October 2003 Part B Medicare Bulletin
Table of Contents
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- 2004 Annual Update for Skilled Nursing Facility (SNF) Consolidated Billing For the Common Working File (CWF) and Medicare Carriers
- 4th Quarter 2003 Update - Part B Not Otherwise Classified Drug Fee Schedule
- Addition of Three New ICD-9-CM Diagnosis Codes to be Effective as Part of the October 1, 2003, ICD-9-CM Update
- Billing Guidelines for Outpatient Rehabilitation Services
- Changes to Code List for Therapy Services
- Contingency Plan for Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Sets
- Correction to Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
- Evaluation and Management Visit Prior to Screening Colonoscopy
- Final Update to the 2003 Medicare Physician Fee Schedule Database
- Guidelines For Filing Paper Claims
- Guidelines For Medicare Part B Laboratory Testing
- Guidelines For Skilled Nursing Facility (SNF) Consolidated Billing
- Incorrect Billing of Anzemet
- Implantable Automatic Defibrillators Billing Instructions
- Medicare Appeals
- Medicare Carriers Manual Part 3 - Claims Process, Section 3000 - 3004.2
- Medicare EDI Enrollment Requirements
- Overpayment Refunds
- Participation of Anesthesia Professionals in Gastrointestinal Endoscopic Procedures
- Payment for the Fecal Leukocyte Examination Under a Clinical Laboratory Improvement Amendments of 1988 CLIA Certificate for Provider-Performed Microscopy (PPM) Procedures During CY 2003
- Pneumococcal Vaccine Payment Increase Effective October 1, 2003
- Quarterly Provider Update
- Reminder to Independent Laboratories - Separately Billable Laboratory Tests Furnished to ESRD Patients
- Special Alert To All Providers and Suppliers
- Upcoming Provider and Supplier Enrollment Seminars
Contingency Plan for Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Sets
After a careful analysis of Medicare provider, submitter, and other trading partner HIPAA readiness, Medicare will continue to accept and send standard and non-standard versions and/or formats for any electronic transaction for a limited time period beyond October 16, 2003.This is a temporary measure to maintain provider cash flow and minimize operational disruption while trading partners who are not compliant on October 16, 2003, work with Medicare to achieve full compliance. This contingency plan is only for a limited time. Providers who must continue to bill and receive non-compliant formats, should test and move into production on the HIPAA required formats as soon as possible, or risk possible cash flow problems.
(04-0098)
TopAddition of Three New ICD-9-CM Diagnosis Codes to be Effective as Part of the October 1, 2003, ICD-9-CM Update
The three new ICD-9-CM diagnosis codes are:
| 079.82 | SARS-associated coronavirus |
| 480.3 | Pneumonia due to SARS-associated coronavirus |
| V01.82 | Exposure to SARS-associated coronavirus |
(04-0056)
Billing Guidelines for Outpatient Rehabilitation Services
This provider education article discusses the background of the outpatient rehabilitation services limitation regulation, therapy modifiers, applicable outpatient rehabilitation Healthcare Common Procedure Coding System (HCPCS) and revenue codes, and billing instructions. In addition, it includes information resources for outpatient rehabilitation services.
Background
Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997 required payment under a prospective payment system for outpatient rehabilitation services, which includes the following services:
- Physical therapy, including outpatient speech-language pathology; and
- Occupational therapy.
Section 4541(c) of the BBA required application of a financial limitation to all outpatient rehabilitation services. These limits do not apply to therapy rendered by outpatient departments of hospitals unless the beneficiary is a resident of either a Medicare-certified skilled nursing facility or a Medicare-certified portion of a skilled nursing facility. These limits were applied in 1999. However, due to a Congressionally imposed moratorium, the limits have not been effective during the years 2000, 2001, or 2002. The outpatient rehabilitation services financial limitations were initially planned to resume on July 1, 2003, but their implementation has been delayed. The limitations on outpatient rehabilitation therapy services have been implemented again on September 1, 2003.
Therapy Modifiers
- For any applicable rehabilitation therapy service that is rendered, providers/suppliers must report one of the following therapy modifiers, which were effective on January 1, 2003:
| GN | Services delivered under an outpatient speech-language pathology plan of care. |
| GO | Services delivered under an outpatient occupational therapy plan of care. |
| GP | Services delivered under an outpatient physical therapy plan of care. |
NOTE: These therapy modifiers do not allow a provider to deliver services that they are not recognized by Medicare to perform.
Applicable Outpatient Rehabilitation HCPCS and Revenue Codes
- The HCPCS code list for outpatient rehabilitation services was revised in Transmittal B-03-065 to include additional codes that will not apply to the financial limitations when billed by physicians and non-physician practitioners, as appropriate.
- These codes supersede the codes listed in §3653 of the Medicare Part A Intermediary Manual, Part 3.
- This listing of HCPCS codes does not imply that services are covered.
- HCPCS codes apply to each financial limitation except as noted below.
29065+ 29075+ 29085+ 29086+ 29105+ 29125+ 29126+ 29130+ 29131+ 29200+ 29220+ 29240+ 29260+ 29280+ 29345+ 29355+ 29365+ 29405+ 29425+ 29445+ 29505+ 29515+ 29520+ 29530+ 29540+ 29550+ 29580+ 29590+ 64550+ 90901+ 90911+ 92506 92507 92508 92526 92597 92601++ 92602++ 92603++ 92604++ 92607 92608 92609 92610+ 92611+ 92612+ 92614+ 92616+ 95831+ 95832+ 95833+ 95834+ 95851+ 95852+ 96000+ 96001+ 96002+ 96003+ 96105+ 96110+* 96111+ 96115+ 97001 97002 97003 97004 97012 97016 97018 97020 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97504** 97520 97530 97532 97533 97535 97537 97542 97601+ 97703 97750 97799* V5362* V5363* V5364* G0279+*** G0280+*** G0281 G0283 0020T+*** 0029T+***
| * | The physician fee schedule abstract file does not contain a price for codes 96110, 97799, V5362, V5363, and V5364 since they are priced by the carrier. Therefore, contact the carrier to obtain the appropriate fee schedule amount in order to make proper payment for these codes. |
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| ** | Code 97504 should not be reported with code 97116. However, if code 97504 was performed on an upper extremity and code 97116 (gait training) was also performed, both codes may be billed with modifier 59 to denote a separate anatomic site. |
| *** | The physician fee schedule abstract file does not contain a price for codes G0279, G0280, 0020T, 0029T since they are priced by the carrier. In addition, coverage for these codes is determined by the carrier. Therefore, contact the carrier to obtain the appropriate fee schedule amount. |
| + | These codes will not apply to the financial limits when they are not done under a therapy plan of care and they are billed by providers of services who are represented by any specialty codes except 65 and 67 (PT in Private Practice, OT in Private Practice), also 73 and 74 (which were incorrectly noted in AB-03-018 and have since been reassigned to specialties that are not therapy services.) Specialty codes 73 and 74 will be removed in a future instruction. Physicians and non-physician practitioners should only use therapy modifiers (GP, GN, GO) with the above codes when the services are provided under a therapy plan of care. |
| ++ | If an audiology procedure (HCPCS) code is performed by an audiologist, the above modifiers should not be reported, as these procedures are not subject to the financial limitation. When these HCPCS codes are billed under a speech-language pathology plan of care, they should be accompanied with a GN modifier and applied to the financial limitation. |
Carrier Billing Instructions
- Claims must include PT, OT, or SLP modifiers (GP, GO, and GN) when any of the HCPCS codes listed above are used (see exceptions noted by + and ++ in the footnote following the list above). Claims will be returned to providers/suppliers and processing will be delayed if the modifiers are not included.
- In addition, it has been noted that some providers are using modifiers inappropriately with HCPCS codes that are not on the above list. As a result, charges will be incorrectly applied to therapy caps.
Intermediary Billing Instructions
- If the PT, OT, and SLP modifiers (GP, GO, and GN) are not billed with revenue codes 42x, 43x, or 44x, the claim will be returned to the provider.
- Claims with the appropriate modifiers under revenue codes 42x, 43x or 44x, but with HCPCS other than those identified above, may result in charges being incorrectly applied to the therapy caps.
General Billing Instructions
- Providers should be aware that billing a modifier inappropriately with HCPCS or revenue codes that are not listed above may result in charges incorrectly applied to whichever therapy cap the modifier denotes. This incorrect billing deprives the recipient of benefits to which they are entitled and which are not subject to the financial limitation.
- The HCPCS codes marked + on the list above may or may not be considered outpatient rehabilitation services, depending on the circumstances and the practitioners involved. These codes always represent therapy services when done by therapists. They also represent rehabilitation therapy services when done by physicians and non-physician practitioners who are licensed to provide therapy services and the services are not isolated medical services (e.g., a cast) but part of an episode of care whose goal is rehabilitation. When outpatient rehabilitation therapy services are billed, therapy modifiers must be used and all requirements for rehabilitation therapy services must be followed, including a plan of care.
- Diagnostic audiology codes do not require therapy modifiers (see audiology procedure footnote ++ in above list). Audiology services are not subject to therapy caps. Speech-language pathologists are not qualified to perform diagnostic audiology services. The audiology codes will be removed from the list in a future instruction.
Outpatient Rehabilitation Services Information Resources
- Program Memorandums
- Transmittal B-03-065 dated August 22, 2003
- Transmittal B-03-051 dated July 16, 2003
- Transmittal AB-03-097 dated July 3, 2003
- Transmittal AB-03-085 dated June 10, 2003
- Transmittal AB-03-073 dated May 23, 2003
- Transmittal AB-03-057 dated May 2, 2003
- Transmittal AB-03-018 dated February 7, 2003
- Therapy Resources Web Site www.cms.hhs.gov/medlearn/therapy
- Medicare therapy news
- Frequently asked questions
- General information documents
- Therapy medical review operations
- General research tools for therapy topics
- Research tools for specific therapy topics
- Evidence-based literature review
- Join therapy cap listserv (electronic mailing list)
(04-0065)
Changes to Code List for Therapy Services
This Program Memorandum (PM) supplements PM AB-03-018, Change Request 2183 and updates the code list for therapy services that will not apply to the financial limitations when billed by physicians and certain non-physician practitioners when not done under a therapy plan of care. This PM supersedes the effective date and implementation dates of PM AB-03-057 (CR 2709) only with respect to the “+” indicators on the list of HCPCS codes.
All providers/suppliers are reminded that a plan of care must be on file, when appropriate, for all outpatient therapy services. Providers are advised to resubmit claims returned for lack of therapy modifiers (GP, GN, GO) on the above codes newly designated with “+” (bolded) for services provided during July and August 2003. In addition, therapy modifiers should not be used with claims with HCPCS codes noted with “+” unless that service is performed under a therapy plan of care
Background
Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, required payment under a prospective payment system for outpatient rehabilitation services. Outpatient rehabilitation services include the following services:
§ Physical therapy (which includes outpatient speech-language pathology); and
§ Occupational therapy.
Section 4541(c) of the BBA required application of a financial limitation to all outpatient rehabilitation services (with the exception of outpatient departments of a hospital). These limits were in effect in 1999, but were removed in 2000-2002. Beginning September 1, 2003, the limitations on outpatient therapy services will be implemented again.
Applicable Outpatient Rehabilitation HCPCS Codes
The following is a complete list of the 55 “+” codes. It includes 36 newly designated codes in bold and 19 codes previously designated “+”.
| 29065+ | 29075+ | 29085+ | 29086+ | 29105+ | 29125+ | 29126+ | 29130+ | 29131+ | 29200+ |
| 29220+ | 29240+ | 29260+ | 29280+ | 29345+ | 29355+ | 29365+ | 29405+ | 29425+ | 29445+ |
| 29505+ | 29515+ | 29520+ | 29530+ | 29540+ | 29550+ | 29580+ | 29590+ | 64550+ | 90901+ |
| 90911+ | 92610+ | 92611+ | 92612+ | 92614+ | 92616+ | 95831+ | 95832+ | 95833+ | 95834+ |
| 95851+ | 95852+ | 96000+ | 96001+ | 96002+ | 96003+ | 96105+ | 96110+ | 96111+ | 96115+ |
| 97601+ | G0279+ | G0280+ | 0020T+ | 0029T+ |
+ These codes will not apply to the financial limits when they are not done under a therapy plan of care and they are billed by providers of services who are represented by any specialty codes except 65 and 67 (PT in Private Practice, OT in Private Practice), also 73 and 74 (which were incorrectly noted in AB-03-018 and have since been reassigned to specialties that are not therapy services). Specialty codes 73 and 74 will be removed in a future instruction. Physicians and non-physician practitioners should only use therapy modifiers (GP, GN, GO) with the above codes when the services are provided under a therapy plan of care.
[EM 2003-0802/CR 2821]
(04-0041)
Correction to Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
The Program Memorandum AB-03-096, the third quarterly HH consolidated billing update for calendar year 2003, was published on July 3, 2003. It is also located in our August 2003 Medicare bulletin. Among other changes, it removed code A4421 from the list of supply codes subject to home health consolidated billing. Removing code A4421 was an error.
This instruction is to notify providers that the following code will not be deleted from home health consolidated billing enforcement:
- A4421 Ostomy Supply misc
Providers and suppliers interested in an updated complete list of codes subject to HH consolidated billing can go to the HH consolidated billing master code list available at http://cms.hhs.gov/providers/hhapps/
(04-0055)
Evaluation and Management Visit Prior to Screening Colonoscopy
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(04-0010)
Final Update to the 2003 Medicare Physician Fee Schedule Database
Changes included in this Final Update to the 2003 Medicare Physician Fee Schedule Database are as follows:
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(04-0140)
Guidelines for Skilled Nursing Facility (SNF) Consolidated Billing
This provider education article discusses the background of the Skilled Nursing Facility (SNF) consolidated billing regulation; services, supplies, and facilities included and excluded from SNF consolidated billing; professional and technical components of diagnostic tests; and ambulance services. In addition, the article includes information resources for SNF consolidated billing.
Background
Skilled Nursing Facility (SNF) consolidated billing, which was effective for cost reporting periods beginning on or after July 1, 1998, states that SNFs must submit Medicare claims to the fiscal intermediary (FI) for all Part A and Part B services that its residents receive during the course of a covered Part A stay, except for a limited number of specifically excluded services. These services must be furnished either directly or under arrangement with outside providers. Section 4432(b) of the Balanced Budget Act of 1997 (BBA, PL 105-33), mandated the exclusion of entire categories of services from SNF consolidated billing. These services are separately billable to the Part B Medicare carrier and include the services of physicians and certain other types of medical practitioners.
Section 103 of the Balanced Budget Refinement Act of 1999 (BBRA, PL 106-113, Appendix F), effective on April 1, 2000, enacted a second more targeted set of exclusions for high cost, low probability services within a number of broader service categories (e.g., chemotherapy services) that otherwise remained subject to consolidated billing.
Effective January 1, 2002, Section 313 of the Benefits Improvement and Protection Act restricted SNF consolidated billing to the majority of services provided to patients in a Medicare Part A covered stay and only to physical, occupational, and speech-language therapy services provided to patients in a noncovered stay.
For claims with dates of service on or after April 1, 2001, for those services and supplies that are not specifically excluded by law and furnished to a SNF resident covered under the Part A benefit, physicians must forward the technical portions of any services to the SNF to be billed by the SNF to the FI. The SNF cannot receive additional payment for these technical services and is to pay the physician for the technical portion of the service. Physical, occupational, and speech-language therapy services provided to patients in a non-covered stay must also be forwarded to the SNF to be billed by the SNF to the FI for payment. It is the responsibility of the rendering physician or non-physician practitioner to develop a business relationship with the SNF in order to receive payment from the SNF for services they render that are included in consolidated billing.
Services and Supplies Included in SNF Consolidated Billing
The SNF consolidated billing requirement confers on SNFs the billing responsibility for the entire package of services that residents receive including:
All services and supplies received during the course of a Part A covered stay (including physical, occupational, and speech-language therapy services), with the exception of statutory exclusions; and
- For SNF residents in noncovered stays (e.g., Part A benefits exhausted or no prior qualifying hospital stay), physical, occupational, and speech-language therapy services.
Services and Supplies Excluded from SNF Consolidated Billing
A. The following are excluded from SNF consolidated billing and must be billed separately to the Medicare carrier:
- The professional component of physician services (see Section 1861(r) of the Social Security Act for the definition of a physician for Medicare purposes) except physical, occupational, and speech-language therapy services;
- Physician assistant services, when a physician assistant is working under a physician's supervision;
- Nurse practitioner services, when a nurse practitioner is working in collaboration with a physician;
- Clinical nurse specialists, when a clinical nurse specialist is working in collaboration with a physician;
- Certified mid-wife services;
- Qualified psychologist services; and
- Certified registered nurse anesthetist services.
NOTE: Physical, occupational, and speech-language therapy services included in SNF consolidated billing are subject to SNF consolidated billing regardless of who provides them, even if the services that type of practitioner normally provides are excluded from SNF consolidated billing.
B. The following are excluded from SNF consolidated billing and the institutional or technical component must be billed separately to the Medicare FI:
- The following services furnished on an outpatient basis by a hospital or
critical access hospital (CAH):
- Cardiac catheterization services;
- Computerized axial tomography scans;
- Magnetic resonance imaging;
- Ambulatory surgery involving the use of an operating room;
- Radiation therapy;
- Emergency services;
- Angiography;
- Lymphatic and venous procedures; and
- Ambulance services furnished in connection with any of the above outpatient hospital services.
- Maintenance dialysis received in a Renal Dialysis Facility by an End Stage Renal Disease patient;
- Certain dialysis-related services including covered ambulance transportation to obtain dialysis services;
- Erythropoietin for certain dialysis patients when given along with dialysis; and
- Hospice care related to a patient's terminal condition;
C. The following are excluded from SNF consolidated billing and must be billed separately to the Medicare carrier or FI, as appropriate:
- Ambulance trips that transport a patient to the SNF for initial admission or from the SNF following a final discharge (see below for additional ambulance services information);
- Services to risk based HMO enrollees; and
- The following services for residents in a Part A covered stay (only certain services in these categories are excluded):
- Certain chemotherapy drugs;
- Certain chemotherapy administrative services;
- Certain radioisotope services; and
- Certain customized prosthetic devices.
Facilities Included in SNF Consolidated Billing
- Medicare participating SNFs, including Medicare-certified distinct part SNFs and swing beds in all hospitals except CAHs.
Facilities Excluded from SNF Consolidated Billing
- Nursing homes that have no Medicare certification (e.g., do not participate at all in either the Medicare or Medicaid program);
- Nursing homes that exclusively participate only in the Medicaid program as a nursing facility;
- The non-participating portion of a nursing home that also contains a Medicare-certified distinct part SNF; and
- Swing beds in CAHs.
Professional and Technical Components of Diagnostic Tests
The professional component, or the physician's interpretation of a diagnostic test, is considered a physician service and is separately billable to the Medicare carrier. The technical component, or the diagnostic test itself, is considered a diagnostic test and is subject to consolidated billing. As an example, for diagnostic radiology services, the exclusion of physician services from consolidated billing applies only to the professional component of the diagnostic radiology service. The technical component of the diagnostic radiology service is considered a diagnostic test that must be billed to the
Medicare FI by the SNF and is included in the SNF consolidated billing payment for covered Part A stays. Because the technical component is already included within Part A's comprehensive per diem payment to the SNF for the covered stay, an outside entity that actually furnishes the technical component would look to the SNF, rather than Part B, for payment.
Ambulance Services
Except for specific exclusions, SNF consolidated billing includes those medically necessary ambulance trips that are furnished during the course of a Part A stay. In most cases, ambulance trips are excluded from SNF consolidated billing when the covered Part A stay has ended, at which time the ambulance company must bill the Medicare carrier or FI directly for payment. The specific circumstances under which a patient may receive ambulance services that are covered by Medicare but excluded from SNF consolidated billing are:
- A medically necessary ambulance trip to a Medicare participating hospital or CAH for the specific purpose of receiving emergency or other excluded outpatient hospital services;
- A medically necessary ambulance trip after a formal discharge or other departure from the SNF, unless the patient is readmitted or returns to that or another SNF before midnight of the same day;
- An ambulance trip to receive dialysis or dialysis-related services;
- An ambulance trip for an inpatient admission to a Medicare participating hospital or CAH; and
- After discharge from a SNF, a medically necessary ambulance trip to the patient's home where he/she will receive services from a Medicare participating home health agency under a plan of care.
NOTE: A patient's transfer from one SNF to another before midnight of the same day is not excluded from SNF consolidated billing. The first SNF is responsible for the ambulance services.
SNF Consolidated Billing Information Resources
- Consolidated Billing Web Site www.cms.hhs.gov/medlearn/snfcode.asp
- General SNF consolidated billing information.
- HCPCS codes that can be separately paid by the Medicare carrier (i.e., services not included in consolidated billing).
- Therapy codes that must be consolidated in a non-covered stay.
- All code lists are subject to quarterly and annual updates and should be reviewed periodically for the latest revisions.
- Program Memorandums www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp
- Transmittal AB-03-094 dated July 3, 2003
- Transmittal AB-02-175 dated December 13, 2002
- Transmittal A-02-118 dated November 8, 2002
- Updated codes for exclusions
- SNF Help File
a) HCPCS codes included in the SNF Part A payment.
b) Codes that may be paid and on what basis to a SNF by the FI under Part B.
- Transmittal AB-02-038 dated March 27, 2002
- The SNF Help File will be available on a new CMS web site in the near future.
- Medicare Carriers Manual Part 3, Section 4210.
(04-0054)
Incorrect Billing of Anzemet
| Article Publication Date | 09/04/2003 |
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| Article Beginning Effective Date | 09/04/2003 |
| Article Text |
Providers are being cautioned to carefully review how they have and are submitting charges for Anzemet (dolasetron mesylate), an antiemetic given prior to chemotherapy. Although this drug may be administered at dosages up to 1.8mg/kg of body weight, a single intravenous dose of 100mg is frequently the standard dose given. The code to bill for this drug is J1260 which is per 10 mg. Subsequently, the standard dose would be billed as 10 numbers of service (nos) of J1260. CIGNA Government Services Part B Medical Review department has seen charges exceeding greater than 10 numbers of service upwards to 100 nos. Whereas the latter could be from simply confusing the standard dose for the nos to bill, there have been other incidences of providers billing 20 to 40 numbers of services. Even considering the maximum dosage based the patient's body weight in kilograms plus any wastage, these numbers of service seem highly unlikely. Providers are encouraged to minimize wastage as much as possible by scheduling more than one patient at a time to receive this drug. Providers should carefully bill the correct number of services for this drug with medical record documentation on file supporting the dose given. |
| Coverage Topic | Prescription Drugs |
(04-0063)
Medicare Appeals
As a Medicare provider/supplier, you are responsible for documenting Medicare claims with all the information that is necessary for the carrier to make coverage and reimbursement determinations. Claims that are submitted with incomplete or inaccurate information will be rejected as unprocessable.
The Medicare Remittance Notice (MRN) will identify MOA Code MA130 for any claim rejected for incomplete or invalid information. There are NO appeal rights for rejected claims. These must be resubmitted as NEW claims with the correct and complete information.
If the appeal request is not complex, providers may request a telephone review. Telephone reviews offer providers a more cost effective and efficient way to appeal Medicare's decision. It saves the providers and their staff the time it takes to write and mail a review request. Additionally, written request are completed within 45 days; however, most telephone review decisions are completed within 30 days of a provider's telephone conversation with the customer service representative.
This process will not eliminate the option or need for written review requests. The telephone review option is merely an alternative appeals method that can be used for certain types of reviews. When the request for an appeal is complex or if significant documentation is needed to adjudicate the appeal request, then a written request for a review must be filed.
Time Limits
For claims processed on or after October 1, 2002 the request must be received within the 120 days (approximately 4 months) of the original claim determination (i.e., the date on the Medicare Remittance Notice).
Contents of a Written Request for Reconsideration or Review
For Part B appeals, the Medicare regulation states that a party who is dissatisfied with an initial determination may request that the carrier review such determination. The request for review must not only identify the initial determination with which the party is dissatisfied, but must also meet the requirements for the contents of an appeal request outlined below.
If a fully-completed Form CMS-1964, Request for Review of Part B Medicare Claim, is not used to express disagreement with the initial determination, then the appeal request must contain the following information:
- Request for a review;
- Beneficiary name;
- Medicare health insurance claim (HIC) number;
- Name and address of provider/supplier of item/service;
- Date of initial determination;
- Date(s) of service for which the initial determination was issued (dates must be reported in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form); and which item(s) and/or service(s) are at issue in the appeal.
You may access Form CMS-1964 at http://www.cms.hhs.gov/forms/cms1964.pdf.
Supporting Documentation
Incoming appeal requests submitted without necessary supporting documentation will be given second priority to appeal requests submitted with appropriate documentation. Consequently, determinations or decisions on appeal requests that are submitted without appropriate documentation to support the contention that the initial determination was incorrect could possibly be delayed.
Providers should be specific about what they want reviewed and why. A copy of the claim and any supporting documentation should be sent with the request. Mark your envelope to the attention of the Appeals department and clearly state in the inquiry that a review is being requested. Allow 45 days for completion of your request for a review. Do not submit second requests or check the status of your review before the 45 days have elapsed. NOTE: Some issues can be handled by telephone.
Written requests for appeal should be sent to:
Idaho Providers:
CIGNA Government Services Administration
Attn: Appeals Department
P.O. Box 22599
Nashville, TN 37202
North Carolina Providers:
CIGNA Government Services Administration
Attn: Appeals Department
P.O. Box 671
Nashville, TN 37202
Tennessee Providers
CIGNA Government Services Administration
Attn: Appeals Department
P.O. Box 1465
Nashville, TN 37202
Tips for Requesting Appeals:
- A review must be requested within four months of the original claim determination (i.e., the date on the Medicare Remittance Notice). Also, as a safeguard, we ask that all telephone reviews be requested within at least three months of the original claim determination. If it is determined that the issue cannot be resolved through Telephone Review, you will still have one full month to meet the four-month time limitation for filing a written request.
- When documentation is submitted with your request, be sure the patient's name is identified on every page. The Appeals department cannot accept documentation that does not indicate the name of the patient even if the name is on previous pages of the documentation.
- If you wish to appeal remarks code CO-97 (Medicare does not pay for these
charges because the cost of the care before surgery is part of the approved
amount for the surgery."), be sure the modifier you append is applicable to
the actual procedure code and that you include documentation to support the
modifier identified on the corrected claim. Otherwise, we cannot honor
your modifier without supporting documentation.
- Modifiers 24, 25, and 57 should only be appended on evaluation and management procedure codes. The Appeals department has received corrected claims with these modifiers appended to a surgical code, which isn't appropriate. They have also received corrected claims with modifiers appended, but no documentation to support the modifier being used in this case the modifier cannot be acknowledged.
- Modifiers 54, 55, 58, 78, and 79 should only be appended on surgical procedure codes.
- If "Review", "Reconsideration" or "Appeal" is indicated somewhere within the body of your letter, this will override the department for which the letter is being addressed. Please do not use this terminology, unless you are requesting an appeal. Otherwise, your request for an adjustment may end up in the Review Department.
- If you wish to appeal remarks code CO-50, (The information we have does not support the need for this service.), effective October 1, 2002, the Appeals department can no longer add any diagnosis to a claim. If the documentation submitted supports another diagnosis than what was submitted on the initial claim, they cannot add that diagnosis, unless the claim has the new diagnosis on it. This is part of the new HIPAA guidelines.
Telephone Reviews
Issues that can be handled by telephone include, but are not limited to:
- Date of service or year of service correction (Based only on a denied charge. If the procedure was paid, send a corrected claim to the appropriate department (i.e., Adjustments or Accounting).
- Diagnosis correction (CO-50 denial)
- Procedure code modification (paid claims that do not result in an overpayment)
- Processing errors caused by the carrier
- Incorrect number of services submitted (paid claims only that do not result in an overpayment)
- Adding or changing modifiers (CO-97, CO-B15, CO-52)
- Place of service correction (CO-58)
- Charges denied as duplicate in error (CO-18)
- Adding or changing CLIA number (CO-B7)
Note: Claims denied with CO-B7 normally result from a scanning error. Otherwise, claims lacking the CLIA number or claims containing an invalid CLIA number will be returned as unprocessable. These denials have no appeal rights and must be resubmitted as a brand new claim. - Missing modifier added resulting in additional payment (CO-B10)
Issues that cannot be handled by telephone include:
- Modifiers 22, 53, and 52
- Claims that are older than four months from the check date
- Progressive Corrective Action (PCA) "Probe" Reviews ( request for review must be written)
- Return Unprocessable Claims (these must be corrected and refiled as new claims)
- Rejected claim with any of the following denial types: CO-31, CO-17, CO-57, CO-B11, CO-31, CO-27, CO-29, CO-B9, CO-29
- MSP denials CO-20, CO-21, CO-22, CO-19
IMPORTANT: Please note that MOA Code MA130 will be present on the remittance notice for any claim rejected for incomplete or invalid information. Telephone Review cannot handle these claims. They must be corrected and refiled as new claims.
In order to access the Telephone Review Hotline, please dial:
Idaho
866.520.4021 between the hours of 8:30 a.m. and 11:30 a.m. (Mountain Time), Monday through Friday or 1:30 p.m. to 3:30 p.m. (MT), Monday through Thursday.
North Carolina
866.352.6695 between the hours of 9:00 a.m. and 12:30 p.m. (ET), and 1:30 p.m. to 4:30 p.m. (ET) Monday through Friday.
Tennessee
866.520.4021 between the hours of 8:30 a.m. and 11:30 a.m. (CST), Monday through Friday or 1:30 p.m. to 3:30 p.m. (CST), Monday through Thursday.
Please indicate at the beginning of the call that you are requesting a telephone review as all other issues are still to be handled on the regularly designated telephone lines.
Please have on hand the beneficiary's Medicare Health Insurance Claim Number, provider number, date of service, a list of corrections to be made, initial date of claim determination and beneficiary's date of birth.
Because we want to be able to assist as many callers as possible each day, we ask that the caller limit each call to one beneficiary. We will continue to handle more than one claim (up to five) as long it's for the same beneficiary. Also, as a safeguard, we ask that all reviews be requested within at least three months of the original determination. If at this time it was determined that the issue could not be resolved as a telephone review, you will still have one full month to meet the four-month time limitation for filing a written review request. Review requests which require medical documentation from the doctor must be sent in writing.
Hearings
If you disagree with the findings of the review, you may ask for a Medicare hearing.
A hearing gives a dissatisfied beneficiary or provider/supplier an opportunity to present reasons for their dissatisfaction with a claim decision. The goal of a hearing is to reach a correct determination for that particular case.
The beneficiary or his/her authorized representative may request a hearing on a claim whether it is assigned or nonassigned claim if the service being billed was deemed medically unnecessary (under Section 7330 of the Medicare Carriers Manual). Otherwise, providers/suppliers may only request hearings on assigned claims. Other requirements that must be met concerning a hearing request include:
- Other than in cases where an overpayment in excess of $100.00 has been requested based on a review of medical records, the case must have been through the review process and have a review determination;
- The hearings must be requested in writing within six (6) months of the date of the review determination; and
- The amount of benefits in question must be $100.00 or more. The amount in question would be 80% of the difference between the amount billed and the amount previously allowed. (To meet the $100.00 minimum, you may combine claims that have been reviewed and denied within the last six months. You may combine claims for two or more patients in order to meet this requirement).
There are three types of hearings:
- In-Person (appearance): claimants and/or their representative appear before a hearing officer to present oral and/or written testimony;
- Telephone Hearings: These are conducted via telephone at a mutually agreeable time (more convenient, less costly). The claimant/representative presents oral testimony and there is opportunity for oral challenge.
- On-The-Record Hearings: These are based on the facts of the case file and any additional information obtained by or furnished to the hearing officer. The advantage of this type of hearing is the speed with which a decision can be made.
NOTE: For all three types of hearings, a written decision must be prepared and a copy sent to the claimant within 30 days of the hearing.
A hearing decision will fall into one of three categories:
- Affirmation: the hearing officer agrees with the review decision.
- Reversal: The hearing officer reverses the review determination (either totally or partially).
- Dismissal: The hearing officer determines that the hearing cannot be held.
Though the carrier appoints the hearing officer, the hearing officer acts as an officer of the federal government and must comply with the provisions of Medicare law. A hearing officer's job is to obtain all the facts necessary to make a fair decision.
Requests for hearings should be mailed to:
Idaho
CIGNA Government Services
ATTN: Hearing Department
720 Park Blvd., Suite 105
Boise, ID 83712
(When requesting a hearing for services or procedures performed in Idaho, please send a copy of the original claim, any additional information you wish to submit for the hearing and a brief explanation of the issue.)
North Carolina
CIGNA Government Services
ATTN: Hearing Department
4135 Mendenhall Oaks Parkway
High Point, NC 27265
Tennessee
CIGNA Government Services
ATTN: Hearing Department
Two Vantage Way
Nashville, TN 37228
Hearings are conducted within 120 days of receipt.
Administrative Law Judge Hearing
If you are dissatisfied with the results of the hearing, you may request a hearing before an Administrative Law Judge (ALJ). The following requirements must be met:
1. The request for an ALJ hearing must be submitted within 60 days of receipt of the hearing decision; and
2. The amount in controversy is $100 or more. You may combine claims for two or more patients with similar services in order to meet this requirement.
When requesting this action, be sure to include a copy of the hearing decision letter and any new information that may not have been provided previously.
Requests for ALJ hearings should be mailed to:
Idaho
CIGNA Government Services
ATTN: Hearing Department
720 Park Blvd., Suite 105
Boise, ID 83712
North Carolina
CIGNA Government Services
ATTN: Hearing Department
4135 Mendenhall Oaks Parkway
High Point, NC 27265
Tennessee
CIGNA Government Services
ATTN: Hearing Department
Two Vantage Way
Nashville, TN 37228
(04-0061)
Medicare Carriers Manual Part 3 - Claims Process, Section 3000 - 3004.2
Medicare Carriers Manual Part 3 - Claims Process, Section 3000 - 3004.2, Filing the Request for Payment, has been updated to more accurately reflect timely filing as it relates to claims for payment. These changes are in red and become effective October 1, 2003.
Filing the Request for Payment
3000. DEFINITION OF A CLAIM
A claim is a writing, identifying or permitting the identification of an enrollee, which requests payment for what appears to be Part B medical or other health services furnished by a physician or supplier. (See §5240, in MCM, Part 2 concerning process controls on claims.)
The writing must contain sufficient identifying information about the enrollee to permit the obtaining of any missing information through routine methods, e.g., file check, microfilm reference, mail or telephone contact based on an address or telephone number in file. Where the writing is not submitted on a claims form, there must be enough information about the nature of the medical or other health service to enable the contractor with claims processing jurisdiction to determine that the service was apparently furnished by a physician or supplier.
Under this definition, the following do not constitute claims:
- A claims form not containing sufficient information to permit you to identify the enrollee;
- Bills or claims forms referring only to services unrelated to medical or other health services;
- A writing not contained on a claims form and not accompanied by an itemized bill which does not permit you to identify the enrollee and to determine that the medical or other health services were apparently performed by a physician or supplier: and
- Claims forms, or that portion of a claims form, requesting a payment or coverage determination for services that are not within your claims processing jurisdiction (e.g., misdirected claims/services). Handle misdirected claims/services in accordance with §§3110 and 4267.1, as appropriate.
Under the foregoing definition, the following are examples of claims requiring control:
- A claim form containing full identifying information;
- A claim form giving sufficient information for basing requests for further identifying information;
- Bills for medical or other health services which permit you to identify the enrollee and to determine that the services for which you have claims processing jurisdiction were apparently performed by a physician or supplier. The bills need not be accompanied by a claim form. (See §3040.1.); and
- A writing not on a claims form or on a bill which requests payment, which permits identification of the enrollee, and which permits you to determine that the medical or other health services in question and for which you have claims processing jurisdiction were apparently performed by a physician or supplier. See §§33ll and 33l9 for the procedures where additional evidence or information is needed to complete the claim.
3. In Accordance with CMS Instructions. - CMS instructions for submitting claims to Medicare are contained in Chapter III, Claims, Filing, Jurisdiction and Development Procedures of the Medicare Carriers Manual (MCM), these instruction are supplemented by Program Memoranda which are published on the CMS Web site and are generally incorporated into the MCM within one year of publication. In order for a request for payment to be considered to have been filed timely in accordance with CMS instructions, the claim must not be considered to be unprocessable under the definition of an unprocessable claim found in MCM, Part 3, §§3005ff.
Carriers use different processes for handling unprocessable claims. Some carrier's claims processing systems suspend and develop claims considered unprocessable because of incomplete or invalid information. Note that developed claims are not considered clean claims, and no Claims Processing Timeliness (CPT) interest is payable. If the corrections for a suspended claim are received by the carrier within the suspense period, the claim is considered to be timely, even if the corrections are submitted after the timely filing period has closed, provided the claim was filed timely. Other carrier's claims processing systems return unprocessable claims to the submitter, but do not suspend and develop to allow for corrections. Such returned requests for payment, do not constitute claims nor satisfy the timely filing requirement. In those instances, a processable claim that conforms to the requirements of MCM Part 3, §3005 as a minimum must be resubmitted within the timely filing period.
3000.1 Splitting Claims for Processing.
There are a number of prescribed situations where a claim is received for certain services that require the splitting of the single claim into one or more additional claims. The splitting of such a claim is necessary for various reasons such as proper recording of deductibles, separating expenses payable on a cost basis from those paid on a charge basis, or for accounting and statistical purposes. Split a claim for processing in the following situations:
- Expenses incurred in different calendar years cannot be processed as a
single claim. A separate claim is required for the expenses incurred in each
calendar year;
EXCEPTION FOR DURABLE MEDICAL EQUIPMENT REGIONAL CARRIERS (DMERCs):
Expendable items (disposable items such as blood glucose test strips and PEN nutrients) that will be used in a time frame that spans two calendar years and are required to be billed with appropriately spanned "from" and "to" dates of service may be processed on a single claim line. For these types of items, DMERCs must base pricing and deductible calculations on the "from" date, since that is the date when the item was furnished.
- A claim other than a DMERC claim that spans two
calendar years where the "from" date of service is untimely but
the "to" date of service is timely should be split and processed
as follows:
- Where the number of services on the claim is evenly divisible by the number of days spanned, assume that the number of services for each day is equal. Determine the number of services per day by dividing the number of services by the number of days spanned. Then split the claim into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.
- Where the number of services on the claim is not evenly divisible by the number of days spanned and it is not otherwise possible to determine from the claim the dates of services, suspend and develop the claim in order to determine the dates of services. After determining the dates of services, split the claim accordingly into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.
- A claim containing both assigned and unassigned charges. Split assigned and unassigned services from non-participating physicians/suppliers into separate assigned and unassigned claims for workload counts and processing;
- Assigned claims from different physicians/suppliers (excluding group practices and persons or organizations to whom benefits may be reassigned). (See §§3060ff.) Process a separate claim for the services from each physician/supplier. Where the assigned claim is from a person or organization to which the physicians performing the services have reassigned their benefits in accordance with §§3060ff., process all of the services as a single claim;
- A claim where there is more than one beneficiary on a single claim. There
can only be one beneficiary per claim; and
NOTE: Roster bills for covered immunization services furnished by mass immunizers may be submitted for multiple beneficiaries. You must create individual claims for each Medicare beneficiary based on the roster bill information.
- Outpatient physical therapy services furnished on a cost basis by a physician-directed clinic cannot be processed when combined on the same claim with other charge-related services by the clinic. Process the cost related services as a separate claim.
- If an unassigned claim includes services by an independent physical therapist together with other physician services, process the physical therapy services as a separate claim. Process an assigned claim from an independent physical therapist as a single claim.
- A claim that is a duplicate of a claim previously denied is treated as a new claim if there is no indication that the claim is a resubmittal of a previous claim with additional information, or there is no indication on the second claim that the beneficiary is protesting the previous determination.
- In a claim containing services from physicians/suppliers covering more than one carrier jurisdiction, the carrier receiving the claim must split off the services to be forwarded to another contractor and count the material within the local jurisdiction as a claim. The carrier receiving the transferred material must also count it as a separate claim.
- When services in a claim by the same physician/supplier can be identified as being both second/third opinion services and services not related to second/third opinion, the "opinion" services must be split off from the "non-opinion" services and counted as a separate claim. When one physician/supplier in an unassigned claim has provided the "opinion" service and another physician(s)/supplier(s) has provided the "non-opinion" services, the claim may not be split.
- Claims containing any combination of the following types of services must
be split to process each type of service as a separate claim. These services
are:
- Physical therapy by an independent practitioner,
- outpatient psychiatric, or
- any services paid at l00 percent of reasonable charges.
- Any of these types of services may be combined on the same claim with any other type of service.
Do not deviate from defining claims as described above. Split claims in accordance with the appropriate definition. Throughout the claims process count each of the separate claims, resulting from the split, as an individual claim. See §§13310ff. for instructions on reporting claims.
3000.2 Replicating Claims for Processing.
There are no prescribed reasons other than those listed in §3000.l for splitting claims and for counting additional claims into your workload. However, claims are frequently split for other reasons that are dictated by the systems or the methods of processing them. Such additional claims are labeled "Replicate Claims." Tally and report all replicate claims (claims created for any reasons other than those listed in §3000.l) separately. Identify replicate claims and report them in the appropriate categories for claims. (See §§l33l0ff.) Some examples of replicate claims are:
- Additional claims created because of a line item limitation (regardless of the methodology used for coding line items);
- Extra claims created in making partial payments;
- Claims created for carving out individual specialty types of services or for any other occurrence that is not provided for in §3000.l, e.g., unassigned claims containing both services of a podiatrist and services of a physician; and
- Extra claims created to apply special payment reductions (e.g., Gramm-Rudmann-Hollings) efficiently for applicable dates of service.
NOTE: For budget requests and cost reports (CMS-l524, CMS-l528, CMS-l6l6, and CMS-2599), the workload must exclude the number of replicate claims produced.
3001. FILING PART B CLAIMS FOR PHYSICIANS' AND SUPPLIERS' SERVICES
- Methods of Claiming Benefits. - The method of claiming Part B benefits depends upon whether the patient is claiming payment or is assigning benefit payments to his/her source of medical treatment or services.
- Itemized Claims by Patient. - As a rule, beneficiaries do not submit claims for reimbursement. However, if there is reason for a beneficiary to submit a claim for reimbursement, the beneficiary uses the Form CMS-1490S. For covered services furnished on or after September 1, 1990 , physicians and suppliers must complete and submit in accordance with SSA §1848(g)(4)(A) all Part B claims whether assigned or unassigned for beneficiaries who desire Medicare benefit payment determinations.
- Assignment Method. - The physician/supplier (or the facility or organization to which the physician may reassign benefits (§§3060 - 3060.3)) claims the payment. The patient or his representative agrees to assign the benefits and the physician/supplier agreeing to the assignment accepts the Medicare reasonable charge determination as the full charge for the services. (See §§3045ff. about specific assignment procedures and the nature and effect of assignments.)
3002. CLAIMS FORMS
A number of prescribed claims forms have been developed for use when requesting payment for Part B Medicare services. Many are printed and distributed nationally free of cost through CMS's Printing and Publications Branch. (See NOTE below for exception.)
In order to maintain control over the content and format of the forms, private printing of a Government form is not routinely permitted. However, if you or another organization wishes to independently print a prescribed claims form, the reproduction of a claims form must be in accordance with §422.527 of Title 20, Chapter III, Part 422 of the Code of Federal Regulations. Obtain CMS approval for printing a prescribed form. Route the written request for approval through the RO. Include the following:
- The reason or need for such reproduction;
- The intended user of the form;
- The proposed modifications or format changes, with printing or other specifications (such as realignment of data or line designations);
- The type of automatic data processing machinery, if any, for which the form is designed; and
- Estimates of printing quantity, cost per thousand, and annual usage.
NOTE: This procedure does not apply to the Form CMS-1500, Health Insurance Claim Form. Carriers, physicians and suppliers are responsible for purchasing their own forms. This form can be bought in single, multipart snap-out sets or in continuous pin-feed format. Medicare accepts any version. Forms can be obtained from local printers or printed in-house as long as it follows the CMS approved specifications developed by the American Medical Association.
- General. - The Form CMS-l490 was formerly the basic Part B claims form. It was replaced by the Form CMS-l500 for claims completed by physicians and suppliers (except ambulance suppliers), and the Form CMS-l490S for claims from beneficiaries. You must, however, continue to accept and process claims received on the Form CMS-1490 form after conversion to the Form CMS-l500 and Form CMS-l490S.
- Form CMS-1500 (Health Insurance Claim Form).
- Sometimes referred to as the AMA form, the Form CMS-1500 is the prescribed
form for claims prepared and submitted by physicians or suppliers (except
for ambulance services), whether or not the claims are assigned. It
can be purchased in any version required i.e., single sheet, snap-out, continuous,
etc. Instructions for completing Form CMS-1500
for Medicare claims are in §§4020ff.
The forms described below are printed and distributed to contractors by CMS and are available in single sheets, multipart snap-out sets, or in pin-feed format.
- Form CMS-1490S (Patient's Request for Medicare Payment). - This form is used only by beneficiaries (or their representatives) who complete and file their own claims. It contains only the first six comparable items of data that are on the Form CMS-1500. When the Form CMS-1490S is used, an itemized bill must be submitted with the claim. Social Security Offices use the Form CMS-1490S when assisting beneficiaries in filing Part B Medicare claims. For Medicare covered services received on or after September 1, 1990, the Form CMS-1490S is used by beneficiaries to submit Part B claims only if the service provider refuses to do so