Separately Identifiable Service

Separately Identifiable Service Please define the appropriate use of modifier 57 to identify a separately payable E/M with an initial decision for surgery. Answer: Modifier 57 is added to an E/M service that resulted in an initial [...]

Skilled Nursing Facility Services

Skilled Nursing Facility Services Please define rules for initial and subsequent SNF services, when the same provider has treated the patient at another site on the same date of service. Answer: This depends on the site of the prior [...]

Smoking Cessation

Smoking Cessation Please clarify appropriate codes for smoking cessation services. Answer: CPT codes 99406 and 99407 may be used for smoking and tobacco-use cessation counseling visits. Please clarify what constitutes a session which [...]

Time-Based Services

Time-Based Services Please define rules for using time to level-set a service. Answer: In both the office and observation/inpatient setting, the provider’s time is calculated based on pre-visit, intra-visit, and post-visit activities [...]

Transitional Care Management

Transitional Care Management Please clarify responsibility for the TCM interactive contact. Can this be performed by a hospital-employed nurse prior to discharge? Answer: The provider who is billing the TCM service is responsible for the [...]

Urgent Care

Urgent Care Please explain the concepts of split/shared and incident to E/M services in the urgent care setting. Answer: The urgent care setting is defined by CMS as a nonfacility setting. This means the split/shared concept does not [...]

Jurisdiction K Part B Top Claim Errors Are Updated

Jurisdiction K Part B Top Claim Errors Are Updated Did you know we publish the top claim errors on our website? This resources provides detailed information including: the error reason code; a description of the error; the error type; [...]

What are the administration codes for the pneumococcal vaccine?

Can a mass immunizer combine pneumococcal with other vaccines on one roster bill?

Does Medicare pay for counseling and education of the pneumococcal vaccine?

If I administer two different vaccinations during the same visit, e.g., influenza and pneumococcal, can I bill for two separate administrations?

Is an order required to administer the pneumococcal vaccine?

Is the pneumococcal vaccine subject to coinsurance and deductible?

What are the allowance limits for the cost of the pneumococcal vaccine?

What is the frequency requirement for the pneumococcal vaccine?

With the end of the PHE, will HIPAA compliant telehealth platforms only be allowed, or can we continue to use any platform?

Can a resident in a teaching physician program that’s located in a Metropolitan Statistical Area continue to provide telehealth services when the teaching physician is physically present with the resident during the key portions of the service?

Are telephone E/M codes (99441-99443) allowed for new patients after the end of the PHE?

Are CPT codes 98966-98968 (telephone assessment and management services) billable to Medicare after 5/11/2023?

Are both place of service 02 and place of service 10 billable to Medicare?

Can principal care management and chronic care management services be permanently allowed for telehealth?

During the PHE, our pharmacy provided COVID-19 vaccines in the nursing home to patients. Is this still allowed?

For mental health services provided via telehealth do we need to bill with both modifier 95 and FQ?

I thought CMS was permanently allowing the beneficiary to have telehealth sessions in their homes. Is there an end date to this?

Is the GT modifier not accepted for professional telehealth services after the PHE or at the end of December?

Will the originating site fee (Q3014) be billable for telehealth services when the patient is located in their home?

With the end of the PHE on 5/11/2023, will Medicare beneficiaries be required to have a physician order to receive a laboratory conducted COVID-19 test?

Frequently Asked Questions Have Been Reviewed and Updated

Frequently Asked Questions Have Been Reviewed and Updated We’ve reviewed and updated our educational FAQs. Visit our Help and FAQs page located within the Education section of our website. Please take time to review these FAQs for answers to [...]

Medicare Telehealth Changes for 2024/2025

Medicare Telehealth Changes for 2024/2025 Table of Contents Major Medicare Telehealth Flexibilities Not Affected by the End of the PHE Reporting Home Address Direct Supervision Requirements Teaching Physicians Remote Evaluations, [...]

Colorectal Cancer Screening

Preventive Services Guide Colorectal Cancer Screening Screenings are performed to diagnose colorectal cancer or to determine a beneficiary’s risk for developing colorectal cancer. Colorectal cancer screening may consist of several different [...]

Top Claim Errors Reviewed and Updated

Top Claim Errors Reviewed and Updated Using data analysis, we review and update the Top Claim Errors on a quarterly basis. View Top Claim Errors to quickly identify the information you need to avoid processing delays and get [...]

Top Claim Errors Reviewed and Updated

Top Claim Errors Reviewed and Updated Using data analysis, we review and 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 [...]

Admission and Discharge Services

Admission and Discharge Services Is it permissible for an NPP to perform an initial hospital admission or discharge service on behalf of the attending physician, or on a split/shared basis, when both are members of the same provider [...]

General E/M Information

General E/M Information Please explain the terms “auxiliary personnel” and “clinical staff” in the context of Medicare services.   Answer: These terms are often used in defining which staff members can perform Medicare services [...]

Hospitals Must Correctly Code Claims Involving Chimeric Antigen Receptor T-cell and Other Immunotherapy to Receive Proper Payment

Hospitals Must Correctly Code Claims Involving Chimeric Antigen Receptor T-cell and Other Immunotherapy to Receive Proper Payment We have noticed that inpatient hospital claims for CAR T-cell and other immunotherapy are not always coded [...]

17729

Avoiding/Correcting This Error This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Attending field do not match the physician’s NPI and first four letters of the physician’s last [...]

17730

Avoiding/Correcting This Error This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Referring field do not match the physician’s NPI and first four letters of the physician’s last [...]

55H1S

Avoiding/Correcting This Error Include all face-to-face encounter attestations for the third benefit period and after with your medical record submission to the ADR. Ensure that the CMS requirements for the face-to-face encounter have been met [...]

U5601

Avoiding/Correcting This Error Verify the dates of service on your claim. If the information on your claim is correct, contact the other provider to have them correct their claim. If the information on your claim is incorrect, resubmit your [...]

U5233

Avoiding/Correcting This Error Collect all insurance information from the beneficiary when admitted to your HHA. Talk to the beneficiary about insurance changes and check CWF before billing Medicare. Many times a claim will overlap an MAO [...]

U5113

Avoiding/Correcting This Error The 8xB (NOTR) transaction should only be submitted when the beneficiary revokes the hospice benefit or is discharged alive and there is no final claim in the system indicating termination of the hospice benefit. [...]

31644

Avoiding/Correcting This Error Hospice room and board denials should be submitted as non-covered charges with revenue code 0659, HCPCS A9270, and the ‘GY’ modifier. Review the information submitted on your claim, correct, and resubmit.

32005

Avoiding/Correcting This Error No dates of service prior to the provider effective date can be billed to Medicare. Verify the dates of service billed on your claim are on or after the agency’s Medicare effective date, correct and resubmit.

U537I

Avoiding/Correcting This Error All dates of service reported on a period of care claim must be on or after the date of admission. Verify the from and through dates billed and all line item dates of service to ensure the dates are within the [...]

U523A

Avoiding/Correcting This Error This reason code is a notification to the provider of a VBID patient. For more information, including calendar-year specific downloadable lists of service area PBPs and contact information, please refer to the [...]

17729

Avoiding/Correcting This Error This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Attending field do not match the physician’s NPI and first four letters of the physician’s last [...]

17730

Avoiding/Correcting This Error This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Referring field do not match the physician’s NPI and first four letters of the physician’s last [...]

38032

Avoiding/Correcting This Error Providers should develop and implement a process to ensure that duplicate claims are not being submitted. If the claim is truly a duplicate, no action is necessary. If this is not a duplicate and the provider [...]

39929

Avoiding/Correcting This Error Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. Providers can see line details in NGSConnex and hover over the line item reason code(s) for [...]

32072

Avoiding/Correcting This Error The attending physician reported on your claim must be active in PECOS to be considered a valid attending physician for the home health patient.

37236

Avoiding/Correcting This Error Verify eligibility of the attending/ordering physicians in PECOS. Print that verification and make it part of the medical record. If applicable, submit a reopen request to the Appeals Department indicating error [...]

55H1L

Avoiding/Correcting This Error Clinical progress notes should show evidence of a steady decline or downward trajectory in the beneficiary’s clinical status over time. Documentation should be objective, measurable and must support a life [...]

55H1R

Avoiding/Correcting This Error Review coverage and billing guidelines for the NOE to ensure that your NOEs are accurately billed. Related Content CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section [...]

Frequently Asked Questions Have Been Reviewed and Updated

Frequently Asked Questions Have Been Reviewed and Updated We’ve reviewed and updated our educational FAQs. Visit our Help and FAQs page located within the Education section of our website. Topics available are: ASCA Appeals CAR T-cell [...]

Overpayment: How Should I Respond?

Table of Contents Overpayment: How Should I Respond? What Action Should I Take? Complete a Voluntary Refund Where Should I Send my Forms and Payments? [Return to Top] Overpayment: How Should I Respond? An overpayment may be [...]

Request an Immediate Recoupment

National Government Services has implemented a standardized “immediate recoupment” process that gives you the option to avoid interest from accruing on claims overpayments when the debt is recouped in full prior to or by the 30th day from the [...]

Complete a Voluntary Refund

A voluntary refund is when you have self-identified you have been overpaid and you need to refund the excess funds to Medicare. All checks are made payable to National Government Services. Whenever possible, the refund to Medicare should be [...]

Set Up an Extended Repayment Schedule

If repaying an overpayment would constitute a “hardship” on the provider, a request for an ERS should be submitted immediately. While you may request an ERS at any time during the debt-collection process, timely submission of a valid request [...]

Payment Withholding Information

Payment Withholding Information What Is a Payment Withholding? Why Are Payments Withheld? Who Can I Contact for Further Assistance? What About Cost Report Interim and Final Settlement Withholdings? What Is a Payment Withholding? An [...]

MSP Post-Pay Adjustments

If you have received an overpayment because Medicare paid as the primary insurer and another insurance carrier should be the primary payer, follow the instructions on the Part A voluntary refund form. A separate refund form is needed for [...]