Phonetic Alphabet

table, td, th table { border-collapse: collapse; width: 50%; } Phonetic Alphabet To assist you when speaking terms that are alpha-numeric, we've implemented the phonetic alphabet. When speaking an alpha character, please use the [...]

APPEALS: We are a large group with many physicians and nonphysician practitioners. When we submit claims for nonphysician practitioners working in different sub-specialties, we get claim denials that state: “D463: New patient qualifications were not met or M13: Only one initial visit is covered per specialty per medical group.” How can we avoid these?

APPEALS: Is documentation required for an appeal?

APPEALS: What is the solution to avoiding claim denials?

APPEALS: Is there a time limit for filing an appeal?

APPEALS: Where can I find the regulations on Medicare appeals?

APPEALS: Can one appeal a claim that rejected with MA130?

APPEALS: I received a remittance advice with the message “this care may be covered by another payer per coordination of benefits.” Is this an appealable claim?

APPEALS: Another denial we see is “This service has been provided at a frequency that is more than the medically appropriate indication by policy or regulation.” How can we avoid these denials?

APPEALS: What are the top appeals submitted to NGS?

APPEALS: We are a large group with many physician and nonphysician practitioners. When we submit claims for nonphysician practitioners working in different sub-specialties, we receive denials that state: D984: Coverage/program guidelines not met, N20: Service not payable with other service rendered on the same day.

MLN Connects® Newsletter: July 15, 2025

MLN Connects® Newsletter: July 15, 2025 CMS Proposes Physician Payment Rule to Significantly Cut Spending Waste, Enhance Quality Measures, and Improve Chronic Disease Management for People with Medicare Posted 7/15/2025

[RESOLVED] NGSConnex and IVR Experiencing Outages

[RESOLVED] NGSConnex and IVR Experiencing Outages We were experiencing outages with our web portal, NGSConnex and the IVR System. Part B providers were unable to check claim status, appeal status or submit appeal and reopening requests via [...]

Modifier 22 Supporting Documentation for Part B claims

Modifier 22 Supporting Documentation for Part B claims The Centers for Medicare & Medicaid Services, Internet-Only-Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2.10 Unusual Circumstances states: [...]

Behavioral/Mental Health Services

Behavioral/Mental Health Services Please explain the parameters for mental health services delivered via telehealth to a beneficiary who is at home. Answer: As of 1/1/2025, CMS has permanently extended permission for behavioral and mental [...]

Chronic Care Management

Chronic Care Management The guidelines state moderate or high complex MDM. Do the E/M guidelines apply here? Answer: Yes, the E/M guidelines for MDM are applicable, since chronic care management (CPT 99490) is included within the E/M [...]

Consultations

Consultations Does CMS permit payment for consultative E/M services? Answer: CMS permits payment for medically necessary consultative E/M services. The specific E/M codes previously used to represent consultative services were [...]

Critical Care Services

Critical Care Services Please define the time requirement for billing CPT code 99292. Answer: Whether critical care is performed by a single provider or on a split (or shared) basis, the time requirement for CPT code 99292 remains the [...]

Documentation

Documentation What are the basic documentation requirements for a service submitted to Medicare for payment? Answer: For all services submitted to Medicare, the medical record (whether electronic or paper) must clearly define the provider [...]

Emergency Department

Emergency Department When a consultant has seen a patient in the ED and billed an ED code, how are subsequent services billed when the patient is then admitted to inpatient status? Answer: The ED consult (billed with an ED code [...]

Examination

As of 1/1/2023, CMS has eliminated prior specifications for the scope of examination and associated documentation in the outpatient office and hospital settings. The provider is expected to perform and document a medically necessary and [...]

Fee-For-Time Compensation Arrangements

Fee-For-Time Compensation Arrangements Can a physician return to work in his or her practice for a short period of time to reset the 60-day clock requirement for the fee-for-time compensation arrangement provider? Answer: In order for the [...]

General E/M Information

General E/M Information Please explain the terms “auxiliary personnel” and “clinical staff” in the context of Medicare services.   Answer: These terms are often used in defining which staff members can perform Medicare services [...]

Global Period Services

Global Period Services Is it permissible for providers (physicians or NPPs) other than the primary surgeon to bill for preoperative or postoperative care within a global period? Answer: The global surgery fee is paid to the primary [...]

History

As of 1/1/2023, CMS has eliminated prior specifications for documentation of a patient’s history for services provided in both the outpatient office and hospital setting, including the emergency department. The provider is expected to obtain [...]

APPEALS: How would one submit a paper appeal?

APPEALS: What is the appeal process?

CAR-T: Will the Part A claim for CAR-T deny if it is submitted with the KX modifier?

CAR-T: What is the effective date for the requirement of the KX modifier for administration of CAR-T?

CAR-T: Is the KX modifier required for Part A and Part B claims?

CAR-T: Is Risk Evaluation and Mitigation Strategy (REMS) verified by the facility’s site name or address?

Home Health Top Claim Errors

Do you see the same rejections and return to providers over and over? Do you know how to correct the most common errors and more importantly how to avoid them in the future? In this session we’ll review the most common reason codes assigned to [...]

Admission and Discharge Services

Admission and Discharge Services Is it permissible for an NPP to perform an initial hospital admission or discharge service on behalf of the attending physician, or on a split/shared basis, when both are members of the same provider [...]

Advanced Care Planning

Advanced Care Planning Please define documentation requirements when billing advanced care planning (CPT 99497 and 99498). Answer: ACP codes may be used with or without a base E/M code on the same date of service, based on whether a [...]

IPPE and AWV Services

IPPE and AWV Providers are reminded that the IPPE and AWV are Medicare-covered services within their own benefit category. As such, they are not subject to standard “incident to” billing guidelines and must be billed by the performing [...]

Medical Decision Making

Medical Decision Making In a split/shared service, when a medical record includes a plan of care developed by the physician, based on a history and/or examination performed by the NPP and a personal review of diagnostic findings, [...]

New vs. Established Patients

New vs. Established Patients How does CMS define a patient as “new” versus “established”? Answer: In 2023, the definition of a “new” patient differs based on whether the patient is being treated in an office or an observation/ inpatient [...]

Nonphysician Practitioner Services

Nonphysician Practitioner Services In addition to the frequently asked questions below, please view NGS’ Nonphysician Practitioners-Reducing Costly Appeals; Increase Provider Revenue article for related information. Is it permissible for [...]

Observation Services

Observation Services Please define guidelines for providers billing observation services. Answer: Observation services are ordered, performed and billed by the practitioner (or group), who is responsible for the patient’s care during the [...]

Preoperative Clearance

Preoperative Clearance What requirements must be met for a preoperative clearance visit to be considered medically necessary and billable? Answer: CMS does not set requirements for medical clearance; these are established by individual [...]

Scribes

Scribes When a physician or NPP performs a service that is documented by a scribe, what are the documentation requirements? Answer: As per CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4: “CMS [...]

Provider Specialty

Provider Specialty Should each MD in the same practice bill with two different taxonomy codes based on whether functioning as a cardiologist or electrophysiologist? Answer: Yes, providers should be billing with their taxonomy codes. The [...]

59132

Avoiding/Correcting This Error RHCs should not bill codes G0108 or G0109. Related Content CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 70.5 - Diabetes Self-Management Training (DSMT) [...]

39928

Avoiding/Correcting This Error To access the line level reason associated with this reason code providers should go to claim page (2) (MAP 1712) and F11 to MAP171D to see the line level denial codes for each line of the claim. If you disagree [...]

39928

Avoiding/Correcting This Error To access the line level reason associated with this reason code providers should go to claim page (2) (MAP 1712) and F11 to MAP171D to see the line level denial codes for each line of the claim. If you disagree [...]

56900

Avoiding/Correcting This Error Regularly access claims in status locations SB6001, SB6098, or SB6099 to obtain a listing of claims for which records have not yet been received by the MAC (Medical Review Department). Look for information on the [...]

CO-109

Avoiding/Correcting This Error This denial is received when your Medicare patient is enrolled in a MA plan, instead of “traditional fee-for-service” Medicare. MA plans are health plans offered by private companies approved by Medicare that [...]

CO-109

Avoiding/Correcting This Error Palmetto GBA is the Medicare Administrative Contractor for processing claims of railroad retirees, regardless of their location. Providers and suppliers must verify patients' Medicare entitlement before [...]

CO-16

Avoiding/Correcting This Error This denial message is specific to chiropractic claims with CPT/HCPCS codes that are not billable by Medicare enrolled chiropractors. Medicare Part B coverage for chiropractic care is limited to spinal [...]

CO-16

Avoiding/Correcting This Error The billing provider's information on the claim is missing or invalid. To avoid this error, ensure the following details are accurate and included: the billing provider's NPI, name, address, ZIP code, and phone [...]

CO-16

Avoiding/Correcting This Error Certain services require the name and NPI of the ordering or referring physician, depending on the service type. Definitions:  Referring physician: Requests an item or service for a Medicare beneficiary. [...]

OA-18

Avoiding/Correcting This Error A duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same provider to the: same beneficiary; for the [...]

PR-31

Avoiding/Correcting This Error Services were denied for one or more of the following reasons: The name or Medicare number was incorrect or missing. The date of death precedes the date of service. Expenses were incurred prior to coverage. [...]

CO-16

Avoiding/Correcting This Error The MBI is necessary for all claims submitted to MAC. Claims without a correct MBI are rejected, requiring providers to verify and resubmit them. To avoid this, use the Eligibility Lookup in NGSConnex before [...]

CO-22

Avoiding/Correcting This Error During patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. Providers shall use [...]

CO-22

Avoiding/Correcting This Error During patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. Providers shall use our [...]

MLN Connects® Newsletter: July 16, 2025

MLN Connects® Newsletter: July 16, 2025 CY 2026 Proposed Payment Rule CMS Proposes Bold Reforms to Modernize Hospital Payments, Strengthen Transparency, and Put Patients Back in Control News CMS Expands Access to Lifesaving Gene [...]

A55

Avoiding/Correcting This Error Medicare Secondary Payer (MSP) claims must include the primary insurance carrier’s payment information, plan details, and subscriber information. Incomplete or inaccurate entries will result in claim rejection. [...]

5WEXC

Avoiding/Correcting This Error Ensure all Medicare coverage and medical necessity requirements are met prior to billing. When the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. [...]

5WEXC

Avoiding/Correcting This Error Ensure all Medicare coverage and medical necessity requirements are met prior to billing. When the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. [...]