Modifiers

Medicare Coverage of Chiropractic Services Modifiers AT Modifier Used to indicate that the covered services billed are for active corrective treatment and the provider’s documentation supports medical necessity and Medicare coverage [...]

Proper Billing for Acupuncture

Medicare Coverage of Chiropractic Services Proper Billing for Acupuncture Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N) Reviewed 9/11/2024

Limited Coverage for Services Ordered or Furnished By a Chiropractor

Limited Coverage for Services Ordered or Furnished By a Chiropractor This article is to remind chiropractors and facilities that X-rays and other diagnostic tests are statutorily excluded services when ordered or furnished by a chiropractor. [...]

Documentation to Support Spinal Manipulation for CPT Code 98942

Documentation to Support Spinal Manipulation for CPT Code 98942 It is not uncommon for chiropractic doctors to perform a full-spine or multi-level manipulation, even when the symptoms or diagnosis reflect a single region. This is a matter of [...]

Advance Beneficiary Notice of Noncoverage Liability

Medicare Coverage of Chiropractic Services Advance Beneficiary Notice of Noncoverage Liability The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a standardized notice that a health care provider/supplier or his/her [...]

Chiropractic Resources

Medicare Coverage of Chiropractic Services Chiropractic Resources Code of Federal Regulations Code of Federal Regulations (Annual Edition) web page 42 CFR Section 410.21 describes limitations on services of a chiropractor 42 CFR [...]

Original Medicare First Level of Appeal Tips Sheet for Medicare Providers

Original Medicare First Level of Appeal Tips Sheet for Medicare Providers If you disagree with Medicare’s claim determination, you may appeal. However, please follow these important tips before you submit a first level of appeal [...]

Coverage of Rural Air Ambulance Services

Coverage of Rural Air Ambulance Services Section 415 of the Medicare Modernization Act of 2003 provides coverage for rural air ambulance services that are reasonable and necessary and ordered by qualified personnel. Medicare considers the [...]

New York State Ambulance Services in Rural Areas (for JK providers only)

New York State Ambulance Services in Rural Areas NYS has unique requirements for the payment of paramedic intercept services when an ambulance company can provide only BLS services. Paramedic intercept services can be approved in counties and [...]

PECOS Starter Guide

PECOS Starter Guide Follow the steps outlined below to assist you and your staff with the PECOS processes. Table of Contents New/Initial Enrollee Revalidation Return for Corrections Change of Information Submit Pending Application [...]

General Information

General Information Original Medicare does not normally cover routine vision services, such as eyeglasses and eye exams. Medicare may cover some vision costs if associated with other covered expenses (that is, Medicare may cover some vision [...]

Provider Qualifications

Provider Qualifications Definition Ophthalmologist An ophthalmologist is a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) who has completed medical school and an ophthalmology residency that specialized in eye and [...]

Local Coverage Determinations

Local Coverage Determinations Table of Contents Cataract Extraction LCD L33558 Corneal Pachymetry LCD L33630 Coding Guidelines Ophthalmic Biometry for Intraocular Lens Power Calculation LCD L33621 A-Scan Ultrasound Ophthalmic [...]

National Coverage Determinations

National Coverage Determinations Table of Contents Hydrophilic Contact Lens for Corneal Bandage Photodynamic Therapy Ocular Photodynamic Therapy Photosensitive Drugs Verteporfin Hydrophilic Contact Lenses Scleral Shell Intraocular [...]

Limitation of Liability (Advance Beneficiary Notice)

Limitation of Liability (Advance Beneficiary Notice) Services denied as not reasonable and medically necessary, under Section 1862(a) (1) of the Social Security Act, are subject to the Limitation of Liability (ABN) provision. The ABN is a [...]

Glaucoma Screening ‒ Preventive Services Coverage

Glaucoma Screening ‒ Preventive Services Coverage Medicare provides coverage of an annual glaucoma screening for beneficiaries in at least one of the following high-risk groups: Individuals with diabetes mellitus; Individuals with a family [...]

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 table of edits for physicians/practitioners [...]

Related Content

Related Content CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 70.5 CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 Includes the [...]

Micro-invasive Glaucoma Surgery Update

Micro-invasive Glaucoma Surgery Update The MIGS LCD, L37244, and Billing and Coding Article, A56588, will not become final and therefore have been removed from the Medicare Coverage Database. Accordingly, at this time there will be no change [...]

Comprehensive Error Rate Testing Program

PECOS Starter Guide

PECOS Starter Guide Follow the steps outlined below to assist you and your staff with the PECOS processes. New/Initial Enrollee Revalidation Return for Corrections Change of Information Submit Pending Application Add a New [...]

Understanding Authorized Official and Delegated Official Roles

Table of Contents Understanding Authorized Official and Delegated Official Roles Medicare Enrollment Records CMS Identity and Access Management System [Return to Top] Understanding Authorized Official and Delegated Official Roles [...]

National Government Services Medicare Part B Care Management Services September Series

National Government Services Medicare Part B Care Management Services September Series According to the CDC, six in ten adults in the U.S. have a chronic disease and four in ten adults have two or more. As your Medicare Contractor for [...]

MLN Connects® Newsletter: September 12, 2024

MLN Connects® Newsletter: September 12, 2024 News COVID-19: Updated Vaccines for 2024–2025 Season Rural Emergency Hospital Provisions, Conversion Process, & Conditions of Participation: Revised Guidance CMS Roundup (September 6, 2024) [...]

Portable X-Ray Pricing Update

Portable X-ray pricing fees for CY 2024 will have new fees in production by 9/6/2024.

Check Appeal Status

Check Appeal Status Table of Contents Check Appeal Status Check Status of Requests Submitted in NGSConnex Check Status of Requests Not Submitted in NGSConnex [Return to Top] Check Appeal Status Click the Appeals button from the [...]

Ambulance Services and Establishing Medical Necessity for Part B Providers

This webinar will help the ambulance community understand the importance of medical necessity as it pertains to Medicare’s coverage guidelines.

Provider Qualifications

Podiatry Billing Guide  Provider Qualifications A doctor of podiatric medicine is a physician, but only with respect to those functions which he/she is legally authorized to perform in the State in which he/she performs them. The [...]

Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)

Billing for FQHC MAO Plan Supplemental Payment (PPS Providers) Medicare will provide supplemental payments to FQHCs that contract with MAOs to cover the difference, between the payment received from the MAO and the payment to which the FQHC [...]

Credit Balance Reporting Reminder: Submissions for Quarter Ending 9/30/2024 Start Soon!

Credit Balance Reporting Reminder: Submissions for Quarter Ending 9/30/2024 Start Soon! CBR submissions can be submitted starting on 10/1/2024 and are due within 30 days to be considered timely. Remember, even if no monies are owed to Medicare [...]

Introduction to Podiatry Services

Podiatry Billing Guide Introduction to Podiatry Services Foot Care Table of Contents Treatment of Subluxation of Foot Exclusions from Coverage Exceptions to Routine Foot Care Exclusion Systemic Conditions That Might Justify Coverage [...]

Podiatry Local Coverage Determinations

Podiatry Billing Guide Podiatry Local Coverage Determinations Table of Contents LCD for Routine Foot Care and Debridement of Nails (L33636) LCD for Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory [...]

Podiatry National Coverage Determinations

Podiatry Billing Guide  Podiatry National Coverage Determinations The following are in reference to CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1. Part 1 Section 20.29 [...]

Modifier Usage

Podiatry Billing Guide  Modifier Usage 25 – Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service  Medicare allows payment for an E/M service performed on the same [...]

Podiatry Coding Tips

Podiatry Billing Guide  Podiatry Coding Tips Coding Information Procedure codes may be subject to NCCI edits or OPPS packaging edits. Refer to CCI and OPPS requirements prior to billing Medicare. For services requiring a [...]

Advance Beneficiary Notice of Noncoverage/National Correct Coding Initiative

Podiatry Billing Guide  Advance Beneficiary Notice of Noncoverage/National Correct Coding Initiative ABN Services denied as not reasonable and medically necessary, under Section 1862(a) (1) of the Social Security Act, are subject to [...]

Related Content

Related Content CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement, Chapter 5, Section 70.3 CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290: Foot Care CMS [...]

Biopsy to Prove Onychomycosis in Routine Foot Care

Biopsy to Prove Onychomycosis in Routine Foot Care National Government Services has been made aware of a situation where podiatrists have been approached by laboratories stating that they need to biopsy their patients to make sure they have [...]

Ambulance Duplicate Claim Denials

Ambulance Duplicate Claim Denials Duplicate trips may be reported on the same claim if the ZIP code for the point of pick-up for both trips is the same. If separate claims are submitted for the same beneficiary on the same day with the same [...]

How to Avoid and Correct Duplicate Claim Denials

How to Avoid and Correct Duplicate Claim Denials A duplicate claim submission occurs when a physician or other qualified healthcare professional resubmits a claim either on paper or electronically for a single encounter and the service is [...]

Care Management: Principal Care Management Services

As part of a continued series, National Government Services (NGS) is raising awareness on the benefits of care management. During this webinar, we’ll discuss principal care management services for patients with a single chronic condition and [...]

Quarterly Top Ten EDI Institutional EDI Edits

Quarterly Top Ten EDI Institutional EDI Edits National Government Services EDI has identified the following top ten CEM edits that were received during the third quarter on the 277CA (Claims Acknowledgement) report for 837I 5010A1 formatted [...]

Quarterly Top Ten EDI Part B EDI Edits

Quarterly Top Ten EDI Part B EDI Edits National Government Services EDI has identified the following Top Ten Claim Edit Module (CEM) edits that were received during the third quarter on the 277CA (Claims Acknowledgement) report for 837P 5010A1 [...]

Third Quarter Top Ten EDI Part B Edits

Third Quarter Top Ten EDI Part B Edits Using data analysis we’ve updated the Top Ten EDI Edits for the third quarter. Visit Quarterly Top Ten EDI Part B Edits to view the edits and their description, and learn how you can quickly identify the [...]

Third Quarter Top Ten EDI Institutional Edits

Third Quarter Top Ten EDI Institutional Edits Using data analysis, we’ve updated the Top Ten EDI Edits for the third quarter. Visit Quarterly Top Ten EDI Institutional Edits to view the edits and their description, and learn how you can [...]

Meeting Minutes

Meeting Minutes Jurisdiction 6 Illinois, Minnesota, Wisconsin Jurisdiction K Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont Jurisdiction 6 and Jurisdiction K Combined Meeting 8/8/2024 4/4/2024 12/7/2023

Audit and Reimbursement

Audit and Reimbursement Cost Report Filing State/Region Contact Information Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont Bobbi Jo Luciano Office: South Portland, ME [...]

Podiatry Services - Routine Foot Care and Debridement of Nails

While the Medicare Program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits. Medicare payment may be made for routine foot care when the patient has [...]

Medicare Part B Final Rule 2024

Medicare Part B Final Rule 2024 CMS announced finalized policy changes for Medicare payments under the PFS, and other Medicare Part B topics, effective on or after 1/1/2024. The CY 2024 PFS final rule is one of several final rules that [...]

Who Can Bill for Diabetes Self-Management and Medical Nutrition Therapy?

Who Can Bill for Diabetes Self-Management and Medical Nutrition Therapy? Table of Contents Who Can Bill for Diabetes Self-Management and Medical Nutrition Therapy? Who Can Bill for DSMT Billable Codes for Diabetes Self-Management Training [...]

Common Questions for Diabetes Self-Management Training and Medical Nutrition Therapy

Common Questions for Diabetes Self-Management Training and Medical Nutrition Therapy Table of Contents Diabetes Programs Billing for Services DSMT and MNT Telehealth Services Related Content [Return to Top] Diabetes Programs [...]

Common Questions for Diabetes Self-Management Program Accreditation

Common Questions for Diabetes Self-Management Program Accreditation Does my organization need to be accredited to bill for DSMT services? Answer: Yes. In order to bill Medicare for DSMT services, your organization’s DSMT program must be [...]

Medical Nutrition Therapy Tool for Billing

Medical Nutrition Therapy Tool for Billing CMS considers 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 [...]

Medicare Diabetes Prevention Program

Medicare Diabetes Prevention Program Table of Contents Background What is the Medicare Diabetes Prevention Program? Overview of MDPP What is Covered Through the Model? How Does the Model Pay for MDPP Services? What Does this [...]

Remote Physiological Monitoring and Cardiovascular Monitoring Service and Billing Information

Remote Physiological Monitoring and Cardiovascular Monitoring Service and Billing Information Table of Contents Remote Physiological Monitoring Services CPT Codes: 99091, 99453, 99454, 99457, 99458 Remote Physiological Monitoring [...]

National Government Services Contractor Advisory Committee Meeting

National Government Services Contractor Advisory Committee Meeting There will be a multi-jurisdictional CAC meeting held on Thursday 10/17/2024 at 3:00-5:00 p.m. ET, 2:00-4:00 p.m. CT. Meeting details can be found on the National Government [...]

Laboratory and Diagnostic Services: Documentation Responsibilities

Laboratory and Diagnostic Services: Documentation Responsibilities When National Government Services is conducting a pre-pay or post-pay review of claims and services, we may request additional documentation. The billing provider must obtain [...]

Global Surgery

Global Surgery Table of Contents Definition of a Global Surgical Package Where can I find the postoperative periods for covered surgical procedures? What services are included in the global surgery payment? What services are not [...]

Duplicate Claim Editing Information

Duplicate Claim Editing Information Part B Duplicate Claim Edit National Government Services implemented a Part B duplicate claim edit in our EDI front-end processing system for Part B providers. Providers are notified that a claim is a [...]

Part A Incorrect Dialysis Payments

We have recently become aware of an issue which began on 7/15/2024 where ESRD claims with demo code 94P were finalizing with incorrect payment amounts (overpayments as well as underpayments). The incorrect payment amount is a result of FISS [...]