Part A Ask the Contractor Teleconference (ACT) Questions and Answers: August 11, 2021

Published 09/09/2021

Areka Freeman, POE Senior Provider Relations Representative
Judy Brown, POE Senior Provider Education Consultant
Wendy Weary, Supervisor, Provider Outreach & Education 

Areka Freeman welcomed participants to the Ask the Contractor Teleconference (ACT). The ACT is intended to open the communication channels between the provider community and Palmetto GBA. We believe this is an excellent forum to encourage dialogue between our providers and Palmetto GBA. Prior to the call, an announcement was sent out via listserv and posted on the Palmetto GBA website.

Areka Freeman advised that Palmetto GBA has implemented an Innovation to Improve Beneficiary Care Deficits Initiative Pilot. This is primarily a Part B project to increase Annual Wellness Visits and Annual Depression Screenings in professional practices. There are two related articles published on the JJ/JM B websites: Annual Depression Screening: HCPCS Code G0444 and Cardiovascular Disease and Intensive Behavioral Therapy.


Areka Freeman addressed the first question.

Question: Our hospital just completed a FY2016 audit with NGS and the auditor posed an adjustment removing all indigent bad debt for the following reasons: Provider did not consider all expenses, only medical expenses in determination. The adjustment is a bottom-line impact of 700k for one year to our hospital. In the past, having an intermediary background, auditors were to consider provider's intent and material impact. The hospital is following current policy and have agreed to update to incorporate all expenses. At a time when hospital volumes have been materially impacted by COVID, why are intermediaries allowed to pose such harsh adjustments, instead of a management letter to allow organizations time to update policies to reflect the most recent update from CMS clarifying acceptable indigency support?

Answer: CMS' recent clarification regarding indigent bad debts is consistent with Palmetto GBA's long-standing practice. Palmetto GBA has historically required consideration of all expenses when determining the indigency of a patient. The review process has not changed with the clarification from CMS. Each audit is reviewed independently and specific concerns with the audit staff's handling of the audit or discussions and notifications of pending adjustments, particularly when the adjustments will have a material reimbursement impact, can be forwarded to JM Audit management.

Areka Freeman addressed the second question.

Question: My question is regarding a reopening request to repay an original claim adjusted but was rejected. We are having a difficult time particularly with rejection C7800, where the reopening was rejected, and the provider is submitting the claim with the original information in the hope to get back that original payment for the claim. This is something not out of the ordinary. Has anything changed, is there a publication available to educate our providers to help minimize this issue?

Answer: Claim has been Rejected due to the beneficiary began a home health episode within three days of discharge from inpatient care. Resolution: When an inpatient hospital discharges a patient to be under the care of a home health agency (HHA) within 72 hours of discharge; a patient status code 06 is billed on the claim to Medicare. Condition Code 42 may be used to indicate that the care provided by the HHA is not related to the Hospital Care and therefore, will result in payment based on the MS-DRG and not a per diem payment. Condition Code 43 may be used to indicate that Home Care was started more than three days after discharge from the Hospital and therefore payment will be based on the MS-DRG and not a per diem payment.


  • SE1411 (PDF, 787 KB) — Clarification of Patient Discharge Status Codes and Hospital Transfer Policies
  • Reason Code C7800

Areka Freeman addressed the third question.

Question: Revenue code 131 and 141 question. The beneficiary goes to the hospital lab to have blood drawn for their wellness visit, ordered by their family physician and on the same day has outpatient service that also has labs ordered by the orthopedic surgeon. The outpatient claim denied as a duplicate. My question is should this have denied since it was 2 different physicians and 2 different unrelated diagnosis codes.

Answer: You pay nothing for this visit if your doctor or other qualified health care provider accepts assignment. The Part B deductible doesn’t apply. However, you may have to pay coinsurance, and the Part B deductible may apply if: Your doctor or other health care provider performs additional tests or services during the same visit. These additional tests or services aren't covered under the preventive benefits.

Areka Freeman addressed the fourth question.

Question: NCD 20.34 has had two common diagnosis codes removed from the covered diagnosis listing I48.2 (chronic atrial fibrillation unspecified) and I48.1 (persistent atrial fibrillation) per CR11491. Diagnosis code I48.11 (longstanding persistent atrial fibrillation), I48.19 (other persistent afib), and I48.21 (permanent afib) were added. There are disputes among the coders and physicians that this verbiage is subjective and chronic vs longstanding can mean the same thing. Can you offer explanation of the rationale for removing these diagnosis codes resulting in denials of the claims? Is there in recourse to appeal these claims with a successful overturn of the denial or are claims simply going to be denied based on the diagnosis code and not the medical necessity?

Answer: NCDs are determined by CMS and not at the MAC level. Both the diagnosis code and medical necessity play a role in a claim being denied or paid. For specific claim information, we ask that you have that claim information and contact our PCC. If you have more than 20 claims that had been impacted this way, you can also call the PCC to schedule a direct meeting with the concierge team so that those claims can be reviewed with you.

Areka Freeman addressed the fifth question.

Question: NCD 20.34 refers to coverage of NVAF (non-valvular atrial fibrillation). Can you provide clarification on this and what it referred to as a valvular or non-valvular atrial fibrillation? Typically, atrial fibrillation is referred to a paroxysmal, chronic, persistent or permanent.

Answer: There is a difference between the two, valvular Afib is seen in individuals that have a heart valve disorder or they may have a prosthetic heart valve, whereas non-valvular Afib (NVAF) is caused by other things such as hypertension and/or stress. That's why it's very important to include such things in documentation to show and support medical necessity. 

Judy Brown addressed the sixth question.

Question: When the patient has Medicare on the date of service, but then has Medicare Advantage for the remaining of the stay; Who is responsible? Example: The patient comes in the emergency department (ED) on April 30, 2021, stays for observation and is not discharged until May 2, 2021. Is Medicare responsible for the entire stay or only the April 30, 2021 date of service?

Answer: in following the example given, it sounds like the patient presented to the emergency room on April 30th under original Medicare, in which Medicare Part B would pay for the emergency room visit. Then whenever the patient became eligible covered for health on a Medicare Advantage, they would then pay for the observation or inpatient status. Now, this depends upon when the date and time this physician wrote the order for the change in status. So, in other words, it’s basically what are they covered for health under which one. If they’re Medicare Advantage for emergency department, then that would be Medicare Advantage will pay because they cover – they have both A and B included under Medicare Advantage. If they were original Medicare only, then Part B would pay for the emergency room visit but being there to look at the doctor’s order, see the date and time when he changed the status to observation for that question number seven and then in question eight for inpatient status. If they are under the original, original will pay out of Part A for inpatient status. Once they became eligible under Medicare Advantage, then they would – you can bill Medicare Advantage for the observation and/or for the inpatient hospitalization.

Areka Freeman addressed the seventh question.

Question: A provider has multiple Patient Driven Payment Model (PDPM) Pricer issues back to October, November, and December 2019 claims continue to return with reason code 31258. Please Advise.

Answer: This information can be found on the MLN Matters MM11727. And the guidance is per the reason code, the provider cannot change the HIPPS code after 120 days. If the problem is the skilled nursing facility PDPM timing, that’s a different issue. The HIPPS code would change, and the provider should be able to adjust. Please note, that individual claims may be reviewed with the Provider Contact Center for exact details. 

Areka Freeman addressed the eight question.

Question: I have a question on how to make corrections to a claim where Medicare has taken their money back 4 years later due to incorrect discharge disposition. The scenario I have is an inpatient account for 2017 and Medicare recouped their payment on August 2, 2021. There is nothing stating that is was due to an audit or Recovery Audit Contractor. How do I correct the discharge disposition with the claim being past timely filing.

Answer: For claims that are beyond the claim filing timeframes (or within one to four years of the date of the initial determination), a "reopening" may be submitted using the direction in MLN Matters® Number: SE1426. Generally, reopenings are written requests for corrections that include supporting documentation and a remedial action taken to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. The reopening request (TOB xxxQ) should only be utilized when the submission falls outside of the period to submit an adjustment bill.

Areka Freeman answered the ninth question.

Question: My payments for my Medicare Part A claims have not matched what my billing system generates. I know there is an issue with this (CR 11992). This was supposed to be corrected on May 4, 2021; however, my payments still do not match my expected payment. I called the Provider Contact Center was advised to send in a corrected claim. I sent in one claim to see it the payment would be adjusted, but the claim was paid exactly as it was the first time. Has this problem been resolved and if so, how does a facility address getting their claims paid correctly?

Answer: CR 11992 implements changes to the SNF Prospective Payment System (PPS), specifically implementing changes required for the PDPM. SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X (subject to SNF PPS) will be subject to these requirements. The CR modifies processing and the Medicare Claims Processing Manual, Chapter 6, to adhere to current policy. The revised text in both Sections 40.3.2 and 40.6 of Chapter 6 of the Manual reads: “For claims that contain both covered days and noncovered days, and those noncovered days are the responsibility of the beneficiary (e.g., days submitted for noncovered level of care), the provider should append span code 76 to indicate the days the beneficiary is liable.” MLN Matters: MM11992 Related CR 11992 Page 2 of 2 This change modifies existing editing to process and pay claims correctly accounting for SNF interrupted stays that are reported at the end of a month effective October 1, 2019. A SNF interrupted stay is identified as follows:

  • TOB = 21X or 18X (excluding CAH); and
  • Occurrence Span Code (OSC) 74 equal to 3 days or less; and 
  • Date of Service (DOS) 10/1/2019 or late

Resource: MM11992 (PDF, 175 KB).

Areka Freeman answered the tenth question.

Question: According to the CMS Newsroom article entitled, CMS Opens National Coverage Determination Analysis on Treatment for Alzheimer’s Disease, it states, "Currently, coverage determinations for aducanumab are being made at the local level by Medicare Administrative Contractors who represent 12 jurisdictions across the country". How will our local contractor adjudicate claims submitted for the newly FDA approved Alzheimer's medication aducanumab, until such time as the coverage and analysis group issues a national coverage determination?

Answer: Palmetto GBA will use the “Full Prescribing Information” and evidence communicated via the FDA label to guide claim adjudication for aducanumab. Providers should use the selection criteria included in Section 14 (“Clinical Studies”) of the aducanumab product label to guide their patient selection. If aducanumab claims were selected for record review, the record review would utilize the labeled indication and evidence contained in Section 14 as important factors in the review process.

Areka Freeman answered the eleventh question.

Question: When there is a 935 adjusted claim on file with Medicare and the provider needs to submit a correction or cancel a claim for this encounter, what is the process for cancelling or correcting these? As we have encounters where we have attempted submitting corrections with both the original Document Control Number (DCN), as well as the DCN for the 11H Type of Bill (TOB) that Medicare generated in DDE, and neither were accepted when we submitted claims for corrections. 

Answer: Providers are required to refund the overpayments following receipt of a demand letter. Failure to repay within 30 days will result in the accrual of interest, and for 935-eligible overpayments, such as RAC adjustments, recoupment does not commence until day 41. A breakout of the offset is not available. Offsets are applied to the oldest overpayment. In order to avoid offset, the provider may submit a check for any Recovery Audit Contractor claims or claims subject to 935. In order to avoid offset, the check must be received and applied within 30 days of the date of the demand letter. There will be no difference on the adjustments/remittance advices for automated/complex reviews. These are the methods used by the Recovery Audit Contractor to identify claims to adjust. Once it is determined that an adjustment is necessary, the adjustment will flow and appear on the RA as it has in the past. The only difference is the new remark code to identify the adjustment was initiated by the Recovery Audit Contractor. Additionally, the adjustment will not immediately offset since it is subject to 935 limitation of recoupment. If the adjustment is a Recovery Audit Contractor 935 adjustment, it usually takes 41 days before the money would collect on an remittance advice. It takes the same length of time for the money to adjust on the Provider and Statistical Reimbursement (PS&R). 

Reference: Frequently Asked Questions: Recovery Audit Contractor

Areka Freeman answered the twelfth question.

Question: An Indirect Medical Education (IME) claim is submitted under a patient’s Medicare Beneficiary’s Identifier (MBI) number. Upon attempting to cancel the claim, the 118 TOB submission rejects, stating original DCN could not be found; after confirming the DCN was correct on the cancel bill, query in DDE for claims and nothing pulled up under the MBI for DOS; however, when searched under the old Medicare ID, the claims for this DOS populated on the DDE Claims Search Screen, and further, all these claims show the patient's MBI under the member ID on the claims. The question here is why is our claim not being accepted with the correct MBI present, and why would Medicare's Direct Data Entry (DDE) system show a member's claims under their old Medicare number instead of the MBI?

Answer: Requests to change a Medicare Beneficiary Identifier (MBI) can occur if a Medicare beneficiary, their authorized representative, or CMS suspects a number is compromised. If CMS reissues MBIs, it is possible your patients will seek care before receiving a new card with their new MBI. Your patient’s MBI may have changed if you receive an eligibility transaction error code (AAA 72) of “invalid member ID,” or the eServices Eligibility Inquiry message, “The beneficiary you requested cannot be found. Please verify your information.” When an MBI changes, the beneficiary is advised to share the new MBI with their providers. If you cannot obtain the new MBI from the patient, you can get it from the eServices MBI Lookup Tool. Sign up for eServices now to use the tool. Instructions for using the MBI Lookup Tool can be found in the eServices User Manual. The Provider Contact Center cannot disclose the new MBI.

Areka Freeman answered the thirteenth question.

Question: Does this apply when the encounter changes from emergency to a different outpatient encounter? A claim has been returned twice with reason code W7098 — claim with pass-through device, drug or biological lacks required procedure. The first submission had an error that was corrected before the second submission. The edit information I see indicates that the W7098 edit does not apply when an inpatient only HCPCS/CPT-4 code is present with a CA modifier.

Answer: Go to the CMS Skilled Nursing Facility (SNF) Consolidated Billing website. CMS identified specific types of outpatient hospital services that are so exceptionally intensive, costly, or emergent that they fall well outside the typical scope of SNF care plans. CMS has excluded these services from SNF CB as well (along with those medically necessary ambulance services that are furnished in conjunction with them). These excluded service categories include:

  • Cardiac catheterization;
  • Computerized axial tomography (CT) scans;
  • Magnetic resonance imaging (MRIs);
  • Ambulatory surgery that involves the use of an operating room;
  • Emergency services;
  • Radiation therapy services;
  • Angiography; and
  • Certain lymphatic and venous procedures.
  • Chemotherapy items and their administration;
  • Radioisotope services; and
  • Customized prosthetic devices.

Reference: Please feel free to view the Part A Skilled Nursing Facility (SNF) Consolidated Billing Overview webinar dated June 29, 2021.