Chapter 11 Flashcards
Government Carriers
(Medicare, Medicaid, TRICARE)
Medicare
*65 and older
*Certain disabilities
*Any age w/ end-stage renal failure or ALS (amyotrophic lateral sclerosis aka Lou Gehrig’s disease.
Medicare has four parts:
Part A: hospital insurance.
Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities.
Part B: medical insurance.
Part B covers things not covered by Part A like physician’s services, medical supplies, laboratory services, etc.
Part C: Medicare Advantage plans.
These are private plans (like HMOs and PPOs) run through Medicare that must at least be equivalent to regular Part A and Part B. Part C plans are managed by private companies contracted with CMS.
Part D:
Prescription drug program
Part A: Hospital Insurance
Part B: Medical Insurance
Part C: Medicare Advantage Plans
Part D: Prescription
MBI: Medicare Beneficiary Identifier
Part C
Medicare Advantage Plans
*Private insurers contract w/ CMS and MAC
(Medicare Administrative Contractors) MAC’s are multi-state, regional contractors.
Noridian in CA
Novitace in CO
Medicare Eligibility
*65 yo if eligible to receive SS benefits
*Receive or eligible to receive railroad retirement or the spouse
*They /spouse worked long enough in Govmnt jobs
*A dependent parent of a fully insured deceased child
If a person does not meet the eligibility requirements, he or she may be able to get Part A by paying a monthly premium.
People may be eligible for Part A Medicare before age 65 if:
*If entitled to SS disability
*Rcv diability pension
*Lou Gehris ALS
*Worked in Gvmnt job and on disability for 24 months
People are eligible for Part B Medicare at age 65 if:
they reside in the United States, and
they are entitled to premium-free Part A benefits.
People who are not eligible for premium-free Part A benefits may be eligible for Part B Medicare if:
they are a U.S. resident, and
they are either citizens or aliens who have been lawfully admitted for permanent residence with five years continuous residence in the U.S. at the time of filing.
People are eligible for Medicare Part C and Part D when they are eligible for Medicare Part A.
EDI
Electronic Data Interchange
Part A
*Hospital care
*Skilled nursing facility care
*Nursing home care
*Hospice
*Home health services
*Inpatient care (for example, chemotherapy performed as in patient)
Part A - Consolidated Coverage
*When a patient is admitted to SNF they are covered by Part A for the first 100 days.
*After that they are covered by Part B
Part B
*Clinical research
*Ambulance services
*Durable medical equipment
*Mental Health
*Certain preventive services
*Doctor and other healthcare providers’ services
*Outpatient care (for example, chemotherapy performed as outpatient)
Part C
*All things covered under Part A except Hospice.
- Hospice is always covered under Part A
*May offer vision, hearing, dental and/or health and wellness programs
Part D
Prescription drugs
Each plan has its own formulary
Part B covers
Alcohol misuse screening and counseling:
AWV Annual Wellness Visit
This is allowed once every 12 months
Part B covers
Blood-based biomarker
Bone mass measurements
Cardiovascular disease screenings
Colorectal cancer screening:
Counseling to prevent tobacco use for asymptomatic beneficiaries
COVID-19 vaccine:
Screening for depression
Diabetes screening tests:
Diabetes self-management training (DSMT)
Glaucoma screening:
Hepatitis B virus (HBV) screening:
Hepatitis B Virus (HBV
Hepatitis C virus (HCV) screening
Hepatitis C virus (HCV) screening
Influenza virus vaccine and administration
Part B
Initial preventive physical examination (IPPE
Intensive behavioral therapy for cardiovascular disease
Intensive behavioral therapy for obesity:
Lung cancer screening counseling and annual screening:
Medicare Part B
First Year of Coverage
Medical nutrition therapy
Pneumococcal vaccine and administration
Prostate cancer screening
Screening for Cervical Cancer with Human Papillomavirus (HPV) tests
Sexually transmitted infections (STIs) screening and high intensity behavioral counseling (HIBC) to prevent STIs:
Screening mammogram:
Screening pap tests:
Screening pelvic examinations:
Ultrasound screening for abdominal aortic aneurysm:
Medicare, like many other insurance programs, does not cover everything.
- Services and supplies that are not medically reasonable and necessary
2.Non-covered items and services
3.Services and supplies that have been denied as bundled or included in the basic allowance of another service
4.Items and services reimbursable by other organizations or furnished without charge
Participating vs. Non-participating Regulations
There are three contractual options for providers in regard to contracting with Medicare.
Providers may sign a participating agreement (PAR) to accept Medicare’s allowed charge as payment in full for all Medicare patients (accept assignment).
Participating providers are listed in the Medicare Provider Data Catalog (PDC) available online at
https://data.cms.gov/provider-data/
Participating providers can collect up to the Medicare allowed fee on assigned claims and receive automatic crossover of Medigap secondary claims.
Medicare Administrative Contractors (MACs) provide toll-free claims processing lines to PAR providers and process their claims more quickly.
Whether the provider is PAR or non-PAR, the claims for the following services are required to accept assignment:
Clinical diagnostic laboratory services and physician lab services;
Physician services to individuals dually entitled to Medicare and Medicaid;
Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians/nutritionists, anesthesiologist assistants, and mass immunization roster billers;
Ambulatory surgical center services;
Drugs and biologicals; and
Ambulance services.
Non-participating (non-PAR) providers have a fee schedule set at 95 percent of Medicare approved amounts for PAR providers. So basically 80-5 it’s 75% and maximum is 115%
Non-PAR providers can charge above the Medicare approved amount with a limiting charge. The limiting charge is set at 115 percent of the Medicare fee schedule amounts for non-PAR providers.
The difference between the provider’s charge and Medicare’s limiting charge cannot be billed to the patient (referred to as balance billing).
When surgical services are provided to Medicare beneficiaries by a non-PAR provider that exceed $500,
the non-PAR provider must have the patient sign a surgical disclosure.
it’s kind of like an ABN
Physicians may also choose to opt-out of Medicare and privately contract to provide healthcare services to patients outside the Medicare system.
A private contract must be signed by the patient… they understand that the patient is giving up Medicare payment. The provider also must file an affidavit that meets specific requirements and submit to the local MAC at 30 days before the first day of the next calendar quarter.
Once a provider opts out of Medicare, they cannot submit Medicare claims for any patient for a two-year period.
Incident-to Guidelines
Medicare defines incident-to as “those services that are furnished incident-to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.”
Incident-to services are not recognized in a facility setting
Services performed by ancillary staff in a hospital are considered hospital expense.
Only services performed in the office, to outpatients, can be considered for incident-to.
To qualify as incident-to services
*Services are part of normal course of treatment.
*The reporting Dr must personally perform the initial service
*Dr must provide direct supervision. Not required to be in the treatment room.
Incident-to services are performed by midlevel providers known as Non-Physician Practitioners (NPPs) which are Physician Assistants (PAs), Nurse Practitioners (NPs), Advanced Registered Nurse Practitioners (ARNPs), Clinical Nurse Specialist (CNS), Clinical Psychologists, Clinical Social Workers, and Certified Nurse Midwives (CNMs).
If you meet the requirements for incident-to billing, the claim is submitted under the physician’s name as if he personally performed the service and the reimbursement will be at 100 percent of the allowed amount. Services performed by NPPs that are not incident-to are billed under the NPPs own NPI numbers, in which case they are reimbursed at 85 percent of the allowed amount.
When submitting incident-to claims, make sure to submit it under the supervising physician. For example, in a group practice, Doctor A established the care plan for which the Advanced Registered Nurse Practitioner (ARNP) is providing the follow up service.
Doctor A may not be in the office the day of the incident-to service, but Doctor B is in the office providing the necessary supervision. In this case, bill the incident-to service under Doctor B. This is important because if incident-to services are audited, the auditor will request the medical record as well as the schedule for the dates of service to make sure the physician who the claim was billed under was in the office.
NPI and Credentialing
All providers who bill Medicare or any other insurer must have a National Provider Identifier (NPI) number. A National Provider Identifier, or NPI, is a unique 10-digit identification number required by HIPAA. In the past, providers had different identification numbers for each payer, but the introduction of the NPI is a single identifier for all payers to improve efficiency of the healthcare system. It will also help reduce fraud and abuse. It is an intelligence-free number, meaning that there is no personal identifying information other than a name and business address.
Information needed to complete an NPI application includes:
Provider’s name and credentials
Provider’s birth information (date, state, country)
Gender
Social Security number
IRS Individual Taxpayer Identification number
Organizations the provider is affiliated with
Business mailing address information
Business practice location information
Other provider identification numbers (Medicare UPIN, Medicare OSCAR/Certification, Medicare PIN, Medicare NSC, Medicaid)
Provider taxonomy code and state license information
(NPPES) website
(https://nppes.cms.hhs.gov/#/).
Advance Beneficiary Notice (ABN)
also called a waiver of liability,
ABN
written notice given by a physician or provider to a Medicare patient before providing certain Part B or Part A items or services.
Medicare defines medically necessary services as those that are:
Reasonable and necessary
For the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member
Not excluded under another provision of the Medicare Program
Reasons to have an ABN signed for these providers includes:
Medicare considers the care to be custodial care
Outpatient therapy services are in excess of the therapy cap amounts and do not qualify for a therapy cap exception
A patient is not terminally ill (only applies to Hospice providers)
Home health services requirements are not met (individual is not confined to the home, individual does not need intermittent skilled nursing care, etc.) for HHA providers
ABN … Draw a line across the words
You may ask to be paid now, but (also)..
I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN>
OPTION 1. I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.
QMB = Qualified Medicare Beneficiary
If the beneficiary is QMB
the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.
ABN
Option 2 – This option states that the patient wants to receive the item or service at issue and accepts financial responsibility. The beneficiary agrees to make payment at the time of service, if requested. A claim will not be filed to Medicare and the patient has no appeal rights.
ABN
Option 3 – This option states that the patient does not want to receive the item or service in question, so there is no charge to the patient, no claim is filed, and no appeal rights are afforded to the patient.
The following modifiers are used with claims for items or services submitted when an ABN has been signed:
GA Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case: (Patient liable for cost)
Modifier with ABN
GX Notice of Liability Issued, Voluntary Under Payer Policy (service excluded not payed)
Modifier with ABN (appended with Medicare denial to secondary insurance if it’s a covered benefit by secondary insurance)
GY Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit: (not a Medicare benefit)
ABN Modifier
GZ Item or Service Expected to Be Denied as Not Reasonable and Necessary: This modifier is appended when the ABN is not obtained.
EXAMPLE
A Medicare patient presents for a binaural behind the ear hearing aid. He has a secondary insurance that he states will cover the hearing aid, even though Medicare will not. For the secondary insurance to adjudicate the claim, there must be a response form the primary insurance first, whether it was paid or denied. Code V5140 Binaural behind the ear hearing aid with modifier GY. This lets Medicare know that the office understands that the item is excluded, but needs the claim adjudicated to receive the denial to submit to the secondary insurance for possible payment.
Medicare as Secondary Payer (MSP)
Sometimes Medicare is the secondary payer, and the claims should be submitted to the primary insurance first, then to Medicare.
Common situations in which Medicare is a secondary payer are when the beneficiary:
*Patient still working and covered under employer insurance, or husband’s insurance.
*65 or older still working and covered under employer insurance.
*Disabled and covered by family member’s current employment.
*ESRD end-stage renal disease but covered by employer’s ins and in the first 30 months of Medicare eligibility.
*ESRD covered by COBRA
*In accident and has liability insurance.
*Worker’s comp
If a liability such as accident or Work’s comp … Medicare will pay but will get reimbursed from settlement.
Medicare Claims Filing Requirements
Any Medicare participating provider must file claims and accept assignment. Accepting assignment means the provider agrees to take the Medicare approved fee schedule amount as payment in full for the services rendered.
Medicare Claims Filing Requirements
Claims must be filed within one calendar year, 12 months, after the date of service. CMS offers four exceptions to the 12-month claim filing period:
Medicare Claims Filing Requirements
Administrative error: Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider, or supplier received notice that an error or misrepresentation was corrected.
Medicare Claims Filing Requirements
Retroactive Medicare entitlement: Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider, or supplier received notice of Medicare entitlement retroactive to or before the date of the furnished service.
Medicare Claims Filing Requirements
Retroactive Disenrollment from a Medicare Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization: Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the MA plan or PACE provider organization recovered its payment from a provider or supplier.
Medicare-Medicaid crossover claims follow Medicare timely filing requirements.
EXAMPLE
At the time, a service was furnished the beneficiary was only entitled to Medicaid benefits. Subsequently, the beneficiary receives notice of Medicare entitlement effective retroactive to before the date of the furnished service, which was 14 months prior. The state Medicaid agency recoups its money from the office and the office cannot submit a claim to Medicare because the timely filing limit has expired. Medicare allows for an exception due to the retroactive Medicare entitlement involving a state Medicaid agency exception.
Medicare Claims Completion Guidelines
requires that Medicare claims be submitted electronically unless providers meet certain exceptions.
The exceptions that allow a provider to submit claims on paper include:
Small provider claims: This refers to providers that have fewer than 25 full-time equivalent employees
The exceptions that allow a provider to submit claims on paper include:
Roster billing of inoculations covered by Medicare. The exception is a provider that agreed to submit to Medicare electronically as a condition for submission of flu shots administered in multiple states to a single MAC
The exceptions that allow a provider to submit claims on paper include:
*Dental claims
*Claims submitted by the Medicare beneficiary
*Claims for services provided outside the United States by non-U.S. providers
CMS has a standard enrollment form that must be completed before submitting any electronic claims or other EDI transactions to Medicare.
The form may be submitted by the provider, billing service, or clearinghouse.
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Common Medicare Denials
Patient cannot be identified as a Medicare patient.
Beginning January 1, 2020, you can no longer submit claims with the Health Insurance Claim Number (HICN).
The Medicare card for railroad retirees will have a Railroad Medicare logo. These claims should be sent to Palmetto GBA, Railroad Medicare Services.
Item 32 requires you to indicate the place where the service was rendered …..where services were rendered is entered in item 32,…The complete address includes a nine-digit ZIP code.
Diagnosis codes are invalid or truncated – Diagnosis codes are typically updated each year
For example, CPT® code 99217 reported for date of service 05/15/2023 would be incorrect. Code 99217 is a deleted code.
Procedure code or modifier is invalid on the date of service, claims are being submitted with deleted procedure codes – CPT® and HCPCS Level II codes are updated annually.
Medicare Appeals Process
Medicare allows for minor errors and omissions to be corrected on a claim without pursuing the formal appeals process
RTP = Return to Provider
through RA… Remittance Advice notice
When claim is incomplete… missing information… incorrect information etc.
If a claim has already been processed, a provider can request a reopening of the claim to correct clerical errors such as:
*mathematical mistakes;
*transposed procedure or diagnostic codes;
an error in data entry;
*misapplication of a fee schedule;
*computer errors;
*denial of claims as duplicates when the claim is not a duplicate; or
*incorrect data items, such as a provider number, use of a modifier, or date of service.
Reopening a claim can be performed by telephone.
Another option for healthcare professionals who are participating providers is to appeal Medicare (Parts A and B) denials.
Level 1—Redetermination
The first level of appeal after initial determination on a claim is the redetermination. A redetermination is an examination of the claim by Medicare Administrative Contractor (MAC) personnel.
A redetermination request must be filed within 120 days from the date of receipt of the Remittance Advice, which lists the initial determination.
The request for redetermination must be a written request or filed on form CMS-20027.
contractor’s information at https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/review-contractor-directory-interactive-map
Level 2—Reconsideration
If dissatisfied with the redetermination decision a reconsideration by a Qualified Independent Contractor (QIC) can be requested.
The request for reconsideration must be filed with a QIC within 180 days of receipt of the redetermination. This request must be submitted on the standard CMS-20033, which is sent with the Medicare Redetermination Notice (MRN) or with a written request including the following information:
Level 3—Administrative Law Judge
If the reconsideration is not fully favorable the next step is to request a hearing with the Administrative Law Judge (ALJ) within 60 days of receipt of the reconsideration decision. To request a hearing, the amount remaining in controversy must meet the threshold requirement, which is recalculated each year.
Request for an ALJ Hearing or Review of Dismissal – OMHA-100 (Office of Medicare Hearings and Appeals) may be used to file a request. You must send a copy of the ALJ hearing request to all other parties to the QIC reconsideration. The ALJ sets hearing preparation procedures.
Level 4—Appeals Council
When dissatisfied with the ALJ’s decision, a request for review by the Medicare Appeals Council is the next level. There are no requirements regarding the amount of money in controversy. The request must be submitted in writing within 60 days of receipt of the ALJ’s decision or dismissal and must specify the issues and findings that are being contested. You must send a copy of the Appeals Council review request to all the parties included in the ALJ’s decision. The Appeal Form DAB-101 should be submitted. Generally, the decision will be issued within 180 days of receipt of a request for review.
Level 5—Judicial Review
The final level of appeal for Medicare is to request a Judicial Review in federal District Court. The threshold for review in federal district court is calculated each year. A request must be made within 60 days of receipt of the Medicare Appeals Council’s decision.
Section Review 11.1
A Medicare patient is seen by her physician. The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the services rendered are $300.00. Medicare’s approved amount would be $200.00. What can the office charge this patient?
Answer: C. $300.00
Rationale: Providers that have opted-out of the Medicare cannot bill Medicare and may charge whatever they desire to patients as they are not subject to Medicare’s fee schedule or limiting charge. A condition of the contract between the provider and the patient is that the patient is liable for all provider charges without any Medicare balance billing limits.
A Medicare patient has prescription drug coverage but does not have Medicare Advantage. What Medicare coverage does the patient have for his medications?
Answer: D. Part D
Rationale: Medicare Part A is hospital insurance, Part B is medical insurance, Part C is Medicare Advantage, and Part D is the prescription drug plan.
A Medicare patient presents for her pelvic, Pap, and breast examination (PPB). The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed? Why or why not?
Answer: B. No. The ABN must be signed before the service is performed.
Rationale: The ABN must be reviewed with the patient and signed by the patient before the item or service is rendered to be valid. If it is not, the patient cannot be billed for the service if Medicare does not approve it.
A Medicare patient presents with an injury sustained at his part-time job. His injury status is verified by his company. After services are rendered, in what order are the claims submitted?
Answer: A. The Workers’ Compensation is primary, and Medicare is secondary
Rationale: If an individual is entitled to Medicare and is covered under Workers’ Compensation because of a job-related illness or injury, Workers’ Compensation is the primary for healthcare items or services related to job-related illness or injury claims.
A Medicare patient receives services from a participating provider on January 6, 2023, but the charges are missed and were not entered into the computer. How long does the office have to bill Medicare for the services?
Answer: B. 12 months
Rationale: The Patient Protection and Affordable Care Act (ACA) amended the time period for filing Medicare fee-for service claims. Claims must be filed within one calendar year, 12 months, from the date of service.
Medicaid
Medicaid is a health insurance program for low-income individuals and families that cannot afford healthcare costs.
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Medicaid Eligibility
*US citizen
*SS #
*TANF Tem Assistance Needy Fam
*Children of low-income fam
*Pregnant women low income
*SSI recipient
*Foster Care or Adoption
*Special protected group (lose cash aid employed)
Infants born to pregnant women who are receiving Medicaid at the time of delivery are automatically eligible for Medicaid until their first birthday.
Medicaid eligibility should be verified at every visit as it can change from month-to-month
Medicaid programs must provide the mandatory benefits to eligible individuals to receive matching federal funds known as Federal Medical Assistance Percentage (FMAP).
*IP & OP services
*Periodic screening, treatment
*SNF
*Home Health
*Physician services
*Rural Health
*Federally qualified centers
*Lab & Xray
*Family Planning
*Midwife services
*Peds & FNP services
*Birth centers
Prior Authorization
TAR treatment authorization review.
If a provider wants to prescribe a drug that is not on the formulary or listed as a drug that needs to be monitored, they must receive prior authorization.
Medicaid Claims Filing Requirements
Be aware of the filing limits for their individual states.
Medicaid cannot make payments to recipients, so the provider that performed the service is required to file a claim and agree to accept assignment (accept the allowed amount as payment in full)
Medicaid is always considered the payer of last resort.
This means that if the patient has any other insurance coverage, Medicaid will be secondary to that coverage. Medicaid will require the explanation of benefits or the electronic equivalent to be filed with the claim.
Frequency of service exceeded—
Medicaid will sometimes put limits on the number of times a procedure or service can be performed. Refer to the provider manuals and medical policies to verify limits on procedures and services.
Medigap
Medigap refers to a Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover, like deductibles, copayments, and coinsurances.
Medigap policies usually don’t cover prescription drugs, long-term care, vision care, dental care, hearing aids, eyeglasses, or private duty nurses. Patients pay a separate premium to the Medigap insurer.
Every Medigap policy must follow federal and state laws and be clearly identified as Medicare Supplement Insurance. In most states, Medigap insurance companies may only sell standardized policies identified by the letters A through N. Each policy must offer the same basic benefits regardless of the company that sells it. Different policies are available in different states.
Medigap Claims Processing
If the Medicare beneficiary has authorized payment to be made to the physician or provider, Medicare must transfer the Medicare claims information to the Medigap insurer. This is indicated by the signature on file notice in box 13 on the CMS-1500 form.
Other information required on the CMS-1500 to process a Medigap claim include:
Item 9a—The policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.
Item 9d—The Coordination of Benefits Agreement (COBA) Medigap claim-based Identifier (ID).
Item 9a and 9d
If the above information is not complete and accurate the claim cannot be forwarded. If a physician is a non-PAR provider, Medicare will not forward the claim and it will be the patient’s responsibility.
MA18—The claim information is also being forwarded to the patient’s supplemental insurer. Send any questions regarding supplemental benefits to them.
When information is missing or incorrect in block 9, MACs do not forward a transaction record to the Medigap carrier and the following remittance notice is sent on the EOMB:
MA19—Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer. Please verify your information and submit your secondary claim directly to that insurer.
TRICARE/CHAMPVA
TRICARE, formerly known as CHAMPUS, is the Department of Defense (DOD) healthcare program for military families and retirees.
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is the healthcare program in which the Department of Veterans Affairs covers spouses, widows and widowers, and the children of a veteran who is rated permanently and totally disabled due to a service-connected disability, died of a service-connected disability, or died on active service and the dependents are not eligible for TRICARE.
In specific instances, veterans may themselves qualify for CHAMPVA, also.
Types of Plans
TRICARE offers coverage choices for health plans: TRICARE Prime®, TRICARE Select®, TRICARE for Life, TRICARE Reserve Select®, TRICARE Retired Reserve®, TRICARE Young Adult, and US Family Health Plan.
To be eligible for TRICARE Prime, you need to live within a Prime Service Area, or within 100 miles of a primary care manager.
All active duty service members and their families are eligible for TRICARE Prime, as well as retired service members and their families
TRICARE for Life is a Medicare-wraparound coverage for TRICARE eligible beneficiaries who have Medicare Part A and B.
TRICARE for Life is not available to family members.
TRICARE/CHAMPVA Claims Processing
TRICARE and CHAMPVA both have a one-year timely filing limit.
Claims for TRICARE and CHAMPVA professional services are submitted on a CMS-1500 form using the specific code sets adopted by HIPAA
Common denials for TRICARE include:
*Not eligible
*No authorization. authorization required for certain services.
*Not medically necessary
TRICARE Appeals
TRICARE allows for a review of a claim without opening an appeal. If there is a concern about how a claim is processed, the provider can request a claim review by sending a letter with the reason for requesting the claim review, a copy of the claim, the remittance advice, supporting medical records, and any new information needed for the review.
Only charges denied as services not covered by TRICARE or not medically necessary can be appealed through TRICARE.
Appeals can be submitted through the MCSC website,
RBRVS/RVU Concepts
. The total RVU is multiplied by a conversion factor (CF) to obtain the reimbursement for the CPT code
The CF is the dollar amount by which each CPT® code’s total RVU value is multiplied to obtain the reimbursement for a given service.
The CF is updated annually by CMS. The CF for 2023 was $33.89. The proposed CF for 2024 is $32.75.
Example of 99284 in 2023 for Arizona
Step 1.(2.74) (1.000) + (0.57) (0.963) + (0.27) (0.855) = 3.52 (Total RVUs) 2.74 + 0.54891 + 0.23085 = 3.51976
RVUs x Conversion factor = Medicare payment
(3.51976) ($33.89) = $119.28 Medicare payment for Arizona
*Calculations are based on the 2023 final rule.
There are also RVUs for the same components for when services are provided at a place of service other than the physician’s office.
Status Codes
A status code reflects Medicare coverage and payment policy. It can indicate if a service is payable, noncovered, bundled into another service, etc. Following are the status codes:
Status Codes
A= Active
B= Bundled
C= Carrier priced code (RVU)
E= Excluded
I= Invalid (MCR uses different code)
M= Measurement codes (PQRS code. No payment and no RUVs attached w/ code)
N= Non covered
P= Bundled/Excluded codes (no separate payment and no RVUs)
Q= Therapy functional information code
R=Restricted coverage
T= Paid as only service (paid only if no other services payable)
X= Statutory exclusion (s/s/p not within the scope of practice)
PC/TC Indicator
This indicates a service’s technical and professional component breakdown.
PC/TC Indicator
0 = Physician service codes
1 = Diagnostic tests or radiology services
2 = Professional component only codes
3 = Technical component only codes
4 = Global test only codes
5 = Incident-to codes
6 = Laboratory physician interpretation codes
7 = Private practice therapist’s service
8 = Physician interpretation codes
9 = Not applicable
This can help in understanding if modifiers TC or 26 are applicable.
Each listing contains the appropriate RVU breakdown for the type of service (professional, technical, or global) that it represents.
EXAMPLES
Code 71100, X-ray of ribs has an indicator of 1, indicating it is a diagnostic test or radiology service. It is listed three times in the RBRVS table as such:
71100– 1.11 total RVU
71100TC – 0.79 total RVU
7110026 – 0.32 total RVU
Note: RVU values based on 2023 finalized CMS National Payment Amount.
Code 93040 Rhythm ECG, 1–3 leads, with interpretation and report has an indicator of 4, indicating it is a global test only code.
The code incorporates the technical and professional components and should not be billed with either a TC or a 26 modifier.
Global Surgery Indicators
000 =Global surgery period includes day of procedure only
010 =Global surgery period includes day of and 10 days after surgery
090 =Global surgery period includes day before, day of, and 90 days after surgical procedure
MMM =The usual global surgery period does not apply; used for maternity codes
XXX =Global surgery period concept does not apply
YYY =Global surgery period concept determined by local Medicare carrier
ZZZ =Code falls within global surgery period for another service
The global surgery days’ field allows the biller to understand information regarding the billing of E/M visits, such as when a related E/M is billable, or when modifier 24, unrelated E/M service during the postop period should be appended so an unrelated visit is not denied.
The three fields following the global surgery days’ field breakdown the percentage of payment for the preoperative, postoperative, and intraoperative portions of the surgery.
The next fields on the table indicate whether certain modifiers may be used and what type of payment will be made.
Multiple procedure—indicates the applicable payment adjustment rule for multiple procedures. The indicators are:
0= no payment
1= standard payment adjustment
3= special rules for multiple endoscopic procedures
4= special rules for technical component
5= subject to 20% of the expense component
6=special rules for the technical component of multiple diagnostic
7= special rules for TC of multiple ophthalmology
9= concept does not apply
Bilateral surgery—indicates services subject to payment adjustment for bilateral procedures. The indicators are:
0= 150% adjustment for bilateral procedure NOT APPLY
1= 150% adjustment for bilateral does APPLY
2= 150% adjustment for bilateral DOES NOT APPLY. RVUs applied already
3= payment adjustment NOT APPLY. payment based on 100% fee schedule
9= concept does not apply
Assistant at Surgery—indicates services where an assistant at surgery is never paid for per the Medicare Claims Manual. The indicators are:
0= payment restriction unless LOMN
1= restriction for assistants at surgery
2= payment restriction does NOT APPLY for surgery assistant
9= concept does not apply
Co-surgeons—indicates services for which two surgeons, each in a different specialty, may be paid. The indicators are:
0= Co surgeons not permitted for this procedure
1= co surgeons could be paid. documentation needed
2= co surgeons permitted. no documentation required
9= concept does not apply
Team Surgery—indicates services for which team surgeons may be paid. The indicators are:
0= TS not permitted
1= TS could be paid, documentation needed
2= TS permitted
9= concept does not apply
The last field in the global surgery indicators is the Endoscopic Base Code field. It identifies the endoscopic base code for any code with a multiple surgery indicator of 3.
EXAMPLE
Colonoscopy codes 45379–45393, 45398 are listed in the table with the endoscopic base code of 45378. If any code from 45379–45392 is billed alone with 45378, no payment for the base code (45378) is made. If two or more codes from the same family are billed, the first code is paid in full. The fee schedule amount for the base code (45378) is subtracted from all additional endoscopic procedures, then the difference is paid.
Consider the following fee schedule:
Code 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) - $341.39
Code 45382, Colonoscopy, flexible; with control of bleeding, any method - $681.12
Code 45385, Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique - $457.50
If codes 45382 and 45385 are both billed together, payment will be made as such:
45382- $681.12
45385- $116.11 ($457.50 – $341.39)
$797.23
Section Review 11.2
A patient has Medicare and a Medigap policy. Box 13, signature on file, is checked off on the electronic claim submission. An EOMB is received with remittance notice MA19. What does the office need to do?
The biller must file the secondary insurance as the cross-over claim is not going to be sent due to missing information.
Which coverage under TRICARE is a Medicare wrap around plan?
Answer: A. TRICARE for Life
A 21-year-old patient presents for fillings for two of his teeth. Are these services covered under EPSDT?
Answer: C. No, because the patient is not under the age of 21.
Rationale: The EPSDT benefit provides comprehensive and preventive healthcare services for enrolled children under the age of 21.
Using the portion of the schedule above, what is true about the codes?
The tables has rows…
Status Code
Global Days
Pre OP
Intra OP
Post OP
Mult Proc
Bilat Surg
Answer: C. Code 12034 may not be billed with modifier 62.
Rationale: Modifier 62 is the modifier to indicate two surgeons shared a surgery. The co-surgery status code for 12034 is a 0, indicating that co-surgery is not permitted. Code 12032 has a status code of A, indicating it is an active code that is payable under the fee schedule. Code 12035 has a status code for bilateral procedures of 0, indicating that bilateral billing of this code is inappropriate. Code 12037 has a status code for co-surgery of 1, indicating that a co-surgery may be paid with supporting documentation that supports medical necessity.
What is true regarding Medigap policies?
Answer: B. They cover deductibles, copayments, and coinsurances usually.
Rationale: Medigap refers to a Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover, like deductibles, copayments, and coinsurances.
Glossary
Crossover Claim—
The transfer of processed claim data from Medicare operations to Medicaid (or state) agencies and Medigap insurers.
EPSDT)—
Early and Periodic Screening, Diagnostic and Treatment
(RBRVS)—
Resource Based Relative Value System
A system of payments to physicians for treating Medicare patients
TRICARE
The Department of Defense healthcare program for military families and retirees.
