CLAIMS: How do I prevent monthly End Stage Renal Disease claims from denying?

CLAIMS: How do I know if a HCPCS/CPT code is subject to MUE (medically unlikely edit)?

CLAIMS: During the patient check in process, may we have the patient check a box on a form at each visit stating they agree to allow us to bill Medicare and have that serve as the patient’s acceptance for our filing a claim?

When billing for waste on a single use vial would you round units up or down for a half unit?

When billing an unclassified drug code such as J3490, are the units of service on the claim always equal to one?

What is the proper way to submit professional physician claim with multiple NDC numbers for the same drug code?

J3357, Ustekinumab (Stelara) is listed on the Self-Administered Drug Exclusion List: Medical Policy Article A53021, and it says “acceptable”. Does this mean it is excluded or not?

What is the correct way to bill an unlisted drug or biological?

Is the shingles vaccine covered by Medicare?

Is the GY modifier required on the drug code and the administration code for noncovered self-administered drugs?

Have the payable diagnoses for IVIG and Rituximab changed? I don’t see all of the previously payable diagnoses in the applicable drug local coverage determinations (LCDs) and articles.

How do I bill a bilateral joint injection and HCPCS J1040 for two units?

Do all established drug HCPCS codes require the dosage amount in its description on the claim?

Does the waste with the JW modifier appended always go on the second line regardless of the billed amount? For example, the billed amount for the waste is higher than the administered amount.

Are unclassified drug codes included in average sales price (ASP) files?

Can chemotherapy be split into two doses on two different dates of service if the patient was unable to complete a full dose in one day? For example, the patient's port was not functioning properly.

Does Medicare Part B make payment for the unused portion of a multi-dose vial of a drug/biological?

Can Medicare Part B providers who bill on the professional CMS-1500 claim form, and electronic equivalent, bill unclassified drug code C9399?

Additional Events Links

Resources Education Partnership Request Form Five Steps to Webinar Success Provider Outreach and Education Reminders

Additional Events Links

Resources Education Partnership Request Form Five Steps to Webinar Success Provider Outreach and Education Reminders

MEDICAL REVIEW: Why did I receive a Comparative Billing Report?

MEDICAL REVIEW: Where can I get answers to billing questions?

MEDICAL REVIEW: Where can I find more details about the reasons my claims were denied?

MEDICAL REVIEW: What constitutes a valid signature?

MEDICAL REVIEW: What mailing address does NGS use to send Medical Review additional documentation requests (ADRs) to providers?

MEDICAL REVIEW: We are a large group and could potentially have many providers on TPE review. We have difficulty managing the process for each provider. Does NGS have any guidance for large groups?

MEDICAL REVIEW: The Medical Review Department did a post payment review of my Medicare claim and it was denied. How do I pay the money back to NGS Medicare?

MEDICAL REVIEW: My claim was denied “56900 Documentation not received”; however, I did send in documentation. What now?

MEDICAL REVIEW: My claim was reopened or adjusted by Medical Review. Does this impact the appeal window?

MEDICAL REVIEW: How do I sign up for the CMS and NGS Listserv messages?

MEDICAL REVIEW: I am under TPE review and my claims were denied, who can I speak to about this?

MEDICAL REVIEW: I’m appealing my claim but received a letter to recoup funds from the TPE denial. What do I do about these letters?

MEDICAL REVIEW: How do I change my address and which address exactly am I changing to ensure receipt of the MR letters and ADRs?

MEDICAL REVIEW: How do I respond to an ADR Not In List?

MEDICAL REVIEW: How do I request an appeal on a claim reviewed by the Medical Review Department?

MEDICAL REVIEW: How do I appeal a claim that MR reviewed but went to a T status or R status because of a CWF issue after MR processed?

MEDICAL REVIEW: How can I use NGSConnex to respond to Medical Review additional documentation requests?

Resources

Resources You Can Help Your Patients Quit Tobacco Use Smoking Cessation Tools and Resources Smokefree.gov Centers for Disease Control and Prevention: Tips from Former Smokers campaign Centers for Disease Control and Prevention: Office on [...]

COVID-19 Vaccine and Monoclonal Antibody

COVID-19 Vaccine and Monoclonal Antibody With the end of the PHE, as of 5/11/2023, this information no longer applies. We will keep the information available for PHE-related services that occurred prior to the expiration date that have not yet [...]

National A/B Medicare Administrative Contractor Ambulance Provider/Supplier Coalition

National A/B Medicare Administrative Contractor Ambulance Provider/Supplier Coalition Attention Ambulance Providers In response to numerous and continued requests from the ambulance community, the AB MACs have put together a National AB MAC [...]

FQHC Example of a Per Visit Rate Calculation for MAO Supplemental Payments

National AB Medicare Administrative Contractor Ambulance Provider/Supplier Coalition

National AB Medicare Administrative Contractor Ambulance Provider/Supplier Coalition Attention Ambulance Providers In response to numerous and continued requests from the ambulance community, the AB MACs have put together a National AB MAC [...]

Part A Summit- Skilled Nursing Facility: Coverage and Documentation

During this collaborative education session between Case Management and Medical Review, attendees will learn documentation requirements for skilled nursing facility (SNF) coverage, how to properly respond to Additional Documentation Requests [...]

Part A Summit Let’s Chat: Prior Authorization for Certain Hospital Outpatient Department Services

This Let’s Chat session focuses on Prior Authorization for certain hospital outpatient department (OPD) services and is an informal opportunity for you to chat with our staff about the selected topic. During the session, you may ask us [...]

Part A Summit -Need Answers? The Options to Consider Before Calling or Writing into Medicare

During this session, we will review top trends on why providers are reaching out to Medicare and the best options to resolve those inquires. Plus, valuable tips and resources to help get the most out of Medicare.

Part A Summit- Medicare Secondary Payer: Preventing Rejections of Your Medicare Primary Claims

Increase your cash flow by preventing rejections of your Medicare primary claims! In this webinar, we review why claims reject for Medicare Secondary Payer and explain how to prevent these rejections by reporting information on your claims that [...]

Part A Summit - Exploring the NGS TPE Process

Join us to explore essential strategies for a successful Targeted Probe and Educate review. We'll cover the purpose of TPE and best practices, roles and responsibilities of National Government Service and providers under review. Gain practical [...]

Part A Summit- Navigating Billing and Documentation for Behavioral Health Services in Federally Qualified Health Centers

Unlock the secrets to effective billing and documentation for behavioral health services within Federally Qualified Health Centers. This collaborative webinar will include insights from Medical Review and is designed to help healthcare [...]

Part A Summit – How to Submit an Appeal Request

Join us for a comprehensive session focused on understanding the appeal submission process within National Government Service. This presentation is designed to guide participants through each step of submitting an appeal, ensuring clarity and [...]

Part A Summit - NGSConnex: User Pain Points Examples/Solutions

Are you experiencing issues while utilizing NGSConnex? Join this informative session to learn what user pain points are and how to resolve these issues from an NGSConnex Agile Product Owner. This session will encompass issues with [...]

Part A Summit - World of Medicare Contractors

Medicare Administrative Contractors are responsible for processing claims, managing policy and payment, and establishing regional policy guidelines. Centers for Medicare & Medicaid Services also uses several additional contractors to manage [...]

Part A Summit - Maintaining Your Provider Files

This virtual webinar will aid in maintaining accurate provider enrollment files for the internet-based Centers for Medicare & Medicaid Services systems: Identity & Access Management System, National Plan & Provider Enumeration System and the [...]

Part A Summit- Navigating NGS and CMS Websites

Join us for this informative session where we will review how to find helpful Medicare references and resources on the National Government Services website (www.NGSMedicare.com) and the Centers for Medicare & Medicaid Services website [...]

Part A Summit - Provider Outreach and Education Roundtable

Join us for an interactive and insightful roundtable discussion with the Provider Outreach and Education Manager and team. This session is designed to offer a comprehensive look into the future of POE and explore innovative strategies for [...]

Medicare Part B Secondary Payer Post-Pay Overpayments

During this webinar, providers and office staff members will learn about the Medicare Part B overpayments and the appropriate steps for reporting Medicare Secondary Payer (MSP) overpayments. NGS MSP subject-matter experts will be on hand to [...]

Urgent Care

Urgent Care Please explain the concepts of split/shared and incident to E/M services in the urgent care setting. Answer: The urgent care setting is defined by CMS as a nonfacility setting. This means the split/shared concept does not [...]

Transitional Care Management

Transitional Care Management Please clarify responsibility for the TCM interactive contact. Can this be performed by a hospital-employed nurse prior to discharge? Answer: The provider who is billing the TCM service is responsible for the [...]

Time-Based Services

Time-Based Services Please define rules for using time to level-set a service. Answer: In both the office and observation/inpatient setting, the provider’s time is calculated based on pre-visit, intra-visit, and post-visit activities [...]

Telehealth Services

Telehealth Services Please explain Medicare’s definition of a telehealth service. Answer: Medicare defines a telehealth service as a service provided by a Medicare-enrolled practitioner from an approved distant site for a beneficiary who [...]