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Are You Aware of Medicare Advantage Plans Timely Filing Rules?
August 20th, 2019
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 ...
Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?
August 13th, 2019
By Wyn Staheli, Director of Research | Published August 13th, 2019
Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.
The OIG Work Plan: What Is It and Why Should I Care?
August 9th, 2019
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 ...
Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage
July 26th, 2019
By Namas | Published July 26th, 2019 - Last Review/Update August 8th, 2019
Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky.
In their notice, Anthem states:
"Effective for all commercial ...
Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?
July 22nd, 2019
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
July 17th, 2019
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
July 5th, 2019
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 ...
Now is Your Chance to Speak Up! Tell CMS What You Think!
June 13th, 2019
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 13th, 2019
CMS is asking for your input, we all have ideas on how we would change healthcare documentation requirements and get rid of the burdensome requirements and regulations if it were up to us, so go ahead, speak up! Patients over Paperwork Initiative is being looked at to help significantly cut ...
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 ...
By Wyn Staheli, Director of Content | Published April 26th, 2019
There are policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 taking place June 13, 2019. This will give you a heads up on those changes.
What is Medical Necessity and How Does Documentation Support It?
April 23rd, 2019
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 ...
By By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow Clinical Director, PayDC Chiropractic EHR Software President, Gwilliam Consulting LLC drgwil@gmail.com | Published April 22nd, 2019
Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
April 8th, 2019
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 ...
Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?
April 1st, 2019
By Wyn Staheli, Director of Research | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
Question
My patient seemed confused about which of the options they should check. Can I just tell them which one they should check?
Answer
No! That could be construed as coercion. The official instructions state “Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.”
Now, this ...
Clearing Up Some Medicare Participation Misunderstandings
March 25th, 2019
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
March 21st, 2019
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 ...
By Wyn Staheli, Director of Research | Published March 7th, 2019
Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.
Q/A: Can you Help me Understand the New Medicare Insurance Cards?
March 7th, 2019
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
February 25th, 2019
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 ...
HHS Proposes Significant Changes to Patient Access Rules
February 11th, 2019
By Wyn Staheli, Director of Research | Published February 11th, 2019
In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...
Charging Missed Appointment Fees for Medicare Patients
February 7th, 2019
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
February 1st, 2019
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
December 18th, 2018
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
November 29th, 2018
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 Chris Woolstenhulme, QCC, CMCS, 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
November 26th, 2018
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?
November 7th, 2018
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
November 1st, 2018
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...
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
Type of bill codes identifies the type of bill being submitted to a payer. Type of bill codes are four-digit alphanumeric codes that specify different pieces of information on claim form UB-04 or form CMS-1450 and is reported in box 4 on line 1.
First Digit = Leading zero. Ignored by CMSSecond ...
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 ...
By Terry Ketchersid, MD, MBA | Published July 27th, 2018 - Last Review/Update September 24th, 2018
Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...
CMS Proposes Changes to Evaluation & Management Requirements
July 25th, 2018
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?
July 18th, 2018
By NAMAS | 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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 18th, 2018
Spend more time with patients and less time documenting? Great Concept!
Document meaningful information? Sound good?
CMS is proposing just that! CMS released a new proposal July 12, 2018, focused on streamlining clinician billing and expanding access to high-quality care. The goal is to improve and restore the doctor-patient relationship, modernize Medicare ...
Attention Providers - Please Make Time to Read this Letter
July 17th, 2018
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 17th, 2018
In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 16th, 2018 - Last Review/Update July 17th, 2018
According to CMS changes are coming for E/M codes. A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...
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
July 9th, 2018
By Chris Woolstenhulme, QCC, CMCS, 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 ...
How Does the Physician Compare Website Affect You?
June 25th, 2018
By Wyn Staheli, Director of Research | Published June 25th, 2018
The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the ...
Q/A: Can a PT Assistant Perform Physical Therapy Modalities?
June 18th, 2018
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?
June 12th, 2018
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 ...
Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?
June 4th, 2018
By BC Advantage | Published June 4th, 2018
When Medicare updated their systems with the updates to mammography and breast biopsy policies some ICD-10-CM codes were inadvertently left out. The omitted new codes are N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42, which will replace the truncated ICD-10 diagnosis N63. The Centers for Medicare & Medicaid Services (CMS) will...
By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...
By Shannon Cameron, MBA, MHIIM, CPC | Published May 14th, 2018 - Last Review/Update May 24th, 2018
The release of the 2018 Final Rule for the Outpatient Prospective Payment System (OPPS) in November 2017 has created quite a stir across the orthopedic healthcare community. In what has been deemed a questionable decision, the Centers for Medicare and Medicaid Services (CMS) decided to remove Total Knee Arthroplasty...
Join us for AAPC CEU approved Education and Outreach with Noridian BASIC E AND M AVOIDING COMMON ERRORS Start Date: 5/15/18 Duration: 11:00 AM – 12:00 PM - Pacific Daylight Time Type: Web-based Workshop Register Now: https://attendee.gotowebinar.com/register/7977003427311130113 Abstract: This presentation is designed to provide basic information on the billing and...
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 ...
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
April 20th, 2018
By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018
As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....
Indications for Serotypes A and B Botulinum Toxins
April 16th, 2018
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 9th, 2018
Since the publication of the Compliance Program Guidelines in 2012, the Medicare Part C & D Oversight and Enforcement Group, Division of Compliance Enforcement, has presented a series of focused trainings for the industry on the application of the seven elements of an effective compliance program. These trainings are designed ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 29th, 2018
Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below.
Originating Site Fee
Each ...
Medicare Beneficiary Identifier (MBI) Beginning April 1, 2018 (This is Not a Joke)
March 21st, 2018
By Brittney Murdock, QCC, CMCS, CPC | Published March 21st, 2018
The law requires the Centers for Medicare & Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new unique Medicare number will replace the current Health Insurance Claim Number (HICN) on the new Medicare cards. The new cards will be mailed in...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 21st, 2018 - Last Review/Update March 27th, 2018
Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary.
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:
For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.
For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...
By Wyn Staheli, Director of Research | Published March 1st, 2018
On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References.
Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...
Medicare Using Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting January 2018
February 6th, 2018
By Chris Woolstenhulme, QCC, CMCS, 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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2018
CMS announced today, during the time that the partial government shutdown is in effect, Medicare Administrative Contractors will continue to perform all functions related to Medicare fee-for-service claims processing and 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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 31st, 2018
With this year's Flu season being the most widespread on record, providers are seeing more patients and giving more immunizations for influenza than normal. Here are a few things to keep in mind during this flu season.
Know the rules with your payers to ensure proper reimbursement and correct billing. For example, did you ...
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)
January 23rd, 2018
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's Integrated Behavioral Healthcare Services and Collaborative Care Program
January 18th, 2018
By Wyn Staheli, Director of Research | Published January 18th, 2018
Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...
Medicare Requiring Specific Modifiers on Therapy Services
January 15th, 2018
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 10th, 2018
On January 2, 2018, CMS announced a new data submission system for eligible clinicians to report quality measures for the Quality Payment Program. Data may be submitted through the new platform on the qpp.cms.gov website. The announcement stated:
Data can be submitted and updated any time from January 2, 2018 to March ...
MIPS - To Participate or Not Participate - That is the Question
January 10th, 2018
By Wyn Staheli, Director of Research | Published January 10th, 2018
Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...
CMS Launches Data Submission System for Clinicians in the Quality Payment Program
January 4th, 2018
By Find-A-Code | Published January 4th, 2018
Today, the Centers for Medicare & Medicaid Services (CMS) announced that doctors and other eligible clinicians participating in the Quality Payment Program can begin submitting their 2017 performance data using a new system on the Quality Payment Program website (qpp.cms.gov). The data submission system is an improvement from the former...
Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1
January 4th, 2018
By Find-A-Code | Published January 4th, 2018
An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ...
Physical Therapist can now bill for a substitute Physical Therapist
January 4th, 2018
By Find-A-Code | Published January 4th, 2018
As of 6/13/2017 Medicare contractors shall accept claims from Physical Therapists, Provider Specialty 65 – Physical Therapist in Private Practice, for services provided by a substitute physical therapist under a fee-for-time compensation arrangement when submitted with the Q6 modifier.
The A/B MAC Part B may pay the patient’s regular physician for physicians' ...
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
December 13th, 2017
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?
Appropriate Use Criteria for Advanced Diagnostic Imaging Services - 2018 Final Rule
December 13th, 2017
By Jared Staheli | Published December 13th, 2017
What is the AUC program? From the CMS website:
Section 218(b) of the Protecting Access to Medicare Act of 2014 amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging ...
Medicare Diabetes Prevention Program (MDPP) Expanded Model Information
December 12th, 2017
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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 11th, 2017
CMS posted new Merit-based Incentive Payment System (MIPS) resources on Quality Payment Program Resource Library webpage:
CMS Web Interface: Excel template for uploading sample beneficiary data with corresponding user guide and instructional video
Extreme and Uncontrollable Circumstances Fact Sheet: Overview of the policy established in the interim final rule with comment period to support clinicians affected by the California wildfires and ...
By Wyn Staheli, Director of Research | Published November 28th, 2017
In 2015, the CMS Innovation Center announced plans for new value-based Medicare Advantage plans in an effort to reduce healthcare costs while improving quality of care. This five year pilot program began in 2017 with seven states and is expanding to ten states for 2018. Results must have been positive because they ...
By Chris Woolstenhulme, QCC, CMCS, 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.
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 23rd, 2017
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 ...
Avoid Deactivation of your Medicare Billing Privileges
October 18th, 2017
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 18th, 2017
According to the Affordable Care Act all Medicare providers are required to re-validate their enrollment information every three or five years. To determine if you are due for re-validation the list below will display a re-validation due date. If you have a due date of “TBD”, this means there has not ...
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.
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 20th, 2017
CMS recently released a new LCD for Jurisdiction F, Bladder/Urothelial Tumor Markers (L36680).
Documentation Requirements
The medical record must clearly identify the number and frequency of bladder marker testing. Medical record documentation must be legible, must be maintained in the patient’s medical record (hard copy or electronic copy), and must meet the ...
Medicare Improper Payment Report for Chiropractic (2016)
September 1st, 2017
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)
September 1st, 2017
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 ...
American Chiropractic Association Comments on MACRA 2018 Proposed Rule
September 1st, 2017
By ChiroCode | Published September 1st, 2017 - Last Review/Update January 30th, 2019
Arlington, Va. - The American Chiropractic Association (ACA) recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to the federal agency's proposed rule changes to the Quality Payment Program (QPP) for 2018.
QPP is a new payment model for physicians, including chiropractors, created by the Medicare Access and CHIP ...
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance from the Department of Health and Human Services on Cardiovascular Disease Screening Tests:
80061 -
Lipid panel, this panel must include the following:
82465 - Cholesterol, serum, total
83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
84478 - Triglycerides
Z13.6
All Medicare beneficiaries without apparent signs or symptoms ...
Preventive Services: Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
September 1st, 2017
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)....
Preventive Services: Lung Cancer Counseling and Annual Screening for Lung Cancer With LDCT
September 1st, 2017
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Lung Cancer Screening Counseling, and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)....
Preventive Services: Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
September 1st, 2017
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests....
Preventive Services: Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
September 1st, 2017
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.....
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening Pelvic Examinations (includes a clinical breast examination)....
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 Chris Woolstenhulme, QCC, CMCS, 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 ChiroCode | Published May 12th, 2017 - Last Review/Update January 31st, 2019
The Medicare contractor, NGS, made changes to its E/M coding guidelines for level 3 exams. Even if you don't bill NGS, this change could be a sign of things to come for other payers. Watch here.
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 Chris Woolstenhulme, QCC, CMCS, 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 23rd, 2017
Compliance has a new standard for emergency preparedness plans. On September 8, 2016, CMS issued the final rule titled “Emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers.” This rule creates emergency preparedness Medicare Conditions of Participation (COPs).
There are specific standards for each of the named types of providers ...
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
February 15th, 2017
By CMS.gov | Published February 15th, 2017
The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients.
By Wyn Staheli, Director of Research | Published February 11th, 2017
The following modifiers are required when reporting medically necessary routine foot care services per Medicare guidelines:
Q7: One Class A finding
Q8: Two Class B findings
Q9: One Class B and two Class C findings
Appropriate: With foot care (podiatry) codes to indicate covered foot care
Inapproriate:
With any code not related to foot care
When the foot ...
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
January 24th, 2017
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
January 16th, 2017
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 ...
By Brittney Murdock, QCC, CMCS, CPC | Published January 6th, 2017
An "assistant at surgery" is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The "assistant at surgery" provides more than just ancillary services.
Codes eligible for reimbursement for an assistant surgeon are designated by the Centers for Medicare and Medicaid Services (CMS) ...
By Brittney Murdock, QCC, CMCS, CPC | Published December 30th, 2016
The payment rates for most separately payable medical and surgical services are determined by multiplying the prospectively established scaled relative weight for the service’s clinical APC by a conversion factor (CF) to arrive at a national unadjusted payment rate for the APC.
Medicare’s Quality Payment Program: Getting Paid for Value Instead of Volume
December 28th, 2016
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
December 16th, 2016
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 ...
International Classification of Diseases (ICD)-10 Code Updates and Impact to 4th Quarter 2016 Eligible Professional Medicare Quality Programs
December 15th, 2016
By CMS.gov | Published December 15th, 2016
On October 1, 2016, new International Classification of Diseases (ICD)-10-CM and ICD-10-PCS code sets went into effect. Updating of these codes traditionally occurs on an annual basis, however, during the immediate years leading up to the ICD-9 to ICD-10 transition there was an extended freeze to code updates to support...
CMS Announces Additional Opportunities for Clinicians Under the Quality Payment Program
December 15th, 2016
By Brittney Murdock, QCC, CMCS, CPC | Published December 15th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 13th, 2016
Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar ...
By Wyn Staheli, Director of Research | Published December 12th, 2016
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling
overpayments for both Medicare and Medicaid takes effect. Failure to report and
subsequently return an overpayment within 60 days after the overpayment was
“identified” is a violation of the False Claims Act.
By Chris Woolstenhulme, QCC, CMCS, 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
October 17th, 2016
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 ...
Looking forward to a 9% payment increase for Medicare Part B
September 9th, 2016
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 9th, 2016
What in the world is MACRA, MIPS and APM? More acronyms, rules and payment changes are headed our way. If you are a Medicare Part B provider, you will want to pay special attention.
MACRA- Medicare Access and CHIP Reauthorization Act of 2015
MIPS- Merit-Based Incentive Payment System
APM – Alternative Payment Model ...
CMS offering options for MACRA Participation. You Choose - Be prepared!
September 9th, 2016
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Continuing the commitment to greater data transparency, the Centers for Medicare & Medicare Services (CMS) today released privacy-protected data on the prescription drugs that were paid for under the Medicare Part D Prescription Drug Program in 2014. This is the second release of the data on an annual basis, which...
The final list of the new ICD-10- CM codes that become effective October 1, 2016 has been released. There are approximately 1600 changes to the code set, making up for the four years the ICD-10- CM codes have not had a complete update. For fiscal year (FY) 2017, updates to...
The 2017 ICD-10-CM and ICD-10-PCS code updates, including a complete list of code titles, are available on the 2017 ICD-10-CM and GEMs and 2017 ICD-10-PCS and GEMs webpages.
The federal government’s readmission penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released Tuesday show. The government will punish more than half of the nation’s hospitals — a total of 2,597...
CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)
June 27th, 2016
By Brittney Murdock, QCC, CMCS, CPC | Published June 27th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home ...
Medicare Will Use Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting in 2018
June 23rd, 2016
By Brittney Murdock, QCC, CMCS, CPC | Published June 23rd, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer ...
Mastering Medicare: When Opting Out is not an Option
June 15th, 2016
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?
Mandatory Submission of Staffing Data via PBJ Begins July 1 for Long – Term care facilities
June 9th, 2016
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 9th, 2016
Electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all long-term care facilities starting July 1. The last day to submit data for fiscal quarter four (July 1 through September 30) is November 14, 2016. Nursing homes can register now in the PBJ system to prepare:
Obtain ...
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
May 19th, 2016
By Chris Woolstenhulme, QCC, CMCS, 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
May 3rd, 2016
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
May 3rd, 2016
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 ...
CMS Publishes Final Rule on Fire Safety Requirements for Certain Health Care Facilities
May 3rd, 2016
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; ...
By Wyn Staheli, Director of Research | Published April 13th, 2016
Telehealth and telemedicine are covered for many payers for services such as consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.
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 InstaCode Institute | Published February 15th, 2016
CMS is developing a new Unified Program Integrity Contractor (UPIC) program to consolidate Medicare and Medicaid reviews. This consolidation of the Medicaid Integrity Contractors (MICs) and the Medicare Zone Program Integrity Contractors (ZPICs) could relieve some of the overlap and burdens under the current systems.
For inpatient coding, there are times when the diagnosis(es) cannot be established at the time of admit or throughout the course of the admission. In these cases, they are documented in the medical record as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out” conditions. This guideline is true for certain...
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.
6 ways to stop filing duplicate Medicare claims - Duplicates could expose your practice to fraud investigation
January 6th, 2016
By | Published January 6th, 2016
Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims. When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing...
Preventive Medicine Services for Medicare Patients
January 6th, 2016
By Codapedia | Published January 6th, 2016
The most widely known fact about Medicare and preventive medicine is that fee-for-service Medicare does not cover an annual physical exam. This is because in its beginning, Medicare was prohibited from paying for routine services. Over the years, Congress has mandated the payment of some screening...
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he...
CMS Announces: Final Rule on Authorization Process for Certain Durable Medical Equipment
January 5th, 2016
By Brittney Murdock, QCC, CMCS, CPC | Published January 5th, 2016
CMS has established a new prior authorization process for DMEPOS items that are frequently subject to unnecessary utilization. The final rule will create an initial Master list that includes items that meet specific criteria.
Items already on the Master List that are identified by a GAO/OIG, or CERT DME and/or DMEPOS ...
By Aimee Wilcox, MA CST CCS-P | Published December 21st, 2015
If your organization performs incident-to services, be sure to perform a periodic review of the rules that govern incident to and then compare them to the practices of your providers to ensure they would pass an audit. Here are just a few of the guidelines that should be reviewed; however, ...
CMS clarified in 2007 that a physician practice may bill Medicare patients for failing to keep an appointment. The CMS MedLearn matters article is attached as a resource. Check with your state Medicaid to see if you can bill Medicaid patients. If you are billing Medicare...
CMS clarifies the ways physician practices can respond to additional documentation requests
December 2nd, 2015
By Codapedia | Published December 2nd, 2015
It’s one of the inevitabilities of running a physician practices that never happens at a good time and seems to rarely go very smoothly. You see an additional documentation request – known as an ADR – from either your Medicare Administrative Contractor (MAC) or one of...
You do not need to change or rewrite your original orders
November 24th, 2015
By Find-A-Code | Published November 24th, 2015
CMS wants to remind you not to change or rewrite your original orders for any service or product due to the change of code sets from ICD-9-CM to ICD-10-CM.
For any type of product or service prior to October 1, 2015, do not change the order, even if it will be ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 24th, 2015
Prescription (order) Requirements face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required by Medicare:
• For all claims for purchases or initial rentals
• When there is a change in the prescription for the accessory, supply, drug, etc.
• If ...
After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of its own like ...
Fee For Service Advance Beneficiary Notice of Noncoverage - Free
November 9th, 2015
By Find-A-Code | Published November 9th, 2015
Fee For Service Advance Beneficiary Notice of Noncoverage
The Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied. Guidelines ...
National Supplier Clearinghouse - SUGGESTED TEMPLATES FOR COMPLIANCE WITH CERTAIN SUPPLIER STANDARDS - FREE
November 9th, 2015
By Find-A-Code | Published November 9th, 2015
The attached model forms were created in an effort to educate suppliers regarding certain supplier standards listed in 42 CFR.424.57(c). Please note that these forms are simply templates and suppliers should feel free to create their own forms. Suppliers using their own forms must ensure the forms are capturing and documenting information ...
DME MAC Jurisdiction A ASCA Waiver Request Form - Free
November 9th, 2015
By Find-A-Code | Published November 9th, 2015
Submit this form, along with your supporting documentation, when requesting an Administration Simplification Compliance Act (ASCA) waiver which grants the ability to submit paper claims for suppliers in specific circumstances.
...
Medicare Redetermination Request Form - The Redetermination Request Form is for all DMEPOS suppliers to use when submitting a redetermination request. The form is designed so that users can easily include all of the basic information needed to submit a redetermination request and is valid in all four DME MAC Jurisdictions. A ...
Medicare Reopening Request Form - The Reopening Request Form is for all DMEPOS suppliers to use when submitting a Reopening request. The form is designed so that users can easily include all of the basic information needed to submit a Reopening request and is valid in all four DME MAC Jurisdictions. A ...
PMD Prior Authorization Demonstration Coversheet - This coversheet is used for items associated with the PMD Prior Authorization Demonstration. More information concerning the PMD Prior Authorization Demonstration can be found on the CMS Web site.
...
By Christine Taxin | Published September 25th, 2015
Coordination of benefits, (COB) is a clause in most group policies, which is in place to minimize the over-payment or duplicate payment of claims. COB applies to patients covered by more than one insurance plan and limits the amount paid by each plan.
With the COB clause the payments made by ...
Medicare Makes Moderate Sedation Payable
Christine Taxin
Should your primary care physicians ever find cause to perform moderate sedation, you’ll be interested in a new Medicare policy that may make it payable as of Oct. 1. Medicare Pub. 100-04 Transmittal 1324 finally makes Medicare policy consistent with the fee schedule pricing for ...
Dental practices that do not work with medical are truly confused when it comes to Medicare. I decided to put together a simple outline of what we should be doing to be compliant with Medicare.
Summary of Adjustments to Fee Schedule Computations (Rev.1931, Issued:03-12-10)
August 19th, 2015
By Find-A-Code | Published August 19th, 2015
For services prior to January 1, 1994, B/MACs computed the fee schedule amount for every service. Through 1995, the fee schedule amount is the transition fee schedule amount. For services after 1995, CMS computes and provides the fee schedule amount for every service discussed below. Certain adjustments are made in ...
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
August 19th, 2015
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...
First Physician Fee Schedule Proposed Rule Since SGR Repeal
August 19th, 2015
By Wyn Staheli, Director of Research | Published August 19th, 2015
Even though the SGR has been repealed, providers still need to be aware of annual fee revisions by CMS. On July 8, 2015, CMS announced their first proposed Medicare Physician Fee Schedule (MFPS) since the SGR repeal. As in years past, there will continue to be reviews of the Relative Value ...
G-Codes for Functional Reporting and Severity/Complexity Modifiers
August 19th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 19th, 2015
Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report non-payable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.
For the severity modifiers, providers should include a description of how the modifiers were determined.
Functional ...
Opting out of Medicare Electing to Order/Certify Items and Services to Medicare Beneficiaries
August 10th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare. This means that neither the physician, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private ...
Notice of Election (NOE) - Form CMS - 1450 (Rev. 3118)
August 3rd, 2015
By Find-A-Code | Published August 3rd, 2015
When a Medicare beneficiary elects hospice services, hospices must complete form locators identified in section 20.1.2 for the Uniform (Institutional Provider) Bill (Form CMS-1450), which is an election notice.
In addition, the hospice must complete the Form CMS-1450 when the election is for a patient who has changed an election from one ...
Levels of Care Data Required on the Institutional Claim to Medicare Contractor
August 3rd, 2015
By Find-A-Code | Published August 3rd, 2015
With the exception of payment for physician services, Medicare payment for hospice care is made at one of four predetermined rates for each day that a Medicare beneficiary is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments other than the application ...
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
August 3rd, 2015
By Find-A-Code | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
Carriers pay for physicians’ services furnished on or after January 1, 1992, on the basis of a fee schedule. The Medicare allowed charge for such physicians’ services is the lower of the actual charge or the fee schedule amount. The Medicare payment is 80 percent of the allowed charge after ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 3rd, 2015
Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare.
Primary payers are those that have the primary responsibility for paying a claim. Medicare remains the primary payer for ...
Hospice Pre - Election Evaluation and Counseling Services (Rev. 2258)
July 20th, 2015
By Find-A-Code | Published July 20th, 2015
Effective January 1, 2005, Medicare allows payment to a hospice for specified hospice pre-election evaluation and counseling services when furnished by a physician who is either the medical director of or employee of the hospice.
Medicare covers a one-time only payment on behalf of a beneficiary who is terminally ill, (defined ...
Formats for Submitting Claims to Medicare - Electronic Submission Requirements
July 20th, 2015
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 ...
(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 standards adopted under HIPAA include both a transaction standard and an implementation guide.
Claims sent electronically to Medicare must abide by the HIPAA standards ...
Payment Jurisdiction Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services (Rev. 3086)
July 20th, 2015
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 jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is ...
Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation
July 20th, 2015
By Find-A-Code | Published July 20th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; ImplementationJanuary 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are subject ...
Claims Processing Requirements for Deported Beneficiaries (Rev. 943, Issued: 05-05-06)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation. Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if there is no monthly benefit ...
Implementation of Payment Policy for Deported Medicare Beneficiaries (Rev. 943, Issued: 05-05-06)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A. CWF Editing of Claims
1. An auxiliary file shall be established in the Common Working File to contain deportation status.
2. This auxiliary file will be the basis for an edit that rejects claims submitted by Medicare contractors.
3. The edit will reject a claim where the beneficiary HIC number on ...
Provider Assignment to FIs and MACs (Rev. 1707; Issued: 03-27-09)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A. The Process of Moving Providers from FIs to MACs
1. The General Case
An existing Medicare provider with a claims history will remain in its current workload assignment. As each MAC contract is awarded, the new MAC will take over workload from the carriers and FIs that serviced the state(s) in ...
FI Service to HHAs and Hospices (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Under 42 CFR 421.117, CMS is authorized to designate RHHIs to service HHAs and hospices. This provision was implemented through the designation of regional FIs to service all HHAs and hospices. See http://www.cms.hhs.gov/contacts/incardir.asp for RHHI jurisdictions.
An HHA or hospice chain may request to be served under an arrangement involving a ...
Provider Change of Ownership (CHOW) (Rev. 861, Issued: 02-17-06)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Providers (as defined in 1861(u) of the Act, and institutional suppliers such as RHCs) that undergo a change in their ownership structure are required to notify CMS concerning the identity of the old and new owners. They are also required to inform CMS on how they will organize the new ...
CMS No Longer Accepts Provider Requests to Change Their FI (Rev. 2876, Issued: 02-07-14)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Medicare providers will no longer be able to request a change of FI, they must remain with the FI to which they have been assigned.
Pub 100-04 Medicare Claims Processing Manual
...
The RO uses the provider tie-in notice, Form CMS-2007 (see the CMS forms page at http://www.cms.hhs.gov/forms/), as an official notification to the FI of a change in its list of providers. The RO completes and transmits a Form CMS-2007 to the home office of the FI in each of the ...
Content and Terms of Provider Participation Agreements (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
In the agreement/attestation statement signed by a provider serviced by an FI, the provider agrees to maintain its compliance with all of the conditions for certification in 42 CFR 491. If a provider fails to maintain compliance with one or more of the conditions, it must promptly report this (usually ...
Provider Charges to Beneficiaries (Rev. 2921, Issued: 04-04-14)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary’s behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. This includes items or services for ...
Charges to Hold a Bed During SNF Absence (Rev. 1522, Issued: 05-30-08)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Charges to the beneficiary for admission or readmission are not allowable. However, when temporarily leaving a SNF, a resident can choose to make bed-hold payments to the SNF.
Bed-hold payments are readily distinguishable from payments made prior to initial admission, in that the absent individual has already been admitted to the ...
Provider Refunds to Beneficiaries (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
In the agreement between CMS and a provider, the provider agrees to refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.
Money incorrectly collected means any amount for covered services that is greater than the amount for which the beneficiary is liable ...
Provider Treatment of Beneficiaries (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
In the agreement between CMS and a provider, the provider agrees to accept Medicare beneficiaries for care and treatment. The provider cannot impose any limitations with respect to care and treatment of Medicare beneficiaries that it does not also impose on all other persons seeking care and treatment. If the ...
Assignment of Provider’s Right to Payment (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Except as provided in §30.2.1, FIs pay benefits due a provider only to the provider.
Carriers may pay assigned benefits only to the physician, practitioner, or supplier who furnished the service. They do not pay the benefits to any other person or organization under an assignment or reassignment, power of attorney, ...
Exceptions to Assignment of Provider’s Right to Payment – Claims Submitted to A/B MACs (Rev. 1931, Issued: 03-12-10)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A. Payment to Government Agency
Medicare payment for the services of a provider is not made to a governmental agency or entity except when payment to the governmental agency or entity is permissible under the other listed reassignment exceptions, e.g., where the agency is the employer of the physician.
B. Payment ...
Background and Purpose of Reassignment Rules - Claims Submitted to B/MACs (Rev. 1931, Issued: 03-12-10)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
In 1972, Congress acted to stop a practice under which some physicians and other suppliers providing covered services reassigned their Medicare and Medicaid receivables to other organizations and groups, which then claimed and received payment. Often the organizations acquired the claims at a percentage of face value. It had become ...
Reassignments by Nonphysician Suppliers - Claims Submitted to FIs (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Definition of Participating From MIM 3005
Nonphysician suppliers may reassign benefits under conditions similar to those under which physicians reassign benefits. Note, however, that when a supplier furnishes services to patients of a participating provider (e.g., a participating hospital or SNF) under arrangement (within the meaning of §1861(w) of the ...
Effect of Payment to Ineligible Recipient (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
An otherwise correct Medicare payment made to an ineligible recipient under an assignment or other authorization by the provider does not constitute a program overpayment. Sanctions may be invoked against a provider (see §30.2.15) to prevent it from executing or continuing in effect such an authorization in the future. Neither ...
Payment to Agent - Claims Submitted to Carriers (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A. Conditions
The FI or carrier makes payment in the name of the provider (Carriers additionally may pay in the name of supplier or employer, facility, or organized health care delivery system.) to an agent who furnishes billing or collection services if:
• The agent receives the payment under an agreement ...
Medicare payments due a provider or supplier of services may be sent to a bank (or similar financial institution) for deposit in the provider/supplier’s account so long as the following requirements are met:
• The bank may provide financing to the provider/supplier, as long as the bank states in writing, in ...
Payment to Employer of Physician - Carrier Claims Only (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
The carrier may pay Part B benefits for covered physician services under an assignment or for enrollees that did not execute assignment before death to the physician’s employer, provided that under the terms of the physician’s employment, only the employer and not the physician has the right to charge or ...
Payment for Services Provided Under a Contractual Arrangement - Carrier Claims Only (Rev. 472, Issued: 02-11-05)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A carrier may make payment to an entity (i.e., a person, group, or facility) enrolled in the Medicare program that submits a claim for services provided by a physician or other person under a contractual arrangement with that entity, regardless of where the service is furnished. Thus, the service may ...
University-Affiliated Medical Faculty Practice Plans - Claims Submitted to Carriers (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A carrier may make Part B payment to a university-affiliated medical faculty practice plan that has the following attributes:
• There is a written agreement between the Governing Board of the University and the Governing Board of the Medical Faculty Practice Plan describing the relationship between both parties.
• The Medical Faculty ...
Indirect Payment Procedure (IPP) - Payment to Entities that Provide Coverage Complementary to Medicare Part B (Rev. 2896, Issued: 03-07-14)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Medicare Part B payment otherwise payable to a beneficiary for the services of a physician or supplier who charges on a fee-for-service basis may be paid to an entity using the indirect payment procedure (IPP). Any entity registered in accordance with the instructions in Pub. 100-08, chapter 15, sections 15.7.9 ...
Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation - Claims Submitted to A/B MACs (B) (Rev. 3089, Issued: 10-21-14)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; ImplementationJanuary 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
A physician or other supplier may bill for the technical component (TC) and/or professional ...
Payment Under Reciprocal Billing Arrangements - Claims Submitted to Carriers (Rev. 1486, Issued: 04-04-08)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
The patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:
• The regular physician is ...
Physician Payment Under Locum Tenens Arrangements - Claims Submitted to Carriers (Rev. 1486, Issued: 04-04-08)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A. Background
It is a longstanding and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the ...
Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Any person or entity wishing to receive Part B payment as a reassignee of one or more physicians (or other practitioner or supplier), or as the supplier of the services, must furnish to the carrier sufficient information to establish clearly that it qualifies to receive payment for those services. Where ...
Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for A/B MAC (B) Processed Claims (Rev. 3086, Issued: 10-03-14)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Except where otherwise noted, the following procedures apply to both assigned and unassigned claims submitted by medical groups and other entities entitled to bill and receive payment for physician services under §§30.2-30.2.8. They are used whether the charges are compensation related or non-compensation related.
A General
Chapter 26 contains general claims ...
A. Disseminating Information
From time to time, A/B MACs must disseminate through professional relations media information regarding the prohibition in §30.2.
A/MACs
The following language may be used by A/MACs or adapted for this purpose: The Medicare law prohibits us from paying benefits due a provider to another person or organization ...
A. Developing Questionable Payment Arrangements
Contractors (both FIs and Carriers) should assume that an arrangement in which Medicare payment is being sent or is to be sent to an address other than the physical location of the provider/supplier is consistent with the requirements of §30.2 in the absence of evidence ...
Sanctions for Prohibited Payment Arrangement (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
A. Advice to Provider
If the contractor finds that a provider (for Part B, physician or other supplier, or party eligible to receive the payment under §30.2 as an employer, facility or organization) has entered into, or is considering entering into, a payment arrangement prohibited by §30.2, the contractor must ...
A. Basic Prohibition
Except as provided in subsection B, carriers pay only the beneficiary (or beneficiary legal representative or representative payee) benefits payable directly to the beneficiary FIs do not send money directly to beneficiaries, they must require providers they pay to refund monies to beneficiaries when circumstances so warrant ...
Institutional providers (those that bill Fiscal Intermediaries (FIs)) are paid direct by the FI. In contrast, physicians, practitioners, and suppliers that bill the carrier may choose to enter into a participation agreement.
Carrier “Participating Providers” are paid at 100 percent of the physician fee schedule and must accept assignment (must accept ...
Mandatory Assignment on Carrier Claims (Rev. 2487, Issued: 06-08-12)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
The following practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus ...
Processing Claims for Services of Participating Physicians or Suppliers by Carriers (Rev. 1, 10-01-03)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
The participating physician or supplier submits any claims for services furnished by the physician or supplier, except in the limited circumstances specified in §30.2.8.3 or §30.2.16. (The exception concerns situations where the physician or supplier accepts, as full payment, payment by certain organizations.) When an unassigned claim is received from ...
Nature and Effect of Assignment on Carrier Claims (Rev. 643, Issued: 08-12-05)
July 17th, 2015
By Find-A-Code | Published July 17th, 2015
Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to let the physician or other supplier request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician/supplier in return ...
Dentists: Prescriptions and Referring to other providers with Medicare
July 13th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 13th, 2015
Are you aware you must be participating with Medicare Part D to be eligible to prescribe medication's to patients that have Medicare? If you are not participating, your patients will not be able to fill their prescriptions.
You may also enroll to become an ordering and referring Medicare provider. You will not be recognized ...
Transfer of Claims Material Between Carrier and Intermediary (FI) (Rev. 2474, Issued: 05-18-12)
July 13th, 2015
By Find-A-Code | Published July 13th, 2015
If a beneficiary erroneously submits a Form CMS-1490 (beneficiary-filed claim form) to a carrier with an itemized bill for services that must be paid by the FI, the carrier forwards such claims to the FI for the necessary action. The FI will inform the provider to submit a claim once ...
A DME MAC receives a Paper Claim with Items or Services that are in Another DME MAC's Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
July 13th, 2015
By Find-A-Code | Published July 13th, 2015
When a DME MAC receives a claim submitted on the Form CMS-1500 for Medicare payment that should be processed by a DME MAC but was sent to the wrong DME MAC, the claim shall be returned as unprocessable.
Use the following messages:
CARC 109 – Claim not covered by this payer/contractor. You ...
FI Jurisdiction of Requests for Payment (Rev. 1, 10-01-03)
July 13th, 2015
By Find-A-Code | Published July 13th, 2015
The FIs have jurisdiction for the following:
• All Part A services (hospital, SNF, HHA, and hospice);
• Most Part B services from providers that furnish Part A services; and
• Part B facility services from CORFs, Renal; Dialysis Facilities, Rural Health Clinics, Religious Nonmedical Institutions, Outpatient Physical Therapy Centers, Federally Qualified Health ...
FI Payment for Emergency and Foreign Hospital Services (Rev. 1, 10-01-03)
July 13th, 2015
By Find-A-Code | Published July 13th, 2015
A. Beneficiary Services Outside United States - Emergency Hospital Admissions
See chapter 3, for detailed information concerning beneficiary services outside the United States. Generally, payment is made for emergency inpatient hospital services in qualified Canadian or Mexican hospitals in the following circumstances:
• A Medicare beneficiary is in the United States ...
Payments Under Part B for Services Furnished by Suppliers of Services to Patients of a Provider (Rev. 1, 10-01-03)
July 13th, 2015
By Find-A-Code | Published July 13th, 2015
Section 1861(w)(1) of the Act permits a hospital, critical access hospital, skilled nursing facility, home health agency, or hospice to obtain under arrangement, services for which an individual is entitled to under Medicare. Doing so discharges the liability of such individual or any other person to pay for the services. ...
Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority (Rev. 1944, Issued: 04-09-10)
July 13th, 2015
By Find-A-Code | Published July 13th, 2015
Under Section 1862(a)(2) of the Social Security Act (“the Act”), the Medicare program does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or organization has a legal obligation to provide or pay for that service. Also, under Section ...
Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04)
July 10th, 2015
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 ...
Medicare Carrier or RRB-Named Carrier to Welfare Carrier (Rev. 2474, Issued: 05-18-12)
July 10th, 2015
By Find-A-Code | Published July 10th, 2015
When a Medicare carrier or RRB-named carrier receives a query reply from CMS that includes a disposition code 46 and a welfare administration carrier number, it transfers the claim to the welfare carrier and notifies the beneficiary. Any pertinent information received or developed is transferred with the claim.
This occurs only ...
Protests Concerning Transfer of Requests for Payment to Carrier (Rev. 2474, Issued: 05-18-12)
July 10th, 2015
By Find-A-Code | Published July 10th, 2015
If Palmetto GBA receives a protest concerning the transfer of a request for Medicare payment to the carrier, the protest, including pertinent name and claim number(s) information, is forwarded to:
Railroad Retirement Board Medicare Section
844 Rush Street
Chicago, IL 60611
Pub 100-04 Medicare Claims Processing Manual
...
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)
July 10th, 2015
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 ...
HCPCS Subject To and Excluded From CLIA Edits (Rev. 865, 07-03-06)
July 10th, 2015
By Jared Staheli | Published July 10th, 2015
At this time, all claims submitted for laboratory tests subject to CLIA are edited at the CLIA certificate level. However, the HCPCS codes that are considered a laboratory test under CLIA change each year. The CMS identifies the new HCPCS (non-waived, nonprovider-performed procedure) codes, including any modifiers that are subject ...
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)
July 9th, 2015
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, ...
Payment Jurisdiction for Reassigned Services (Rev. 1987)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
Though a supplier or provider may reassign payment for his services to another entity, suppliers are still required to bill the correct B/MAC for reassigned services when they are paid under the MPFS. The billing entity must submit claims to the B/MAC that has jurisdiction over the geographic area where ...
Application of Local Medical Review Policies (Rev. 866, 07-03-06) - Competitive Acquisition Program
July 9th, 2015
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 ...
Exceptions to Jurisdictional Payment (Rev. 1, 10-01-03)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
Exceptions to billing the area carrier are:
• A claim for covered services performed in the United States by a legally authorized Canadian or Mexican physician is within the jurisdiction of the carrier servicing the location where the services were rendered.
• Because coverage of Part B services furnished in Canada or ...
Creation of Internal Vendor Provider Files (Rev. 866, 07-03-06) - Competitive Acquisition Program
July 9th, 2015
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 ...
Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies, Parental and Enteral Nutrition (PEN) (Rev. 2487)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
(Issued: 06-08-12, Effective: 01-01-11, Implementation: 06-19-12) B3-3116, B-3102
Claims for DMEPOS submitted by suppliers for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are handled by Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
To determine which services are processed by DME MACs vs. local carriers, CMS maintains and updates a table ...
Supplier of Portable X-Ray, EKG, or Similar Portable Services (Rev. 1, 10-01-03)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
If a supplier operates mobile units in geographic areas served by more than one carrier, the carrier serving the area where the service was performed must process the claims.
Pub 100-04 Medicare Claims Processing Manual
...
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 ...
Ambulance Services Submitted to Carriers (Rev. 1, 10-01-03)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
Jurisdiction of the claim is based on whether only one ambulance vehicle or multiple vehicles were used.
A. One Ambulance Vehicle Used
If only one vehicle is used to transport the patient from the point of initial pickup to the final destination, jurisdiction is with the carrier serving the point 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
July 9th, 2015
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)
July 9th, 2015
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)
July 9th, 2015
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)
July 9th, 2015
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
July 9th, 2015
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)
July 9th, 2015
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 ...
Jurisdiction of claims for laboratory services furnished by an independent laboratory normally lies with the carrier serving the area in which the laboratory test is performed. However, there are some situations where a regional or national lab chain jurisdiction is with a single carrier.
Pub 100-04 Medicare Claims Processing Manual
...
Method of Payment for Clinical Laboratory Tests - Place of Service Variation (Rev. 2971, 07-07-14)
July 9th, 2015
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)
July 9th, 2015
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 ...
If the specimen is drawn or received by an independent laboratory approved under the Medicare program that performs a covered test, but the lab refers the specimen to another laboratory in a different carrier jurisdiction for additional tests, the carrier servicing the referring laboratory retains jurisdiction for services performed by ...
Carrier jurisdiction claims for individuals who are QRRBs, including those who are entitled to both social security and railroad retirement benefits, are handled by the Palmetto Government Benefits Administrators (GBA) LLC, a subsidiary of Blue Cross and Blue Shield of South Carolina, with the following exceptions:
• The services are furnished ...
Section 1843(f) of Title XVIII permits a State agency that administers a plan under Titles I, XVI, or XIX to become the carrier for individuals enrolled in the State’s Buy In agreement. Currently there are no State agencies that are serving as carriers.
Pub 100-04 Medicare Claims Processing Manual
...
Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC (Rev. 2474, Issued: 05-18-12)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
A “misdirected claim” is a claim that has been submitted to the wrong place. This section summarizes the disposition of misdirected claims by B MACs, carriers, and DME MACs.
Each fee-for-service claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing. Physicians and other suppliers are ...
Which Contractor to Bill for Laboratory Services Furnished to a Medicare Beneficiary in a Skilled Nursing Facility (SNF) (Rev. 1, 10-01-03)
July 9th, 2015
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 ...
A Local B/MAC/Carrier Receives a Claim for Services that are in Another Local B/MAC/Carrier’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services furnished outside of its payment jurisdiction, the claim shall be returned as unprocessable.
NOTE: This instruction also applies to claims for DMEPOS items/services that are appropriately billed to the B MAC/carrier, ...
A Local B/MAC/Carrier Receives a Claim for Services that are in A DME MAC’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a DME MAC’s payment jurisdiction, the claim shall be returned as unprocessable.
Use the following messages for claims indicated above except for claims that are identified as UMWA ...
A DME MAC Receives a Claim for Services that are in A Local B/MAC/Carrier’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
When a local DME MAC receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a Part B MAC or carrier’s payment jurisdiction, the claim shall be returned as unprocessable.
Use the following messages for claims indicated above except for claims that are identified as UMWA claims:
CARC ...
A Local B/MAC/Carrier Receives a Claim for an RRB Beneficiary (Rev. 2474, Issued: 05-18-12)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a Form CMS-1500 or electronic claim that is identified as a RRB claim for Medicare payment that should be processed by the RRB contractor, the claim shall be returned as unprocessable. Use the following messages:
CARC 109 – Claim not covered ...
A Local B/MAC/Carrier/DME MAC Receives a Claim for a UMWA Beneficiary (Rev. 2474, Issued: 05-18-12)
July 9th, 2015
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier/DME MAC) receives a Form CMS-1500 or electronic claim that is identified as a UMWA claim for Medicare payment that should be processed by the UMWA, the claim shall be returned as unprocessable.
Use the following messages:
CARC 109 - Claim not covered by ...
Date of Service (DOS) for Clinical Laboratory and Pathology Specimens (Rev. 1515, 01-05-09)
July 9th, 2015
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)
July 9th, 2015
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)
July 9th, 2015
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
July 8th, 2015
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
July 8th, 2015
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
July 8th, 2015
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)
July 8th, 2015
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)
July 8th, 2015
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)
July 8th, 2015
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)
July 8th, 2015
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)
July 8th, 2015
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)
July 8th, 2015
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)
July 8th, 2015
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)
July 7th, 2015
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)
July 7th, 2015
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)
July 7th, 2015
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)
July 7th, 2015
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
July 7th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 6th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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)
July 5th, 2015
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 ...
Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation
June 30th, 2015
By Find-A-Code | Published June 30th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; Implementation January 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are ...
MSN Messages for Screening Pap Smears (Rev. 1, 10-01-03)
June 29th, 2015
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 ...
(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 standards adopted under HIPAA include both a transaction standard and an implementation guide. The following are the claims transactions and the implementation ...
Claims Processing Instructions for Payment Jurisdiction
June 29th, 2015
By Find-A-Code | Published June 29th, 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)
A. Instructions for the 4010/4010A1 Version of the ASC X12 837 Professional Electronic Claim (for Claims Processed Before Implementation of Version 5010)
Note that ...
MSN Messages for Screening Pelvic Examinations (Rev. 440, 07-05-05)
June 29th, 2015
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)
June 29th, 2015
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)
June 26th, 2015
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)
June 26th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 25th, 2015
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)
June 24th, 2015
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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 22nd, 2015 - Last Review/Update August 7th, 2017
The Centers for Medicare & Medicaid Services (CMS) has further defined Chiropractic Maintenance Therapy. Section 2251.3 of the Medicare Carriers Manual (MCM) has been amended to clarify Medicare requirements for treatment of chiropractic therapy.
"MCM 2251.3 Necessity for Treatment.--
A. The patient must have a significant health problem in the form of a neuromusculoskeletal ...
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)
June 22nd, 2015
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)
June 22nd, 2015
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)
June 19th, 2015
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)
June 18th, 2015
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)
June 18th, 2015
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)
June 18th, 2015
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)
June 18th, 2015
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)
June 17th, 2015
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)
June 17th, 2015
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)
June 17th, 2015
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)
June 17th, 2015
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)
June 17th, 2015
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 ...
HO-400, HO-400.G, HO-403, HO-412
The hospital may bill only for services provided. If the provider billing system initiates billing based on services ordered, the provider must confirm that the service has been provided before billing either the carrier or intermediary (FI).
The provider agreement to participate in the program requires the provider ...
Carrier Jurisdiction of Requests for Payment (Rev. 2487)
June 15th, 2015
By Find-A-Code | Published June 15th, 2015
Carriers have jurisdiction for all claims from the following:
• Physicians;
• Other individual practitioners;
• Groups of physicians or practitioners;
• Labs not part of a hospital;
• Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the intermediary (FI));
• Ambulatory ...
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
April 28th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 28th, 2015 - Last Review/Update January 25th, 2017
FACT SHEET
April 24, 2015
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
OVERVIEW: On April 24, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and ...
By Dr. Chris Andersn | Published April 24th, 2015 - Last Review/Update June 9th, 2016
Compliance is an issue that you should look at as an expedition rather than an endpoint. Board complaints can be a terrifying ordeal, especially if you don’t keep up on compliance in your clinic. Board complaints are something that you have to expect to happen but you can turn that ...
Medicare Updates Preventive Exam and Wellness Visit Information
April 15th, 2015
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 April 15th, 2015 - Last Review/Update February 3rd, 2017
On April 14, 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed the Senate by an overwhelming vote of 92-8. Although President Obama has not officially signed the bill into law, weeks ago he indicated his full support when H.R. 2 passed the House of Representatives.
For over a decade, ...
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 ...
Billing Imminuzation for Pneumococcal, Influenza, and Hepatitis B with Medicare
March 9th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 9th, 2015 - Last Review/Update August 9th, 2017
The current diagnosis pointer for, Influenza, Pneumococcal or Hepatitis B vaccines is ICD-10-CM code Z23. Listed are tips for coding, and also the diagnosis pointers used for claims previous to 10/01/15:
Influenza: G0008
Procedure codes:
90630
90653-90662
90672-90674
90685-90688
Medicare codes:
Q2034-Q2039
Expired diagnosis code:
V04.81
Pneumococcal: G0009
Procedure codes:
90670
90732
Expired diagnosis code:
V03.82
Hepatitis B: G0010
Procedure codes
90739-90747
Expired diagnosis code
V05.3
Both Influenza and Pneumococcal Vaccines received in same visit: G0008 with G0009
Procedure codes:
(See previous)
Expired diagnosis code:
V06.6 (effective 10/01/06 - 09/30/15)
Extra Tips:
Be sure ...
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 ChiroCode | 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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 26th, 2015 - Last Review/Update March 2nd, 2016
Be sure you know and understand the levels of supervision required so as not to result in non-compliance audits, possible fines and take-backs. Supervision requirements may also affect your documentation requirements; be sure to document the presence during the procedure or performance if it requires personal supervision.
Find-A-Code has levels of supervision ...
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 Chris Woolstenhulme, QCC, CMCS, 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.
...
Billing Requirements for G0466, G0467, G0468, G0469 or G0470 - MLN
February 21st, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update February 18th, 2016
Basic Billing Requirements
When reporting an encounter/visit for payment, the claim (77X TOB) must contain a FQHC specific payment code (G0466, G0467, G0468, G0469 or G0470) that corresponds to the type of visit.
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under revenue code 052X or under ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 15th, 2015 - Last Review/Update March 1st, 2016
40-Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
(Rev. 194, 09-03-14)
Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B. Also, they are ...
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
December 23rd, 2014
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 ...
Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training
December 19th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 19th, 2014 - Last Review/Update March 1st, 2016
All persons who provide health or administrative services to Medicare enrollees must satisfy general compliance and FWA training requirements. This module may be used to satisfy both requirements.
This training module consists of two parts:
(1) Medicare Parts C & D Fraud, Waste, and Abuse (FWA) Training and Compliance
Objectives:
Meet the regulatory requirement ...
Compliance Program - What are the Requirements to Implement an Effective Program
December 19th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 19th, 2014 - Last Review/Update March 1st, 2016
All sponsors are required to adopt and implement an effective compliance program,which must include measures to prevent, detect and correct Part C or D program noncompliance as well as FWA.
The compliance program must, at a minimum, include the following core requirements:
1. Written Policies, Procedures and Standards of Conduct;
2. Compliance ...
Coding for ICD-10-CM: More of the Basics MLN Connectsâ„¢ Video
December 18th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 18th, 2014 - Last Review/Update March 1st, 2016
In this MLN Connects™ video on Coding for ICD-10-CM: More of the Basics, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) provide a basic introduction to ICD-10-CM coding. The objective of this video is to enhance viewers’ understanding of ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
OASIS Data to be Submitted via Assessment Submission and Processing (ASAP) System Effective Jan 1, 2015
December 4th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Effective January 1, 2015, OASIS assessment data will be submitted to CMS via the national OASIS Assessment Submission and Processing (ASAP) system. With the implementation of the OASIS ASAP system, Home Health Agencies will no longer submit OASIS assessment data to CMS via their state databases. To access the ...
CMS - Final Rule to Deny or Revoke the Enrollment of Entities that Pose an Integrity Risk to Medicare
December 4th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
On December 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.
This fact sheet summarizes CMS’ regulatory additions and changes.
SUMMARY OF THE PROVIDER ...
Durable Medical Equipment - Documenting Continued Use
December 4th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Treating physicians’ records often omit documentation of a beneficiary’s continuing use of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). By Medicare statute, lack of physician documentation regarding a beneficiary’s continued need and use of an item of DMEPOS will result in claim denials. Many “model charts” from various clinical ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Vacuum pumps coded L7900 must demonstrate a capability to generate a negative pressure in the range of greater than 3.9 and less than 17 inches of mercury (100 and 432 mmHg, respectively). All devices coded L7900 for reimbursement by Medicare must include a vacuum limiter such that a maximum vacuum ...
Q & A: Establishing a Multi-Disciplinary Practice and Being Legal
December 1st, 2014
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)?
November 25th, 2014
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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
The outcome of care measures and the utilization measures are risk adjusted. The process of care measures aren't risk adjusted. Risk adjustment of the outcome of care and utilization measures is a multi-step process. These are the major steps in this process displayed in temporal order:
OASIS-C assessment data collection and ...
Aligning the Way Providers are Paid to Reward Value Rather than Volume (Value Based Modifiers)
November 21st, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
CMS is aligning the way providers are paid to reward value rather than volume.
Paying providers for quality, not quantity of care. In 2015, Medicare is continuing to phase in the Value-based Payment Modifier, which adjusts traditional Medicare payments to physicians and other eligible professionals based on the quality and ...
CMS Will Begin Applying the Value Modifier in Calendar Year (CY) 2017 to All Physicians
November 21st, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
CMS will begin applying the Value Modifier in calendar year (CY) 2017 to all physicians; including those in groups with two or more eligible professionals (EPs), and to physicians who are solo practitioners. This policy completes the phase-in of the Value Modifier to all physicians and groups of physicians as ...
CMS Announces a Getting Started with Quality Measures Virtual Office Hours Session for 2014 Physician Quality Reporting System (PQRS)
November 21st, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a Virtual Office Hours session regarding Getting Started with Quality Measures has been scheduled for Monday, November 17, 2014 from 3:00–4:00 PM ET
This session will allow stakeholders an opportunity to ask a CMS representative questions about getting ...
By Chris Woolstenhulme, QCC, CMCS, 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 Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | 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 contains information about each zone as well as activity and updates in those regions.Â
ZPIC
Zone
States in Zone
Safeguard Services (SGS)
1
California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands
Health Integrity
(subcontractor ...
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
November 17th, 2014
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 ...
CMS Announces 2013 eRx Incentive Program Payments are Now Available
October 20th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 20th, 2014 - Last Review/Update March 2nd, 2016
CMS is pleased to announce that the 2013 Electronic Prescribing (eRx) Incentive Program incentive payments are now available for eligible professionals and group practices who submitted data for Medicare Physician Fee Schedule Part B services provided January 1, 2013 through December 31, 2013.
As required by law, President Obama issued a ...
Medicare Billing Information for Rural Providers and Suppliers Booklet - Revised
October 17th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
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, see the “Medicare Billing Information for Rural Providers and Suppliers Text-Only”
Booklet is available in text-only format. This booklet is designed ...
Billing Requirements for Medicare Secondary Payer (MSP) Provisions
October 17th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage. Before you submit a claim, you must determine whether Medicare is the primary or secondary payer for all inpatient admissions and outpatient encounters, thereby assisting in ensuring the appropriate use of Medicare funds. If another ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Visit this site to view the top rejection messages and avoid costly mistakes. Using the top denial reason codes, NGS will show you how to avoid this and the steps needed to correct this error. Take a look at the National Government Services web site: NGS
For example:
CO-16 Claim/service lacks information which is ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous ...
Chiropractic is Listed as a Priority in the 2014 OIG Work Plan...Find Out Why
October 16th, 2014
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Each year the Office of Inspector General (OIG) issues an updated work plan which outlines the objectives and enforcement priorities for each new year. For Medical providers, including Chiropractic, this information is necessary to review and be familiar with so we may evaluate our own practice systems to ensure compliance ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
For a list of HACs and Codes
Medicare learning network ICN 901045 October 2012
(This list was current with Medicare when published October 2012)
Affected Hospitals
The Hospital-Acquired Conditions payment provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the HAC payment provision:
Critical Access Hospitals (CAHs)
Long-Term Care Hospitals ...
The Role of Statistical Analysis in Fighting Fraud
October 16th, 2014
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 Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | 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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 23rd, 2017
Medicare has set annual therapy caps at $1920 and they start over Jan. 1 of each year. Medicare combined the therapy limits SLP (Speech-Language Pathology) and PT (Physical Therapy) for a combined total of $1920.00 in 2014. There is also a therapy cap limit for OT (Occupational Therapy) Services of $1920. ...
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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 30th, 2017
After a claim has been submitted and a reimbursement decision has been made, you or your billing agent receive a Remittance Advice (RA). The RA is a notice of payments and adjustments that the MAC produces as a companion to claim payments or an explanation when there is no payment. ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 3rd, 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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 26th, 2014 - Last Review/Update January 30th, 2017
MEASURE COMPLIANCE - Meeting the Patient Electronic Access Objective
Starting in 2014, CMS requires that providers participating in both Stage 1 and Stage 2 of the EHR Incentive Programs must meet the Patient Electronic Access objective, which gives patients access to their health information in a timely manner. Providers participating in ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Questions and Answers for Psychologists and PQRS. In 2007, Psychologists had very limited opportunity to participate in PQRS. As of 2014, there are 11 measures available for claims-based reporting and two for registry reporting.
For the entire article read more here: PracticeCentral.org
Below are the 11 new measures for 2014
Major depressive disorder: diagnostic evaluation (#106)
Major ...
CMS - How to Understand Medicare's ID Numbers (HIC or HICN)
September 23rd, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 23rd, 2014 - Last Review/Update January 30th, 2017
A HIC number (HICN) is a Medicare beneficiary’s identification number. Also, remember when billing, ALWAYS use the name as it appears on the patient's Medicare card.
Both CMS and the Railroad Retirement Board (RRB) issue Medicare HIC numbers. The format of a HIC number issued by CMS is a Social Security ...
By Chris Woolstenhulme, QCC, CMCS, 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.
Face-to-Face Encounter Compliance Requirement for Certain Durable Medical Equipment
September 9th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 9th, 2014 - Last Review/Update January 30th, 2017
On September 9, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that it would begin actively enforcing and would expect full compliance with new DME face-to-face requirements on a date to be announced in Calendar Year 2014. We are publishing this announcement to make clear that the delay ...
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?
Q & A: Does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology?
August 26th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update August 9th, 2017
Q: When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update January 23rd, 2017
Information related to Medicare's E-Health programs can be viewed here. (Click Here) E-Health includes: E-Prescribing Electronic Health Records Personal Health Records EHR Incentive Programs  eRx Electronic Prescribing Incentive Program (Click Here) The eRx Incentive Program Ended in 2013, but Electronic Prescribing Continues with Meaningful Use. ...
How do I find a HCPCS code for a laxative given to a patient in our office?
August 12th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update August 9th, 2017
A Laxative is considered a “Self Administered Drug” (SAD). Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV. Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
August 7th, 2014
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Medicare Requiring Prior Authorization for Power Mobility Devices
July 31st, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 31st, 2014 - Last Review/Update January 25th, 2017
Due to the fact that Power Mobility Devices have a climbing high rate of fraud and improper payments the Centers for Medicare & Medicaid announced in May it has extended the pre authorization process to 12 more states for power mobility devices. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017
The -GP modifier needs to be appended to physio-therapy codes when submitting Medicare claims. However, be aware of differing policies for different types of payers. Chiropractors typically use the following Physical Medicine codes from the CPT book: 97010 thru 97799 (except for 97597-97610 for active wound care management). The current ...
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
By | Published April 17th, 2014 - Last Review/Update January 25th, 2017
January 1, 2014 was the required date for adoption of standards for both Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). The Centers for Medicare & Medicaid Services (CMS) recently announced that the implementation of these new standards has resulted in benefits for both providers and CMS. Not surprisingly, ...
Will mandatory Medicare payment cuts (due to the SGR) get repealed?
March 2nd, 2014
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.
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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?
November 26th, 2013
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
September 11th, 2013
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
August 30th, 2012
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
June 21st, 2010
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.
In this webinar, Aimee will review wound care coding and auditing information for wound care services, including proper modifier use, NCCI edits, Medicare coverage guidelines, and documentation requirements.
Find-A-Code's 2020 specialty specific Reimbursement Guides give you the coding, billing, and documentation support you need to get paid properly and keep it.
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