Coordination of Benefits

National Correct Coding Initiative Edits

About PC-ACE

About PC-ACE The National Government Services PC-ACE free billing software is available for NGS J6 and JK providers only. If you are not a J6 or JK provider, the free billing software must be obtained from your MAC. PC-ACE is a [...]

PCACE Download Text - ALOB

The installation code to run the full install or the upgrade for PC-ACE is: NGSMAC1 Important Warning: For PC-ACE version 6.4 updated version: please be patient and allow the full install or update complete. It is important that you do not [...]

Download PC Print

Download PC Print Please select from the two available versions of PC Print below. PC Print 7.1.5 PC Print 9.3.2 For the most current CARC/RARC code sets with full narrative and business scenarios, please download PC Print 9.3.2. and [...]

PCACE Upgrade Text - ALOB

Version 6.4 (Institutional and Professional) PC-ACE users

PCACE Full Install Text - ALOB

Version 6.4 (Institutional and Professional) PC-ACE users

About PC-ACE

About PC-ACE The National Government Services PC-ACE free billing software is available for NGS J6 and JK providers only. If you are not a J6 or JK provider, the free billing software must be obtained from your MAC. PC-ACE is a stand-alone [...]

History

As of 1/1/2023, CMS has eliminated prior specifications for documentation of a patient’s history for services provided in both the outpatient office and hospital setting, including the emergency department. The provider is expected to obtain [...]

IPPE and AWV Services

IPPE and AWV Providers are reminded that the IPPE and AWV are Medicare-covered services within their own benefit category. As such, they are not subject to standard “incident to” billing guidelines and must be billed by the performing [...]

Medical Decision Making

Medical Decision Making In a split/shared service, when a medical record includes a plan of care developed by the physician, based on a history and/or examination performed by the NPP and a personal review of diagnostic findings, [...]

New vs. Established Patients

New vs. Established Patients How does CMS define a patient as “new” versus “established”? Answer: In 2023, the definition of a “new” patient differs based on whether the patient is being treated in an office or an observation/ inpatient [...]

Nonphysician Practitioner Services

Nonphysician Practitioner Services In addition to the frequently asked questions below, please view NGS’ Nonphysician Practitioners-Reducing Costly Appeals; Increase Provider Revenue article for related information. Is it permissible for [...]

Observation Services

Observation Services Please define guidelines for providers billing observation services. Answer: Observation services are ordered, performed and billed by the practitioner (or group), who is responsible for the patient’s care during the [...]

Preoperative Clearance

Preoperative Clearance What requirements must be met for a preoperative clearance visit to be considered medically necessary and billable? Answer: CMS does not set requirements for medical clearance; these are established by individual [...]

Prolonged Services

Prolonged Services Note: View NGS’ Prolonged Services Timetable for CPT codes and time requirements.  Please explain why time thresholds for some E/M services vary between AMA/CPT and CMS guidance. Answer: The CMS RVU RUC assessed [...]

Provider Specialty

Provider Specialty Should each MD in the same practice bill with two different taxonomy codes based on whether functioning as a cardiologist or electrophysiologist? Answer: Yes, providers should be billing with their taxonomy codes. The [...]

Scribes

Scribes When a physician or NPP performs a service that is documented by a scribe, what are the documentation requirements? Answer: As per CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4: “CMS [...]

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 [...]

Teaching Environment E/M Services

Teaching Environment E/M Services Please define levels of care for E/M services that can be performed by residents in a hospital outpatient setting under the PCE rules. Answer: CMS PCE guidelines for the hospital outpatient setting permit [...]

Telehealth Services

Telehealth Services Note: View National Government Services' Place of Service Codes for CY 2024 Updates Please explain Medicare’s definition of a telehealth service. Answer: Medicare defines a telehealth service as a service provided by [...]

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 [...]

Why is radiofrequency ablation (RFA) noncovered?

Can SIJIs be performed under sedation? How about monitored anesthesia care (MAC)? Is “twilight” allowed?

Emergency Department

Emergency Department When a consultant has seen a patient in the ED and billed an ED code, how are subsequent services billed when the patient is then admitted to inpatient status? Answer: The ED consult (billed with an ED code [...]

Repetitive Scheduled Non-Emergent Ambulance Transports Prior Authorization

Attention All Independent Ambulance Suppliers! If you are providing repetitive, scheduled, non-emergent ambulance transports (RSNAT), you'll want to attend this webinar. Join us to learn everything you need to know about the RSNAT program.

ASCA: Must an Administrative Simplification Compliance Act waiver be mailed or can it be faxed?

ASCA: When applying for an ASCA waiver, do I need to complete the Waiver Request form for each provider number?

ASCA: I was under Administrative Simplification Compliance Act review once and received an approved waiver request to send paper claims, why am I under review again?

EDI: Is the 277CA returned for each test submission?

EDI: After I receive a 277CA will I receive anything else?

EDI: How can I tell if I am set up for electronic billing?

EDI: How do I restore a remit file?

EDI: How long are Electronic Remittance Advices (ERAs) available in my mailbox?

EDI: I am missing an Electronic Remittance Advice (ERA). How do I order a duplicate?

EDI: I am receiving the following CSC and EIC code on my 277CA. How do I make the correction?

EDI: I am receiving the following Claim Status Code and EIC code on my 277CA. What do these codes mean?

EDI: I heard that 5010 requires a physical address in box 33 and P.O. boxes are no longer accepted. Is this true?

EDI: I received a payer acknowledgement/acceptance report from my clearinghouse. Does this mean you accepted my claims?

EDI: I received my application back with errors on my Provider Authorization Form. Can I correct it or will I have to complete an entirely new application and authorization form?

EDI: What Entity Name should I enter on the EDI Enrollment Agreement form?

EDI: What PTAN should I enter on the EDI enrollment forms if the provider is a member of a group?

EDI: What information do I need to have available when calling for Electronic Data Interchange (EDI) assistance?

EDI: What is a Network Service Vendor (NSV)?

EDI: What is an Approved Entity?

EDI: What provider address should I include on the EDI enrollment forms?

EDI: When is a provider authorization form required?

EDI: Where in the 277 CA file can we find the rejection message that provides the detailed rejection reason description?

EDI: Will you reject claims where the group number and policy number are the same values?

EDI: Will you reject claims with a P.O. Box in the billing provider address?

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?

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

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?

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?