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Printed Date: 9/22/2015
Question: Why is my claim being reduced because another surgery was done on the same day?
Answer: This can happen when multiple surgical procedures are performed by a single physician or physicians in the same group practice, on the same patient, at the same operative session or on the same day for which separate payment may be allowed.
Multiple surgery adjustments are made in order to arrive at the final fee schedule amount. Details regarding multiple surgeries, how to determine if surgeries are applicable to the multiple surgery payment rule, payment information and important reminders are outlined in the Palmetto GBA Multiple Surgeries on the Same Day article.
Question: How do I know if my surgical CPT® code requires prior authorization?
Answer: The Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) process and requirements for certain hospital outpatient department (OPD) services.
A full list of codes requiring OPD PA (PDF, 119 KB) is available on the CMS website.
Question: How can I obtain my PTAN (provider transaction account number) in PECOS (Provider Enrollment, Chain and Ownership System)?
Answer: The Provider Enrollment, Chain and Ownership System (PECOS) is the most efficient way to find a PTAN. Follow these steps to find PTANs in PECOS.
Question: What is a Medically Unlikely Edit (MUE)?
Answer: A Medically Unlikely Edit (MUE) for a specific HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE and CMS does not publish all MUEs. Nonpublished MUEs are not releasable by CMS or the Medicare Administrative Contractor. MUEs are adjudicated as claim line edits or date of service edits. The type of MUE edit is noted on the published MUE file.
See Medically Unlikely Edits on the CMS website.
Question: What are the therapy caps for 2021?
Answer: Therapy thresholds, formerly referred to as therapy cap amounts, are thresholds above which outpatient physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record. There is one threshold amount for PT and SLP services combined and a separate threshold amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI).
For CY 2021, the KX modifier threshold amounts are:
Resource: MLN Article 12014 “2021 Annual Update of Per-Beneficiary Threshold Amounts” (PDF, 147 KB).
Question: My claim denied due to timely filing. Can I file an appeal for my claim?
Answer: If an appeal request is filed late, the time period may be extended for filing a redetermination if good cause can be shown. These extensions are not routinely granted. It is important to provide detailed supporting documentation if requesting an extension of this time limit.
There are only four exceptions that may be considered when a redetermination is submitted past the time limit for filing the appeal.
If your claim does not fall within one of the above categories, or you do not provide the necessary supporting documentation, filing an appeal for timely filing will not change the outcome of the timely filing decision, although you have the right to file an appeal of the timely filing decision if you disagree..
Question: Why am I unable to get the status of a second level appeal, (reconsideration) when I call the Provider Contact Center?
Answer: Reconsiderations are conducted by a qualified independent contractor (QIC). Generally, the QIC will send their decision to all parties within 60 days of receipt of the request for reconsideration. If a provider has not received any correspondences regarding their reconsideration (second level appeal), you must contact the QIC, C2C Innovative Solutions at (904) 224–2613 for details. Palmetto GBA does not have access to the status of the QIC’s reconsideration determinations.
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Last Updated: 01/25/2021