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 [...]

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: [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

Advance Beneficiary Notice of Noncoverage for Not Reasonable and Necessary Denials

Medicare Part B 101 Manual Advance Beneficiary Notice of Noncoverage for Not Reasonable and Necessary Denials Table of Contents Limited Coverage Medical Necessity Expectations ICD-10-CM Coding Reasons for Noncoverage Beneficiary [...]

Provider Enrollment

Medicare Part B 101 Manual Provider Enrollment Table of Contents National Provider Identifier Required Tips for Successfully Enrolling with the Medicare Part B Contractor When Mailing Paper Applications Tip 1: Submit the correct [...]

Assignment of Benefits

Medicare Part B 101 Manual Assignment of Benefits Table of Contents Assignment of Benefits Mandatory Assignment Collecting from Medicare Patients on Assigned Claims Related Content [Return to Top] Assignment of Benefits An [...]

PECOS: In PECOS, please advise how to respond when the MAC needs additional information or supporting documentation for a submitted application.

APPLICATION FEE: Who needs to pay an application fee?

PECOS: In PECOS, how do I know what enrollment information Medicare currently has on file for a provider or supplier?

Return/Reject

Medicare Part B 101 Manual Return/Reject While it's easy to group processed claims as either approved or denied, there are differences in the way claims are returned unpaid by Medicare. Only claims that are filed with complete and correct [...]

Health Professional Shortage Area

Medicare Part B 101 Manual Health Professional Shortage Area What is a HPSA? What is the HPSA Incentive Bonus? Who is Eligible for the Incentive Bonus? How is the Bonus Billed? What Else You Should Know To Learn More [Return to [...]

Electronic Data Interchange

Medicare Part B 101 Manual Electronic Data Interchange Table of Contents Electronic Data Interchange Transactions Benefits of Submitting Electronically Becoming an Electronic Submitter PC-ACE EDI: Beyond Claims and Extra Features [...]

Appendix 3: Place of Service Codes

Medicare Part B 101 Manual Appendix 3: Place of Service Codes Table of Contents Place of Service Codes Health Insurance Portability and Accountability Act Special Considerations Homeless Shelter (Code 04) Indian Health Service [...]

National Provider Identifier

Medicare Part B 101 Manual National Provider Identifier Table of Contents National Provider Identifier Background Application Process Sharing Your NPI NPI Contractor Mailing Address NPI Registry [Return to Top] National [...]

About Provider Outreach and Education

Medicare Part B 101 Manual About Provider Outreach and Education Table of Contents About Provider Outreach and Education Educational Activities Provider Outreach and Education Advisory Group [Return to Top] About Provider Outreach [...]

APPLICATION STATUS: Where can I find the status of a submitted application?

APPROVAL RECOMMENDATION STATUS: The status of my application is approval recommendation, how can I verify if the state agency or CMS has completed their process?

APPROVAL RECOMMENDATION STATUS: Whom can I contact for questions about an application in approval recommendation status?

Initiate Patient Status Lookup

Initiate Patient Status Lookup Click the Eligibility Lookup button from the NGSConnex homepage. In the Select a Provider panel, click the Select button next to the applicable provider account. In the Select a Beneficiary panel, [...]

MLN Connects® Newsletter: October 17, 2024

MLN Connects® Newsletter: October 17, 2024 News Inpatient Psychiatric Facilities: Guidance on All-Inclusive Cost Reporting No-Pay Medicare Summary Notice Mailing Frequency Changed to Every 120 Days Health Literacy: Help Your Patients Get [...]

Navigating Medicare Part B Insights for Providers Podcast

Navigating Medicare Part B Insights for Providers Podcast   Listen to our podcast, Navigating Medicare Part B Insights for Providers, on Spotify and Apple Podcasts! We will be posting a new episode on the 2nd and 4th Wednesday of each [...]

Hospice Payment Rates

Hospice Payment Rates National Government Services publishes hospice rate sheets you can use to validate hospice payments based on your service location. Although FISS is the official payment made by the Medicare Program, you can use the rates [...]

Accelerated and Advanced Payment Program

COVID-19 Accelerated/Advanced Payment Revised Repayment Terms On 3/28/2020, CMS expanded the existing CAAP to a broader group of Medicare Part B Providers. The CMS CAAP Program was established to increase case flow to Medicare providers and [...]

Bankruptcy Notifications

Notify us if you file bankruptcy. If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, National Government Services requests that you notify us immediately so that we can properly coordinate with the CMS and the [...]

Complete a Voluntary Refund

Table of Contents Forms Used for Providers NOT on Automatic Immediate Recoupments and Check(s) Are Attached to This Form(s) Option 1: Completing the Voluntary Refund Form High Volume Spreadsheet Instructions Option 2: Large [...]

How Should I Respond?

An overpayment may be identified and self-reported by a provider via clerfical error reopening or an overpayment, may be discovered by Medicare contractors as part of the claim and reimbursement review process. The key to reporting and repaying [...]

Nettings/Offsets Across Organization Affiliations

Effective 1/4/2016, CMS implemented a change to begin netting/offsetting provider money across affiliated providers within the same and also across workloads within a single organization. This CMS change brings consistency to all Part B [...]

Overpayment Rebuttal Process

You’ll need to know what the rebuttal process is before initiating and know that the outcome of the rebuttal may not change the National Government Services recoupment process. The overpayment rebuttal process is a protocol used when an [...]

Overpayment Request

Table of Contents Forms You'll Need Large Scale Overpayments Overpayment Notification Process Timeline for Processing a Demand Letter [Return to Top] Forms You'll Need Forms for non MSP-related are generally done via NGSConnex, but [...]

Respond to a Demand Letter

Table of Contents Form(s) you’ll need Timeline for Processing a Demand Letter [Return to Top] Form(s) you’ll need Providers on Automatic immediate Recoupments Do nothing as this automation process will automatically be done and [...]

Request an Immediate Recoupment

Forms You’ll Need These forms apply to providers that are NOT on Automatic Immediate Recoupments. Electronic Submissions JK or J6 Immediate Recoupment Request Form - Electronic/E-mail Paper Submissions Jurisdiction K [...]

Set Up an Extended Repayment Schedule

Forms you’ll need J6 Applying for an Extended Repayment Schedule JK Applying for an Extended Repayment Schedule If repaying an overpayment would constitute a “hardship” on the provider, a request for an ERS should be submitted [...]

Resources

MLN® Fact Sheet: Medicare Overpayments CMS Internet-Only Manual Publication 100-06, Medicare Financial Management Manual, Chapter 3 - Overpayments Reviewed 10/17/2024

Hospice Payment Rates

MSP Post-Pay Overpayments

Forms You’ll Need Jurisdiction K CT-MA-ME-NH-NY-RI-VT Medicare Part B MSP Overpayment Request Form Jurisdiction 6 IL-MN-WI Medicare Part B MSP Overpayment Request Form JK or J6 Medicare Secondary Payer Part B Voluntary [...]

Set Up a Beneficiary's Medicare Secondary Payer Record

Table of Contents Background: Set Up a Beneficiary’s Medicare Secondary Payer Record Step 1: Provider Receives New MSP Information for a Beneficiary Step 2: Check for a Matching Medicare Secondary Payer Record for the Beneficiary in the [...]

ABN Modifiers

ABN Modifiers Modifier Description GA Waiver of liability statement issued, as required by payer policy, individual case GX Notice of liability issued, voluntary under payer policy GY Item [...]

American Medical Association and Current Procedural Terminology

American Medical Association and Current Procedural Terminology The AMA is your trusted source for official CPT. The most widely accepted medical nomenclature used to report medical procedures and services under public and private health [...]

CMS Forms and Publications

CMS Forms and Publications CMS publishes and maintains numerous Medicare forms that are used daily by the provider community. Some commonly used forms are: Provider Enrollment CMS-855 forms (CMS-855B, CMS-855I and CMS-855O) Medicare [...]

CMS Regional Offices

CMS Regional Offices CMS has ten RO reorganized in a Consortia structure based on the agency’s key lines of business: Medicare Health Plans Operations Financial Management and Fee-for-Service Operations Medicaid and Children’s Health [...]

Clinical Lab Improvement Amendment 

Clinical Lab Improvement Amendment  CMS regulates all laboratory testing (except research) performed on humans in the U.S. through the CLIA. The objective of the CLIA program is to ensure quality laboratory testing. Although all [...]

Comprehensive Error Rate Testing

Comprehensive Error Rate Testing The CERT program was established by CMS to monitor the accuracy of claim payment in the Medicare FFS Program. The intent of the CERT program is to protect the Medicare Trust Fund by identifying errors and [...]

Electronic Health Records

Electronic Health Records Eligible professionals under the Medicare EHR Incentive Program include: Doctor of medicine or osteopathy Doctor of dental surgery or dental medicine Doctor of podiatry Doctor of optometry Chiropractor If [...]

Electronic Prescribing

Electronic Prescribing In 2013, the eRx Incentive Program for participating and reporting in the Medicare Electronic Prescribing (eRx) Incentive Program ended. The six-month 2014, eRx payment adjustment reporting period began on 1/1/2013 and [...]

Evaluation and Management Documentation Guidelines

Evaluation and Management Documentation Guidelines Health care professionals may use the most current documentation guidelines for the date of service performed. Refer to these resources for guidance: CMS Evaluation and Management AMA [...]

Federal Register

Federal Register The OFR provides access to the official text of: Federal laws Presidential documents Administrative regulations and notices The ACFR oversees the functions of the Federal Register publications system.   For more [...]

Health Insurance Portability and Accountability Act of 1996

Health Insurance Portability and Accountability Act of 1996 The HIPAA was signed in to law to improve and simplify the administration of the Medicare Program under title XVIII of the Social Security Act, the Medicaid program under title XIX [...]

Limitation of Liability (Advance Beneficiary Notice of Noncoverage)

Limitation of Liability (Advance Beneficiary Notice of Noncoverage) 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. [...]

Medically Unlikely Edits

Medically Unlikely Edits In January 2007, CMS developed MUEs to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS /CPT code is the maximum units of service that a provider would report under most circumstances for a [...]

Medicare Coverage Database

Medicare Coverage Database The Medicare Coverage Database is an administrative and educational tool to assist providers, physicians and suppliers in submitting correct claims for payment. The Medicare Coverage Database features LCDs developed [...]

Medicare Electronic Data Interchange

Medicare Electronic Data Interchange Information about how providers can communicate electronically with the Medicare Program can be found on the CMS website at Medicare Electronic Billing & EDI Transactions. This web page contains EDI [...]