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Jurisdiction 11 Part B
Frequently Asked Questions

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How often are CARCs and RARCs updated?07/30/2014
Where can I find a list of CARCs and RARCs?07/30/2014
What are CARCs and RARCs?07/29/2014
Will supporting documentation be required for all adjustments such as paper and electronic claim?07/24/2014
Is AmnioFix covered by Medicare?07/21/2014
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?07/15/2014
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?07/15/2014
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?07/15/2014
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?07/15/2014
If an attending physician requests a medical house physician see a patient for a specific problem, can this be submitted as a consultation?07/15/2014
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?07/15/2014
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?07/15/2014
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?07/15/2014
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)?07/15/2014
If I provide a statutorily excluded service am I required to have the patient sign an ABN?07/15/2014
If Medicare determines that my records are not legible, will you treat this as if no documentation is available?07/15/2014
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?07/15/2014
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?07/15/2014
If the physician documents that 'the patient was a difficult historian' without further elaboration, is this documentation sufficient?07/15/2014
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?07/15/2014
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?07/15/2014
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?07/15/2014
Is it appropriate to submit a health and behavior code for a patient that has dementia?07/15/2014
Is the immunosuppressive therapy included in the 90-day global period for kidney transplants?07/15/2014
Is the Part B deductible applied to claims based on the date of service?07/15/2014
Is the Shingles vaccine (Herpes Zoster) covered under Medicare Part B when administered in a physician’s office?07/15/2014
Is there a deductible or coinsurance/copayment for the Annual Wellness Visit (AWV)?07/15/2014
Is there a protocol for how many glucose and cholesterol tests a patient may have done per year?07/15/2014
May we appeal the CERT contractor's decision?07/15/2014
May we fax documentation in response to Additional Documentation Request (ADR) letters using the fax attachments for electronic claims?07/15/2014
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?07/15/2014
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?07/15/2014
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,')?07/15/2014
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?07/15/2014
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?07/15/2014
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?07/15/2014
On the initial physical therapy claim, which date should be used to determine when a recertification is due?07/15/2014
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?07/15/2014
Our group submitted two claims for office visits for two group providers. Why was the second one denied? (This applies to hospital visits also.)07/15/2014
Provider Enrollment Application: Frequently Asked Questions07/15/2014
Should I submit the modifier for multiple services with claims that include more than one service or surgery?07/15/2014
Should the patient responsibility (PT RESP field) be used as the final determination of whether the patient or another payer may be billed?07/15/2014
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?07/15/2014
Telephone calls are not a billable service for providers. Does this rule apply to nurse practitioners?07/15/2014
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?07/15/2014
The MSP claims I submit are not being paid. Where can I find information on how to correctly submit these claims?07/15/2014
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?07/15/2014
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?07/15/2014
We have multiple diagnostic tests subject to the anti-markup payment limitation; may we include all the tests on the same claim?07/15/2014
We received a denial on the second initial consultation that was performed. Why wasn't the second consultation paid?07/15/2014
What actions are being taken to assist providers who do not have a one-to-one match with their PTANs and NPI?07/15/2014
What are the documentation requirements for hospital visits in a teaching facility?07/15/2014
What are the guidelines for placement of cardiac pacemakers and defibrillators?07/15/2014
What are the guidelines for submitting claims with date-span coding?07/15/2014
What are the Medicare requirements for shared services?07/15/2014
What are the requirements for returning medical documentation requests to CERT Documentation Contractor?07/15/2014
What can you do to prepare for a medical review?07/15/2014
What clinical documentation, when requested, is required to be submitted to support 'reasonable and necessary' for psychotherapeutic services?07/15/2014
What code will Medicare contractors accept for purposes of determining when Medicare is the secondary payer?07/15/2014
What documentation should be included with a Recovery Audit Contractor (RAC) appeal?07/15/2014
What does 'Reasonable and Necessary' mean?07/15/2014
What does it mean to be a participating provider?07/15/2014
What is an add-on code and when is it used?07/15/2014
What is Comprehensive Error Rate Testing?07/15/2014
What is meant by intensity as it pertains to the statement that a physical or occupational therapy treatment plan must be of the appropriate type, frequency, duration and intensity?07/15/2014
What is the CERT provider compliance error rate?07/15/2014
What is the difference between Medigap and Crossover?07/15/2014
What is the RAC adjustment code?07/15/2014
What is the Recovery Audit Contractor (RAC) appeal process?07/15/2014
What measureable goals are acceptable?07/15/2014
What should I do if I receive two primary payments?07/15/2014
What should I do when Medicare Part B is denying claims indicating the patient is enrolled in hospice when the patient states they are no longer receiving hospice benefits?07/15/2014
What should I do when the primary insurer updates/changes its records to reflect that it is now secondary, not primary? Medicare has already made secondary payments.07/15/2014
What should we do if we receive multiple requests for medical records from the CERT contractor?07/15/2014
What subsequent hospital visits guidelines/criteria must be met in order for an interval history to be considered problem focused, expanded problem focused or detailed?07/15/2014
What will happen to my claim if submitted with the patient’s incorrect date of birth?07/15/2014
What would constitute the complete single system exam?07/15/2014
When a hospital requests a 'hospital to hospital' transport in a rapid/urgent manner, without lights and sirens, would this type of transport be considered emergent? Or, is this transport based solely on the patient’s condition at the time of transport?07/15/2014
When a patient is admitted to observation status must the place of service and codes billed by the Part B provider always match what the hospital bills on the UB claim form?07/15/2014
When a resident performs a procedure such as sutures, intubation or a central line in an emergency department, is it sufficient that the physician is readily available or must he/she be at the bedside the entire time?07/15/2014
When an LCD is retired, does this mean that the information in the LCD is obsolete?07/15/2014
When I call the Interactive Voice Response (IVR) system and select option #2 'Payment Information' then option #1 for 'Payment Floor Information', the IVR states that I have 256 claims on the payment floor for $10,652.10. Where do those numbers come from and what is the payment floor?07/15/2014
When I receive a request for medical records from the CERT contractor for services provided to an inpatient, outpatient, or nursing home patient, may I just forward the request to the facility for them to fulfill the request and submit the records?07/15/2014
When is a beneficiary eligible for the Annual Wellness Visit?07/15/2014
When is a Medicare Participation Agreement effective? Can providers sign up to become participating providers any time during the year?07/15/2014
When Medicare is secondary for the beneficiary, can we bill a different charge to the third party payer than to Medicare?07/15/2014
When multiple patients are included in an overpayment situation, how do I know the reason for the overpayment?07/15/2014
When scoring the part of an evaluation and management (E/M) visit under Table of Risk, would surgery with risk factors be the procedure itself or does this refer to the patient’s condition at the time he/she is seen and not the procedure that may be performed?07/15/2014
When should we have an Advance Beneficiary Notice (ABN) signed?07/15/2014
When should we submit an invoice with not otherwise classified (NOC) drug claims?07/15/2014
When submitting a laboratory/pathology service for medical review, what documentation is required?07/15/2014
When submitting psychotherapy services for medical review, what documentation is required?07/15/2014
When using bilateral procedure modifier, do I always submit '1' in the units field?07/15/2014
Where are the medically unlikely edit code limits listed?07/15/2014
Where can I find a list of ICD-9-CM codes that may qualify for the cap exception?07/15/2014
Where can I find information on telephone pacemaker analysis?07/15/2014
Where should I send documentation for CERT reviews?07/15/2014
Where would a polysomnography (PSG), a sleep study, be rated on the table of risk?07/15/2014
Who are the CERT contractors?07/15/2014
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last updated on 9/01/2014
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