Critical Care Tip Sheet

Critical Care Tip Sheet Table of Contents Service and Medical Necessity The Following CMS Billing Consideration Guidelines Apply Provider Time Assessment and Documentation The Following CMS Billing Consideration Guidelines [...]

Critical Care Services: CPT Codes 99291-99292

Critical Care Services: CPT Codes 99291-99292 Table of Contents Definition Context Providers Who May Perform Critical Care Services and Medical Necessity Palliative and Hospice Patients Full Attention of the Provider and Provider [...]

Certification or Recertification of Medicare Covered Home Health Services

Certification or Recertification of Medicare Covered Home Health Services Billing HCPCS Codes G0180 and G0179 of Patient Eligibility for Medicare-covered Home Health Services under a Home Health Plan of Care Physician [...]

Initial Episode Clarified for Home Health Face-to-Face Encounter

Initial Episode Clarified for Home Health Face-to-Face Encounter CMS requires a patient receiving HH services under the Medicare HH benefit have a FTF encounter with the certifying physician for the initial episode. CMS has clarified that this [...]

Sacroiliac Joint Injections and Procedures

Sacroiliac Joint Injections and Procedures Table of Contents Sacroiliac Joint Injections and Procedures Diagnostic SIJI Diagnostic SIJI Limitations Therapeutic SIJI Therapeutic SIJI Limitations SIJ Denervation [...]

Eligible Part B Physicians and Nonphysicians to Enroll as Ordering and Referring Only

Eligible Part B Physicians and Nonphysicians to Enroll as Ordering and Referring Only Physician and nonphysician practitioners who can enroll in Medicare solely to order or refer: Doctors of medicine or osteopathy Doctors of dental surgery [...]

Approval or Denial

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

Acknowledgement Email

Acknowledgement Email Upon receipt of your application submission, the contact person (identified on application) will receive an email confirmation from: CustomerService-DoNotReply@cms.hhs.gov containing the PECOS web tracking number. [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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

Benefits of Quitting Table of Contents Benefits of Quitting Health Benefits of Quitting Smoking Economical Benefits of Quitting Smoking Related Content [Return to Top] Benefits of Quitting Quitting tobacco use in any form is one of [...]

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 [...]