Approved Pending Regional Office Review

Approved Pending Regional Office Review For ambulatory surgical centers (ASCs) and portable x-ray suppliers (PXRS): When credentialing, you will receive an approved pending regional office review status in PECOS. National Government [...]

Acknowledgement Email

Acknowledgement Email Upon receipt of your application submission, the contact person (identified on application) will receive an email confirmation from: NGS-PE-Communications@elevancehealth.com containing the NGS case number for tracking [...]

Approval or Denial

Approval or Denial Approval Once your application is approved, you will receive an email containing a Medicare letter with PTAN. Review this letter to ensure that everything is accurate and if you have any questions, please contact the [...]

Medicare Secondary Payer Provisions Group and Nongroup Health Plans

Who pays first? This Medicare Secondary Payer learning session will be on the provisions of group health plans that include working aged, disability and end stage renal disease and nongroup health plans that include auto, liability, no-fault, [...]

Local Coverage Determination Open Meeting Announcement

Local Coverage Determination Open Meeting Announcement Table of Contents Jurisdiction 6/Jurisdiction K Part A/Part B MAC Requests to Present Registered Presenters (Slide Presentations Only) Observers Comments on Proposed LCDs [...]

Local Coverage Determination Open Meeting

Local Coverage Determination Open Meeting National Government Services is hosting a Proposed Local Coverage Determination Open Meeting on 10/24/2024.  Details are available by accessing the Local Coverage Determination Open Meeting [...]

MSP Right Hand

Helpful Resources BCRC Contact Information Note: Providers should not contact the BCRC to set up new MSP records. Instead, report MSP coding on your MSP and conditional claims. Providers should not contact the BCRC to correct MSP records to [...]

10/7/2024

Self-Service Pulse: What You Need To Know This Week As your MAC, National Government Services wants to provide you with a comprehensive source containing the most current information available for our self-service tools.   All [...]

CMS Links

Accreditation Medicare Provider/Supplier Enrollment  National Provider Identifier Registry  National Provider Identifier Standard (NPI)  Advance Beneficiary Notice Beneficiary Notices Initiative (BNI)  Appeals [...]

Claim Denials During Hospice Elections Liability Reminder

Claim Denials During Hospice Elections Liability Reminder When a Medicare beneficiary elects hospice benefits, the hospice is required to provide all items and services needed for the hospice treatment and palliative care associated with it in [...]

MLN Connects® Newsletter: October 3, 2024

MLN Connects® Newsletter: October 3, 2024   News HHS Releases Final Guidance for Second Cycle of Historic Medicare Drug Price Negotiation Program Resources & Flexibilities to Assist with the Public Health Emergency in Florida, [...]

HCPCS 75580 Returning to Provider With Reason Code 32402

Part A claims being billed with HCPCS 75580 are receiving reason code 32402 when billed with the cardiology revenue code (048X) and cannot process for payment. CMS has determined that claims should be allowed to process when HCPCS 75580 is [...]

Accountable Care Organization Realizing Equity, Access, and Community Health Model Claims Adjusted in Error

Accountable Care Organization Realizing Equity, Access, and Community Health Model Claims Adjusted in Error CMS informed NGS of an issue that occurred on 7/26/2024 impacting some claims from 2021 – 2024 related to the ACO REACH Model. CMS [...]

[RESOLVED] The Provider Contact Center Is Experiencing Phone Outages for All Lines of Business

[RESOLVED] The Provider Contact Center Is Experiencing Phone Outages for All Lines of Business Our Provider Contact Center Customer Services Representative phone lines were down for all lines of business. Technical support was engaged and the [...]

Influenza Virus Vaccine and Administration

Preventive Services Guide Influenza Virus Vaccine and Administration Influenza (flu) is a contagious respiratory illness caused by the influenza virus that causes mild to severe illness. According to the CDC, millions of people get the flu [...]

Part B Medicare Administrative Contractor Overview for Dental Providers

The purpose of this webinar is to introduce dental providers to National Government Services and explain our role as the Medicare Administrative Contractor for Jurisdictions 6 and K. We’ll also share helpful resources related to coverage, [...]

Introduction to Outpatient OT and PT Services

Outpatient OT and PT Services Billing Guide Introduction to Outpatient OT and PT Services Therapy services are a covered benefit in Sections 1861(g), 1861(p), and 1861(ll) of the Act. Therapy services may also be provided incident to the [...]

KX Modifier Threshold

KX Modifier Threshold The Bipartisan Budget Act of 2018 repealed application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold above which claims must include the KX modifier as a confirmation that [...]

Annual Update to the Therapy Code List

Annual Update to the Therapy Code List Annual CRs update the list of codes that are described as “sometimes” or “always” therapy services. This will include additions, changes and deletions to the therapy code list. The current and previous [...]

Targeted Medical Review

Targeted Medical Review CMS knows in certain circumstances you may need to treat a patient whose condition exceeds the KX modifier threshold amounts. This is always based on the medical necessity of the patient. If this is the case, you must [...]

Functional Reporting - Using the G Codes

Functional Reporting ‒ Using the G Codes Effective for dates of service on and after 1/1/2019, the functional reporting requirements of reporting the functional limitation nonpayable HCPCS G-codes and severity modifiers on claims for therapy [...]

What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy

What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy The ABN is a notice given to the Medicare patient before services are rendered when you believe Medicare may deny services. These may be for medical [...]

Maintenance Programs

Outpatient OT and PT Services Billing Guide Maintenance Programs Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. [...]

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 [...]

Caregiver Training Services

Caregiver Training Services Effective 1/1/2024, payment will be made when practitioners train caregivers to support patients with certain diseases or illnesses (e.g., dementia) in carrying out a treatment plan. A caregiver is defined as a [...]

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 [...]

Medicare Physician Fee Schedule Database

Medicare offers several tools to help providers bill their services. Many questions you have can be answered by learning how to access and use the Medicare Physician Fee Schedule Database. We hope you'll join us for an overview of this database.

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 [...]

PR-B9

Avoiding/Correcting This Error When a Medicare beneficiary, or their authorized representative, elects hospice, all services related to the patient's terminal condition are handled by the hospice, and not billed to Medicare Part B. If the [...]

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. [...]

NGSConnex: Inquiries and Remittance Advice

Did you know you can initiate general claim inquiries through the NGSConnex portal? Do you have trouble understanding the remittance advice? If you answered yes, this session is for you! During this webinar, we’ll provide instruction on how to [...]

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 [...]

EDI Front End Clinical Edits

EDI Front End Clinical Edits EDI has begun to implement EDI clinical business edits into the NGS EDI front end. These edits will assist in proactively alerting providers of potential claim issues and provide resources to assist with avoiding [...]

CO-29

Avoiding/Correcting This Error Providers must file claims within a qualifying time limit to be eligible for Medicare reimbursement. The timely filing requirement is one calendar year after the date of service. The provider may not charge the [...]

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 [...]

Advanced Care Planning

Advanced Care Planning Please define documentation requirements when billing advanced care planning (CPT 99497 and 99498). Answer: ACP codes may be used with or without a base E/M code on the same date of service, based on whether a [...]

Behavioral/Mental Health Services

Behavioral/Mental Health Services Please explain the parameters for mental health services delivered via telehealth to a beneficiary who is at home. Note: CMS has extended the PHE-period waiver for in-person visit requirements for [...]

Chronic Care Management

Chronic Care Management The guidelines state moderate or high complex MDM. Do the E/M guidelines apply here? Answer: Yes, the E/M guidelines for MDM are applicable, since chronic care management (CPT 99490) is included within the E/M [...]

Consultations

Consultations Does CMS permit payment for consultative E/M services? Answer: CMS permits payment for medically necessary consultative E/M services. The specific E/M codes previously used to represent consultative services were [...]

Critical Care Services

Critical Care Services Please define the time requirement for billing CPT code 99292. Answer: Whether critical care is performed by a single provider or on a split (or shared) basis, the time requirement for CPT code 99292 remains the [...]

Examination

As of 1/1/2023, CMS has eliminated prior specifications for the scope of examination and associated documentation in the outpatient office and hospital settings. The provider is expected to perform and document a medically necessary and [...]

Fee-For-Time Compensation Arrangements

Fee-For-Time Compensation Arrangements Can a physician return to work in his or her practice for a short period of time to reset the 60-day clock requirement for the fee-for-time compensation arrangement provider? Answer: In order for the [...]

Global Period Services

Global Period Services Is it permissible for a provider (physician or NPP) who has served as an assistant surgeon, or another provider in the surgeon’s group, to bill for preoperative or postoperative care relative to the surgery? Answer: [...]

Medicare Remit Easy Print

Coordination of Benefits

Internet-only Manuals

National Correct Coding Initiative Edits

Medicare Remit Easy Print

Internet-only Manuals