Part B Appeals Process
Medicare regulations allow providers and beneficiaries who are dissatisfied with Medicare's determination to request that the determination be reconsidered. Through the process, Medicare seeks to ensure that the correct payment is made or a clear and adequate explanation is given supporting nonpayment.
Read More about appealing denied claims.
Part B Clerical Error Reopenings Process For Denied Claims
The Benefits & Protection Act of 2000 (BIPA) requires Contractors to provide a mechanism for
providers to telephone simple and/or minor corrections to denied claims.
(See Clerical Error Reopening Instructions)
Emergency Update to the 2008 Medicare Physician Fee Schedule Database (MPSDB)
The article is based on Change Request (CR) 5902 which amends payment files that were issued to Medicare contractors based upon the November 1, 2007 Medicare Physician Fee Schedule (MPFS) Final Rule.
Read more about how Change Request (CR) 5902 amends those payment files.
Importance of Supplying Correct Provider Identification Information
On the form CMS-1500 (12-90), or electronic equivalent, the provider must submit the appropriate referring or ordering physician name in item 17, and the Unique Physician Identification Number (UPIN) of the referring/ordering physician in item 17a. The Centers for Medicare & Medicaid Services (CMS) would like to remind providers and their billing staffs of the importance of reporting the correct provider identification information to help reduce denials.
Please be aware of the instructions provided.
Remember to take advantage the many Educational Events provided by administrators such as Centers for Medicare & Medicaid Services, Cahaba Government Benefits, TrailBlazer Health Enterprises, LLC and MAG Mutual Healthcare Solutions, Inc.
ONLINE COURSES from Cahaba Government Benefits
Provider Outreach and Educational Part B Upcoming Events Also From Cahaba Government Benefits
Events offered by Centers for Medicare & Medicaid Services
As always, MAG Mutual offers Coding Certification Workshops
Registration Information
03/10/2008- Physician Fee Schedule - Remember, Congress reversed the proposed -10.1% 2008 conversion factor, the new conversion factor for 2008 is 38.0870, which is a 0.5 % update. However, those rates will only be effective until June 30, 2008. Beginning with dates of service July 1, 2008 and after, the 0.5 % update to the conversion factor will no longer apply and the -10.1 % will go into effect, unless Congress acts again.
For more information and a handy reference chart, see the CAHABA Web site.
03/10/2008 - Claim Filing Time Limits Reminder - Medicare providers have at least 15 months from the date of the service to submit a claim to Medicare for consideration. However claim payment for assigned claims will be reduced by 10 percent if the claim is not filed within one year (12 months) of the date of service. For more information and a handy reference chart, see the CAHABA Web site.
02/21/2008 - Telephone Calls – a reminder
Prior to 2008, Medicare took the position that telephone calls were not normally billable to Medicare beneficiaries. Telephone calls were considered bundled into other services However, in a CMS Transmittal (to Medicare carriers) dated 02/01/2008, CMS said the following (Transmittal 1423 is available at www.cms.hhs.gov/transmittals/downloads/R1423CP.pdf): "Medicare does not pay separately for physician or nonphysician telephone conversations with patients (or their families), but that these conversations may be taken into account when the physician is determining which level of evaluation and management (E/M) code to assign on the next claim for a face-to-face E/M visit. Codes meeting this criteria are bundled under the Medicare physician fee schedule. However, because the code descriptors for CPT codes 98966 through 98969 and 99441 through 99444 state "not originating from a related E/M service nor leading to an E/M service" we assigned a status indicator of "N" (Non-covered service) to these services. Because these are noncovered services under the Medicare physician fee schedule, the physician or nonphysician practitioner may bill the beneficiary directly for these services as defined in the CPT, at his/her established rate.
[Note: We encourage you to watch for carrier announcements because this is a shift in policy.]
CPT® 2008 guidelines state: "Telephone services are non-face-to-face evaluation and management (E/M) services provided by a physician to a patient using the telephone. These codes are used to report episodes of care by the physician initiated by an established patient or guardian of an established patient. If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of the subsequent E/M service, procedure, and visit. Likewise if the telephone call refers to an E/M service performed and reported by the physician within the previous seven days (either physician requested or unsolicited patient followup) or within the postoperative period of the previously completed procedure, then the service(s) are considered part of that previous E/M service or procedure. (Do not report 99441-99443 if reporting 99441-99444 performed in the previous seven days.) (For telephone services provided by a qualified nonphysician health care professional, see 989666, 98968.) (Do not report 99441-99443 when using 99339-99340, 99374-99380 for the same call[s]) (Do not report 99441-99443 for anticoagulation management when reporting 99363-99364)"
OIG ISSUES ADVISORY OPINION ON PROMPT-PAY DISCOUNTS
On Feb. 8, the Department of Health and Human Services' Office of Inspector General (OIG), issued an advisory opinion on the provision of prompt-pay discounts to patients.
The OIG specifically focused on the requester's certifications that it would:
· Not advertise the opportunity for a discount. Patients would only be advised of the availability of the discount during the billing process.
· Notify other third-party payers of its prompt-payment policies.
· Bear all of the costs of the arrangement.
· Ensure that the prompt-pay discounts bear a reasonable relationship to the amount of avoided collection costs.
Read More Here!
2/15/2008 - PHYSICIAN SELF-REFERRAL LAW "STARK LAWS"
CMS has released guidance to help providers interpret its recent rule-making on the physician self-referral (Stark) law.
The Stark II, Phase III regulations took effect Dec. 4, 2007, and contained several new terms and concepts. In response to questions from the provider community, CMS posted 12 new "Frequently Asked Questions" or FAQs on its Web site. Topics include the definitions of a physician organization and a physician practice and further clarifications of the newly introduced "stand in the shoes" concept.
Remember however, these FAQs do not have the same legal weight as the text of the regulations, but they provide insight into CMS' interpretation of its regulations.
Read More Here!
MARCH 1ST IS A CRITICAL DATE!
Last week, CMS issued the January NPI message to all providers. (You can view the January NPI message online at http://www.cms.hhs.gov/NationalProvIdentStand/02_WhatsNew.asp on the CMS website.) This week begins a weekly messaging campaign for Medicare Fee-For-Service providers in order to raise the level of urgency as the March 1st implementation date approaches.
Prior to March 1, 2008:
Claims with both an NPI and a Medicare legacy number are rejected if the pair is not found on the Medicare NPI Crosswalk.
Claims submitted with just a Medicare legacy number are being paid (unless of course, they have other errors that cause them to be rejected).
As of March 1, 2008:
Claims with both an NPI and a Medicare legacy number will continue to be rejected if the pair is not found on the Medicare NPI Crosswalk.
Claims without an NPI in the primary provider field will be rejected!
Claims with only a Medicare legacy number in the primary provider field will be rejected!
This means that you will not be able to get paid for any Medicare services you provide until you begin using your NPI. Also, if needed, you must correct any data which may be preventing an NPI/legacy match on the NPI crosswalk. The correction might require that you file a CMS-855 Medicare Provider Enrollment form with your Medicare carrier, A/B MAC, or DME MAC a process which can take a number of months to accomplish.
TEST NPI-only NOW: If you have been submitting claims with both an NPI and a Medicare legacy number and those claims have been paid, you need to test your ability to get paid using only your NPI by submitting one or two claims today with just the NPI (i.e., no Medicare legacy number). If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. You can and should do this test now! If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims reject, call your Medicare carrier or A/B MAC enrollment staff for advice right away. The enrollment number is likely to be quite busy after the March 1 deadline, so don't wait.
Reminder - CMS to Host National NPI Roundtable on 2/6/2008
CMS will host a national NPI Roundtable on Wednesday, February 6th from 2:30 – 4PM ET. This call will focus on the status of the Medicare implementation and a related question and answer session. Registration details are available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/listservwording2-6-08npicall.pdf on the CMS website.
Need More Information?
Not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.
12/29/07 - Medicare, Medicaid, and SCHIP Extension Act of 2007"
On Saturday, December 29, 2007, the President signed into law S. 2499, the "Medicare, Medicaid, and SCHIP Extension Act of 2007," which Provides a 0.5 percent Medicare payment increase for physicians for 6 months; (2) extends SCHIP through March 31, 2009; and (3) extends the Medicaid Qualifying Individual provision, Title V Abstinence Education grant program, and Transitional Medical Assistance eligibility for Medicaid beneficiaries for 6 months.
11/26/07 - The NPI is here! The NPI is now!
ARE YOU USING IT?
As we get closer to May 23, 2008, be sure to pay attention to information from Medicare and other health plans regarding NPI implementation timelines.
If you are a health care provider who bills for services, you probably need an NPI. If you bill Medicare for services, you definitely need an NPI. Getting an NPI is easy and free. If you delay applying for your NPI, you risk your cash flow and that of your health care partners as well.
Take a look at Key Medicare NPI Implementation Dates along with information on the revised NPI application form (CMS-10114) and “How To Apply” for your NPI.
Important Message for Residents at Teaching Hospitals and Academic
Medical Centers: Why get your NPI now?
Still Confused?
NOT SURE WHAT AN NPI IS AND HOW YOU CAN GET IT, SHARE IT AND USE IT?
As always, more information and education on the NPI can be found through the CMS NPI Page
https://www.cms.hhs.gov/NationalProvIdentStand on the CMS website.
Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.
Getting an NPI is free - not having one can be costly.
10/24/07 - Care Plan Oversight (CPO)
CMS has clarified the policy associated with Non-Physician Practitioners (NPPs) billing for physician home health Care Plan Oversight (CPO). This change; CR4374, (note that changes are in red) effectuates a revision to the policy that the same provider that signs the plan of care does not have to be the same provider that bills for physician Care Plan Oversight (CPO). Learn more about CR4374 at the CMS Website.
10/23/07 – Medicare Summary Notice (MSN) Revised 38.13
This article is informational for providers and the article is based on Change
Request (CR) 5722, which outlines a change to MSN message 38.13 that will
advise beneficiaries that they may need to pay their provider before receiving their
MSN due to the change to quarterly mailing schedule. Read the entire article on this revision in MLN Matters along with links to additional information at the CAHABA Website.
10/05/07 – New CLIA Waived Tests Are Announced (New waived test are approved by the FDA.) Note: The CPT Codes for the test must include the modifier “QW” to be recognized as a waived test. Your Medicare carrier will not automatically adjust claims processed prior to the implementation of these changes unless you bring such claims to their attention. See the table of waived test and additional information at the CAHABA Website.
10/08/2007 - Tamper Resistant Prescription Pads Update:
President Bush has signed the "Extenders Law," delaying the implementation date for all paper Medicaid prescriptions to be written on tamper-resistant paper. Under the new law, as of April 1, 2008, all written Medicaid prescriptions must be on tamper-resistant prescription pads. For more information see the CMS Web site.
10/08/2007 - Reminder - Medicare's fall open enrollment for the Drug Plan (Part D) is from November 15th December 31, 2007. No doubt physicians and their staff will get inquiries from many elderly patients. Medicare.gov has some tools to help beneficiaries decide on which option to choose.
10/02/2007 - CMS has announced a contract to the American Health Information Management Association (AHIMA) to begin assessing the impact on CMS of replacing the ICD-9 code sets now used in reporting health care transactions with the ICD-10 versions.
The AHIMA will analyze CMS’ systems, policies and operations to determine potential impacts of transitioning from the ICD-9 to the ICD-10, including the ICD-10’s ability to support more accurate payment for new procedures, efficient claims processing, and improved disease management.
As most of you know, ICD-10 has been about to happen since the early to mid 1990s. Perhaps this isn’t just another false alert.
10/08/2007 – Stark Laws. CMS has a good section on Physician Self Referral On their Web site. Everyone should take a few minutes to read over the info including some very good FAQs
9/10/2007 – Blue Cross of California announces switch to only NPIs.
Effective January 26, 2008, Blue Cross of California will begin accepting only National Provider Identifier (NPI) numbers on electronic claims and other transactions requiring a provider number to meet required HIPAA compliance. Currently, Blue Cross of California accepts electronic transactions with NPIs and Blue Cross of California provider numbers (“legacy IDs”). Blue Cross of California will continue accepting electronic transactions with either NPI numbers only, Blue Cross of California provider numbers or both until January 25, 2008. On January 26, 2008, the 10-digit NPI numbers will become the only compliant provider numbers we will accept.
For more information see the release at BC/BS of California's Web site.
08/17/2007 – PQRI News
It’s been almost two months since reporting quality data codes for the 2007 Physician Quality Reporting Initiative (PQRI) began. Be sure to check with your carrier for updates.
Additionally, information about the 2008 PQRI was released in the Notice of Proposed Rulemaking for the 2008 Medicare Physician Fee Schedule.
Finally, CMS has posted a letter to Medicare beneficiaries with important information about the PQRI on the CMS Web site. The letter is from Medicare to the patient explaining what the program is, and the implications for the patient. Physicians may choose to provide a copy to their patients in support of their PQRI participation
07/30/2007 – Tamper-Proof Prescription Pads for Medicaid Beneficiaries Required By October 1st, 2007
Although, Reps. Charlie Wilson (D-Ohio), Marion Berry (D-Ark.) and Mike Ross (D-Ark.) have introduced a measure that would delay implementation of a law that will require physicians to write prescriptions for Medicaid beneficiaries on tamper-proof pads. If the deadline stands, millions of Medicaid beneficiaries might not be able to obtain their medications after October 1st.
The law was designed to make it more difficult for patients to obtain controlled substances through forged prescriptions and to save the government money. However, most physicians are not aware of the law and do not use tamper-proof prescription pads.
Don’t be unprepared! Order your secure/tamper-proof prescription pads now.
7/23/2007 Important PQRI Notice
Empire Medical, the Medicare carrier for part of NY and some other states, reports it has come to the attention CMS that some Clearinghouses are stripping the National Provider Identifier (NPI) prior to submission of the claim to Medicare. This will adversely affect Eligible Professionals in that these claims will not count toward PQRI participation. CMS urges Eligible Professionals that use clearinghouses to check with their clearinghouse to assure NPIs are not being stripped from claims. If the Eligible Professional determines that their clearinghouse is stripping NPIs from the claim, the Eligible Professional may want to consider other billing options.
A recent Special Edition MLN Matters article contains important information for Medicare providers and suppliers, including how to use the NPI correctly on Part A and Part B claims. You can view this article by visiting http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf on the CMS Web site.
07/12/2008 - CPT® 2008 will include 242 new codes, 298 revised codes, and 51 deleted codes and every section of CPT will be impacted. That's 25% more changes than last year! It's time to order your CPT Books AND your Physicians Fee & Coding Guide! In fact, try one of our special coder's packages and save.
4/26/2007 - Reminder – Medicare Extending Date for Accepting Form CMS-1500 (12-90)
While Medicare began to accept the revised Form CMS-1500 (08-05) on January 1, 2007 and was positioned to completely cutover to the new form on April 1, 2007, it has recently come to our attention that there are incorrectly formatted versions of the revised form being sold by the Government Printing Office (GPO). After reviewing the situation, the GPO has determined that the source files they received from the NUCC’s authorized forms designer were improperly formatted. The error resulted in the sale of both printed forms and negatives which do not comply with the form specifications. However, not all of the new forms are in error.
Given the circumstances, CMS is extending the acceptance period of the Form CMS-1500 (12-90) version beyond the original April 1, 2007 deadline while this situation is resolved. Medicare contractors will be directed to continue to accept the Form CMS-1500 (12-90) until notified by CMS to cease. At present, we are targeting June 1, 2007 as that date. During the interim, contractors will be directed to return, not manually key, any Form CMS-1500 (08-05) forms received which are not printed to specification. By returning the incorrectly formatted claim forms back to providers, we are able to make them aware of the situation so they can begin communications with their form suppliers.
For more details, and to learn how to identify the proper version of the new form, visit a recent MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5568.pdf on the CMS website.
4/18/2007 - CMS will host a Special Open Door Forum on the use of registries for reporting data on quality measures to the Physician Quality Reporting Initiative (PQRI).
To participate in the Special Open Door Forum in person or by phone, you will need to register on this web site: http://registration.intercall.com/go/cms2 . Once you complete your registration you will receive a confirmation email that will include conference dial-in information.
Registration will close at 4:00 p.m. EDT on Wednesday May 9, 2007. Please be sure to register prior to this time.
For those who will be unable to attend, the Special Open Door Forum will be recorded. A replay option will be available beginning the close of business May 18, 2007 and will be accessible for 3 days. Please visit the website http://www.cms.hhs.gov/center/hospital.asp to download an audio recording.
If you have questions or require special accommodations, please contact Diane Stern at diane.stern@cms.hhs.gov at (410) 786-1133.
4/10/2007 – Medicare’s Physician Quality Reporting Initiative (PQRI) establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible physicians who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, can earn a bonus payment of up to 1.5% of total allowed charges for covered Medicare physician fee schedule services.
To help physicians understand this new program and successfully participate, MAG Mutual Healthcare Solutions, Inc. is offering a new publication, Medicare’s Physician Quality Reporting Initiative and Beyond 2007-2008.
4/10/2007 – CMS has released a document called “Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule.” To view this guidance, visit http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf on the CMS website.
Essentially, CMS has allowed a one year grace period on the May 23, 2007 NPI deadline. CMS will not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners (e.g. those healthcare providers who bill them). The posted guidance document can be used by covered entities to design and implement a contingency plan.
Finally, the will be a National Roundtable (conference call) to discuss the NPI Compliance Contingency Guidance. The toll-free call will take place from 2:30 p.m. – 4:00 p.m., EDT, on Wednesday April 18, 2007. To register for the call participants need to go to:
https://ww4.premconf.com/webrsvp/register?conf_id=7749423
03/13/2007 CMS announces an extension for accpeting 12/90 versions of the CMS-1500 form. Here is the CMS press release:
CMS Breaking News!! RE: Form CMS-1500
The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional contractors (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies.
The National Uniform Claim Committee (NUCC) is responsible for the maintenance of the CMS-1500 form. CMS does not provide the form to providers for claim submission.
It has come to our attention that there are incorrectly formatted versions of the revised form. Given, the circumstances, CMS has decided to extend the acceptance period of the Form CMS-1500-(12-90) version beyond the original April 1, 2007 deadline while this situation is resolved. Contractors will be directed to continue to accept the Form CMS-1500 (12-90) until notified by CMS to cease.
The following link will help you to properly identify which form is which and to read more about the implementation of the CMS-1500 go to
http://www.cms.hhs.gov/ElectronicBillingEDITrans/16_1500.asp
Pdf download: http://www.cms.hhs.gov/ElectronicBillingEDITrans/Downloads/1500%20problems.pdf
3/01/2007 – CMS Plans To Revise The Advance Beneficiary Notice (ABN)
The ABN is used to inform beneficiaries of potential financial liability, except in home health care and inpatient hospital settings
While the basic content of the ABN remains the same, there were several changes to the notice including but not limited to the following:
(1) Revised, more user friendly language;
(2) combining the two versions of the ABN, the General Use ABN, form CMS-R-131-G, and CMS-R-131-L, which was used specifically for physician-ordered laboratory tests, into a single general notice meeting both needs;
(3) adding the 1-800-MEDICARE number on the notice;
(4) adding information about the beneficiary's right to demand Medicare be billed;
(5) increasing the selection options to 3 from 2, to allow beneficiaries' the right to pay out of pocket when they desire;
(6) allowing a place for other insurance information to be recorded; and
(7) describing the significance of the signature
Physicians, practitioners, providers and suppliers already required to use ABNs will continue to use the currently approved ABN until the revised notice is finalized and approved. You can see the proposed ABN here.
02/20/2007 – Do you have a new National Provider Identifier (NPI)?
Failure to prepare could result in a disruption in cash flow. Will you be ready to use your National Provider Identifier (NPI)? Time is running out!
To date, over 1.6 million providers have obtained an NPI. Now, only about 90 days are left to implement the NPI into business practices prior to the compliance date. A recent survey of the health care industry, conducted by the Workgroup for Electronic Data Interchange (WEDI), indicates that providers should have already obtained an NPI and be focusing on implementation and testing with health plans and clearinghouses. If providers have not obtained their NPI by now they should do so immediately so that they can begin the implementation and testing process.
Reminder to Supply Legacy Identifiers on NPI Application
CMS continues to urge providers to include legacy identifiers, as well as associated provider identifier type(s), on their NPI applications. This will help all health plans, including Medicare, to get ready for May 23, 2007. If reporting a Medicaid legacy number, include the associated state name. If providers have already been assigned NPIs, CMS asks them to go back into the National Plan and Provider Enumeration System (NPPES) and update their information with their legacy identifiers if they did not include those identifiers when they applied for NPIs. Providers should verify these legacy identifiers are the ones used to bill for services and should ensure the NPPES is updated with this information for all health plans. This information is critical for health plans and health care clearinghouses in the development of crosswalks to aid in the transition to the NPI.
Still Confused?
Not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found on the CMS NPI Web page. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or call the NPI enumerator to request a paper application at (800) 465-3203.
Getting an NPI is free - not having one can be costly.
1/3/2007 – Download a more detailed update of the HCPCS codes changes effective 1/1/2007 here. Stay tuned for more information on the HCPCS update for April
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