Claims


No. Medicare does not pay for missed appointments, so these charges should not be submitted to Medicare. The Centers for Medicare & Medicaid Services (CMS) policy is to allow physicians and suppliers to charge Medicare patients for missed appointments.

Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 1, Section 30.3.13 (PDF, 1.63 MB).

Last Reviewed: 1/20/2022

Claims that have been rejected as unprocessable should be corrected and resubmitted as new claims.

If you need assistance determining why your claim rejected, check the Palmetto GBA Denial Resolution Tool by selecting Tools from the home page. The Denial Resolution Tool is alphabetized by type of service and reason for denial. After checking this tool, if you need assistance to understand why your claim was rejected as unprocessable, call the provider contact center. Our customer service representatives have the resources to help you to determine what information may be needed.

Last Reviewed: 1/20/2022

You are responsible for determining the correct diagnostic and procedural coding for the services you furnish to Medicare patients. Medicare contractors cannot make determinations about the proper use of codes for you or your staff. If you have a question about interpretation of procedural and diagnostic coding, please contact the entities that have responsibility for those coding sets:

  • Current Procedural Terminology (CPT) codes are proprietary to the American Medical Association (AMA). As such, CPT coding questions should be referred to the AMA. The AMA offers CPT Information Services (CPT-IS). This internet-based service is a benefit to AMA members and is available as a subscription fee-based service for non-members and nonphysicians. The AMA also offers CPT Assistant. Information about these resources is found on the AMA's website.
  • The American Hospital Association (AHA) has a website with many resources for answers to coding questions. The website also has a direct link to the AHA Coding Clinic whereby coding questions may be submitted and tracked.
  • Level II Healthcare Common Procedure Coding System (HCPCS) codes related to durable medical equipment or prosthetics, orthotics, and supplies are answered by the Pricing, Data Analysis and Coding (PDAC) Contractor. Information about the PDAC Contractor and the services it provides can be found on the PDAC's website.
  • Additional information can be found about these resources on the CMS HCPCS General Information web page.

The information above can be found on the CMS IOM ManualsPublication 100-09, Chapter 6, and Section 30.1.1 (PDF, 1.32 MB).

Last Reviewed: 1/20/2022

As a new calendar year approaches, beneficiaries may be electing different options for their Medicare coverage. Some beneficiaries will choose to stay with Medicare fee-for-service for their Part B benefits, while others will choose a Medicare Advantage (MA) plan.  

Facts About MA Plans

  • MA plans are available to beneficiaries in all 50 states
  • Many plans offer additional benefits not included in Medicare fee-for-service, such as prescription drug coverage, hearing aids, glasses and routine physical exams
  • Beneficiary enrollment in Medicare plans is handled through the Social Security Administration or through the Medicare.gov website
  • When a patient enrolls in an MA plan, the MA plan replaces that beneficiary’s coverage through fee-for-service Medicare, or original Medicare

How Can MA Plans Affect Your Practice?

  • Some patients do not realize that they have selected an MA plan and may still give you their red, white and blue Medicare card
  • Some patients think they should always give you their red, white and blue Medicare card even though they have a different plan
  • Some patients think their MA card is just for prescription drugs

Tips for Easy Claim Submission and Troubleshooting

  • Submitting a claim is not the best way to verify a patient’s enrollment. There can be a lag time between the effective date of a patient’s change in coverage (e.g., from original Medicare to an MA plan) and Medicare records being updated by Social Security.
  • Ask each patient to present all of his/her insurance cards at each visit to ensure that you are getting the most accurate information possible
  • If you cannot ascertain whether or not the patient has coverage through an MA plan, you should verify this information through the Palmetto GBA eServices portal or by using the Palmetto GBA Interactive Voice Response (IVR) system to verify eligibility  
  • If a patient insists that his Medicare coverage is wrong (he believes he should have original Medicare and not an MA plan), the patient must call 1–800–MEDICARE to correct his enrollment

eServices 
Palmetto GBA is pleased to offer eServices, our free internet-based, provider self-service portal. This application provides information access over the Internet for the following online services:

  • Eligibility
  • Claims status
  • Remittances online
  • Financial information (payment floor and last three checks paid)
  • All providers that have an EDI Enrollment Agreement on file may register to use this tool. Simply access the introductory article to learn more. Select the eServices link across the top of any of our site pages. The eServices User Manual (PDF, 8.2 MB) is a great guide on how to use the tool.

Note: Billing services and clearinghouses should contact their provider clients to gain access to the system.

Resource: To access the MA Plan Directory and CMS instructions for MA Plans, go to the CMS Medical Advantage (MA) Plan Directory page on the CMS website.

Last Reviewed: 1/20/2022

You can get general information on Medigap, as well as a list of Medigap claim-based COBA IDs to be used on incoming claims at the Coordination of Benefits Agreement page on the CMS website.

Last Reviewed: 1/20/2022

No. There is no Medicare reimbursement for drug wastage of a multi-dose or multi-use vial when an unused portion must be discarded.

Last Reviewed: 1/20/2022

Medicare does not require a taxonomy code to process a claim; however, we will verify that the taxonomy code is valid by comparing it with the latest National Uniform Claim Committee (NUCC) Healthcare Provider Taxonomy Codes (HPTC) code set if it is submitted on the claim. We would include the taxonomy code on any crossover to another insurance company. You may wish to check with your clearinghouse or billing company to ensure they are not stripping the taxonomy number from your claim prior to transmitting to Medicare.

In order for your claim to process with the taxonomy number, it must be in the correct position on your electronic claim. Placement of the taxonomy number depends on if the provider is an option code one or three billing provider.

Option Code 1 (Group Practice, Individual Provider Is an Option Code 4)

  • The taxonomy number goes at the rendering provider level
  • Loop 2310B, Segment PRV, Element 01=PE, Element 02=PXC, and Element 03=taxonomy #

Option Code 3 (Provider Is in a Solo Practice)

  • The taxonomy number goes at the billing provider level
  • Loop 2000A, Segment PRV, Element 02=BI, Element 02=PXC, and Element 03=taxonomy #

If the taxonomy is submitted in any other position it will be rejected before it comes into our claims processing system (referred to as a front-end rejection). It is equally important that the taxonomy code billed matches the primary type and specialty on your Medicare enrollment record, as well as the enrollment records of other payers. Failure to do so may result in claim denials.

Resource:  Health Care Provider Taxonomy Codes (HPTC) Information

Last Reviewed: 1/20/2022

Failure to submit one or more of the following requirements can result in the rejection of services billed with CPT modifier 55.  

CMS-1500 (02/12) Paper Claims

  • Enter the total number of post-op days in either item 24G or in item 19
  • Enter the date(s) the post-op care was assumed and/or relinquished in item 19
  • Enter the date the surgical procedure was performed as the date of service    

Electronic claims — ASC 837 v5010 Loop, Segment, Element

  • Enter the total number of post-operative days in either the:
    • Days or units field, Loop 2400, SV1, 04 (03=UN)
    • Narrative Loop 2300 or 2400, NTE, 02
  • Enter the date(s) the post-op care was assumed and/or relinquished in either:
    • Loop 2300, DTP/90, or 91, 03
    • Narrative Loop 2300 or 2400, NTE, 02
  • Enter the date the surgical procedure was performed as the date of service  

As a reminder, claims that are rejected with remittance message MA130 should be corrected and resubmitted as new claims. Rejected claims do not have appeal rights. Reopening and redeterminatation requests received for rejected claims will be dismissed.  

Last Reviewed: 1/20/2022

The Multi-Carrier System (MCS) requires the functional (pricing) modifier to be placed in the first modifier field in order to process the claim correctly. To avoid processing delays, informational (statistical) modifiers should follow the functional modifier. 

The following is a list of functional modifiers recognized by MCS: 

HCPCS Modifiers
CPT Modifiers
AA
22
AD
26
AS
50
KD
51*
QK
52
QX
53
QY
54
QZ
55
TC
62
 
66
 
73
 
74
 
78
 
80
 
81
 
82

*We strongly recommend that you do not submit this modifier to Palmetto GBA. Palmetto GBA will apply this modifier to indicate when special pricing rules have been used to calculate the reimbursement.

Please refer to the Palmetto GBA Modifier Lookup under Tools tab at the top of the page for more information about each modifier.

Last Reviewed: 1/20/2022

For all services paid under the Medicare Physician Fee Schedule (MPFS), with two exceptions, the place of service (POS) code to be used by the physician and other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. In cases where the face-to-face requirement is obviated, such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test from a distant site, the POS code assigned by the physician/practitioner will be the setting in which the beneficiary received the technical component of the service.

The two exceptions to this general rule are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus or on campus).

Resources

  • IOM 100-04, Claims Processing Manual, Chapter 13 (PDF), Section 150 
  • IOM 100-04, Claims Processing Manual, Chapter 26 (PDF), Section 10.6

Last Reviewed: 1/20/2022

After additional reviews, Palmetto GBA has modified guidance regarding documentation requirements for assistants at surgery or surgical assistants (billed with HCPCS modifier AS and CPT modifiers 80, 81 or 82).

To bill for an assistant at surgery or surgical assistant, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant. Contractors that request the operative report in order to process the assistant’s claim will deny claims if there is no accounting by the surgeon for what was performed by the assistant.

Last Reviewed: 1/20/2022

There are guidelines for cardiac pacemakers and implantable automatic defibrillators in the Medicare National Coverage Determinations (NCD) Manual. It contains guidelines for single and dual-chamber pacemakers and implantable automatic defibrillators.

Resource: The CMS Medicare National Coverage Determinations Manual (Pub. 100-03) (PDF, 608 KB), Chapter 1, Part 1, 20.4 for Implantable Automatic Defibrillators and 20.8 for Cardiac Pacemakers.

Last Reviewed: 1/20/2022

There are two reasons your service may be denied, even though you submitted it with CPT modifier 59.

The most common reason is that you submitted CPT modifier 59 with the "Column I" code instead of the "Column II" code.

  • Codes are bundled in pairs. The primary code is a Column I code, and the component code is a Column II code. The CCI edit list shows which codes are in which columns.
  • If documentation in the patient’s medical record supports the use of CPT modifier 59 for your code pair (containing a Column I and Column II code), the CPT modifier must be submitted with the Column II code only 
  • If you submit CPT modifier 59 with the Column I code instead, the service may still be denied
  • Check the columns before submitting CPT modifier 59 to ensure that you are submitting it with the component (Column II) procedure

You may also have received a denial because the code pair cannot be unbundled. 

  • Code pairs identified with indicator "0" in the CCI list cannot be submitted separately for reimbursement under any circumstances. There are no exceptions to the CCI edits for indicator "0" codes.
  • Code pairs identified with indicator 1 may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter; different procedure or surgery; different site or organ system; separate incision/excision; or separate lesion or injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. Documentation must be maintained in the medical record to support the use of this modifier. No special documentation is required with the claim when CPT modifier 59 is submitted.
  • Code pairs identified with indicator 9 are not subject to CCI edits. No modifier is required in these situations.
  • Check the indicator for the CCI code pair before submitting CPT modifier 59

Resource: CMS National Correct Coding Initiative web page.

Last Reviewed: 1/20/2022

The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. Claims on the payment floor are in the waiting period for payments to be released. The dollar amount given by the IVR for payment floor claims is the total amount of allowed charges for those claims that have had a claim determination made on them but still in the waiting period for payment to be issued.

It is possible for the number of claims on the payment floor and dollar amount for those claims to change each day as new claims are submitted, a claim determination made which adds those claims to the payment floor while other claims complete through for payment and are removed from the payment floor.

The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. The payment floor represents the earliest date contractors may release payment for a completed clean claim. 

Reference: Publication 100-04, Chapter 1, Section 80.2.1.2 (PDF, 1.62 MB).

Last Reviewed: 1/20/2022

It would not be appropriate to use the UB code as a guide for Part B physician or nonphysician practitioner billing for observation services. Part A and Part B billing instructions may be different. The Internet Only Manual Publication 100-4, Chapter 12, Section 30.6.8 specifically states observation services, "include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital." While it is true that medical documentation should clearly indicate the official "status" of the patient at the facility (i.e., inpatient, observation, or emergency department) billing guidelines for Part B also relate to the length of time the patient is in observation status as well as whether they are discharged or admitted as an inpatient when selecting the CPT code billed by the Part B provider.

When a patient is admitted as an inpatient from observation status, CMS has clear guidelines regarding how the Part B provider should bill. In Internet Only Manual Publication 100-4, Chapter 12, Section 30.6.8, CMS makes no reference to the UB bill code but places an emphasis on the patient’s length of time in observation and whether the patient was admitted as an inpatient or discharged. Below is a portion of the CMS Internet Only Manual that provides further guidance on Part B billing for observation services. Providers may find additional valuable information in the other sections if this manual.

Resource: Internet Only Manual Publication 100-4, Chapter 12, Section 30.6.8 (PDF, 1.19 MB).

Section D: Admission to Inpatient Status Following Observation Care
If the same physician who ordered hospital outpatient observation services also admits the patient to inpatient status before the end of the date on which the patient began receiving hospital outpatient observation services, pay only an initial hospital visit for the evaluation and management services provided on that date. Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service. The physician may not bill an initial observation care code for services on the date that he or she admits the patient to inpatient status. If the patient is admitted to inpatient status from hospital outpatient observation care subsequent to the date of initiation of observation services, the physician must bill an initial hospital visit for the services provided on that date. The physician may not bill the hospital observation.

Last Reviewed: 1/20/2022

The CMS Medicare Beneficiary Identifiers (MBIs) web page is a great resource for additional information.

Last Reviewed: 1/20/2022

All services performed (by any provider) within a patient's hospice period must be submitted with one of the following hospice HCPCS modifiers:

  • GW — Service not related to hospice patient’s terminal condition
  • GV — Attending physician not employed or paid under arrangement by the provider's hospice provider

In this case, HCPCS modifier GW should be submitted.

Last Reviewed: 1/20/2022

The Centers for Medicare & Medicaid Services (CMS) requires contractors to offer self-service and electronic communication technologies as efficient, cost-effective means of disseminating Medicare provider information, education and assistance. Our Interactive Voice Response (IVR) System is an important self-service tool available to providers for obtaining a wide variety of information, including claim status, beneficiary eligibility and deductible information. CMS Internet Only Manual (IOM) Publication 100-09, Chapter 6, Section 50.1 states:

"Contractors shall require providers to use the IVR to access claims status, beneficiary eligibility and remittance advice notices. Provider telephone CSRs are not intended to answer questions that can be answered through the IVR; they shall refer or transfer callers to the IVR when such questions arise."

Another option is to use the eServices, our free Internet-based, provider self-service portal. The eServices application provides information access over the web for the following online services: 

  • Eligibility
  • Claims Status
  • Remittances Online
  • Financial Information (amount "approved to pay" and last three checks paid)

You can participate in eServices if you have a signed electronic data interchange (EDI) enrollment agreement on file with Palmetto GBA. If you are already submitting claims electronically, you do not have to submit a new EDI enrollment agreement.

Access eServices by selecting "eServices" at the top of this web page.

Resource: For additional information on CMS guidelines for Provider Contact Centers, refer to the CMS Beneficiary and Provider Communications Manual, Pub. 100-09, Chapter 6, Section 50.1 (PDF, 1.32 MB).

Last Reviewed: 1/20/2022

In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered Skilled Nursing Facility (SNF) stay be included in a bundled prospective payment made through the fiscal intermediary to the SNF. These bundled services had to be billed by the SNF to the fiscal intermediary (FI) in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in a Part A covered SNF stay, which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board is not.

For Medicare beneficiaries in a non-covered stay, only therapy services are subject to consolidated billing. All other covered SNF services for these beneficiaries can be separately billed to and paid by contractors or FIs.

Medicare recovery letters will contain a spreadsheet identifying the patients and claims that are included in the SNF consolidated billing overpayment.

Reference: The CMS SNF Consolidated Billing web page.

Last Reviewed: 1/20/2022

There may be many reasons as to why the code is not listed.

  • The code may be priced on a fee schedule other than the MPFS. Check the other fee schedules, if appropriate, to locate the reimbursement amount.
  • The code may be designated as "contractor priced" in the MPFS, which means that the MPFS will not contain a fee schedule amount
  • The Centers for Medicare & Medicaid Services (CMS) establishes reimbursement amounts for many procedures through various fee schedules and other pricing methodologies. Medicare contractors, however, have the authority to determine reimbursement for some services. These codes are designated as status C in the Medicare Physician Fee Schedule Database (MPFSDB). These services are known as contractor priced procedures. Contractors will establish relative value units (RVUs) and payment amounts for these services, generally on an individual case basis following review of documentation such as an operative report.
  • If Palmetto GBA can establish reimbursement for individual contractor priced procedures, these reimbursement procedures will be listed on our website:
    • Select Topics, then select Fee Schedules
    • For contractor priced procedures, Palmetto GBA determines the reimbursement amount based on the complexity or variable nature of the procedure and payment will be determined on the documentation submitted with the claim

Last Reviewed: 1/20/2022

The Centers for Medicare & Medicaid Services (CMS) requires providers to use the Palmetto GBA eServices portal or the Interactive Voice Response (IVR) system to access claim status and beneficiary eligibility information.

The Palmetto GBA eServices portal provides additional tools to assist the provider community. Review the eServices User Guide (PDF, 8.33 MB) to learn about available eService functions.

The process of using these tools allows Palmetto GBA to meet CMS requirements and our customer service representatives (CSRs) to assist callers with more complex inquiries which cannot be answered through the above-mentioned self-service tools.

Resources

CMS Reference
CMS Internet Only Manual, Publication 100-09, Chapter 6, Section 50.1 (PDF, 1.32 MB), "Providers shall be required to use IVRs to access claim status and beneficiary eligibility information. CSRs shall refer providers back to the IVR if they have questions about claims status or eligibility that can be handled by the IVR... Each MAC has the discretion to also require that providers use the Internet-based provider portal for claim status and eligibility inquiries if the portal has these functionalities."

Last Reviewed: 1/20/2022





Claims Articles


Last Updated: 01/20/2022