July 25, 2007
Part B Customer Service Frequently Asked Questions
Q1. How does Medicare calculate Medicare secondary payments?
A1. Providers can familiarize themselves with how Medicare secondary payments are calculated. Secondary payments are calculated as followed:
- The amount Medicare would pay as primary payer is calculated in the usual way.
- Medicare's allowed amount is compared to the allowed amount of the primary insurer. The higher allowed amount is identified. (On a non-assigned claim, the primary insurer's allowed amount is reduced to the Medicare limiting charge in the computation.)
- The amount paid by the primary insurer is subtracted from the allowed determined in step 2.
- Medicare pays the lower of Medicare's primary payment amount (step 1) or the difference between the higher allowed amount and the primary insurer's payment amount (step 3).
This information and a MSP Refund Calculation sheet, along with examples of MSP payments for both assigned and non-assigned claims can be viewed at the following link:
http://www.cignagovernmentservices.com/partb/pubs/news/2006/1106/cope5035.html
Q2. I'm trying to bill a claim for an office visit and pulse oximetry (94761), why is my charge for the pulse oximetry being denied?
A2. Effective for services on and after January 1, 2000, the Centers for Medicare & Medicaid Services (CMS) changed the status for code 94761 from "A" (active) to "T" (injection). This means that although this code is not performed as an injection, the relative value units fall under the same category as some injection procedures. Code 94761 is only paid if there are no other services, payable under the physician fee schedule, billed on the same date, by the same provider. If an office visit was billed and allowed for payment, then payment cannot be made for code 94761. This service would be bundled into the office visit.
The pulse oximetry LCD (Local Coverage Determination) can be found at the following link: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=6465&lcd_version=16&show=all
Q3. What type of adjustments can Telephone Reopenings handle?
A3. Telephone Reopenings can handle several issues with easy access to correct minor or clerical errors.
To access the CIGNA Government Services Part B Telephone Reopening line, please call Monday-Friday 8:30 am-4:30 pm (EST) at:
Tennessee and Idaho - 866.520.4021
North Carolina - 866.352.6695
Please indicate at the beginning of the call that you are requesting a reopening and that you will need to explain exactly what you need corrected. All other inquiries (i.e. billing issues, claim denials, etc.) should be directed to the Provider Contact Center at the following numbers:
- Idaho - 866.824.8593
- North Carolina - 866.655.7996
- Tennessee - 866.824.8572
You may view the Telephone Reopenings reminder at the following link:
http://www.cignagovernmentservices.com/partb/pubs/mb/2007/07_07/index.html
Q4. I am trying to update the mailing address for our practice. Can this information be faxed or emailed to your office?
A4. An address change requires submitting the appropriate CMS-855 Medicare enrollment application. You will need to ensure the provider is using the correct CMS-855. The instructions with the form give the best guidance on what is needed to complete an address change.
The provider will need to have a National Provider Identifier, and may need to complete an Electronic Funds Transfer Authorization Agreement (CMS-588) with the address change. Please understand that to change a "pay to" address, the Provider Enrollment Department must validate all information to determine that funds are appropriately being redirected.
You may obtain the current version of the CMS 855 form through the Centers for Medicare and Medicaid Services website at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp. From this page, under "Select From the Following Options,"
- Select "Show only (select one or more options):"
- Select "Show only items containing the following word"
- Type "855" in the box
- Click the "Show Items" button
- Select the proper CMS-855 form
Q5. Where may I find additional information regarding PQRI (Physician Quality Reporting Initiative)?
A5. You may access information on PQRI on the following website: www.cms.hhs.gov/PQRI.
The following chart will also help with more specific PQRI questions:
| Topic | Action |
|---|---|
| 2008 PQRI | Refer to PQRI web site 2008 section |
| Measure design, (e.g. why certain codes are associated with a measure), or intent of a measure | Refer to the measure developer. Cite FAQ 8515, 8516, 8517, 8518, 8543 and 8570, then select Measures and Codes FAQs from the Related Links Inside CMS section of the page. |
| Coding guidance (e.g. what measures should be submitted) | Refer to the Coding Handbook or Data worksheets on the PQRI Tool Kit web page |
| Analysis of PQRI claims and bonus calculations | Refer to PQRI website analysis and payment section |
| Questions on the statute or PQRI regulations | Refer to PQRI website statute and regulations section |
| Measure Specifications | Refer to PQRI website measures/codes section |
| Confidential feedback reports | Refer to PQRI website analysis and payment section |
| Validation | Refer to PQRI website reporting section |
Q6. I would like to bill paper claims, am I eligible?
A6. Providers who are eligible to bill paper claims will have to meet the requirements for the ASCA exception.
The Administrative Simplification Compliance Act (ASCA) prohibits payment of initial health care claims not sent electronically as of October 16, 2003, except in limited situations:
- Small Provider Claims-- The word "provider" is being used generically here to refer to physicians, suppliers, and other providers of health care services. Providers that have fewer than 25 full-time equivalent employees (FTEs) and that are required to bill a Medicare intermediary are considered to be small. Physicians and suppliers with fewer than 10 FTEs and that are required to bill a Medicare carrier or durable medical equipment regional carrier (DMERC) are classified as small. See section 90.1 of Chapter 24 of the Medicare Claims Processing Manual (Pub. 100-04) for more detailed information on calculation of FTE employees and this ASCA requirement in general.
- Roster billing of inoculations covered by Medicare, except for those companies that agreed to submit these claims electronically as a condition for submission of flu shots administered in multiple states to a single carrier;
- Claims for payment under a Medicare demonstration project that specifies claims be submitted on paper;
- Medicare Secondary Payer Claims when there is more than one primary payer and one or more of those payers made an "Obligated to accept as payment in Full" (OTAF) adjustment;
- Claims submitted by Medicare beneficiaries or Medicare Managed Care Plans;
- Dental Claims;
- Claims for services or supplies furnished outside of the U.S. by non-U.S. providers;
- Disruption in electricity or communication connections outside of a provider's control expected to last more than two business days.
- Claims from providers that submit fewer than 10 claims per month on average during a calendar year
This information can be accessed at the following link:
http://www.cms.hhs.gov/ElectronicBillingEDITrans/01_Overview.asp
Q7. How does the therapy cap process work for 2007?
A7. The therapy cap exception process changed for the 2007 calendar year. Providers are no longer required to fax over exception requests to be reviewed for consideration as they did in 2006.
For the therapy HCPCS codes subject to the cap limits expected to exceed the limitation, you must include the KX modifier to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record. In CY 2007, when claims contain a KX modifier, contractors will override edits that indicate that a therapy service has exceeded the financial limitation, and will pay for the service if it is otherwise covered and payable.
The automatic exceptions process for therapy claims reporting the KX modifier does not preclude these claims from being subject to review. The contractor may review claims when they are potentially fraudulent, where there is evidence of misrepresentation of facts, or where there is a pattern of aberrant billing.
This information was obtained from the March 2007 Medicare Bulletin. You may access this bulletin article from the following link to our site: http://www.cignagovernmentservices.com/partb/pubs/mb/2007/03_07/base_March03.html
Q8. I'm having trouble billing for Benign Skin Lesions. Also, when would I use the modifier KX?
A8. There may be instances in which the removal of benign seborrhea kurtosis, sebaceous cysts and viral warts is medically appropriate. Medicare will therefore consider their removal as medically necessary, and not cosmetic, if one or more of the following conditions is presented and clearly documented in the medical record. When this criterion is met, modifier KX must be appended to the applicable procedure code(s).
- The lesion has one or more of the following characteristics:
- bleeding, or
- intense itching, or
- pain, or
- The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythematic, etc., or
- The lesion obstructs an orifice or clinically restricts vision, or
- There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance, or
- The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.
Wart removals are covered under the guidelines above. In addition, wart destructions are covered when any one of the following clinical circumstances is present:
- Per ocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding, or
- Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients, or
- Lesions are condyloma acuminate or molluscum contagiosum, or
- Cervical dysplasia or pregnancy is associated with genital warts.
Removal or destruction of benign skin lesions is denied as not reasonable and necessary if the criteria above are not met.
To view this LCD and the complete guidelines, you can access this information on the CMS website at the following link: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=6509&lcd_version=17&show=all
Q9. On the IVR, it states we can come to the website to get addresses for the Medicare HMO plans but we can not find where these addresses are listed on the website. Can you please help?
A9. There is a website that will give information on the Medicare Advantage Plans, based on the number given on the Interactive Voice Response (IVR), including address and the type of plan. The link to this website is listed below:
www.cms.hhs.gov/healthplansgeninfo/downloads/claims_processing_20060120.pdf
Q10. If we are having problems filing electronic claims or if we need to send additional documentation with our electronic claim, can we file paper claims instead?
A10. No, the electronic claim filing is required under the Administrative Simplification Compliance Act (ASCA). There are populations identified in this Act that are exempted from the requirements however, you are required to prove your exemption. If it is determined that you do not meet the guidelines to qualify for the exemption then you will be required to submit all claims electronically, including Medicare Secondary Payer (MSP) claims. For need additional information about the exemption process, please contact the appropriate Electronic Data Interchange (EDI) department.
North Carolina EDI Department: 1.866.352.1608.
Tennessee/Idaho EDI Department: 1.866.520.4022
