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Posting Date: 07/17/2025
Prior Authorization Outpatient Department Claim Billing
Prior Authorization Outpatient Department Claim Billing Providers may observe an increase in claim denials for PA services due to a mismatch of information provided on the PAR compared to the information supplied on the claim. Prior [...]
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Posting Date: 10/26/2022
Prior Authorization OPD Alerts
Prior Authorization OPD Alerts Month/Year Topic July 2025 Prior Authorization Outpatient Department Claim Billing July 2025 Prior Authorization Outpatient Department Exemption and ABN ADRs [...]
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Posting Date: 07/18/2025
You Asked, We Listened - Introducing the Modifier Lookup Tool
You Asked, We Listened - Introducing the Modifier Lookup Tool We value and appreciate the feedback from our providers, which drives continuous improvement to enhance your experience. We're pleased to announce the launch of our new Modifier [...]
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Posting Date: 07/18/2025
Medical Policy and Billing and Coding Updates
Medical Policy and Billing and Coding Updates LCDs in Notice Period (7/24/2025-9/6/2025) L38367 - Fluid Jet System Treatment for LUTS/BPH Based on a Reconsideration Request, the Indications of Coverage have been revised by removing the [...]
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Posting Date: 07/16/2025
Understanding the Reopening and Appeal Process Open Forum
National Government Services is committed to reducing provider burden associated with Medicare claim denials, reopenings and appeals. Filing an inquiry on a Medicare claim can be frustrating and costly to your organization. This delay in [...]
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Posting Date: 07/16/2025
Understanding the Reopening and Appeal Process Open Forum
National Government Services is committed to reducing provider burden associated with Medicare claim denials, reopenings and appeals. Filing an inquiry on a Medicare claim can be frustrating and costly to your organization. This delay in [...]
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Posting Date: 07/16/2025
Care Coordination Services for FQHC/RHC Claims Improperly Paid
Care coordination services for FQHC and RHC providers are being reimbursed incorrectly. According to CR 13581, they should be paid at the national nonfacility fee rate, but FISS is using the facility fee rate.
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Posting Date: 07/16/2025
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 [...]
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Posting Date: 07/16/2025
Top JK Part B Claim Errors are Available
Top JK Part B Claim Errors are Available We conduct a comprehensive data analysis on a quarterly basis to update and disseminate the latest insights on the most common claim errors. This initiative provides: Claim Error Reason Code [...]
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Posting Date: 07/16/2025
Top J6 Part B Claim Errors are Available
Top J6 Part B Claim Errors are Available We conduct a comprehensive data analysis on a quarterly basis to update and disseminate the latest insights on the most common claim errors. This initiative provides: Claim Error Reason Code [...]
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Posting Date: 07/16/2025
Hospital, CMHC, CORF/ORF and ESRD Facilities Quarterly Top Claim Errors
Do you struggle with your claim denials, rejections and return to provider (RTP) claims? Do you want to be proactive in preventing unnecessary errors? Join us in a review of top claim errors for your provider type based on recent data analysis [...]
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Posting Date: 02/21/2020
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 [...]
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Posting Date: 04/29/2021
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, [...]
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Posting Date: 01/27/2022
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 [...]
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Posting Date: 10/26/2022
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 [...]
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Posting Date: 01/27/2022
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 [...]
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Posting Date: 01/28/2022
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 [...]
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Posting Date: 01/28/2022
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 [...]
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Posting Date: 01/28/2022
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 [...]
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Posting Date: 01/27/2022
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 [...]
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Posting Date: 05/11/2022
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 [...]
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Posting Date: 01/27/2022
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 [...]
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Posting Date: 01/28/2022
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 [...]
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Posting Date: 01/27/2022
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 [...]
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Posting Date: 01/27/2022
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 [...]
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