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Jurisdiction 11 Part B
Frequently Asked Questions

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A patient is transported by ambulance to hospice prior to the initial assessment and development of the plan of care. Change Request 6778 states this transport would be covered under the ambulance benefit, not the hospice benefit. What destination modifier do I use?04/15/2014
Am I violating the Health Insurance Portability and Accountability Act (HIPAA) privacy rules by sending documentation to the CERT Documentation Contractor (CDC) and/or AdvanceMed?04/15/2014
Appeals: What happens to an incomplete redetermination request?04/15/2014
Are health care providers required to comply with the CERT contractor’s request for medical records?04/15/2014
Can a single visit be counted as both the IPPE and an AWV?04/15/2014
Can other medical services be performed at the same time as an AWV? If so, how are they coded?04/15/2014
Can you clarify the exact timeframe between Annual Wellness Visits (AWVs)? Is it 365 days from the date of the last AWV or 11 months, etc.?04/15/2014
Do I submit the rendering National Provider Identifier (NPI) number when submitting ambulatory surgical center (ASC) claims?04/15/2014
Does Medicare publish a listing of skilled nursing facilities, non-skilled nursing facilities and residential facilities?04/15/2014
Does Medicare reimburse for ambulance transportation to and from a physician’s office?04/15/2014
How can I recognize a CERT contractor request for medical records?04/15/2014
How does the CERT process work?04/15/2014
How is a claim selected and reviewed as part of the CERT process?04/15/2014
How is compliance with the CERT contractor's request for medical records beneficial to providers?04/15/2014
How is the CERT paid claims error rate determined?04/15/2014
How long does the CERT contractor have to review the medical records?04/15/2014
How will we be notified of the review decision?04/15/2014
I'm submitting post-op care only by using the appropriate modifier and procedure code. I am including the number of post-op days in the days/units field and the assumed/relinquished date in the electronic documentation record, but the service is not getting paid. Why?04/15/2014
I have a Physician Quality Reporting System (PQRS) code, formerly PQRI code, that is being returned as unprocessable with the message 'Missing/Incomplete/Invalid Charge.' Another code was returned stating 'Procedure code was invalid on the date of service.' Why won’t these codes process for 2011 dates of service?04/15/2014
I have an ambulatory surgical center (ASC) claim for brachytherapy treatment planning that was returned as unprocessable. The message states the claim was processed in accordance with ASC guidelines, but this code is on the ASC list of ancillary services that are separately payable. Why wasn’t the claim processed?04/15/2014
I have received a denial for my submission of specialty care transport HCPCS code A0434. What could be wrong?04/15/2014
I have received a primary payment for a consultation service. My software does not allow me to change the procedure code to an evaluation and management (E/M) code that Medicare will accept. Since Medicare no longer accepts consultation codes, can I bill the patient for the co-pay from the primary insurance and not submit a claim to Medicare?04/15/2014
I keep receiving denials from my vendor/clearinghouse whenever I submit MSP claims. The remittance advice indicates error message/required element 1044. Please assist with denial code.04/15/2014
I provided split post-op care to a patient who had cataract surgery by another doctor. I added the split post-op care modifier to my visit code, but the service was not paid. Why?04/15/2014
I received a denial for my submission of a specialty care transport code. What could be wrong?04/15/2014
I received a primary payment from another insurer and a secondary payment from Medicare. Now we have too much money for that patient’s account. What should I do?04/15/2014
I received a remittance notice showing all of the Physician Quality Reporting System (PQRS) codes submitted were returned as unprocessable. The message stated 'the procedure code is inconsistent with the modifier used or a required modifier is missing.' We used HCPCS modifier GP because the PQRS codes were related to the patient’s physical therapy. Why were the PQRS codes returned?04/15/2014
I see a reason code message J1 on my remittance notice that I have never seen before. Could you explain what this message means?04/15/2014
I sent in a redetermination request for an overpayment, when will I receive a response?04/15/2014
I sent my electronic claim to the clearinghouse a week ago but the IVR indicates it was never received, why?04/15/2014
I submitted 10 units of a code for different patients on different dates. Why was my code allowed for one date of service and denied for another?04/15/2014
I submitted a claim for bilateral 'ophthalmic diagnostic imaging' with the appropriate modifier, but only received payment for one eye. Why didn’t I receive payment for both eyes?04/15/2014
I submitted a claim with an add-on procedure code during the postoperative period. Why was it returned as unprocessable due to a missing or invalid modifier?04/15/2014
I submitted a modifier with a visit code to indicate it was unrelated to a minor surgery performed the same day. Why was the visit denied with a message indicating the visit is included in payment of another service?04/15/2014
I submitted a visit code with a modifier to indicate 'unrelated to surgery' and indicated in the electronic documentation record that the visit was unrelated to the recent surgery. Why was the visit denied?04/15/2014
I submitted an E/M service within the post-op period of a fracture repair for an unrelated reason. I added the modifier to indicate 'unrelated procedure or service by the same physician during the postoperative period' but the service was rejected. Can you tell me why?04/15/2014
I submitted my form and a copy of a deposit ticket as the form mentions, but it was returned to me requesting a voided check or bank letter. Why do I need to provide additional documentation?04/15/2014
I submitted numerous claims for fundus photography with the bilateral procedure modifier to indicate that the procedure was performed on both eyes, but the services were rejected. Why?04/15/2014
I submitted services that my lab referred to another lab. Why were the referred lab services denied?04/15/2014
If a child has chronic asthma and I document that parents in the home smoke, would that qualify as social history?04/15/2014
If a patient is a minor, can I receive 'credit' for 'review and summarize old records and/or history obtained from others?04/15/2014
If a patient is admitted to observation late in the evening but not discharged until the following day, do I have one or two observation days?04/15/2014
If a patient is being transported to a wound care center located within a hospital or on hospital grounds, which destination modifier would be used when filing the claim?04/15/2014
If a patient presents to the office for an injection, infusion or venipuncture, would it be acceptable to submit an office or other outpatient visit CPT code?04/15/2014
If a Physician Quality Reporting System (PQRS) code is separated from the qualifying procedure code and returned as unprocessable, is the PQRS code still reported to CMS?04/15/2014
If a physician talks with a patient about a do not resuscitate (DNR) order and documents his or her discussion, would this be a high-level risk management option under medical decision making even though their prognosis may not be poor?04/15/2014
If an attending physician requests a medical house physician see a patient for a specific problem, can this be submitted as a consultation?04/15/2014
If an established patient exhibits symptoms from which the physician diagnoses the condition and begins treatment by performing a minor procedure on the same day, can we bill an evaluation and management (E/M) service?04/15/2014
If anesthesia begins at 11 p.m. and ends at 12:15 a.m. the next day, what date of service should be used when submitting the claim?04/15/2014
If I am uncertain as to whether Medicare or the CERT contractor can read my doctor's signature may I voluntarily submit a signature log when asked to provide documentation?04/15/2014
If I order a diagnostic test in the office and I independently review the image, tracing or specimen do I receive three points (one for ordering the test and two for independently reviewing)?04/15/2014
If I provide a statutorily excluded service am I required to have the patient sign an ABN?04/15/2014
If Medicare determines that my records are not legible, will you treat this as if no documentation is available?04/15/2014
If our claim denies for a Medically Unlikely Edit (MUE), do we have to submit a first level appeal (Redetermination) or can we submit a Clerical Error Reopening Request form instead?04/15/2014
If our office incorrectly reconstituted Herceptin (Trastuzumab) using sterile water instead of bacteriostatic water, and we are unable to store and use the rest of the vial, can our facility bill for the wasted drug and the administered amount?04/15/2014
If the physician documents that 'the patient was a difficult historian' without further elaboration, is this documentation sufficient?04/15/2014
If the Recovery Audit Contractor (RAC) seeks an overpayment, does the provider have to pay the money back right then or can they file an appeal on the request?04/15/2014
In the following Medicare Secondary Payer calculations, can a patient be billed: primary insurer allowed $200, amount applied to primary insurance deductible was $0, primary insurance paid $160, Medicare allowed amount $100, amount applied to Medicare deductible was $100, and Medicare payment was $0?04/15/2014
Is a chiropractor required to submit claims for non-covered services, such as an office visit? How do I know if the patient's secondary insurance will consider the service if Medicare does not cover it?04/15/2014
Is it appropriate to submit a health and behavior code for a patient that has dementia?04/15/2014
Is the Annual Wellness Visit (AWV) the same as a beneficiary's yearly physical?04/15/2014
Is the immunosuppressive therapy included in the 90-day global period for kidney transplants?04/15/2014
Is the Part B deductible applied to claims based on the date of service?04/15/2014
Is the Shingles vaccine (Herpes Zoster) covered under Medicare Part B when administered in a physician’s office?04/15/2014
Is there a deductible or coinsurance/copayment for the Annual Wellness Visit (AWV)?04/15/2014
Is there a protocol for how many glucose and cholesterol tests a patient may have done per year?04/15/2014
May we appeal the CERT contractor's decision?04/15/2014
May we fax documentation in response to Additional Documentation Request (ADR) letters using the fax attachments for electronic claims?04/15/2014
Medicaid is denying a claim crossed over from Medicare stating it is missing the provider's taxonomy number. The claim included the taxonomy number so why was it removed when the claim crossed over to Medicaid?04/15/2014
Must the surgeon follow the patient post-operatively in a rehabilitation unit or could he/she turn the care over to another physician in the same practice?04/15/2014
My claim for 'external circulation assist: each additional 24 hours,' was denied stating an add-on code cannot be submitted by itself (it is on the same claim as the service for 'external circulation assist: initial 24 hours,')?04/15/2014
My claim was returned with the message ‘the procedure code is inconsistent with the modifier used or a required modifier is missing.’ I submitted two modifiers, and they should both be valid for the procedure code. Why was my claim rejected?04/15/2014
My clearinghouse told me that I have to contact the primary insurer and instruct them to forward the explanation of benefits (EOB) electronically to MSP. Is this correct?04/15/2014
My paper claim was rejected with message N34, incorrect claim form/format for this service. What is wrong with my claim form?04/15/2014
Often as a physician I am asked/required by a third party to order or perform annual lab tests and/or lab panels for certain patients. Will Medicare cover these required services?04/15/2014
On the initial physical therapy claim, which date should be used to determine when a recertification is due?04/15/2014
Our doctor pays a medical group to perform the technical component (TC) of diagnostic tests and performs the professional component (PC) himself. Does the medical group performing the TC have to be enrolled in Medicare in order for our doctor to submit a claim under the anti-markup provision?04/15/2014
Our group submitted two claims for office visits for two group providers. Why was the second one denied? (This applies to hospital visits also.)04/15/2014
Provider Enrollment Application: Frequently Asked Questions04/15/2014
Should I submit the modifier for multiple services with claims that include more than one service or surgery?04/15/2014
Should the patient responsibility (PT RESP field) be used as the final determination of whether the patient or another payer may be billed?04/15/2014
Some nursing facilities provide all three types of services (skilled care, non-skilled care and residential care) at the same facility. How do we verify what area of that facility the patient resides in so we know what modifier to use when filing our claims?04/15/2014
Telephone calls are not a billable service for providers. Does this rule apply to nurse practitioners?04/15/2014
The CO-97 denial is 'Patient was an inpatient on the date of service'. Some hospital facilities do not understand why we bill them for our transports in order for us to get paid for our services. Is the hospital responsible for the payment of the transports while the patient is an inpatient?04/15/2014
The MSP claims I submit are not being paid. Where can I find information on how to correctly submit these claims?04/15/2014
To determine the application of the MSP provisions based on the size of the employer, does Medicare consider the number of employees enrolled in the group health plan or the total number of employees?04/15/2014
We are receiving a bundling denial even though we submitted a CPT modifier to indicate the service was distinct or independent from the other non-E/M services performed on the same day. Why is the service being denied?04/15/2014
We have multiple diagnostic tests subject to the anti-markup payment limitation; may we include all the tests on the same claim?04/15/2014
We received a denial on the second initial consultation that was performed. Why wasn't the second consultation paid?04/15/2014
What actions are being taken to assist providers who do not have a one-to-one match with their PTANs and NPI?04/15/2014
What are the appropriate procedure codes for the first and subsequent AWVs?04/15/2014
What are the documentation requirements for hospital visits in a teaching facility?04/15/2014
What are the guidelines for placement of cardiac pacemakers and defibrillators?04/15/2014
What are the guidelines for submitting claims with date-span coding?04/15/2014
What are the Medicare requirements for shared services?04/15/2014
What are the requirements for returning medical documentation requests to CERT Documentation Contractor?04/15/2014
What can you do to prepare for a medical review?04/15/2014
What clinical documentation, when requested, is required to be submitted to support 'reasonable and necessary' for psychotherapeutic services?04/15/2014
What code will Medicare contractors accept for purposes of determining when Medicare is the secondary payer?04/15/2014
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last updated on 4/01/2014
ver 1.0.43