April 30, 2007
Part B Customer Service Frequently Asked Questions
Q1. You are not allowing the Medicare Physician Fee Schedule amount for my diagnostic tests. Can you please explain why our charges are being reduced ?
A1. CMS has implemented two provisions this year that affected imaging services. The first provision for 2007 is payment for certain multiple diagnostic imaging procedures. For this provision, the carriers will allow full payment for the first procedure. However, a 25 percent reduction will be applied on the technical component payment for additional procedures (furnished on contiguous body parts during the same sessions). The second provision limits the technical component payment for most imaging procedures paid under the Medicare Physician Fee Schedule to the amount paid under the Outpatient Prospective Payment System (OPPS). Both provisions apply to the technical component only services and the technical component of global services. The professional component is paid in full for all procedures.
Please refer to the following link for more information and details:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0665.pdf 
http://www.cms.hhs.gov/apps/media/press/testimony.asp?Counter=1903
Q2. When are we required to submit the revised CMS 1500 forms?
A2. Previous instructions indicated that the revised Form CMS-1500 (08-05) was to be used for claims received on of after April 1, 2007. However, it has come CMS's attention there are incorrectly formatted versions of the revised form being sold by print vendors. Therefore, CMS has extended the acceptance period of the Form CMS-1500 (12/90) beyond the April 1, 2007 deadline. Carriers will continue to accept Form CMS-1500 (12/90) until CMS instructs otherwise.
Please refer to the following links for more information and details:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5568.pdf
http://www.cms.hhs.gov/ElectronicBillingEDITrans/16_1500.asp
Q3. Do you have instructions for completing the revised CMS 1500 form?
A3. Instructions for completing the CMS-1500 forms can be found in Chapter 26 of the Medicare Claims Processing Manual (Pub. 100-4). You can access this information on the CMS web site at http://www.cms.hhs.gov/Manuals/IOM/list.asp.
Q4. I'm having trouble with reading my Remittance Advice notice. Can you help me understand how to read this information?
A4. The CMS has published and released a national
educational guide for Medicare Fee-For-Services providers, physicians,
suppliers and their billing staff who may wish to use the guide to
help increase their understanding of the Remittance Advice. This
guide can be accessed on the CMS web site at http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf. Also,
a complete listing, including definitions, of the Claim Adjustment
Reason Codes (CARCs) and Remittance Advice Remarks Codes (RARCs)
can also be viewed at http://www.wpc-edi.com/codes on
the web.
Q5. What codes and services are included in Consolidated Billing? Where can I find a listing of what the carrier pays?
A5. Guidelines concerning consolidated billing, including a section titled "Skilled Nursing Facility Consolidated Billing" can be found on the CMS web site. The afore mentioned section gives helpful information, including a listing of procedure codes excluded from Consolidated Billing that are billed to the carrier. The tabs for this section will show annual updates for these excluded codes and services. A complete listing of all procedures codes billable to the carrier can be found under files "Part A Stay-Physician Services" and "Part A Stay-Professional Components of Services to be Submitted with a 26 Modifier". You can access this information at http://www.cms.hhs.gov/SNFConsolidatedBilling/.
Q6. My claims being denied with Remark Code B7, what does this mean?
A6. Services denied with remark Code B7 means that the Fee-For-Service contractor has deactivated a provider or supplier's Medicare billing privileges when:
- A provider or supplier does not submit any Medicare claims for 12 consecutive calendar months. The 12 month period begins the first day of the first month without a claim submission through the last day of the 12 th month without a submitted claim,
- A provider or supplier fails to report a change to the information supplied on the enrollment application within 90 calendar days of when the changes occurred. Changes that must be reported include, but are not limited to, a change in practice location, a change of any managing employee, and a change in billing services; or
- A provider or supplier fails to report a change in ownership or control within 30 calendar days.
Providers and suppliers deactivated for non-submission of a claim are required to complete and submit a Medicare enrollment application to recertify that the enrollment information currently on file with Medicare is correct and furnish any missing information as appropriate. The provider or supplier must meet all current Medicare requirements in place at the time of reactivation, and be prepared to submit a valid Medicare claim.
Providers and suppliers who fail to promptly notify a fee-for service contractor of a change must complete and submit a complete Medicare enrollment application to reactivate its Medicare billing privileges or, when deemed appropriate, recertify that the enrollment information currently on file with Medicare is correct.
Please refer to Chapter 10 of the CMS Medicare Program Integrity Manual (Pub. 100-08) for more details. You can access this information on the CMS web site at http://www.cms.hhs.gov/Manuals/IOM/list.asp.
Q7. Where can I find the RVU, global days, etc., for the 2007 codes?
A7. The Relative Value Unit (RVU) information, including global days, for CPT codes can be found on the CMS Web site. However, there are two options in which this information may be accessed. One option is to use the fee schedule "look-up" tool. Please refer to the following instructions for the look-up tool:
You can access the look-up tool at http://www.cms.hhs.gov/apps/pfslookup/step0.asp. Scroll down to the bottom of the page and click on the "Start" button.
On the next page, choose the year for which you are interested in information. You can choose to look up a single procedure code, a list of procedure codes or a range of codes. You can also choose what type of information you are interested in viewing; for your question you should choose "Payment Policy Indicators." Then click "Next."
- On the next screen, choose leave "Default fields" selected and click "Next."
- On the next page, enter the procedure code(s) and select "All Modifiers" from the "Modifier" drop down list. Click on the "Submit" button.
The other option in which you can access this information is to download the physician fee schedule relative value unit (RVU) file. You can access this information at http://www.cms.hhs.gov/FeeScheduleGenInfo/.
- Click on "Physician Fee Schedule."
- Next, click on "PFS Relative Value Files."
- Under the "Calendar Year" column, select the year in which you would like to download. You will be taken to another page where you will need to click on the file name that is found in the "Downloads" section of the page. When the screen pops up asking what you want to do with the file, select "Open."
The file you will want to select is usually titled "PPRRVU##" (## is the last two digits of the year). There are three versions of the file available, depending on what programs you may or may not have available to you. (The last file in the list is a word document that provides an explanation of all the various fields of the RVU fee schedule.)
Q8. How is the fee schedule calculation determined for Ambulatory Surgical Centers (ASCs)?
A8. The payment rates established for the groups of ASC procedures are standard base rates that have been adjusted to remove the effects of regional wage variations. When the carrier process claims for ASC facility services, they adjust the base rates to reflect the wage index value applicable to the area in which the ASC is located. The Medicare payment for ASC facility services is equal to 80 percent of the wage-adjusted standard payment rate. Beneficiaries are responsible for the Medicare co-payment for ASC facility services once their deductible is satisfied.
The wage index includes the wage and salary levels of certain health care professionals in both urban and non-urban locations. Each MSA within a State has a separate index, and there is one index for all rural areas within a State. Also, each group's payment rate has a labor and a non-labor component, and only the labor component is adjusted for the wage index.
The formula for the ASC calculation is as followed:
(group rate x labor component) x wage index for applicable FY + (group rate x non-labor component)
(total sum x wage index) + total sum
total sum + total sum = the Medicare ASC fee schedule allowable for the code.
Please refer to the following links for more guidelines and information regarding ASCs:
http://www.cms.hhs.gov/center/asc.asp
http://www.cms.hhs.gov/manuals/downloads/clm104c14.pdf
Q9. Why are my diagnostic mammogram claims being denied for a FDA certification number? Isn't the certification number used only for "screening" mammograms?
A9. The Mammography Quality Standards Act (MQSA) requires all that facilities who provide mammography services meet national quality standards. Effective October 1, 1994 , all facilities providing screening and diagnostic mammography services (except VA) must have a certificate issued by the Food and Drug Administration in order to be reimbursed by Medicare.
Please refer to the following links for more information and details:
http://www.fda.gov/cdrh/mammography/index.html
http://www.cms.hhs.gov/Mammography/
http://www.cms.hhs.gov/manuals/downloads/clm104c18.pdf
Q10. What is the fee schedule amount paid for assist-at-surgery services?
A10. For assistant at surgery services performed by physicians, the fee schedule amount equals 16 percent of the amount otherwise applicable for the global surgery. Covered non-physician practitioners (NPP) assist-at-surgery services are paid at 85 percent of the 16 percent of the physician fee schedule amount. (Chapter 12 of the Medicare Claims Processing Manual, http://www.cms.hhs.gov/Manuals/IOM/list.asp)
