Multiple Procedure Payment Reduction

Multiple Procedure Payment Reduction Medicare applied MPPR to the PE payment of select therapy services paid under the physician fee schedule or paid at the physician fee schedule rate. Currently, the reduction is 50 percent for therapy [...]

The National Correct Coding Initiative

Outpatient OT and PT Services Billing Guide The National Correct Coding Initiative The purpose of the NCCI Procedure-to-Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one [...]

Recovery Auditor

Recovery Auditor The mission of the Recovery Audit Program is to detect and correct past improper payments made on health care claims for services provided to Medicare beneficiaries. The goal is to help CMS and the MACs implement actions that [...]

Common Billing Errors and Remittance Message

Common Billing Errors and Remittance Message Remittance Remark Code Listing: X12 Message Narrative 119 Benefit maximum for this time period or occurrence has been met. 18 Duplicate claim/service. [...]

Medical Review Therapy Documentation Checklist for Additional Development Request Letters

Medical Review Therapy Documentation Checklist for Additional Development Request Letters Refer to the checklist below when preparing your documentation in response to an ADR: Doctor’s orders Certifications/recertifications Initial [...]

Related Content

Outpatient OT and PT Services Billing Guide Related Content Therapy Services American Physical Therapy Association (APTA) American Occupational Therapy Association (AOTA) Reviewed 10/07/2024

Counting Units for Therapy Codes

Counting Units for Therapy Codes Counting units for therapy services can be complicated; therefore, we are providing guidance. First, you must understand the difference between timed codes and untimed codes in order to determine how to [...]

Outpatient Occupational and Physical Therapy Coverage

Outpatient OT and PT Services Billing Guide Outpatient Occupational and Physical Therapy Coverage Table of Contents CMS References LCDs and Billing and Coding Articles CMS MLN Matters® Certifying Physician/NPP Therapy Plan of [...]

2024 Annual Update to the Therapy Code List: Remote Therapeutic Monitoring

2024 Annual Update to the Therapy Code List: Remote Therapeutic Monitoring As of 1/1/2024, physical and occupational therapists in private practice may provide general supervision of their therapy assistants when they don’t personally furnish [...]

Common Questions and Answers

Outpatient OT and PT Services Billing Guide Common Questions and Answers Can a PTA treat a Medicare B patient in an outpatient setting with direct supervision by the physical therapist? Answer: Yes, however PTAs are limited in the [...]

Availability of the Essential Medicines Shortage List for the Recently Finalized Separate IPPS Payment for Establishing and Maintaining Access

Availability of the Essential Medicines Shortage List for the Recently Finalized Separate IPPS Payment for Establishing and Maintaining Access  On Thursday, 8/1/2024, CMS issued the FY 2025 Medicare Hospital IPPS and LTCH PPS final rule. [...]

Jurisdiction K Part B Top Claim Errors are Updated

Jurisdiction K Part B Top Claim Errors are Updated Using data analysis we update the Top Claim Errors on a quarterly basis and provide: the error reason code; a description of the error; the error type; details that include steps you can [...]

Diabetic Self-Management Tool for Billing

Diabetic Self-Management Tool for Billing DSMT and MNT complementary services. This means Medicare will cover both DSMT and MNT without decreasing either benefit as long as the referring physician determines that both are medically necessary. [...]

Reimbursement for Pre-exposure Prophylaxis Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus Infection

Reimbursement for Pre-exposure Prophylaxis Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus Infection CMS has issued NCD 210.15 Pre-exposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency [...]

Medicare Remit Easy Print

Coordination of Benefits

Internet-only Manuals

National Correct Coding Initiative Edits

Medicare Remit Easy Print

Internet-only Manuals

Coordination of Benefits

National Correct Coding Initiative Edits

Beneficiary Eligibility Information Not Offered on the IVR Beginning 11/18/2024

Beneficiary Eligibility Information Not Offered on the IVR Beginning 11/18/2024 To help protect Medicare beneficiaries against fraud, CMS is instructing all MACs to remove beneficiary eligibility information from our IVR systems. Starting [...]

Navigating Medicare: Part B Insights for Providers Podcast

MLN Connects® Newsletter: October 10, 2024

MLN Connects® Newsletter: October 10, 2024 News Resources & Flexibilities to Assist with the Public Health Emergency in Florida CMS Roundup (October 4, 2024) Clinical Laboratory Fee Schedule: Reporting Delayed Until 2026 Respiratory [...]

Jurisdiction 6 Part B Top Claim Errors are Updated

Jurisdiction 6 Part B Top Claim Errors are Updated Using data analysis we update the Top Claim Errors on a quarterly basis and provide: the error reason code; a description of the error; the error type; details that include steps you can [...]

Tobacco Cessation Telehealth Guide

Tobacco Cessation Telehealth Guide Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Each year, nearly half a million Americans die prematurely of smoking or exposure to secondhand smoke. [...]

Tobacco Counseling Documentation

Tobacco Counseling Documentation Many healthcare providers perform tobacco use counseling, but they may not be documenting or reporting it appropriately. Providers must ensure all performed services are claimed and supported by complete [...]

Clinical Guidelines and Recommendations

Clinical Guidelines and Recommendations Treating Tobacco Use and Dependence All health care providers, especially those with direct patient contact, have a unique opportunity to help tobacco users quit. Smokers cite a doctor's advice to quit [...]

Rural Health Clinic

Rural Health Clinic Table of Contents Counseling to Prevent Tobacco Use Diagnosis Coding Billing RHC for Smoking and Tobacco Cessation Services Billing Multiple Visits on the Same Day Related Content [Return to Top] [...]

Tobacco and Health Effects

Tobacco and Health Effects Tobacco use is the leading cause of preventable disease, disability and death in the United States. Tobacco dependence is a chronic, relapsing disorder that, like other chronic diseases, often requires repeated [...]

Benefits of Quitting

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Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low-Dose Computed Tomography

Preventive Services Guide Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low-Dose Computed Tomography Table of Contents Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low-Dose [...]

Federally Qualified Health Center

Federally Qualified Health Center Table of Contents Counseling to Prevent Tobacco Use Diagnosis Coding Billing FQHC for Smoking and Tobacco Cessation Services Related Content [Return to Top] Counseling to Prevent Tobacco [...]

Local Coverage Determination Retirement

Local Coverage Determination Retirement An LCD is a policy decision made by a MAC concerning whether to allow coverage of a particular item or service. The Centers for Medicare & Medicaid Services, Internet-Only Manual Publication 100-08, [...]

Lab National Coverage Determinations (NCDs) Alphabetical Index

Pneumococcal Vaccine and Administration

Preventive Services Guide Pneumococcal Vaccine and Administration Pneumonia affects approximately 450 million people globally (seven percent of the population) and results in about four million deaths per year. Pneumonia was regarded by [...]

Vaccinations

Vaccinations Part B Medicare provides coverage for specific vaccination types: Seasonal Influenza Virus Pneumococcal Hepatitis B COVID-19 Vaccines and Administration [Return to Top] Seasonal Influenza Virus Annual Influenza Vaccine [...]

Assistants at Surgery at Teaching Hospitals

Assistants at Surgery at Teaching Hospitals CMS instructs providers to use specific modifiers on claims representing assistance during a surgical procedure: Modifier 80 denotes service by an assistant surgeon Modifier 82 denotes service by [...]

Bundled Services Missing Appropriate Modifiers at Time of Initial Claim Submission

Bundled Services Missing Appropriate Modifiers at Time of Initial Claim Submission Accurate coding and reporting of services are critical aspects of proper billing. Services denied based on the NCCI code pair edits or MUEs may not be billed to [...]

Clarification for Billing Services on Fingers and Toes Using Modifiers F1-F9, FA, T1-T9 and TA vs. Modifier 50

Clarification for Billing Services on Fingers and Toes Using Modifiers F1-F9, FA, T1-T9 and TA vs. Modifier 50 National Government Services has identified some providers who have been billing for services on the fingers and/or the toes with [...]

Modifier 25

Modifier 25 National Government Services has identified problems common with claims submitted for evaluation and management (E/M) services where modifier 25 was appended. This article is designed to provide education regarding the correct [...]

Modifier 33

Modifier 33 Table of Contents Preventive Services Anesthesia Services Moderate Sedation Related Content [Return to Top] Preventive Services When the primary purpose of the service is the delivery of an evidence-based service in [...]

Medicare Part A and B Billing for the COVID-19 Vaccine and Monoclonal Antibody

Medicare Part A and B Billing for the COVID-19 Vaccine and Monoclonal Antibody Table of Contents Medicare Part A and B Billing for the COVID-19 Vaccine and Monoclonal Antibody Roster Billing How to Submit a Centralized Bill Medicare [...]

Medicare Coverage of Over-the-Counter COVID-19 Tests

Medicare Coverage of Over-the-Counter COVID-19 Tests The OTC COVID-19 test demonstration ended on 5/11/2023. Starting on 5/12/2023, Medicare no longer covers or pays for OTC COVID-19 tests for those with Medicare Part B benefits. Beginning [...]

Electronic Data Interchange

Medicare Part B 101 Manual Electronic Data Interchange Table of Contents Electronic Data Interchange Transactions Benefits of Submitting Electronically Becoming an Electronic Submitter PC-ACE EDI: Beyond Claims and Extra Features [...]

National Provider Identifier

Medicare Part B 101 Manual National Provider Identifier Table of Contents National Provider Identifier Background Application Process Sharing Your NPI NPI Contractor Mailing Address NPI Registry [Return to Top] National [...]

About Provider Outreach and Education

Medicare Part B 101 Manual About Provider Outreach and Education Table of Contents About Provider Outreach and Education Educational Activities Provider Outreach and Education Advisory Group [Return to Top] About Provider Outreach [...]

Appendix 3: Place of Service Codes

Medicare Part B 101 Manual Appendix 3: Place of Service Codes Table of Contents Place of Service Codes Health Insurance Portability and Accountability Act Special Considerations Homeless Shelter (Code 04) Indian Health Service [...]

Reminder – Beginning 11/18/2024, Beneficiary Eligibility Information Not Offered on the IVR

Reminder – Beginning 11/18/2024, Beneficiary Eligibility Information Not Offered on the IVR To help protect Medicare beneficiaries against fraud, CMS is instructing all MACs to remove beneficiary eligibility information from our IVR [...]

Inpatient Hospital Issued Notices

Inpatient Hospital Issued Notices Applies to: All hospitals Medicare beneficiaries and hospitals have certain rights and protections related to financial liability and appeals under the Medicare Program. These financial liability and appeal [...]

Modifiers

Modifiers Table of Contents General Modifier Information CPT Modifiers (Used in Medicare Part B) HCPCS Modifiers ABN Modifiers GA, GX, GY and GZ Ambulance Origin and Destination Modifiers [Return to Top] General Modifier [...]

Modifier Usage

Modifier Usage Table of Contents E/M Services Within a Global Surgical Period – Modifiers 24, 25 and 57 24 – Unrelated E/M Service by the Same Physician During a Postoperative Period 25 – Significant, Separately Identifiable E/M [...]

Proper Use of Modifiers 59 and 91

Proper Use of Modifiers 59 and 91 Table of Contents Modifier 59 Appropriate Usage Inappropriate Usage Modifier 91 Appropriate Usage Inappropriate Usage Additional Information Related Content [Return to Top] [...]

Repeat Procedures - Modifiers 76 and 77

Repeat Procedures - Modifiers 76 and 77 Exact duplicate data fields submitted for claims include: Same beneficiary Same provider Same dates of service Same types of services Same place of service Same procedure codes Same billed [...]

Deceased Beneficiary Claims

Medicare Part B 101 Deceased Beneficiary Claims Table of Contents Deceased Beneficiary Claims Unpaid Bills Paid Bills Assigned Claims [Return to Top] Deceased Beneficiary Claims Medicare law outlining the payment of the medical [...]

Payment Floor Standards

Medicare Part B 101 Manual Payment Floor Standards The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail or otherwise finalize the initial determination on a clean claim. The “payment [...]

Limiting Charge

Medicare Part B 101 Manual Limiting Charge Table of Contents Federal Limiting Charge Federal Limiting Charge for Medicare Secondary Payer [Return to Top] Federal Limiting Charge As part of the Omnibus Budget Reconciliation Act of [...]