates, and IRF Quality Reporting Program.
October 16, 2014 - "Reading the Institutional Remittance Advice (RA)" Booklet - Released - The "Reading the Institutional Remittance Advice (RA)" Booklet (ICN 908326) was released and is now available in downloadable format. This booklet is designed to provide education on the institutional remittance advice (RA). It includes screen shots of an institutional RA with an explanation of what you will find on each screen.
October 16, 2014 - "Medicare Disproportionate Share Hospital" Fact Sheet - Revised - The "Medicare Disproportionate Share Hospital" Fact Sheet (ICN 006741) was revised and is now available in downloadable format. This fact sheet is designed to provide education on Medicare Disproportionate Share Hospitals (DSHs). It includes the following information: background; methods to qualify for the Medicare DSH adjustment; Affordable Care Act provision that impacts Medicare DSHs; Medicare Prescription Drug, Improvement, and Modernization Act provisions that impact Medicare DSHs; number of beds in hospital determination; Medicare DSH payment adjustment formulas; resources; and lists of helpful websites and Regional Office Rural Health Coordinators.
October 16, 2014 - "The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers" Fact Sheet - Reminder - "The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers" Fact Sheet (ICN 903768) is available in downloadable format. This fact sheet is designed to provide education on basic Medicare enrollment information and how to ensure physicians and other Part B suppliers are qualified and eligible to enroll in the Medicare Program. It includes information on how to enroll in the Medicare Program, how to report changes, and a list of resources.
October 9, 2014 - "Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs" Fact Sheet - Revised The "Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs" Fact Sheet (previously titled "Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) At a Glance") (ICN 006977) was revised in September 2014 and is now available in downloadable format. This fact sheet is designed to provide education on dual eligible beneficiaries under the Medicare and Medicaid Programs. It includes the following information: the Medicare and Medicaid Programs; dual eligible beneficiaries; assignment; and prohibited billing.
October 2, 2014 - "Medicare Appeals Process" Fact Sheet - Revised - The "Medicare Appeals Process" Fact Sheet (ICN 006562) was revised and is now available in a downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in Original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers, in addition to including more information on available appeals-related resources.
September 25, 2014 - "Medicare Billing Information for Rural Providers and Suppliers" Booklet - Revised - The "Medicare Billing Information for Rural Providers and Suppliers" Booklet (ICN 006762) was revised and is now available in downloadable format. To assist rural providers who have limited internet access, the "Medicare Billing Information for Rural Providers and Suppliers Text-Only" Booklet is available in text-only format. This booklet is designed to provide education on Medicare rural billing. It includes information for Critical Access Hospitals, Federally Qualified Health Centers, Home Health Agencies, Rural Health Clinics, Skilled Nursing Facilities, and Swing Beds.
September 25, 2014 - "Rural Health Clinic" Fact Sheet - Revised - The "Rural Health Clinic" Fact Sheet (ICN 006398) was revised and is now available in downloadable format. To assist rural providers who have limited internet access, the "Rural Health Clinic Text-Only" Fact Sheet is available in text-only format. This fact sheet is designed to provide education on Rural Health Clinics (RHC). It includes the following information: background, RHC services, Medicare certification as a RHC, RHC visits, RHC payments, cost reports, annual reconciliation, resources, and lists of helpful websites and Regional Office Rural Health Coordinators.
September 25, 2014 - "Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians" Fact Sheet - Revised - The "Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians" Fact Sheet (ICN 905645) was revised and is now available in a downloadable format. This fact sheet is designed to provide education for physicians on understanding how to comply with Federal laws that combat fraud and abuse and ensure appropriate quality medical care. It includes information on identifying "red flags" that could lead to potential liability in law enforcement and administrative actions.
September 25, 2014 - "Critical Access Hospital" Fact Sheet - Revised - The "Critical Access Hospital" Fact Sheet (ICN 006400) was revised and is now available in downloadable format. This fact sheet is designed to provide education on Critical Access Hospitals (CAHs). It includes the following information: background, CAH designation, CAH payments (including hospital inpatient admission certification requirements), additional Medicare payments, grants to States under the Medicare Rural Hospital Flexibility Program, resources, and lists of helpful websites and Regional Office Rural Health Coordinators.
September 18, 2014 - "Medicare Vision Services" Fact Sheet (ICN 907165) is designed to provide education on Medicare coverage and billing information for vision services. It includes specific information concerning coding requirements and an overview of coverage guidelines and exclusions.
September 18, 2014 - "Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs" Fact Sheet - Revised - The "Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs" Fact Sheet, previously titled Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) At a Glance (ICN 006977), was revised and is now available in downloadable format. This fact sheet is designed to provide education on dual eligible beneficiaries under the Medicare and Medicaid Programs. It includes the following information: the Medicare and Medicaid Programs; deductibles, coinsurance, and copayments; dual eligible beneficiaries; assignment; and prohibited billing.
September 18, 2014 - "2014-2015 Influenza (Flu) Resources for Health Care Professionals" MLN Matters® Article - Released - MLN Matters® Special Edition Article #SE1431, "2014-2015 Influenza (Flu) Resources for Health Care Professionals" was released and is now available in downloadable format. This article is designed to provide education on resources and quick tips that health care professionals can use to help prevent the spread of the flu. It includes a list of educational resources designed to help health care professionals understand Medicare guidelines for seasonal flu vaccines and their administration.
September 15, 2014 - "Examining the Difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN)" MLN Matters® Article - Revised - MLN Matters® Special Edition Article #SE1216, "Examining the Difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN)" was revised and is now available in downloadable format. This article is designed to provide education on the differences between an NPI and a PTAN. It includes information about new enrollees, revalidation, the relationship between the NPI and PTAN, and how providers can protect their identity in the Provider Enrollment Chain & Ownership System (PECOS). The article was revised to add the "Where Can I Find My PTAN?" section on page 3.
September 4, 2014 - "Quick Reference Information: Coverage and Billing Requirements for Medicare Ambulance Transports" Educational Tool - Released - The "Quick Reference Information: Coverage and Billing Requirements for Medicare Ambulance Transports" Educational Tool (ICN 909008) was released and is now available in downloadable format. This product is designed to provide education on ground and air ambulance coverage and billing requirements that apply to destinations covered under the Medicare ambulance transport benefit. It includes the following information: the ambulance transport benefit; ambulance providers and suppliers; documentation requirements; coverage and billing requirements; and Advance Beneficiary Notice of Noncoverage.
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