Showing posts with label Medicare billing question. Show all posts
Showing posts with label Medicare billing question. Show all posts
What is the new Therapy Cap process
New Therapy Cap Process: Frequently Asked Questions
What is the new Therapy Cap process?
Answer:
Starting October 1, 2012, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to prior authorization. For outpatient therapy services that exceed $3700 there will be a prior authorization approval process that will be implemented in three distinct phases. Providers will be assigned to one of three phases for manual medical review and will receive notification from CMS by letter and contractor websites regarding which phase they are included.
Why is CMS doing this?
Answer:
This process is required by Section 1833(g)(5)(C) of the Social Security Act, as added by Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJA), which was signed into law on February 22, 2012.
What is the prior authorization threshold?
Answer:
Starting October 1, 2012, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to prior authorization. For outpatient therapy services that exceed $3700 there will be a prior authorization approval process that will be implemented in three distinct phases.
How is the $3,700 calculated?
Answer:
The $3,700 is calculated using all outpatient therapy services provided (except those provided in Critical Access Hospitals) within the category of physical therapy/speech language therapy and then a separate category for occupational therapy services.
What does the $3,700 threshold represent?
Answer:
The threshold represents the total allowed charges under Part B for services furnished by independent practitioners, and institutional services under Part B (hospital outpatient departments, skilled nursing facilities, and home health agencies).
Does therapy provided in a critical access hospital (CAH) count?
Answer:
No. Services provided in a CAH are not counted and CAHs are not subject to the prior authorization process.
What are the Phases?
Answer:
Phase I October 1, 2012 to December 31, 2012
Phase II November 1, 2012 to December 31, 2012
Phase III December 1, 2012 to December 31, 2012
How do I know what Phase I am in?
Answer:
Each provider subjected to a phase will be notified via US Mail. There will also be a posting to the CMS website external link with the providers in phase I and II. Providers not on the list are deemed to be in Phase III.
How did CMS come up with the phases?
Answer:
The phases were developed taking into account specific provider characteristics (e.g., claims volume and payment) and then adjusted to distribute workload evenly at the Medicare Administrative Contractor.
If I am in Phase III, what happens to my claims during the timeframe of October 1, 2012 to November 30, 2012?
Answer:
Phase III is scheduled to begin for services expected to be furnished on or after December 1, 2012. Claims for services furnished before this time will be treated in the same manner as claims for services below the $3,700 threshold.
If I am in Phase III would a Medicare contractor conduct review of my claims from October 1, 2012 to November 30, 2012?
Answer:
Medicare contractors have the authority to review any claim at any time. However, pre-approval requests shall not be reviewed any sooner than 15 calendar days before the start of each Phase.
How to I know where to submit my request for prior authorization?
Answer:
We prefer you submit your request via Faxgate. The Faxgate numbers and addresses are noted on the job aids and on the forms located on the Palmetto GBA website.
What are the guidelines CMS contractors will use when conducting the review?
Answer:
The contractors will use the coverage and payment policy requirements contained within Pub. 100-02, Section 220 of the Medicare Benefit Policy manual and any applicable local coverage decisions when making decisions as to whether a service shall be preapproved.
How long will a contractor have to make a decision on a pre-approval request?
Answer:
10 business days.
What happens if a contractor’s decision about request for an exception is not made within 10 business days?
Answer:
If a decision is not made within 10 business days, the request for exception will be deemed to be approved. You will receive a letter from Palmetto GBA indicating the approval of your request.
If a decision was made within 10 business days and the request for an exception was denied, and the provider furnishes the service to the beneficiary and submits a claim, what happens?
Answer:
The claim is not payable under Medicare, the claim will be denied, and the
beneficiary will be liable for the services. You will receive a decision letter that will detail the reason for the denial.
Will claims that are pre-approved be guaranteed payment?
Answer:
Authorization does not guarantee payment. Retrospective review may still be performed.
Why would a Medicare contractor review therapy that has been preapproved?
Answer:
There are many reasons retrospective review would be needed after a preapproval:
Clinically inappropriate modalities
Patient’s clinical therapy needs do not match what was reported, e.g.
Patient’s functional level is greater than reported
Patient reached functional independence more quickly than predicted
Excessive or inappropriate therapy was furnished, e.g.
Therapy more often or of longer duration than is reasonable and medically necessary
Therapy provided to clinical treatment area not reasonable and necessary, e.g. therapy to shoulder when knee is the issue
Can I appeal the claim?
Answer:
Yes you may appeal unapproved services.
Why is the beneficiary liable?
Answer:
Medicare only covers therapy services up to $1,880 cap in 2012. For services between $1,880 and $3,700, if the conditions for an exception are not met, the beneficiary is financially responsible. For services above the $3,700 threshold, if a request for an exception to the $3,700 threshold is not met, the beneficiary is financially responsible.
Am I required to provide the beneficiary an Advanced Beneficiary Notice (ABN) for services above the therapy cap of $1,880?
Answer:
There is no legal requirement for issuance of an ABN. However, CMS strongly recommends a voluntary ABN where the provider believes that Medicare may not cover the services.
What happens if I request pre-approval and gain approval for 20 treatment days and I actually furnish 30 treatments?
Answer:
The claim will be subject to prepayment medical review.
How is CMS educating beneficiaries about the therapy cap and the threshold?
Answer:
CMS conducted a mailing in September to beneficiaries who have received therapy services at or near the cap. The mailing informed them of the cap and of the fact that if services above the cap are denied, that they will be financially liable.
What is the therapy cap amount for 2012?
Answer:
The annual per beneficiary therapy cap amount for 2012 is $1880 for physical therapy and speech language pathology services combined (PT/SLP). There is a separate $1880 amount allotted for occupational therapy services.
What provider settings are subject to the therapy cap in 2012?
Answer:
Effective January 1, 2012, the $1880 therapy cap with an exceptions process, applies to services furnished in the following outpatient therapy settings: physical therapists in private practice, physician offices, skilled nursing facilities (SNF) (Part B), rehabilitation agencies (or ORFs), and comprehensive outpatient rehabilitation facilities (CORFs). In addition, the therapy cap with an exceptions process will apply to hospital outpatient departments no later than October 1, 2012, until the end of 2012.
Does the therapy cap with no exceptions process go back into effect on January 1, 2013?
Answer:
Unless Congress passes legislation by the end of the year there will be a therapy cap with no exceptions process for all outpatient therapy settings, except hospitals. Effective January 1, 2013, the therapy cap would not apply to hospitals unless Congress passes legislation.
Does the therapy cap apply to Medicare beneficiaries enrolled in a Medicare Advantage plan?
Answer:
The Medicare Advantage Plan may apply the $1880 therapy cap with an exceptions process if it chooses; however, many Medicare Advantage plans chose not to apply the therapy cap in the past. You should check with your Medicare Advantage plan regarding its payment policies.
If we are not contracted with a Medicare Advantage Plan and they are not required to pay our normal Medicare payment then would we apply the therapy cap for beneficiaries with those plans?
Answer:
The cap will only be tracked through outpatient therapy claims that process through the regular fee for service Medicare system.
Does the cap amount 'reset' for each diagnosis? For instance, if a patient receives PT services January-March for a hip replacement and is discharged, then returns in September as a result of a stroke, is there one cap for the first episode of treatment and a new cap for the second episode of treatment?
Answer:
No. The therapy cap is an annual per beneficiary cap.
With the cap for 2012 of $1880 for Part B PT/SLP benefits, how does the cap count toward the patient responsibility of 20%?
Answer:
For example, the patient is responsible for 20% of allowable charges as an outpatient. Medicare will pay 80% of the allowed charges ($1504.00) and the beneficiary will be responsible for the remaining 20% ($376.00).
Where do I find information about the amount of dollars that my patient has accrued toward the therapy cap?
Answer:
All providers and contractors may access the accrued amount of therapy services from the ELGA screen inquiries into CWF. Providers/suppliers may access the remaining therapy services limitation dollar amount through the 270/271 eligibility inquiry and response transaction. Providers who bill to fiscal intermediaries (FIs) will find the amount a beneficiary has accrued toward the financial limitations on the HIQA. Some suppliers and providers billing to carriers may, in addition, have access to the accrued amount of therapy services from the ELGB screen inquiries into CWF. Suppliers who do not have access to these inquiries may call the contractor to obtain the amount accrued.
Do providers need to include national provider identifiers of the physician who reviews the therapy plan of care on the claim form?
Answer:
Yes. Starting October 1, 2012, each request for payment must include the national provider identifier (NPI) of the physician who periodically reviews the therapy plan of care. APTA anticipates CMS will issue further guidance to providers regarding placement of the NPI on the claim form.
Where can I find additional resources regarding the therapy cap?
Answer:
CMS has issued a fact sheet and a question and answer document external link regarding manual medical review which are now available.
Why was my redetermination request denied when I submitted a letter showing my patient was no longer incarcerated at the time of my service?
Answer:
The claim cannot be allowed until the Common Working File (CWF) is updated with the incarceration end date. Your patient will need to contact the Social Security Administration to have their record updated.
If I submit my Appeal through Palmetto GBA's eServices, do I need to submit the Appeal request and documentation hard copy as well?
Answer:
There is no need to mail or fax a hard copy form once an eAppeals is submitted via Palmetto GBA's eServices. You will receive an acceptance message confirming receipt and then another message with the Document Control Number (DCN) when the appeal has started processing.
Billing Initial Hospital Care and Discharge - multiple e & m service on Same Day
QUESTIONS AND ANSWERS
1 Q: If a patient is seen in the office at 3:00 p.m. and admitted to the hospital at 1:00 a.m. the next day, may both the office visit and the initial hospital care be reported?
A: Yes. Because different dates are involved, both codes may be reported. The CPT states services on the same date must be rolled up into the initial hospital care code. The term "same date" does not mean a 24 hour period. Refer to the CPT book for more information.
2 Q: May a physician report both a hospital visit and hospital discharge day management service on the same day?
A: No. The hospital visit descriptors include the phrase "per day" meaning they include all care for a day. Codes 99238-99239 (hospital discharge day management services) are used to report services on the final day of the hospital stay. To report both the hospital visit code and the hospital discharge day management services code would be duplicative.
3 Q: If a patient is admitted as an inpatient and discharged on the same day, may the hospital discharge day management code be reported?
A: No. To report services for a patient who is admitted as an inpatient and discharged on the same day, use only the appropriate code for Observation or Inpatient Care Services (Including Admission and Discharge Services) as described by CPT codes 99234-99236.
4 Q: May a physician or separate physician of the same group and specialty report multiple hospital visits on the same day for the same patient for unrelated problems?
A: No. The inpatient hospital visit descriptors contain the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single that reflects all services provided during the date of the service.
5 Q: In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, will Oxford pay physician B for the second visit?
A: No. The inpatient hospital visit descriptors include the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single code that reflects all services provided during the date of the service.
6 Q: If a physician sees his patient in the emergency room and decides to admit the person to the hospital, should both services (the emergency department visit and the initial hospital visit) be reported?
A: No. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician's office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.
7 Q: If a patient is seen for more than one E/M or other medical service on a single date of service, and each service is performed by a physician with a different specialty designation, but in the same group practice, would each E/M or other medical service be separately reimbursable?
A: Yes, in certain circumstances. An E/M or other medical service provided on the same date by different physicians who are in a group practice but who have different specialty designations may be separately reimbursable. The Same Day/Same Service policy applies when multiple E/M or other medical services are reported by physicians in the same group and specialty on the same date of service. In that case, only one E/M is separately reimbursable, unless the second service is for an unrelated problem and reported with modifier 25. This would not apply when one of the E/M services is a "per day" code. For additional information regarding inpatient neonatal and pediatric critical care codes, CPT 99468-99480, reported by multiple physicians in the same group, see the policy titled Pediatric and Neonatal Critical and Intensive Care Services.
When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.
When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 – 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.
When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, shall be reported.
REIMBURSEMENT GUIDELINES for multiple e & m service on same day
The Medicare Claims Processing Manual states:
"Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.
In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.
If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses.”
The National Correct Coding Initiative Policy Manual states:
"Procedures should be reported with the most comprehensive CPT code that describes the services performed.
Physicians must not unbundle the services described by a HCPCS/CPT code.
A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services."
Consistent with Medicare, Oxford's Same Day/Same Service policy recognizes physicians or other health care professionals of the same group and specialty as the same physician, physician subspecialty is not considered.
According to correct coding methodology, physicians are to select the code that accurately identifies the service(s) performed. Multiple E/M services, when reported on the same date for the same patient by the same specialty physician, will be subject to edits used by and sourced to third party authorities. As stated above, physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
D. Documentation Requirements for Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)
The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making documentation in the medical record shall include:
• Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;
• Documentation identifying the billing physician was present and personally performed the services; and
• Documentation identifying the admission and discharge notes were written by the billing physician.
1 Q: If a patient is seen in the office at 3:00 p.m. and admitted to the hospital at 1:00 a.m. the next day, may both the office visit and the initial hospital care be reported?
A: Yes. Because different dates are involved, both codes may be reported. The CPT states services on the same date must be rolled up into the initial hospital care code. The term "same date" does not mean a 24 hour period. Refer to the CPT book for more information.
2 Q: May a physician report both a hospital visit and hospital discharge day management service on the same day?
A: No. The hospital visit descriptors include the phrase "per day" meaning they include all care for a day. Codes 99238-99239 (hospital discharge day management services) are used to report services on the final day of the hospital stay. To report both the hospital visit code and the hospital discharge day management services code would be duplicative.
3 Q: If a patient is admitted as an inpatient and discharged on the same day, may the hospital discharge day management code be reported?
A: No. To report services for a patient who is admitted as an inpatient and discharged on the same day, use only the appropriate code for Observation or Inpatient Care Services (Including Admission and Discharge Services) as described by CPT codes 99234-99236.
4 Q: May a physician or separate physician of the same group and specialty report multiple hospital visits on the same day for the same patient for unrelated problems?
A: No. The inpatient hospital visit descriptors contain the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single that reflects all services provided during the date of the service.
5 Q: In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, will Oxford pay physician B for the second visit?
A: No. The inpatient hospital visit descriptors include the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single code that reflects all services provided during the date of the service.
6 Q: If a physician sees his patient in the emergency room and decides to admit the person to the hospital, should both services (the emergency department visit and the initial hospital visit) be reported?
A: No. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician's office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.
7 Q: If a patient is seen for more than one E/M or other medical service on a single date of service, and each service is performed by a physician with a different specialty designation, but in the same group practice, would each E/M or other medical service be separately reimbursable?
A: Yes, in certain circumstances. An E/M or other medical service provided on the same date by different physicians who are in a group practice but who have different specialty designations may be separately reimbursable. The Same Day/Same Service policy applies when multiple E/M or other medical services are reported by physicians in the same group and specialty on the same date of service. In that case, only one E/M is separately reimbursable, unless the second service is for an unrelated problem and reported with modifier 25. This would not apply when one of the E/M services is a "per day" code. For additional information regarding inpatient neonatal and pediatric critical care codes, CPT 99468-99480, reported by multiple physicians in the same group, see the policy titled Pediatric and Neonatal Critical and Intensive Care Services.
When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.
When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 – 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.
When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, shall be reported.
REIMBURSEMENT GUIDELINES for multiple e & m service on same day
The Medicare Claims Processing Manual states:
"Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.
In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.
If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses.”
The National Correct Coding Initiative Policy Manual states:
"Procedures should be reported with the most comprehensive CPT code that describes the services performed.
Physicians must not unbundle the services described by a HCPCS/CPT code.
A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services."
Consistent with Medicare, Oxford's Same Day/Same Service policy recognizes physicians or other health care professionals of the same group and specialty as the same physician, physician subspecialty is not considered.
According to correct coding methodology, physicians are to select the code that accurately identifies the service(s) performed. Multiple E/M services, when reported on the same date for the same patient by the same specialty physician, will be subject to edits used by and sourced to third party authorities. As stated above, physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
D. Documentation Requirements for Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)
The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making documentation in the medical record shall include:
• Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;
• Documentation identifying the billing physician was present and personally performed the services; and
• Documentation identifying the admission and discharge notes were written by the billing physician.
Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission
In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). Contractors consider only one M.D. or D.O. to be the principal physician of record (sometimes referred to as the admitting physician.) The principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. Only the principal physician of record shall append modifier “-AI” (Principal Physician of Record) in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.
A. Initial Hospital Care From Emergency Room
Contractors pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.
B. Initial Hospital Care on Day Following Visit
Contractors pay both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission.
Policy Guideline for provider performed unlisted CPT code
Overview
Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.
According to the Current Procedural Terminology Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. Any service or procedure must be adequately documented in the medical record.
Supporting Documentation Requirements
Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing a claim. Pertinent information should include:
• A clear description of the nature, extent, and need for the procedure or service.
• Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening.
• Any extenuating circumstances which may have complicated the service or procedure.
• Time, effort, and equipment necessary to provide the service.
• The number of times the service was provided.
When submitting supporting documentation, designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code. Required information must be legible and clearly marked.
Provider Billing Guidelines and Documentation
• Claims submitted with unlisted procedure codes and without supporting documentation will be denied.
• Please submit paper claims for unlisted procedure codes. Electronic claims for unlisted procedure codes may be denied, as attachments are not accepted electronically at this time.
• Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedure or service code that most closely approximates the service performed is available.
• No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.
• Unlisted procedure codes appended with a modifier may be denied. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.)
• When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted code should only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example, DME/ unlisted drugs).
Medical Record Documentation and Physician Queries
Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date. Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination. Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim.
Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.
According to the Current Procedural Terminology Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. Any service or procedure must be adequately documented in the medical record.
Supporting Documentation Requirements
Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing a claim. Pertinent information should include:
• A clear description of the nature, extent, and need for the procedure or service.
• Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening.
• Any extenuating circumstances which may have complicated the service or procedure.
• Time, effort, and equipment necessary to provide the service.
• The number of times the service was provided.
When submitting supporting documentation, designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code. Required information must be legible and clearly marked.
Provider Billing Guidelines and Documentation
• Claims submitted with unlisted procedure codes and without supporting documentation will be denied.
• Please submit paper claims for unlisted procedure codes. Electronic claims for unlisted procedure codes may be denied, as attachments are not accepted electronically at this time.
• Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedure or service code that most closely approximates the service performed is available.
• No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.
• Unlisted procedure codes appended with a modifier may be denied. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.)
• When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted code should only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example, DME/ unlisted drugs).
Medical Record Documentation and Physician Queries
Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date. Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination. Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim.
How much payment would get Assitant Surgeon, Co- Surgery and Team surgery
Assistant Surgeon Services
Harvard Pilgrim reimburses assistant surgeon services when the assistant at surgery is a physician, a physician assistant, or a nurse practitioner consistent with CMS’ determination of approved procedure codes payable to an assistant surgeon.
• Assistant surgeon services are reimbursed at 16% of the fee schedule/allowable amount.
• Secondary surgical procedures are reimbursed at 8% of the fee schedule/allowable amount.
Assistant Surgeon Services (in Maine only)
Registered nurse/first assistants and physician assistants are reimbursed as assistant surgeons at a rate equal to 85% of the assistant surgeon 16% allowable rate.
Co-Surgery
Co-surgery is reimbursed at 62.5% of the fee schedule/allowable amount.
Team Surgery
Team surgery is reimbursed after individual consideration and review of operative notes according to the percentage of surgery performed by each respective surgeon.
Attempted Service (discontinued procedure)
Attempted inpatient surgery is reimbursed at 50% of the fee schedule/allowable amount.
Reduced Services
Reduced services are reimbursed at 50% of the fee schedule/allowable amount.
Procedures
Kyphoplasty, vertebroplasty, and radiologic supervision and interpretation, vertebroplasty for multiple myeloma, monostatic and solitary myeloma, spinal cord hemangioma, secondary malignant neoplasm bone and bone marrow, osteoporotic vertebral collapse and vertebral hemangioma.
First Assistant in Surgery
Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.
Reimbursement
• Unless otherwise excluded by the Medicaid Program, coverage of services will be determined by individual licensure, scope of practice, and terms of the physician collaborative agreement. Collaborative agreements must be available for review upon
request by authorized representatives of the Medicaid program.
• Immunizations and KIDMED medical, vision, and hearing screens are reimbursed at 100% of the physician fee on file. All other payable procedures are reimbursed at 80% of the physician fee on file.
• Qualified CNS/CNPs who perform as first assistant in surgery should use the “AS” modifier to identify these services.
Harvard Pilgrim reimburses assistant surgeon services when the assistant at surgery is a physician, a physician assistant, or a nurse practitioner consistent with CMS’ determination of approved procedure codes payable to an assistant surgeon.
• Assistant surgeon services are reimbursed at 16% of the fee schedule/allowable amount.
• Secondary surgical procedures are reimbursed at 8% of the fee schedule/allowable amount.
Assistant Surgeon Services (in Maine only)
Registered nurse/first assistants and physician assistants are reimbursed as assistant surgeons at a rate equal to 85% of the assistant surgeon 16% allowable rate.
Co-Surgery
Co-surgery is reimbursed at 62.5% of the fee schedule/allowable amount.
Team Surgery
Team surgery is reimbursed after individual consideration and review of operative notes according to the percentage of surgery performed by each respective surgeon.
Attempted Service (discontinued procedure)
Attempted inpatient surgery is reimbursed at 50% of the fee schedule/allowable amount.
Reduced Services
Reduced services are reimbursed at 50% of the fee schedule/allowable amount.
Procedures
Kyphoplasty, vertebroplasty, and radiologic supervision and interpretation, vertebroplasty for multiple myeloma, monostatic and solitary myeloma, spinal cord hemangioma, secondary malignant neoplasm bone and bone marrow, osteoporotic vertebral collapse and vertebral hemangioma.
First Assistant in Surgery
Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.
Reimbursement
• Unless otherwise excluded by the Medicaid Program, coverage of services will be determined by individual licensure, scope of practice, and terms of the physician collaborative agreement. Collaborative agreements must be available for review upon
request by authorized representatives of the Medicaid program.
• Immunizations and KIDMED medical, vision, and hearing screens are reimbursed at 100% of the physician fee on file. All other payable procedures are reimbursed at 80% of the physician fee on file.
• Qualified CNS/CNPs who perform as first assistant in surgery should use the “AS” modifier to identify these services.
Insurance payment for E & M service on Global day and multiple procedures
Significant, Separately Identifiable E&M with Global Day Service—Same Day
Policy will apply to all professional services performed in an office place of service, when significant, separately identifiable E/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of 0, 10, 90 or YYY is performed on the same day, E&M service will be reimbursed at 50% of the contracted allowable. When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.
Bundled Services
Harvard Pilgrim reimburses only the most intensive CPT code when:
• A procedure is considered to be normally included as part of a more comprehensive code.
• A single, more comprehensive CPT code more accurately describes a group of procedures.
• If a procedure that is generally carried out as an integral part of a larger surgical procedure is performed alone and independent of other surgical services, it is reimbursable.
Multiple Procedures
• When multiple procedures are performed at the same session, the primary procedure is reimbursed at 100% of the allowable rate and all subsequent reimbursable procedures are paid at 50% of the allowable rate.
• Harvard Pilgrim determines the primary procedure based on the highest allowable rate, not the charge.
Bilateral Surgeries
• Bilateral surgeries are reimbursed at 150% of the allowable rate.
• Bilateral assistant surgeons are reimbursed at 16% of the allowable 150% amount.
Professional, Multiple and Bilateral Surgery Services Performed During the Same Operative Session
When a bilateral procedure code and surgical procedure(s) are performed at the same session and eligible for multiple procedure reduction, claim will be subject to multiple procedure reduction and bilateral procedure payment adjustment in accordance with Harvard Pilgrim payment policy. If the bilateral procedure is the secondary procedure, multiple procedure reduction and bilateral procedure payment adjustment will be applied.
Add-on Codes
• Add-on codes are reimbursed at 100% of the allowable rate and are not subject to the multiple procedure reduction.
• Add-on codes are only those codes designated by CPT and identified by a specific descriptor that includes the phrase
“each additional” or “list separately in addition to the primary procedure.”
• Add-on codes are reimbursable only when billed with their primary procedure.
Cosmetic Surgery
Cosmetic surgery is reimbursable with prior authorization of any cosmetic surgery exceptions, including, but not limited to:
• Repair of an accidental injury (e.g., repair of the face following a serious automobile accident).
• Improved function of a malformed body part.
• Treatment of severe burns.
• For additional information, refer to the Cosmetic, Reconstructive and Restorative Procedures Payment Policy.
E&M services provided within global period
Based on the CMS global surgical period:
• FCHP does not separately reimburse for any E&M service when reported with major surgical procedures (90-day global surgical period)
• FCHP does not separately reimburse for any E&M service when reported with minor procedures with a 10-day post-op period.
• FCHP does separately reimburse for new patient E&M services and E&M services described in Proceure as applying to new or established patients when reported with minor procedures with a 0-day post-op period.
• FCHP does consider reimbursement for services rendered during the global period if the appropriate modifier -24 is appended to the E&M procedure code and medical notes are included.
Services rendered in the office after-hours or on weekends or holidays
• FCHP reimburses Proceure Code 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
• FCHP reimburses Proceure Code 99051 for services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.
Policy will apply to all professional services performed in an office place of service, when significant, separately identifiable E/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of 0, 10, 90 or YYY is performed on the same day, E&M service will be reimbursed at 50% of the contracted allowable. When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.
Bundled Services
Harvard Pilgrim reimburses only the most intensive CPT code when:
• A procedure is considered to be normally included as part of a more comprehensive code.
• A single, more comprehensive CPT code more accurately describes a group of procedures.
• If a procedure that is generally carried out as an integral part of a larger surgical procedure is performed alone and independent of other surgical services, it is reimbursable.
Multiple Procedures
• When multiple procedures are performed at the same session, the primary procedure is reimbursed at 100% of the allowable rate and all subsequent reimbursable procedures are paid at 50% of the allowable rate.
• Harvard Pilgrim determines the primary procedure based on the highest allowable rate, not the charge.
Bilateral Surgeries
• Bilateral surgeries are reimbursed at 150% of the allowable rate.
• Bilateral assistant surgeons are reimbursed at 16% of the allowable 150% amount.
Professional, Multiple and Bilateral Surgery Services Performed During the Same Operative Session
When a bilateral procedure code and surgical procedure(s) are performed at the same session and eligible for multiple procedure reduction, claim will be subject to multiple procedure reduction and bilateral procedure payment adjustment in accordance with Harvard Pilgrim payment policy. If the bilateral procedure is the secondary procedure, multiple procedure reduction and bilateral procedure payment adjustment will be applied.
Add-on Codes
• Add-on codes are reimbursed at 100% of the allowable rate and are not subject to the multiple procedure reduction.
• Add-on codes are only those codes designated by CPT and identified by a specific descriptor that includes the phrase
“each additional” or “list separately in addition to the primary procedure.”
• Add-on codes are reimbursable only when billed with their primary procedure.
Cosmetic Surgery
Cosmetic surgery is reimbursable with prior authorization of any cosmetic surgery exceptions, including, but not limited to:
• Repair of an accidental injury (e.g., repair of the face following a serious automobile accident).
• Improved function of a malformed body part.
• Treatment of severe burns.
• For additional information, refer to the Cosmetic, Reconstructive and Restorative Procedures Payment Policy.
E&M services provided within global period
Based on the CMS global surgical period:
• FCHP does not separately reimburse for any E&M service when reported with major surgical procedures (90-day global surgical period)
• FCHP does not separately reimburse for any E&M service when reported with minor procedures with a 10-day post-op period.
• FCHP does separately reimburse for new patient E&M services and E&M services described in Proceure as applying to new or established patients when reported with minor procedures with a 0-day post-op period.
• FCHP does consider reimbursement for services rendered during the global period if the appropriate modifier -24 is appended to the E&M procedure code and medical notes are included.
Services rendered in the office after-hours or on weekends or holidays
• FCHP reimburses Proceure Code 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
• FCHP reimburses Proceure Code 99051 for services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.
Do we need to report Medicare when new location opened?
Q: If a provider/supplier establishes a new practice, opens a new facility, or closes/changes the address of an existing practice/facility, how long does the provider/supplier have to inform Medicare of the “reportable event”? How should the change be reported?
A: Any change in practice or facility location (e.g., establish new location, move existing location, close existing location) address must be reported to the provider/supplier’s Medicare administrative contractor (MAC) no later than 30 days after the “reportable event” occurred.
Providers and suppliers should utilize the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) external link to update their Medicare enrollment record. Registered users may use the system for initial enrollment as well as to change, reactivate, or voluntarily terminate an existing enrollment record.
When to complete a CMS-460
The CMS-460 may only be completed by new physicians, practitioners, and suppliers looking to become participating providers during initial enrollment and during annual participation open enrollment.
When to complete an EFT (CMS-588)
An EFT (CMS-588) is to be used to enroll in electronic payments. All providers enrolling in Medicare are required to submit an EFT in order to receive payments.
Where do I submit my provider enrollment documentation?
Medicare Provider Enrollment
First Coast Service Options Inc.
P.O. Box 44021
Jacksonville, FL 32231-4021
A: Any change in practice or facility location (e.g., establish new location, move existing location, close existing location) address must be reported to the provider/supplier’s Medicare administrative contractor (MAC) no later than 30 days after the “reportable event” occurred.
Providers and suppliers should utilize the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) external link to update their Medicare enrollment record. Registered users may use the system for initial enrollment as well as to change, reactivate, or voluntarily terminate an existing enrollment record.
When to complete a CMS-460
The CMS-460 may only be completed by new physicians, practitioners, and suppliers looking to become participating providers during initial enrollment and during annual participation open enrollment.
When to complete an EFT (CMS-588)
An EFT (CMS-588) is to be used to enroll in electronic payments. All providers enrolling in Medicare are required to submit an EFT in order to receive payments.
Where do I submit my provider enrollment documentation?
Medicare Provider Enrollment
First Coast Service Options Inc.
P.O. Box 44021
Jacksonville, FL 32231-4021
Would payment vary based on the POS?
Reporting place of service (POS) codes
Physicians are required to report the place of service (POS) on all health insurance claims they submit to Medicare Part B contractors. The POS code is used to identify where the procedure is furnished. Physicians are paid for services according to the Medicare physician fee schedule (MPFS). This schedule is based on a payment system that includes three major categories, which drive the reimbursement for physician services:
• Practice expense (reflects overhead costs involved in providing service(s))
• Physician work
• Malpractice insurance
To account for the increased practice expense physicians incur by performing services in their offices, Medicare reimburses physicians a higher amount for services performed in their offices (POS code 11) than in an outpatient hospital (POS 22-23) or an ambulatory surgical center (ASC) (POS 24). Therefore, it is important to know the POS also plays a factor in the reimbursement.
Note: Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding POS codes.
Important facts when filing a claim to Medicare
• The POS is a required field, entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim or Item 24B on the CMS-1500 paper claim
• The name, address and zip code of where the service(s) were actually performed is required for all POS codes, and is entered in Item 32 on the CMS 1500 claim form or in the corresponding loop on its electronic equivalent
• Must specify the correct location where the service(s) is performed and billed on the claim, since both the POS and the locality address are components of the MPFS
• If the POS is missing, invalid or inconsistent with procedure code on claim form it will be returned as unprocessable (RUC)
• For example, POS 21 (inpatient hospital) is not compatible with procedure code 99211 (Establish patient office or other outpatient visit)
Helpful hints for POS codes for professional claims
• Implement internal control systems to prevent incorrect billing of POS codes
• Keep informed on Medicare coverage and billing requirements
• For example, billing physician's office (POS 11) for a minor surgical procedure that is actually performed in a hospital outpatient department (POS 22) and collecting a higher payment is inappropriate billing and may be viewed as program abuse
Site of Service Payment Differential
Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The CMS furnishes both rates in the MPFSDB update.
The rate, facility or nonfacility, that a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. For the professional component (PC) of diagnostic tests, the facility and nonfacility payment rates are the same – irrespective of the POS code on the claim. See chapter 13, section 150 of this manual for POS instructions for the PC and technical component of diagnostic tests.
The list of settings where a physician’s services are paid at the facility rate include:
*Inpatient Hospital (POS code 21);
*Outpatient Hospital (POS code 22);
*Emergency Room-Hospital (POS code 23);
*Medicare-participating ambulatory surgical center (ASC) for a HCPCS code included on the ASC approved list of procedures (POS code 24);
*Medicare-participating ASC for a procedure not on the ASC list of approved procedures with dates of service on or after January 1, 2008. (POS code 24);
*Skilled Nursing Facility (SNF) for a Part A resident (POS code 31);
*Hospice – for inpatient care (POS code 34);
*Ambulance – Land (POS code 41);
*Ambulance – Air or Water (POS code 42);
*Inpatient Psychiatric Facility (POS code 51);
*Psychiatric Facility -- Partial Hospitalization (POS code 52);
*Community Mental Health Center (POS code 53);
*Psychiatric Residential Treatment Center (POS code 56); and
*Comprehensive Inpatient Rehabilitation Facility (POS code 61).
Physicians’ services are paid at nonfacility rates for procedures furnished in the following settings:
*Pharmacy (POS code 01);
*School (POS code 03);
*Homeless Shelter (POS code 04);
*Prison/Correctional Facility (POS code 09);
*Office (POS code 11);
*Home or Private Residence of Patient (POS code 12);
*Assisted Living Facility (POS code 13);
*Group Home (POS code 14);
*Mobile Unit (POS code 15);
*Temporary Lodging (POS code 16);
*Walk-in Retail Health Clinic (POS code 17);
*Urgent Care Facility (POS code 20);
*Birthing Center (POS code 25);
*Nursing Facility and SNFs to Part B residents (POS code 32);
*Custodial Care Facility (POS code 33);
*Independent Clinic (POS code 49);
*Federally Qualified Health Center (POS code 50);
*Intermediate Health Care Facility/Mentally Retarded (POS code 54);
*Residential Substance Abuse Treatment Facility (POS code 55);
*Non-Residential Substance Abuse Treatment Facility (POS code 57);
*Mass Immunization Center (POS code 60);
*Comprehensive Outpatient Rehabilitation Facility (POS code 62);
*End-Stage Renal Disease Treatment Facility (POS code 65);
*State or Local Health Clinic (POS code 71);
*Rural Health Clinic (POS code 72);
*Independent Laboratory (POS code 81);and
*Other Place of Service (POS code 99).
Physicians are required to report the place of service (POS) on all health insurance claims they submit to Medicare Part B contractors. The POS code is used to identify where the procedure is furnished. Physicians are paid for services according to the Medicare physician fee schedule (MPFS). This schedule is based on a payment system that includes three major categories, which drive the reimbursement for physician services:
• Practice expense (reflects overhead costs involved in providing service(s))
• Physician work
• Malpractice insurance
To account for the increased practice expense physicians incur by performing services in their offices, Medicare reimburses physicians a higher amount for services performed in their offices (POS code 11) than in an outpatient hospital (POS 22-23) or an ambulatory surgical center (ASC) (POS 24). Therefore, it is important to know the POS also plays a factor in the reimbursement.
Note: Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding POS codes.
Important facts when filing a claim to Medicare
• The POS is a required field, entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim or Item 24B on the CMS-1500 paper claim
• The name, address and zip code of where the service(s) were actually performed is required for all POS codes, and is entered in Item 32 on the CMS 1500 claim form or in the corresponding loop on its electronic equivalent
• Must specify the correct location where the service(s) is performed and billed on the claim, since both the POS and the locality address are components of the MPFS
• If the POS is missing, invalid or inconsistent with procedure code on claim form it will be returned as unprocessable (RUC)
• For example, POS 21 (inpatient hospital) is not compatible with procedure code 99211 (Establish patient office or other outpatient visit)
Helpful hints for POS codes for professional claims
• Implement internal control systems to prevent incorrect billing of POS codes
• Keep informed on Medicare coverage and billing requirements
• For example, billing physician's office (POS 11) for a minor surgical procedure that is actually performed in a hospital outpatient department (POS 22) and collecting a higher payment is inappropriate billing and may be viewed as program abuse
Site of Service Payment Differential
Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The CMS furnishes both rates in the MPFSDB update.
The rate, facility or nonfacility, that a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. For the professional component (PC) of diagnostic tests, the facility and nonfacility payment rates are the same – irrespective of the POS code on the claim. See chapter 13, section 150 of this manual for POS instructions for the PC and technical component of diagnostic tests.
The list of settings where a physician’s services are paid at the facility rate include:
*Inpatient Hospital (POS code 21);
*Outpatient Hospital (POS code 22);
*Emergency Room-Hospital (POS code 23);
*Medicare-participating ambulatory surgical center (ASC) for a HCPCS code included on the ASC approved list of procedures (POS code 24);
*Medicare-participating ASC for a procedure not on the ASC list of approved procedures with dates of service on or after January 1, 2008. (POS code 24);
*Skilled Nursing Facility (SNF) for a Part A resident (POS code 31);
*Hospice – for inpatient care (POS code 34);
*Ambulance – Land (POS code 41);
*Ambulance – Air or Water (POS code 42);
*Inpatient Psychiatric Facility (POS code 51);
*Psychiatric Facility -- Partial Hospitalization (POS code 52);
*Community Mental Health Center (POS code 53);
*Psychiatric Residential Treatment Center (POS code 56); and
*Comprehensive Inpatient Rehabilitation Facility (POS code 61).
Physicians’ services are paid at nonfacility rates for procedures furnished in the following settings:
*Pharmacy (POS code 01);
*School (POS code 03);
*Homeless Shelter (POS code 04);
*Prison/Correctional Facility (POS code 09);
*Office (POS code 11);
*Home or Private Residence of Patient (POS code 12);
*Assisted Living Facility (POS code 13);
*Group Home (POS code 14);
*Mobile Unit (POS code 15);
*Temporary Lodging (POS code 16);
*Walk-in Retail Health Clinic (POS code 17);
*Urgent Care Facility (POS code 20);
*Birthing Center (POS code 25);
*Nursing Facility and SNFs to Part B residents (POS code 32);
*Custodial Care Facility (POS code 33);
*Independent Clinic (POS code 49);
*Federally Qualified Health Center (POS code 50);
*Intermediate Health Care Facility/Mentally Retarded (POS code 54);
*Residential Substance Abuse Treatment Facility (POS code 55);
*Non-Residential Substance Abuse Treatment Facility (POS code 57);
*Mass Immunization Center (POS code 60);
*Comprehensive Outpatient Rehabilitation Facility (POS code 62);
*End-Stage Renal Disease Treatment Facility (POS code 65);
*State or Local Health Clinic (POS code 71);
*Rural Health Clinic (POS code 72);
*Independent Laboratory (POS code 81);and
*Other Place of Service (POS code 99).
Who shuould sign Medicare Enrollment form ? Can other than provider sign the form?
Q: Who should sign the certification statement of the CMS-855 provider enrollment application?
A: The following shows the information for the various applications:
CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.
CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.
CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.
CMS-855R
For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.
All CMS-855 applications
If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an "ownership or control interest" in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.
An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.
A: The following shows the information for the various applications:
CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.
CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.
CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.
CMS-855R
For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.
All CMS-855 applications
If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an "ownership or control interest" in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.
An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.
How to appeal against PQRS payment adjustment ?
2016 PQRS Payment Adjustment and Informal Review Process
On September 11, CMS began distributing letters to Physician Quality Reporting System (PQRS) individual Eligible Professionals (EPs), EPs providing services at Critical Access Hospitals billing under method II, and group practices about the 2016 PQRS negative payment adjustment. The letter indicates that an individual or group did not satisfactorily report 2014 PQRS quality measures in order to avoid the 2.0% 2016 negative PQRS payment adjustment.
If I received the payment adjustment letter, what are my options?
If you believe that you have been incorrectly assessed the 2016 PQRS negative payment adjustment, you can submit an informal review through November 9:
• Requests must be submitted electronically via the Communication Support Page under the Related Links section of the Physician and Other Health Care Professionals Quality Reporting Portal.
https://www.qualitynet.org/portal/server.pt/community/pqri_home/212
• See the fact sheet and Analysis and Payment web page for more information
For additional questions, contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7am to 7pm CT Monday through Friday.
On September 11, CMS began distributing letters to Physician Quality Reporting System (PQRS) individual Eligible Professionals (EPs), EPs providing services at Critical Access Hospitals billing under method II, and group practices about the 2016 PQRS negative payment adjustment. The letter indicates that an individual or group did not satisfactorily report 2014 PQRS quality measures in order to avoid the 2.0% 2016 negative PQRS payment adjustment.
If I received the payment adjustment letter, what are my options?
If you believe that you have been incorrectly assessed the 2016 PQRS negative payment adjustment, you can submit an informal review through November 9:
• Requests must be submitted electronically via the Communication Support Page under the Related Links section of the Physician and Other Health Care Professionals Quality Reporting Portal.
https://www.qualitynet.org/portal/server.pt/community/pqri_home/212
• See the fact sheet and Analysis and Payment web page for more information
For additional questions, contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7am to 7pm CT Monday through Friday.
what is Pre-operative Period Billing and post operative billing ? Which modifier can use ?
Pre-operative Period Billing
E /M Service Resulting in the Initial Decision to Perform Surgery
Evaluation/ Management (E/M) services on the day before major surgery or on the day of major
surgery that result in the initial decision to perform the surgery are not included in the global surgery
payment for the major surgery and, therefore, may be billed and paid separately. In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10 day global surgical period.
Day of Procedure Billing
Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.
•Use modifier “-25” with the appropriate level of E/M service.
•Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated, procedure.
Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.
Claims for Multiple Surgeries
Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day. Surgeries subject to the multiple surgery rules have an indicator of “2” in the Physician Fee Schedule look-up tool. The multiple procedure payment reduction will be applied based on the MPFS approved amount and not on the submitted amount from the providers. The major surgery may or may not be the one with the larger submitted amount.
Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable.
There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (for example, in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate.
Claims for Co-Surgeons and Team Surgeons
Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedures and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. The following billing procedures apply when billing for a surgical procedure or procedures that require the use of two surgeons or a team of surgeons:
•If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62” (Two surgeons). Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Certain services that require documentation of medical necessity for two surgeons are identified in the MPFS look-up tool.
•If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66” (Surgical team). Certain services, as identified in the MPFS look-up tool, submitted with modifier “-66” must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”
• If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services.
Post-Operative Period Billing
Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period
Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure.
• Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.
• Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure.
E /M Service Resulting in the Initial Decision to Perform Surgery
Evaluation/ Management (E/M) services on the day before major surgery or on the day of major
surgery that result in the initial decision to perform the surgery are not included in the global surgery
payment for the major surgery and, therefore, may be billed and paid separately. In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10 day global surgical period.
Day of Procedure Billing
Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.
•Use modifier “-25” with the appropriate level of E/M service.
•Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated, procedure.
Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.
Claims for Multiple Surgeries
Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day. Surgeries subject to the multiple surgery rules have an indicator of “2” in the Physician Fee Schedule look-up tool. The multiple procedure payment reduction will be applied based on the MPFS approved amount and not on the submitted amount from the providers. The major surgery may or may not be the one with the larger submitted amount.
Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable.
There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (for example, in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate.
Claims for Co-Surgeons and Team Surgeons
Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedures and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. The following billing procedures apply when billing for a surgical procedure or procedures that require the use of two surgeons or a team of surgeons:
•If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62” (Two surgeons). Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Certain services that require documentation of medical necessity for two surgeons are identified in the MPFS look-up tool.
•If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66” (Surgical team). Certain services, as identified in the MPFS look-up tool, submitted with modifier “-66” must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”
• If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services.
Post-Operative Period Billing
Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period
Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure.
• Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.
• Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure.
Global Surgery Coding and Billing Guidelines - what modifier to use
Physicians Who Furnish the Entire Global Package
Physicians who furnish the surgery and furnish all of the usual pre-and post-operative work may bill for the global package by entering the appropriate CPT code for the surgical procedure only. Separate billing is not allowed for visits or other services that are included in the global package. When different physicians in a group practice participate in the care of the patient, the group practice bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is reported as the performing physician.
Physicians Who Furnish Part of a Global Surgical Package
More than one physician may furnish services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the post-operative, post-discharge care is split among two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where stated policies allow for higher payment. For instance, when the surgeon furnishes only the surgery and a physician other than the surgeon furnishes pre-operative and post-operative inpatient care, the resulting combined payment may not exceed the global allowed amount. The surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case. Split global-care billing does not apply to procedure codes with a zero day post-operative period.
Using Modifiers “-54” and “-55”
Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:
• Surgical care only (modifier “-54”); or
• Post-operative management only (modifier “-55”). For global surgery services billed with modifiers “-54” or “-55,” the same CPT code must be billed. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished. Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.
• Modifier “-54” does not apply to assistant-at-surgery services.
• Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees. The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”
• Use modifier “-55” with the CPT procedure code for global periods of 10 or 90 days.
• Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.
• The receiving physician must provide at least one service before billing for any part of the post-operative care.
• This modifier is not appropriate for assistant-at- surgery services or for ASC’s facility fees.
Exceptions to the Use of Modifiers “-54” and “-55”
Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim.
Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier. If the services of a physician other than the surgeon are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.
GLOBAL SURGERY PERIOD
Louisiana Medicaid’s global surgery period (GSP) policy differs from Louisiana Medicare policy.
• Medicaid does not pay for the day before, the day of, and the assigned GSP after surgery. Louisiana Medicaid assigns a GSP 1, 10, or 90 days. If you look at the Professional Fee Schedule, the Global Surgery Period can be found in column 11.
• If a procedure has a GSP of “1”, the provider cannot bill for an evaluation and management service (E/M) the day before or the day of the procedure.
• If a procedure has a GSP of “10”, the provider cannot bill for an E/M service the day before, the day of, or 10 days following the procedure.
• If a procedure has a GSP of “90”, the provider cannot bill for an E/M service the day before, the day of, or 90 days following the procedure.
• Error code 690 (payment included in surgery fee) results when an E/M service is denied for a date of service within the GSP of the surgery or procedure that has been paid.
• Error code 691 (visit paid in GSP; void visit, rebill surgery) results when a surgery or procedure is denied because an E/M service has been paid for a date of service within the GSP of the surgery or procedure. The paid claim for the E/M service must be voided before the claim for the surgery or procedure can be considered for payment.
• E/M services should be billed separately only if the diagnosis and service rendered are unrelated to the diagnosis of the GSP procedure. If a visit is to be billed for a date of service within the GSP for unrelated diagnosis, it should be filed on a claim form separate from that of the GSP surgery or procedure.
Surgeons and Global Surgery
A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all carrier jurisdictions, thus preventing Medicare payments for services that are more or less comprehensive than
intended. The national global surgery policy became effective for surgeries performed on and after January 1, 1992.
The instructions that follow describe the components of a global surgical package and payment rules for minor surgeries, endoscopies and global surgical packages that are split between two or more physicians. In addition, billing, mandatory edits, claims review, adjudication, and postpayment instructions are included.
In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries.
Definition of a Global Surgical Package
Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and, sometimes, YYY.
Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either minor surgical procedures or endoscopies.
Codes with “YYY” are carrier-priced codes, for which carriers determine the global period (the global period for these codes will be 0, 10, or 90 days). Note that not all carrier-priced codes have a “YYY” global surgical indicator; sometimes the global period is specified.
While codes with “ZZZ” are surgical codes, they are add-on codes that are always billed with another service. There is no postoperative work included in the fee schedule payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.
A.Components of a Global Surgical Package
Carriers apply the national definition of a global surgical package to all procedures with the appropriate entry in Field 16 of the MFSDB.
The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians’ offices. Visits to a patient in an intensive care or critical
care unit are also included if made by the surgeon. However, critical care services (99291 and 99292) are payable separately in some situations.
*Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;
*Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;
*Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;
*Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;
*Postsurgical Pain Management - By the surgeon;
*Supplies - Except for those identified as exclusions; and
*Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
B.Services Not Included in the Global Surgical Package
Carriers do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field 16 of the MFSDB. These services may be paid for separately.
*The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure;
*Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;
*Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
*Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;
*Diagnostic tests and procedures, including diagnostic radiological procedures;
*Clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other;
*Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR);
*If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
*For certain services performed in a physician’s office, separate payment can no longer be made for a surgical tray (code A4550). This code is now a Status B and is no longer a separately payable service on or after January 1, 2002. However, splints and casting supplies are payable separately under the reasonable charge payment methodology;
*Immunosuppressive therapy for organ transplants; and
*Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
C.Minor Surgeries and Endoscopies
Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.
A postoperative period of 10 days applies to some minor surgeries. The postoperative period for these procedures is indicated in Field 16 of the MFSDB. If the Field 16 entry is 010, carriers do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the
10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedures except as otherwise excluded. If the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance.
D.Physicians Furnishing Less Than the Full Global Package B3-4820-4831
There are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, post- discharge care is split between two or more physicians where the physicians agree on the transfer of care.
When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global allowed amount).
Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.
E.Determining the Duration of a Global Period
To determine the global period for major surgeries, carriers count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery.
EXAMPLE:
Date of surgery - January 5 Preoperative period - January 4
Last day of postoperative period - April 5
To determine the global period for minor procedures, carriers count the day of surgery and the appropriate number of days immediately following the date of surgery.
EXAMPLE:
Procedure with 10 follow-up days:
Date of surgery - January 5
Last day of postoperative period - January 15
When Medicare Pays First, Second or Even Third
When Medicare began in the 1960s, it was the primary payer for all services except those covered by workers compensation. Then in 1980, Congress enacted provisions to shift costs from the Medicare program to private insurers, when possible. This legislation stopped Medicare from making payment if the payment has already been made, or would be expected to be made, by Group Health Plans (GHP) and Workers Compensation (WC) Plans.
Medicare Pays First When:
• You have retiree insurance (from either you or your spouse’s former employment)
• You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has less than 20 employees
• You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has less than 100 employees
• You’re also receiving Medicaid benefits
Note: If you have group health care plan coverage that is primary to Medicare (pays first), it will continue to do so until it pays up to the limits of its coverage. Then Medicare becomes primary.
Medicare Pays Second When:
• You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has 20 or more employees
• You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has 100 or more employees
• You have End-Stage Renal Disease (ESRD) and you are in the first 30 months your Medicare eligibility. Then Medicare pays first after that.
• You’re covered by no-fault or liability insurance for an services related to an accident
Insurance that pays after Medicare is referred to as supplemental insurance. Your retiree coverage may act as supplemental insurance or you may purchase a Medigap policy from a private insurance company.
Medicare works supplemental insurance companies through a process called ‘crossover.’ Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.
In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.
If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.
If your supplemental insurance does not participate in crossover with Medicare, you will be responsible for ensuring your insurance receives information about claims Medicare has processed. Many providers will file claims to your supplemental insurance after Medicare has processed your claim. If you provider will not file to your supplemental insurance, contact the plan to verify what information they will need to process a claim. Many supplemental insurance plans will ask you to send a copy of your Medicare Summary Notice (MSN). If you need an MSN, you may request one from our Customer Service unit.
Medicare benefit when patient has worker compensation , veterans administration and automobile accident
d. Worker's Compensation
Medicare is secondary to Worker's Compensation benefits if the patient is being treated for a work related illness or injury. If the claim is contested, pending the Worker's Compensation Board decision, the physician/supplier may bill Medicare first. A statement should be included on the claim form indicating that the worker's compensation claim is being contested.
Claims for beneficiaries who may have worker's compensation insurance will suspend for manual review to determine whether the services are related to a work illness or injury. If the services are obviously not related to a work illness or injury, the claim will be released for final processing.
Physicians/suppliers should complete item 10a of the CMS 1500 claim form if the services are not provided for diagnosis and treatment of a work related illness or injury.
e. Veterans Administration
Veterans entitled to Medicare may choose one of the programs to be responsible for payment of services covered by both programs. If the veteran elects Medicare coverage, it is not necessary to submit a claim to the Veterans Administration (VA) for a denial before submitting the claim to Medicare. Claims submitted to Medicare will be processed without development, assuming that Medicare coverage and eligibility requirements are met.
Claims cannot be submitted to both programs for the same dates and types of treatment. If a veteran elects Medicare coverage, a claim should not be submitted to the VA for the Medicare deductible or co-insurance.
e.1 Submission of Claims to Medicare or the VA
Submit claims to the VA as follows:
When hospital care was authorized by the VA in advance, or within 72 hours of admission.
When outpatient medical services were authorized by the VA in advance. (NOTE: a VA Fee Basis ID card is not considered by Medicare to be an authorization, and the veteran retains his or her right to elect VA or Medicare coverage.)
When care was not authorized by the VA in advance, the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.
Submit claims to Medicare as follows:
When a veteran is eligible for Medicare benefits and hospital care was not authorized by the VA in advance, or within 72 hours of admission. (For services billable on Form 1450, the Medicare provider should enter condition code 26 in field locator 35-39.)
When a veteran is eligible for Medicare benefits, has a VA Fee Basis ID card and elects Medicare coverage over VA.
When a veteran is eligible for Medicare benefits and has no prior authorization from the VA for care—unless the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.
When a veteran is eligible for Medicare benefits, and the VA has authorized care for only a part of the hospital treatment period. A denial from the VA is not needed prior to submitting a claim to Medicare.
VA advance authorization for care will be via sharing agreement, contract, or written communication. Telephone authorization may be granted in emergency situations. All telephone authorizations are documented by the VA at the time the authorization is granted.
Any VA authorization for an inpatient is terminated when the veteran is determined by VA to be stable for transfer to a VA facility, or the veteran states that he or she is not willing to be transferred to a VA facility for continued treatment upon stabilization.
Medicare and VA will be performing periodic computer data matches to assure that instances of duplicate payment are identified. When duplicate payments are found, Medicare will pursue recovery of its payment, and will develop information for potential referral to the Internal Revenue Service or the Office of Inspector General.
e.2 Incarcerated Beneficiaries
Medicare is secondary payer for services furnished to individuals in the custody of penal authorities. The state (or other government component which operates the prison) in which the beneficiary resides is responsible for all medical costs incurred. Medicare is primary only if the following conditions are met:
State or local requires those individuals or groups of individuals to repay the cost of the medical care incurred while in custody.
The state or local government entity enforces the requirement to pay by billing the incarcerated individual, whether or not covered by Medicare or any other health insurance.
f. Automobile Accident
Medicare is secondary to all accident related claims. Beneficiaries may not choose which of these claims will be paid by the automobile insurance and which claims will be paid by Medicare. Providers should submit all accident related claims to the automobile insurance before submitting them to Medicare. To avoid late claim filing, claims may be submitted to Medicare even though payment has not been received from the automobile insurer. In addition, conditional payment can be made by Medicare if 1) the automobile insurance will not pay promptly (within 120 days); or 2) due to physical or mental incapacity, the beneficiary fails to meet the claim filing requirements of the automobile insurer. Conditional payments are made on the condition that the beneficiary will reimburse Medicare if payment is later made by the automobile insurer.
If the automobile insurance benefits are exhausted, Medicare requires a statement of exhaustion from the automobile insurer. The itemized statement must include: the dates of service paid and the actual provider who was reimbursed. Note: Claim processing will be denied without this information.
Providers should complete item 10 of the CMS 1500 claim form if the services are related to an automobile accident. If there is information on our files which indicates that a beneficiary has been involved in an automobile accident, the claim will suspend for manual review. If the details referenced on the claim are not sufficient information to process the claim, a questionnaire will be sent to the beneficiary. If a response is not received from the beneficiary within 45 days, the claim will be denied.
g. No-Fault Insurance
Medicare is secondary to all types of insurance that pay for medical expenses for injuries sustained on the property or premises of the insured, regardless of who caused the accident. This type of insurance includes homeowners and commercial plans. It may also be referred to as medical payments coverage, personal injury protection (PIP), or medical expense coverage.
Providers should follow the claims submission guidelines described in the automobile accident section in this chapter. The exhaustion of benefits and conditional payment rules also apply to no-fault insurance.
Medicare does not pay for services paid for or authorized by governmental entities.
h. Liability Insurance
Liability insurance is insurance (including a self-insured plan) that provides payment based upon legally established responsibility for injury, illness or damage to property. It includes, but is not limited to automobile liability and general casualty insurance. It includes payments under State "wrongful death" statues that provide payment for medical damages.
Providers are required to ask Medicare patients, or their representatives, if the services are for treatment of an injury or illness that resulted from an automobile accident or other incident for which the patient holds another party responsible. The provider should obtain the name, address, and policy number of any automobile or non-automobile liability insurance, no fault insurance, or any other party that may be responsible for payment of medical expenses that result from an accident or injury.
Where a provider has reason to believe that he/she provided services to a Medicare beneficiary for whom payment under liability insurance may be available, the provider may:
Within the 120 day promptly period, the provider must bill only the liability insurer unless there is evidence that the liability insurer will not pay within the 120 day promptly period. If the provider has such evidence, he/she may bill Medicare for conditional payment, provided that documentation is supplied to support the fact that payment will not be made promptly; or
After the 120 day promptly period has ended, the provider may, but is not required to, bill Medicare for conditional payment if the liability insurance claim is not finally resolved. If the provider chooses to bill Medicare, he/she must withdraw claims against the liability insurer or a claim against the beneficiary's settlement. If the provider chooses to continue with a claim against the liability settlement, the provider may not bill Medicare.
h.1 If a provider participates in the Medicare program
Provider bills Medicare - The provider must accept the Medicare approved amount as payment in full and may charge beneficiaries only for deductible and coinsurance; or Provider pursues liability insurance - The provider may charge the beneficiaries actual charges up to the amount of the proceeds of the liability settlement, but he/she may not collect payment from the beneficiary until after the proceeds of the liability insurance are available to the beneficiary.
h.2 If a provider does not participate in the Medicare program:
Provider bills Medicare accepting assignment - The provider may accept the Medicare approved amount as payment in full and may charge the beneficiaries only for deductible and coinsurance; or
Provider bills Medicare not accepting assignment - The provider may charge beneficiaries no more than the limiting charge and may collect without regard to whether the liability insurance is available to the beneficiary.
For services for which there is no Medicare coverage available regardless of whom furnishes them, the provider may charge and collect actual charges from beneficiaries without regard to whether the proceeds of liability insurance are available to the beneficiary.
i. Black Lung Benefits
Medicare is secondary for beneficiaries who have medical benefits under the Federal Black Lung Program. Medicare is secondary only for services provided for the treatment of lung conditions caused by mining. Claims for beneficiaries entitled to benefits under the Federal Black Lung Program may suspend for manual review. If the diagnosis or services reported on the claim are not related to the black lung condition, Medicare is primary and the claim will be released for final processing.
For some beneficiaries entitled to the Federal Black Lung Program, the coal mine operator is responsible for medical benefits. In these cases, providers should submit the claims to the coal mine operator or its Workers' Compensation plan for processing.
j. Primary Insolvency
In accordance with the Centers for Medicare & Medicaid Services (CMS) requirements, when a primary payer becomes insolvent, Medicare payments will not be made unless the claim is accompanied by an Explanation of Benefits from the receiver (substitute primary payer decided on by the courts) and the court order of payment.
Physicians and suppliers who accept assignment may not collect or seek payment from the beneficiary or their estate for any Medicare covered service(s) during the primary insurer's insolvency process. Providers should file their claims with the primary insurer or the receiver if they have not already done so.
The receiver will determine the full primary payment to be made. Once you have been paid by the receiver, you may bill Medicare for secondary payments, if appropriate. You will have six (6) months from the date of the receiver's Explanation of Benefits to file a claim for secondary payments with Medicare. If the claim is received after the six month filing limit, it will be processed as untimely.
In order for Medicare to process these claims for secondary payment, please provide the following:
A hard copy of the claim;
An Explanation of Benefits from the receiver;
A copy of the court order that addresses this issue.
k. Employer Plan HMO Coverage
The Centers for Medicare & Medicaid Services has clarified that providers are responsible for submitting claims to Medicare for secondary payment consideration when the primary insurer is a Health Maintenance Organization (HMO). Medicare may consider secondary payment for all or part of an employer-sponsored HMO's copayment.
An HMO pays providers a monthly capitation fee to care for its members. Because of this reimbursement, there are no billed charges for the rendered services. Medicare will consider the Medicare fee schedule amount as the billed charge. This amount will also be considered the primary insurer's allowed amount in calculating Medicare liability. The Medicare claim form submitted for the HMO copayment can be completed with standard information:
Item 24F (charges) – Enter the charge for each listed service
Item 28 (total charge) – Enter total charges for the services (i.e., total of all charges in item 24f)
Since providers collect HMO copayments at the time of service, a copayment receipt signed by the beneficiary must be submitted with the claim. The receipt will be accepted in lieu of the primary benefits statement or explanation of benefits (EOB) required in all other Medicare secondary payer situations. The receipt must clearly indicate "HMO copayment." To assist you with this requirement, you may copy the form shown below and use it for this purpose.
When an acceptable co-payment receipt is not submitted with a claim, payment for these services may be delayed or could result in a denial of the claims. HMO co-payment receipts submitted with Medicare Secondary Payer claims should meet certain requirements.
The original co-payment receipt, signed by the beneficiary on the date they were seen should be attached to the claim form.
should be one receipt for each date of service submitted on the claim form.
If the patient did not pay the co-pay at the time of the service, a co-pay receipt should not have been submitted with the claim. A receipt should only be issued to the patient if the patient paid the co-pay at the time of their service.
Medicare will send any reimbursement for non-assigned claims submitted for HMO copayment to the beneficiary. For assigned claims submitted for HMO copayment, Medicare's payment will be sent to the provider who in turn must reimburse the beneficiary.
k.1 Services Obtained Outside the HMO Plan
Generally, Medicare will not pay for services obtained from a source outside the HMO plan. If a beneficiary wants or needs to go to a provider outside the plan, an authorization must be obtained from the HMO plan. If authorization is not obtained, the HMO will not make payment. If the beneficiary has not been notified in writing of this rule and the HMO will not make payment, Medicare will process the claim for payment. Once the beneficiary has been notified, Medicare payment will not be made for future services obtained outside the plan.
WORKERS’ DISABILITY COMPENSATION
Workers' Disability Compensation is a system established under state law that provides payments, without regard to fault, to employees injured in the course of their employment. Workers’ Disability Compensation does not cover medical care incidental to or separate from the injury. Providers must establish if the beneficiary is covered by Workers’ Disability Compensation.
If a claim has been filed and is contested, providers may bill Medicaid while the claim is pending resolution by Workers’ Disability Compensation. The provider must bill the appropriate procedure code, the date the claim was submitted (if known), and any other pertinent information (e.g., employer, Workers’ Disability Compensation carrier, and attorney's name). Medicaid may bill the compensation carrier, or may follow up in hearings as to redemption or settlement.
Medicare is secondary to Worker's Compensation benefits if the patient is being treated for a work related illness or injury. If the claim is contested, pending the Worker's Compensation Board decision, the physician/supplier may bill Medicare first. A statement should be included on the claim form indicating that the worker's compensation claim is being contested.
Claims for beneficiaries who may have worker's compensation insurance will suspend for manual review to determine whether the services are related to a work illness or injury. If the services are obviously not related to a work illness or injury, the claim will be released for final processing.
Physicians/suppliers should complete item 10a of the CMS 1500 claim form if the services are not provided for diagnosis and treatment of a work related illness or injury.
e. Veterans Administration
Veterans entitled to Medicare may choose one of the programs to be responsible for payment of services covered by both programs. If the veteran elects Medicare coverage, it is not necessary to submit a claim to the Veterans Administration (VA) for a denial before submitting the claim to Medicare. Claims submitted to Medicare will be processed without development, assuming that Medicare coverage and eligibility requirements are met.
Claims cannot be submitted to both programs for the same dates and types of treatment. If a veteran elects Medicare coverage, a claim should not be submitted to the VA for the Medicare deductible or co-insurance.
e.1 Submission of Claims to Medicare or the VA
Submit claims to the VA as follows:
When hospital care was authorized by the VA in advance, or within 72 hours of admission.
When outpatient medical services were authorized by the VA in advance. (NOTE: a VA Fee Basis ID card is not considered by Medicare to be an authorization, and the veteran retains his or her right to elect VA or Medicare coverage.)
When care was not authorized by the VA in advance, the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.
Submit claims to Medicare as follows:
When a veteran is eligible for Medicare benefits and hospital care was not authorized by the VA in advance, or within 72 hours of admission. (For services billable on Form 1450, the Medicare provider should enter condition code 26 in field locator 35-39.)
When a veteran is eligible for Medicare benefits, has a VA Fee Basis ID card and elects Medicare coverage over VA.
When a veteran is eligible for Medicare benefits and has no prior authorization from the VA for care—unless the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.
When a veteran is eligible for Medicare benefits, and the VA has authorized care for only a part of the hospital treatment period. A denial from the VA is not needed prior to submitting a claim to Medicare.
VA advance authorization for care will be via sharing agreement, contract, or written communication. Telephone authorization may be granted in emergency situations. All telephone authorizations are documented by the VA at the time the authorization is granted.
Any VA authorization for an inpatient is terminated when the veteran is determined by VA to be stable for transfer to a VA facility, or the veteran states that he or she is not willing to be transferred to a VA facility for continued treatment upon stabilization.
Medicare and VA will be performing periodic computer data matches to assure that instances of duplicate payment are identified. When duplicate payments are found, Medicare will pursue recovery of its payment, and will develop information for potential referral to the Internal Revenue Service or the Office of Inspector General.
e.2 Incarcerated Beneficiaries
Medicare is secondary payer for services furnished to individuals in the custody of penal authorities. The state (or other government component which operates the prison) in which the beneficiary resides is responsible for all medical costs incurred. Medicare is primary only if the following conditions are met:
State or local requires those individuals or groups of individuals to repay the cost of the medical care incurred while in custody.
The state or local government entity enforces the requirement to pay by billing the incarcerated individual, whether or not covered by Medicare or any other health insurance.
f. Automobile Accident
Medicare is secondary to all accident related claims. Beneficiaries may not choose which of these claims will be paid by the automobile insurance and which claims will be paid by Medicare. Providers should submit all accident related claims to the automobile insurance before submitting them to Medicare. To avoid late claim filing, claims may be submitted to Medicare even though payment has not been received from the automobile insurer. In addition, conditional payment can be made by Medicare if 1) the automobile insurance will not pay promptly (within 120 days); or 2) due to physical or mental incapacity, the beneficiary fails to meet the claim filing requirements of the automobile insurer. Conditional payments are made on the condition that the beneficiary will reimburse Medicare if payment is later made by the automobile insurer.
If the automobile insurance benefits are exhausted, Medicare requires a statement of exhaustion from the automobile insurer. The itemized statement must include: the dates of service paid and the actual provider who was reimbursed. Note: Claim processing will be denied without this information.
Providers should complete item 10 of the CMS 1500 claim form if the services are related to an automobile accident. If there is information on our files which indicates that a beneficiary has been involved in an automobile accident, the claim will suspend for manual review. If the details referenced on the claim are not sufficient information to process the claim, a questionnaire will be sent to the beneficiary. If a response is not received from the beneficiary within 45 days, the claim will be denied.
g. No-Fault Insurance
Medicare is secondary to all types of insurance that pay for medical expenses for injuries sustained on the property or premises of the insured, regardless of who caused the accident. This type of insurance includes homeowners and commercial plans. It may also be referred to as medical payments coverage, personal injury protection (PIP), or medical expense coverage.
Providers should follow the claims submission guidelines described in the automobile accident section in this chapter. The exhaustion of benefits and conditional payment rules also apply to no-fault insurance.
Medicare does not pay for services paid for or authorized by governmental entities.
h. Liability Insurance
Liability insurance is insurance (including a self-insured plan) that provides payment based upon legally established responsibility for injury, illness or damage to property. It includes, but is not limited to automobile liability and general casualty insurance. It includes payments under State "wrongful death" statues that provide payment for medical damages.
Providers are required to ask Medicare patients, or their representatives, if the services are for treatment of an injury or illness that resulted from an automobile accident or other incident for which the patient holds another party responsible. The provider should obtain the name, address, and policy number of any automobile or non-automobile liability insurance, no fault insurance, or any other party that may be responsible for payment of medical expenses that result from an accident or injury.
Where a provider has reason to believe that he/she provided services to a Medicare beneficiary for whom payment under liability insurance may be available, the provider may:
Within the 120 day promptly period, the provider must bill only the liability insurer unless there is evidence that the liability insurer will not pay within the 120 day promptly period. If the provider has such evidence, he/she may bill Medicare for conditional payment, provided that documentation is supplied to support the fact that payment will not be made promptly; or
After the 120 day promptly period has ended, the provider may, but is not required to, bill Medicare for conditional payment if the liability insurance claim is not finally resolved. If the provider chooses to bill Medicare, he/she must withdraw claims against the liability insurer or a claim against the beneficiary's settlement. If the provider chooses to continue with a claim against the liability settlement, the provider may not bill Medicare.
h.1 If a provider participates in the Medicare program
Provider bills Medicare - The provider must accept the Medicare approved amount as payment in full and may charge beneficiaries only for deductible and coinsurance; or Provider pursues liability insurance - The provider may charge the beneficiaries actual charges up to the amount of the proceeds of the liability settlement, but he/she may not collect payment from the beneficiary until after the proceeds of the liability insurance are available to the beneficiary.
h.2 If a provider does not participate in the Medicare program:
Provider bills Medicare accepting assignment - The provider may accept the Medicare approved amount as payment in full and may charge the beneficiaries only for deductible and coinsurance; or
Provider bills Medicare not accepting assignment - The provider may charge beneficiaries no more than the limiting charge and may collect without regard to whether the liability insurance is available to the beneficiary.
For services for which there is no Medicare coverage available regardless of whom furnishes them, the provider may charge and collect actual charges from beneficiaries without regard to whether the proceeds of liability insurance are available to the beneficiary.
i. Black Lung Benefits
Medicare is secondary for beneficiaries who have medical benefits under the Federal Black Lung Program. Medicare is secondary only for services provided for the treatment of lung conditions caused by mining. Claims for beneficiaries entitled to benefits under the Federal Black Lung Program may suspend for manual review. If the diagnosis or services reported on the claim are not related to the black lung condition, Medicare is primary and the claim will be released for final processing.
For some beneficiaries entitled to the Federal Black Lung Program, the coal mine operator is responsible for medical benefits. In these cases, providers should submit the claims to the coal mine operator or its Workers' Compensation plan for processing.
j. Primary Insolvency
In accordance with the Centers for Medicare & Medicaid Services (CMS) requirements, when a primary payer becomes insolvent, Medicare payments will not be made unless the claim is accompanied by an Explanation of Benefits from the receiver (substitute primary payer decided on by the courts) and the court order of payment.
Physicians and suppliers who accept assignment may not collect or seek payment from the beneficiary or their estate for any Medicare covered service(s) during the primary insurer's insolvency process. Providers should file their claims with the primary insurer or the receiver if they have not already done so.
The receiver will determine the full primary payment to be made. Once you have been paid by the receiver, you may bill Medicare for secondary payments, if appropriate. You will have six (6) months from the date of the receiver's Explanation of Benefits to file a claim for secondary payments with Medicare. If the claim is received after the six month filing limit, it will be processed as untimely.
In order for Medicare to process these claims for secondary payment, please provide the following:
A hard copy of the claim;
An Explanation of Benefits from the receiver;
A copy of the court order that addresses this issue.
k. Employer Plan HMO Coverage
The Centers for Medicare & Medicaid Services has clarified that providers are responsible for submitting claims to Medicare for secondary payment consideration when the primary insurer is a Health Maintenance Organization (HMO). Medicare may consider secondary payment for all or part of an employer-sponsored HMO's copayment.
An HMO pays providers a monthly capitation fee to care for its members. Because of this reimbursement, there are no billed charges for the rendered services. Medicare will consider the Medicare fee schedule amount as the billed charge. This amount will also be considered the primary insurer's allowed amount in calculating Medicare liability. The Medicare claim form submitted for the HMO copayment can be completed with standard information:
Item 24F (charges) – Enter the charge for each listed service
Item 28 (total charge) – Enter total charges for the services (i.e., total of all charges in item 24f)
Since providers collect HMO copayments at the time of service, a copayment receipt signed by the beneficiary must be submitted with the claim. The receipt will be accepted in lieu of the primary benefits statement or explanation of benefits (EOB) required in all other Medicare secondary payer situations. The receipt must clearly indicate "HMO copayment." To assist you with this requirement, you may copy the form shown below and use it for this purpose.
When an acceptable co-payment receipt is not submitted with a claim, payment for these services may be delayed or could result in a denial of the claims. HMO co-payment receipts submitted with Medicare Secondary Payer claims should meet certain requirements.
The original co-payment receipt, signed by the beneficiary on the date they were seen should be attached to the claim form.
should be one receipt for each date of service submitted on the claim form.
If the patient did not pay the co-pay at the time of the service, a co-pay receipt should not have been submitted with the claim. A receipt should only be issued to the patient if the patient paid the co-pay at the time of their service.
Medicare will send any reimbursement for non-assigned claims submitted for HMO copayment to the beneficiary. For assigned claims submitted for HMO copayment, Medicare's payment will be sent to the provider who in turn must reimburse the beneficiary.
k.1 Services Obtained Outside the HMO Plan
Generally, Medicare will not pay for services obtained from a source outside the HMO plan. If a beneficiary wants or needs to go to a provider outside the plan, an authorization must be obtained from the HMO plan. If authorization is not obtained, the HMO will not make payment. If the beneficiary has not been notified in writing of this rule and the HMO will not make payment, Medicare will process the claim for payment. Once the beneficiary has been notified, Medicare payment will not be made for future services obtained outside the plan.
WORKERS’ DISABILITY COMPENSATION
Workers' Disability Compensation is a system established under state law that provides payments, without regard to fault, to employees injured in the course of their employment. Workers’ Disability Compensation does not cover medical care incidental to or separate from the injury. Providers must establish if the beneficiary is covered by Workers’ Disability Compensation.
If a claim has been filed and is contested, providers may bill Medicaid while the claim is pending resolution by Workers’ Disability Compensation. The provider must bill the appropriate procedure code, the date the claim was submitted (if known), and any other pertinent information (e.g., employer, Workers’ Disability Compensation carrier, and attorney's name). Medicaid may bill the compensation carrier, or may follow up in hearings as to redemption or settlement.
what are cases Medicare would be secondary
Medicare As Secondary Payer
Until 1980, Medicare was the primary payer for all Medicare covered services except for services covered by workers' compensation or black lung benefits or paid for by the Department of Veterans Affairs or other government entities. Since 1980, a series of changes in the Medicare law has shifted costs from the Medicare program to private sources of payment. Presently, Medicare is the secondary payer for individuals:
Who are aged 65 or older and currently working with coverage under an employer-sponsored or employee organization (such as a union) group health plan.
Who are aged 65 or older and are covered by a working spouse's employer group health plan or employee organization (such as union) group health plan.
Who are under age 65, disabled, and are covered by a large group health plan due to their own or other family member's current employment status.
With kidney failure. Medicare is the secondary payer during the Coordination of Benefits (COB) period if they have coverage
under their own, a spouse's, or other family member's employer-sponsored or employee organization group health plan.
Who receive services covered under Workers' Compensation, Federal Black Lung, automobile, no-fault, or liability insurance plans.
Who receive services covered under the Veteran Administration.
a. Working Aged
Medicare is secondary payer for individuals aged 65 or older who are currently working and have coverage through an Employer Group Health Plan (EGHP). Medicare is also secondary if the beneficiary has coverage through an employed spouse of any age. In order to meet the Working Aged provision, the employer must have at least 20 employees working for the company. At times, 2 or more smaller employers combine to provide coverage. As long as at least 1 employer has 20 or more employees, the requirement is met.
Medicare is primary in the following situations:
Individuals who are enrolled in Medicare Part B only.
Individuals enrolled in Medicare Part A on the basis of a monthly premium.
EGHP plans where there is less than 20 employees and the employer does not combine with another employer with more than 20 employees.
Individuals covered by a health plan that is not provided by Group Health Plan (GHP). An example would be a plan that is purchased by an individual privately rather than through a group plan.
A plan provided through retirement resulting from past employment. For Medicare to be secondary, the coverage must be the result of current employment status. The Medicare beneficiary may be retired and have retiree coverage. If the spouse is still employed and provides coverage, this coverage will be primary to Medicare.
a.1 Vow of Poverty Provision
The Omnibus Budget Reconciliation Act of 1993 makes an exemption from MSP provisions for members of a religious order who have taken a vow of poverty retroactive to 1981. Employers must certify that an individual has taken a vow of poverty. Medicare is then considered the primary payer for such individuals, (i.e., nuns, priests, etc.)
b. Disability
Effective August 10, 1993, Medicare is secondary payer for individuals under age 65 who are entitled to Medicare due to disability and are covered by a Large Group Health Plan (LGHP). Medicare secondary payer status for disabled Medicare beneficiaries is based on the "current employment status" of the beneficiaries, their spouses or any other family member. An individual has "current employment status" if the individual is actively working as an employee, the employer, or is associated with the employer in a business relationship.
Prior to August 10, 1993, Medicare was secondary for active individuals under age 65, entitled to Medicare due to disability and covered by a LGHP through a relationship to an employer (i.e. employed or retired beneficiary, spouse or other family member). This provision was based on the "active individual" concept rather than the employment status.
Those disabled beneficiaries who have LGHP coverage as a result of their own or a family member's "current employment status" will continue to have Medicare as the secondary payer. Those disabled beneficiaries who do not have primary coverage with a LGHP because they do not have nor does a family member have "current employment status" will have Medicare as the primary payer.
A LGHP is defined as a plan sponsored or contributed to by an employer or employee organization (union). A LGHP provides medical benefits to employees who are currently working for an employer with 100 or more employees. If more than one employer combines to provide health coverage to their employees and at least one of the employers has 100 or more employees, the requirement is met.
Medicare is primary in the following situations:
Individuals who work for employers of fewer than 100 employees;
Individuals who are covered by a LGHP as the result of past employment (i.e. former retired employee or family member) and whose coverage is not based on "current employment status;"
Individuals who are covered by a health plan that is not provided by a LGHP. An example would be a plan that is purchased privately by an individual rather than through a group plan;
Individuals who have COBRA continuation coverage since it is not based on "current employment status."
c. End Stage Renal Disease (ESRD)
Medicare is secondary payer to group health plans (GHP) for individuals eligible for or entitled to Medicare based on ESRD during a Coordination of Benefits (COB) period. This provision differs from other MSP laws as it applies regardless of the number of employees employed by the employer or their employment status, active or retired. The ESRD provision applies to former as well as current employees. The provision applies where an individual is eligible for Medicare based on ESRD but who has not filed an application for entitlement to Medicare. This provision also applies when an individual is entitled based on ESRD only.
c.1 Coordination of Benefits Period
The Coordination of Benefits period defines the time frame that Group Health Plan benefits pay first, or primary, and Medicare pays second. The COB period begins with the earlier of the first month of entitlement or eligibility for Medicare Part A based on ESRD. Eligibility refers to the first month the individual would have become entitled to Medicare Part A on the basis of ESRD if the individual had filed an application for such benefits.
The length of the coordination of benefits periods has changed several times through the enactment of Medicare laws. If entitlement began before November 5, 1990, Medicare was the second payer for 12 months. If the COB began between November 5, 1990 and March 1, 1996, Medicare was the second payer for 18 months based on the OBRA 1990 law. Effective March 1, 1996, coordination of benefit period is in effect for 30 months. Section 4631(b) of the Balanced Budget Act of 1997, permanently extends the COB for 30 months.
c.2 Dual Entitlement
Medicare entitlement based on ESRD and aged or disability is considered dual entitlement. For example: An individual may be entitled to ESRD and then become entitled based on aged or disability. Or, an individual may be entitled to Medicare based on aged or disability and then develop ESRD.
Anytime an individual is entitled to Medicare for 2 different reasons, they are considered dually entitled. Prior to August 10, 1993, Medicare became primary or first payer on the first day of the month an individual became dually entitled.
The enactment of OBRA 1993 on August 10,1993, changed how dual entitlement affects the coordination of benefits period. Under this law, group health plans must continue to pay primary benefits even if the individual becomes dually entitled during the COB period. If the individual’s entitlement to Medicare was on the basis of aged or disability, and then they became entitled based on ESRD, GHPs were required to pay primary for the COB period. If the GHP was a supplemental plan at the time the individual became entitled based on ESRD, the GHP had to convert to primary payment for the COB period. If the individual did not have GHP coverage, Medicare remained primary in this situation.
c.3 Court Injunction
On May 5, 1995, a lawsuit was filed in the United States District Court, challenging the implementation of one aspect of the OBRA'93 provisions involving beneficiaries who have supplemental group health plan coverage. The court issued a preliminary injunction order on June 6, 1995 that prevents Medicare from applying the rule to services furnished between August 10, 1993 and April 24, 1995 to claims involving GHP retirement coverage pending the court's decision.
c.4 ESRD Entitlement Notes
If an individual has more than one period of Part A eligibility or entitlement based on ESRD, a coordination period is determined for each period of eligibility when the individual has GHP coverage.
Entitlement/Eligibility to Medicare based on ESRD ends 12 months after the month the individual no longer requires maintenance dialysis or 36 months after the month of a successful kidney transplant.
c.5 Effect of COBRA Continuation Coverage on ESRD MSP Provision
COBRA (Consolidated Omnibus Budget Reconciliation Act) requires that certain GHPs offer continuation of plan coverage for 18 to 36 months after the occurrence of certain qualifying events. An example of such an event would be loss of employment or reduction of employment hours. These events could result in loss of GHP coverage unless the individual is given the opportunity to elect continued plan coverage at their own expense. Typically Medicare is primary to COBRA plans with limited exceptions.
COBRA plans may terminate coverage upon entitlement to Medicare with one exception. The exception is that a COBRA plan may not terminate continuation coverage of an individual and his/her qualified dependents if the individual retires on or before the date the employer eliminates regular plan coverage by filing for Chapter 11, Bankruptcy. In this instance, if COBRA coverage overlaps the ESRD MSP coordination period, Medicare is secondary. Medicare will also be secondary if the COBRA plan voluntarily chooses to remain in effect even though they are not obligated to do so under COBRA provisions.
Until 1980, Medicare was the primary payer for all Medicare covered services except for services covered by workers' compensation or black lung benefits or paid for by the Department of Veterans Affairs or other government entities. Since 1980, a series of changes in the Medicare law has shifted costs from the Medicare program to private sources of payment. Presently, Medicare is the secondary payer for individuals:
Who are aged 65 or older and currently working with coverage under an employer-sponsored or employee organization (such as a union) group health plan.
Who are aged 65 or older and are covered by a working spouse's employer group health plan or employee organization (such as union) group health plan.
Who are under age 65, disabled, and are covered by a large group health plan due to their own or other family member's current employment status.
With kidney failure. Medicare is the secondary payer during the Coordination of Benefits (COB) period if they have coverage
under their own, a spouse's, or other family member's employer-sponsored or employee organization group health plan.
Who receive services covered under Workers' Compensation, Federal Black Lung, automobile, no-fault, or liability insurance plans.
Who receive services covered under the Veteran Administration.
a. Working Aged
Medicare is secondary payer for individuals aged 65 or older who are currently working and have coverage through an Employer Group Health Plan (EGHP). Medicare is also secondary if the beneficiary has coverage through an employed spouse of any age. In order to meet the Working Aged provision, the employer must have at least 20 employees working for the company. At times, 2 or more smaller employers combine to provide coverage. As long as at least 1 employer has 20 or more employees, the requirement is met.
Medicare is primary in the following situations:
Individuals who are enrolled in Medicare Part B only.
Individuals enrolled in Medicare Part A on the basis of a monthly premium.
EGHP plans where there is less than 20 employees and the employer does not combine with another employer with more than 20 employees.
Individuals covered by a health plan that is not provided by Group Health Plan (GHP). An example would be a plan that is purchased by an individual privately rather than through a group plan.
A plan provided through retirement resulting from past employment. For Medicare to be secondary, the coverage must be the result of current employment status. The Medicare beneficiary may be retired and have retiree coverage. If the spouse is still employed and provides coverage, this coverage will be primary to Medicare.
a.1 Vow of Poverty Provision
The Omnibus Budget Reconciliation Act of 1993 makes an exemption from MSP provisions for members of a religious order who have taken a vow of poverty retroactive to 1981. Employers must certify that an individual has taken a vow of poverty. Medicare is then considered the primary payer for such individuals, (i.e., nuns, priests, etc.)
b. Disability
Effective August 10, 1993, Medicare is secondary payer for individuals under age 65 who are entitled to Medicare due to disability and are covered by a Large Group Health Plan (LGHP). Medicare secondary payer status for disabled Medicare beneficiaries is based on the "current employment status" of the beneficiaries, their spouses or any other family member. An individual has "current employment status" if the individual is actively working as an employee, the employer, or is associated with the employer in a business relationship.
Prior to August 10, 1993, Medicare was secondary for active individuals under age 65, entitled to Medicare due to disability and covered by a LGHP through a relationship to an employer (i.e. employed or retired beneficiary, spouse or other family member). This provision was based on the "active individual" concept rather than the employment status.
Those disabled beneficiaries who have LGHP coverage as a result of their own or a family member's "current employment status" will continue to have Medicare as the secondary payer. Those disabled beneficiaries who do not have primary coverage with a LGHP because they do not have nor does a family member have "current employment status" will have Medicare as the primary payer.
A LGHP is defined as a plan sponsored or contributed to by an employer or employee organization (union). A LGHP provides medical benefits to employees who are currently working for an employer with 100 or more employees. If more than one employer combines to provide health coverage to their employees and at least one of the employers has 100 or more employees, the requirement is met.
Medicare is primary in the following situations:
Individuals who work for employers of fewer than 100 employees;
Individuals who are covered by a LGHP as the result of past employment (i.e. former retired employee or family member) and whose coverage is not based on "current employment status;"
Individuals who are covered by a health plan that is not provided by a LGHP. An example would be a plan that is purchased privately by an individual rather than through a group plan;
Individuals who have COBRA continuation coverage since it is not based on "current employment status."
c. End Stage Renal Disease (ESRD)
Medicare is secondary payer to group health plans (GHP) for individuals eligible for or entitled to Medicare based on ESRD during a Coordination of Benefits (COB) period. This provision differs from other MSP laws as it applies regardless of the number of employees employed by the employer or their employment status, active or retired. The ESRD provision applies to former as well as current employees. The provision applies where an individual is eligible for Medicare based on ESRD but who has not filed an application for entitlement to Medicare. This provision also applies when an individual is entitled based on ESRD only.
c.1 Coordination of Benefits Period
The Coordination of Benefits period defines the time frame that Group Health Plan benefits pay first, or primary, and Medicare pays second. The COB period begins with the earlier of the first month of entitlement or eligibility for Medicare Part A based on ESRD. Eligibility refers to the first month the individual would have become entitled to Medicare Part A on the basis of ESRD if the individual had filed an application for such benefits.
The length of the coordination of benefits periods has changed several times through the enactment of Medicare laws. If entitlement began before November 5, 1990, Medicare was the second payer for 12 months. If the COB began between November 5, 1990 and March 1, 1996, Medicare was the second payer for 18 months based on the OBRA 1990 law. Effective March 1, 1996, coordination of benefit period is in effect for 30 months. Section 4631(b) of the Balanced Budget Act of 1997, permanently extends the COB for 30 months.
c.2 Dual Entitlement
Medicare entitlement based on ESRD and aged or disability is considered dual entitlement. For example: An individual may be entitled to ESRD and then become entitled based on aged or disability. Or, an individual may be entitled to Medicare based on aged or disability and then develop ESRD.
Anytime an individual is entitled to Medicare for 2 different reasons, they are considered dually entitled. Prior to August 10, 1993, Medicare became primary or first payer on the first day of the month an individual became dually entitled.
The enactment of OBRA 1993 on August 10,1993, changed how dual entitlement affects the coordination of benefits period. Under this law, group health plans must continue to pay primary benefits even if the individual becomes dually entitled during the COB period. If the individual’s entitlement to Medicare was on the basis of aged or disability, and then they became entitled based on ESRD, GHPs were required to pay primary for the COB period. If the GHP was a supplemental plan at the time the individual became entitled based on ESRD, the GHP had to convert to primary payment for the COB period. If the individual did not have GHP coverage, Medicare remained primary in this situation.
c.3 Court Injunction
On May 5, 1995, a lawsuit was filed in the United States District Court, challenging the implementation of one aspect of the OBRA'93 provisions involving beneficiaries who have supplemental group health plan coverage. The court issued a preliminary injunction order on June 6, 1995 that prevents Medicare from applying the rule to services furnished between August 10, 1993 and April 24, 1995 to claims involving GHP retirement coverage pending the court's decision.
c.4 ESRD Entitlement Notes
If an individual has more than one period of Part A eligibility or entitlement based on ESRD, a coordination period is determined for each period of eligibility when the individual has GHP coverage.
Entitlement/Eligibility to Medicare based on ESRD ends 12 months after the month the individual no longer requires maintenance dialysis or 36 months after the month of a successful kidney transplant.
c.5 Effect of COBRA Continuation Coverage on ESRD MSP Provision
COBRA (Consolidated Omnibus Budget Reconciliation Act) requires that certain GHPs offer continuation of plan coverage for 18 to 36 months after the occurrence of certain qualifying events. An example of such an event would be loss of employment or reduction of employment hours. These events could result in loss of GHP coverage unless the individual is given the opportunity to elect continued plan coverage at their own expense. Typically Medicare is primary to COBRA plans with limited exceptions.
COBRA plans may terminate coverage upon entitlement to Medicare with one exception. The exception is that a COBRA plan may not terminate continuation coverage of an individual and his/her qualified dependents if the individual retires on or before the date the employer eliminates regular plan coverage by filing for Chapter 11, Bankruptcy. In this instance, if COBRA coverage overlaps the ESRD MSP coordination period, Medicare is secondary. Medicare will also be secondary if the COBRA plan voluntarily chooses to remain in effect even though they are not obligated to do so under COBRA provisions.
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