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, [...]

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 [...]

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

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 [...]

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 [...]

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KX Modifier Threshold The Bipartisan Budget Act of 2018 repealed application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold above which claims must include the KX modifier as a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

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 [...]

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 [...]

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 [...]

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. [...]

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. [...]

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 [...]

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 [...]

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 [...]

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 [...]

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. [...]

Coordination of Benefits

Medicare Remit Easy Print

CMS Links

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

Internet-only Manuals

National Correct Coding Initiative Edits

National Correct Coding Initiative Edits

Coordination of Benefits

Medicare Remit Easy Print

Internet-only Manuals

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 [...]

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 [...]

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

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 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 [...]

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 [...]

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.

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 [...]

CO-16

Avoiding/Correcting This Error The CPT/HCPCS code reported is not valid for the date(s) of service billed on the claim. This may also mean that the digits or alpha characters in the code are incorrectly reported. Please review the claim and [...]

PR-50

Avoiding/Correcting This Error The CPT/HCPCS code reported is not covered for the beneficiary, and the beneficiary is liable for these charges. If you have reported an incorrect code, or forgot a modifier, the claim will need to be reviewed as [...]

CO-16

Avoiding/Correcting This Error The CPT/HCPCS code reported is not valid for the date(s) of service billed on the claim. This may also mean that the digits or alpha characters in the code are incorrectly reported. Please review the claim and [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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, [...]

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 [...]