July 28, 2008
3rd Quarter 2008 Part B Customer Service Frequently Asked Questions
- What are MUEs?
The CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a 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. All HCPCS/CPT codes do not have an MUE. Implemented January 1, 2007 the MUE is utilized to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs. Complete information, including frequently asked questions concerning MUEs, can be accessed on the CMS web site at www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp.
- My patient has a Medicare HMO, how do I find out which
plan they are under?
When checking patient eligibility on the IVR system, an option is given to verify if the Medicare beneficiary is enrolled in a Medicare HMO. A complete listing of the Medicare Advantage Plans is maintained and updated through CMS. You may access this list of the Health Maintenance Organizations on the CMS web site at www.cms.hhs.gov/MCRAdvPartDEnrolData/EP/list.asp. In the left side menu bar, please select "MA Plan Directory."
- Why did my claim deny for timely filing?
Payment may be made for services from October 1, 2006, through December 31, 2006, if the claims are submitted before December 31, 2008. Also, services performed on January 1, 2007, must be submitted before December 31, 2008.
The timeframe established for claim submission was published by the Centers for Medicare and Medicaid Services (CMS) Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 70. This may be accessed at www.cms.hhs.gov/manuals/downloads/clm104c01.pdf. Below, you will find a relevant portion of the excerpt.
70 - Time Limitations for Filing Provider Claims to Fiscal Intermediaries and Carriers
Medicare regulations at 42 CFR 424.44 defines the timely filing period for Medicare fee-for service claims. In general, such claims must be filed on, or before, December 31 of the calendar year following the year in which the services were furnished. (See section §70.7 below for details of the exceptions.) Services furnished in the last quarter of the year are considered furnished in the following year; i.e., the time limit is the second year after the year in which such services were furnished...
Timely Filing Limit Date of Service in: Jan Feb Mar Apr May June Timely Filing Date: Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 1 Year Months to File: * 23 22 21 20 19 18 Timely Filing Limit Date of Service in: July Aug Sept Oct Nov Dec Timely Filing Date: Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 1 Year Dec. 31 of the Service Year Plus 2 Years Dec. 31 of the Service Year Plus 2 Years Dec. 31 of the Service Year Plus 2 Years Months to File: * 17 16 15 26 25 24 - The number specified in the "Months to File" represents the number of full months remaining after the month in which the service was rendered.
- Which HCPCS codes are accepted by Medicare?
CGS does not publish a listing of HCPCS (Health Care Procedure Coding System) codes payable by Part B Medicare. However, the National Level II Medicare Codes that are accepted and billable for Part B physicians and suppliers can be found in the current HCPCS Code Book. Complete information and guidelines for the acceptance and use of HCPCS codes can be found in Chapter 23 of the Medicare Claims Processing Manual. This information can access on the CMS web site at www.cms.hhs.gov/Manuals/IOM/list.asp.
- What can physicians bill to Part B for SNF services?
Services rendered to a Medicare beneficiary in Skilled Nursing Facility (SNF) under a covered Part A stay, falls under the Consolidated Billing guidelines. These g uidelines including a section titled "Skilled Nursing Facility Consolidated Billing" can be found on the CMS web site. The afore mentioned section gives helpful information, including a listing of procedure codes excluded from Consolidated Billing that are billed to the carrier by the physician for consideration. The tabs for this section will show annual updates for these excluded codes and services. A complete listing of all procedures codes billable to the carrier can be found under files "Part A Stay-Physician Services" and "Part A Stay-Professional Components of Services to be Submitted with a 26 Modifier". This information can be accessed at www.cms.hhs.gov/SNFConsolidatedBilling/.
- Can an ASC use the 50 modifier for billing bilateral
surgery procedures?
A procedure performed bilaterally in one operative session is reported as two procedures, either as a single unit on two separate lines or with "2" in the unit field on one line. The 50 modifier is not appropriate for ASC billing. Please refer to Chapter 14 of the Medicare Claims Processing Manual on the CMS web site for complete guidelines and information. (www.cms.hhs.gov/manuals/downloads/clm104c14.pdf)
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How do I find the fee schedule for covered drugs on your web site?
CGS will now provide a web link directly for the Medicare Part B Drugs ASP (Average Sales Price) Payment Allowance located on the CMS web site. This fee schedule can be accessed at www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01_overview.asp. However, "carrier-priced" drugs that do not appear on the CMS listing will be maintained by CGS on a quarterly basis. This carrier-priced list can be accessed on our web site at www.cignagovernmentservices.com/partb/coverage/fees/index.html. Please refer to "Option 3" to select the appropriate State and select "Payment Allowance Limits for Medicare Part B Drugs".
- Do I need an NPI for Item 17a of the CMS 1500-form?
Effective May 23, 2008, the NPI must be used in lieu of legacy provider numbers. Legacy numbers identifiers include:
- Online Survey Certification and Reporting (OSCAR) system numbers;
- National Supplier Clearinghouse (NSC) numbers;
- Provider Identification Numbers (PINs); and
- Unique Physician Identification Numbers (UPINs) used by Medicare.
They do not include taxpayer identifier numbers (TINs) such as:
- Employer Identification Numbers (EINs); or
- Social Security Numbers (SSNs).
For more information regarding the implementation of the NPI, please refer to the CMS web site at www.cms.hhs.gov/NationalProvIdentStand/.
- When are providers required to use NPI only?
The NPI "only"implementation is effective as of May 23, 2008.
- Is the implementation of the NPI only guideline determined
by date of service or receipt of claim?
The NPI "only" implementation is for claims received on and after May 23, 2008.
