When should we expect to find out how and when the transition to Highmark is going to happen?
Answer:
On January 7, 2009, CMS announced it had awarded the remaining five contracts for the combined administration of Part A/Part B Medicare:
Highmark Medicare Services, Inc., (HMS) was awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 15 comprised of Kentucky and Ohio. The contract also included the home health and hospice processing workload in Colorado, Delaware, District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming. However, two protests against the award were filed with Government Accountability Office (GAO).
Four ‘cycle two contracts’ (J6, J8, J11 and J15) are under a stay of performance pending CMS corrective action. In the meantime, the current fiscal intermediaries and carriers will continue to provide Medicare claims processing services under their contracts.
For more details on what providers can expect as they transition from a fiscal intermediary or carrier, read the Special Edition MLN Matters article SE0837 (PDF, 113 KB), ‘Preparing for a Transition from an FI/Carrier to a Medicare Administrative Contractor (MAC).’
I do one-on-one Medicare tele-reviews (telephone reopenings) on claims that have been denied due to diagnosis or modifier corrections in addition to other denials. This has helped me a lot and I would like to know if the new contractor taking over will continue to give the same benefits that I am getting now?
Answer:
The Medicare Administrative Contractor functions will mirror the current functions/procedures that you are currently using for Redeterminations/Reconsiderations process. Contractors follow CMS guidance regarding these functions, which are published in the CMS Medicare Claims Processing Manual (PDF, 586 KB) (Pub. 100-04, chapter 29, section 310).
If there are any changes to the current process, CMS will notify all Medicare Administrative Contractors and allow ample time for provider notification and training.
Why does Medicare deny CPT code 64573 (Incision for implantation of neurostimulator electrodes) when performed with CPT code 69930 (Cochlear implant surgery)? We have also referenced the CCI edit listing in place for this, and, in the past, Medicare had allowed these two procedures when performed on the same date of service. What has changed and is there anything that we can do to get these paid?
Answer:
Coverage guidelines for Cochlear Implant surgery are published in the October 2007 Medicare Advisory and the CMS National Coverage Determination (NCD) (PDF, 518 KB) (Pub. 100-03, chapter 100-03, section 50.3).
Specific diagnoses that are considered to meet coverage criteria are also published on the Palmetto GBA Web site. If these services do not meet the medical necessity guidelines, you may request a redetermination and provide supporting documentation for consideration of payment.
What are the criteria for billing CPT code 99212 (Office or other outpatient visit for the evaluation and management of an established patient)?
Answer:
This CPT code requires at least two of these three key components:
- A problem focused history
- A problem focused examination
- Straight forward medical decision making
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. More information is published in CMS Documentation Guidelines for E/M Services.
We have a problem with Palmetto GBA not paying CPT codes 93320 and 93325 when billed with CPT code 93312. Will you explain the reason?
Answer:
Claims may be denied for any number of reasons. In this case, CPT codes 93320, 93325 and 93312 have been deleted from the Correct Coding Initiative (CCI) listing effective January 1, 2009. We will need claim-specific information in order to fully research your question. If you are seeing denials other than those related to the Correct Coding Initiative, please reference the specific remark codes on your remittance notice for these services. If you still need help after looking at this information, please call our Provider Contact Center at (866) 332-7025 Monday through Friday from 8:30 a.m. to 4:30 p.m. We will be glad to assist you.
My question is regarding Railroad Medicare. We are having a problem with our NPI and where it should be placed on the CMS-1500 claim form. Can you help me with this?
Answer:
Please remember that when submitting the CMS-1500 claim form for Medicare or Railroad Medicare, you should only submit the NPI number for the rendering provider. If you belong to a group practice, submit both the individual NPI and the group practice NPI. For assistance on how to complete the CMS-1500 claim form, please visit the Palmetto GBA Web site for Railroad Medicare at www.PalmettoGBA.com/RR. Under Self Service Tools, select Interactive CMS-1500 Claim Form. For instructions on submitting electronic claims, select EDI.
Please remember to check the Palmetto GBA Web site for additional learning and educational opportunities at: