Palmetto GBA is publishing the following Frequently Asked Questions (FAQs) based upon data analytics identifying topics generating a high volume of telephone inquiries between April 1, 2019, through June 30, 2019. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).
JMA Highest Inquiry Categories, April 1 through June 30, 2019. RTP/Status 7,482. Financial 1,076. Denials/Rejects 6,519. Appeals 1,230. General 3,257. Billing 1,494.

  • RTP/Status 7,482
  • Financial 1,076
  • Denials/Rejects 6,519
  • Appeals 1,230
  • General 3,257
  • Billing 1,494

JJA Highest Inquiry Categories, April 1 through June 30, 2019. RTP/Status 10,328. Financial 1,189. Denials 8,088. Appeals 1,331. General 2,345. Billing 1,424.

  • RTP/Status 10,328
  • Financial 1,189
  • Denials 8,088
  • Appeals 1,331
  • General 2,345
  • Billing 1,424

FAQs Related to Highest Inquiry Categories

Question: How often is the hospital required to complete the MSPQ for recurring outpatient services?

Answer: Hospitals must collect MSP information from the beneficiary or his representative for hospital outpatients receiving recurring services. Both the initial collection of MSP information and any subsequent verification of this information must be obtained from the beneficiary or his representative.

  • Following the initial collection, the MSP information should be verified once every 90 days
  • lf MSP information collected by the hospital from the beneficiary or his representative is no older than 90 calendar days from the date the service was rendered, then that information may be used to bill Medicare for recurring outpatient services furnished by hospitals

Note: This policy, however, will not be a valid defense to Medicare's right to recover when a mistaken payment situation is later found to exist. Hospitals must be able to demonstrate that they collected MSP information that is no older than 90 days from the beneficiary or his representative, when submitting bills for their Medicare patients. Acceptable documentation may be the last dated update of the MSP information, either electronic or hard copy. Please refer to: CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 3, 20.1 (PDF, 243.7 KB).

Question: Please explain condition code 08 in more detail.

Answer: Condition Code 08 is used when a beneficiary actively refuses to give other health information. Use this code along with remarks to indicate refusal to supply other insurance information. Submit the claim as Medicare primary. Condition Code 08 alerts the Benefits Coordination & Recovery Center (BCRC) to develop for other insurance information, including contacting the beneficiary.

Question: On many of our outpatient hospital claims we are receiving reason code W7062, which means “code not recognized by OPPS; alternative code for same service may be available.” Is there any coding guidance for this?

Answer: Outpatient Prospective Payment System (OPPS) guidance concerning alternate codes is available on the CMS Hospital Outpatient PPS webpage. Coding guidance and resources are available on the HCPCS Coding Questions page on the CMS HCPCS Coding Questions webpage.

Question: When is uncorrected return to provider (RTP) claims purged from the Fiscal Intermediary Standard System (FISS)?

Answer: Return to provider (RTP) claims purge after 180 days. Suppress view claims are removed from FISS Claim Correction, but are not removed from the Claim Count Summary in FISS.

Note: The 180-day count begins on the last date of access to the RTP claim under Claims Correction in Direct Data Entry (DDE).

Question: I contacted a Skilled Nursing Facility (SNF) to ask them to update the patient status on their claim. The SNF stated since the patient's benefits are exhausted, they are not responsible for paying the services. What can be done?

Answer: Determine if the services were provided during the covered period of the SNF Part A stay or after the benefits exhausted, since consolidated billing rules may or may not apply. The SNF is required to bill "benefits exhaust" and/or "no pay" claims until the patient is discharged from the facility. To bypass Medicare edits, re-file a corrected claim after the SNF has submitted or corrected their claims. In addition, it is recommended that you work with the SNF to help determine if the patient's services were provided during the covered or non-covered portion of the stay and for claims resolution since timely filing rules apply. You may refer to the following scenarios for guidance.

  • Services were provided during SNF covered Part A Stay
    • SNF consolidated billing rules apply
  • Services were provided after benefits exhausted
    • SNF is only responsible for billing physical, occupational, and speech therapy services
    • All other services may be billed directly to the Medicare Administrative Contractor (MAC)
  • Services were provided after patient was discharged
    • All services may be billed directly to the MAC

Question: What is an Accountable Care Organization (ACO)?

Answer: An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to their Medicare patients. Participating in an ACO is purely voluntary for providers. If you have claims that are subject to the ACO and being reduced providers need to verify within their facility whose authorized participation in the program. Further information is available on CMS website.

Question: How does a provider identify ACO processed claims?

Answer: In Direct Data Entry (DDE) on page 1, providers will see the following value codes that are populated on ACO claims:

  • Q0 — Accountable Care Organization Reduction
  • Q1 — ACO Payment Reduction

These value code amounts will appear as the amount in which the payment has been reduced based on agreements the provider has with their designated ACO.HHH Highest Inquiry Categories, April 1 through June 30, 2019. RTP/Status 5,891. Financial 2,545. Denials 6,905. Appeals 656. General 3,852. Billing 1,470

  • RTP/Status 5,891
  • Financial 2,545
  • Denials 6,905
  • Appeals 656
  • General 3,852
  • Billing 1,470

FAQs Related to Highest Inquiry Categories

Question: Does the patient meet home health homebound criteria if the statement by the physician indicates that they are “medically restricted,” “immune-compromised' or at “high risk of infection,” or would the statement still need to indicate that the patient needs assistance of another person/device to exit the home?

Answer: None of the statements, including “patient needs assistance of another person/device to exit the home” are sufficient to support the beneficiary's homebound status. The face-to-face documentation must explain specifically why the findings from the encounter support the beneficiary's homebound status.

Question: Does the face-to-face (FTF) encounter documentation need to be completed every time a patient is recertified, or only the first time they are admitted to a home health agency?

Answer: The home health FTF encounter is only mandated at the Start of Care, not upon each recertification as explained in CMS' MLN Matters SE1436 (PDF, 502.18 KB). An FTF encounter is only required if there is a new Start of Care OASIS.

Question: What if the hospice face-to-face (FTF) is not completed prior to the start of the third or later hospice benefit period?

Answer: If the FTF is not completed timely (prior to, but no more than 30 calendar days prior to the third benefit period recertification and every benefit period recertification thereafter), the patient would cease to be eligible for the Medicare hospice benefit (unless one of the exceptional circumstances was met) and the hospice must discharge the patient from the Medicare hospice benefit. In these cases, CMS expects the hospice to continue to care for the patient at the hospice's own expense until the required encounter occurs. The hospice can readmit the patient to the Medicare hospice benefit once the required FTF encounter occurs, provided the patient continues to meet all of the eligibility criteria and the patient (or representative) files an election statement as required by Medicare. For more information, refer to Change Request 7478 (PDF, 292.12 KB).

Question: What documentation is required for the face-to-face (FTF) encounter if the claim is selected for Medical Review?

Answer: The hospice physician/NP that completes the FTF must attest in writing that he/she completed the FTF encounter with the patient, and include their signature and the date of the encounter. When the hospice NP performs the FTF, the attestation must also state that the clinical findings were provided to the certifying physician to determine the terminal status of the patient. The clinical findings of the face-to-face encounter are used in the narrative associated with the third benefit period recertification and every subsequent recertification to provide an explanation of why the clinical findings of the FTF encounter support a life expectancy of six months or less. Please refer to the CMS Medicare Benefit Policy Manual, Ch. 9, §20.1 (PDF, 639.74 KB).

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