The purpose of this page is to provide answers to questions about the Medicare program. The official program provisions can be found The Centers for Medicare and Medicaid website at: www.hcfa.gov/pubforms/transmit/memos
Provider Frequently Asked Questions
Q. Can you return my claim for correction? A. Any claim that has not been reviewed by Medical Review may be returned to you for correction. Please contact Provider Relations at (866) 488-0545 for further assistance.
Q. Can you delete or terminate a Medicare Secondary Payer (MSP) record? A. The Coordination of Benefits (COB) contractor is responsible for maintaining MSP records on the Common Working File (CWF). Providers may access CWF through HIQA. If you find that a record on CWF is not correct, you need to contact the COB at 1-800-999-1118 to have them update this file. If the file is correct on CWF, but not correct on DDE, you must contact provider relations at (866) 488-0545 and they will assist you.
Q. Can you check beneficiary eligibility? A. Providers who bill electronically and have access to our mainframe are asked to utilize the Health Insurance Query Part A (HIQA) screen, before calling provider relations. This screen is used to verify the eligibility of a person with Medicare, and to verify if other primary insurance, an HMO or Hospice entitlement exists. It is the responsibility of all facilities to provide their billing staff with all information needed to bill claims properly. All vendors and consultants who do not have access to HIQA are asked to refer to their facilities to obtain access to this information. For questions or assistance with using HIQA, please call Provider Relations at
1-866-488-0545, 9:00am- 4:00pm EST Monday through Friday.
Q. Can you check the status of my claim? A. Providers may check the status of their claims by using the Direct Data Entry (DDE) program. In order to check a claim, enter '01' Inquiries on the main menu, then select option '12' for claims. Once you are on this screen, you can enter in the patient's Medicare number and the dates of service for the claim and press 'enter'. This will bring up your claim that is in processing and will provide you with the status location that your claim is in. If you have any questions regarding status locations or reason codes, please contact Provider Relations.
Q. Where can I look for HCPC code inquiry? A. Providers may determine the validity of a HCPCS code by using Option 14 (HCPC Codes) under the inquiries menu on DDE. From your main menu, select '01' for inquiries then select '14' for HCPC codes. Next you will type in the HCPCS code in question and press 'enter'. On this screen you will see the effective/term dates of the HCPCS, as well as the fee schedule amount and a list of revenue codes that the HCPCS may be billed with.
Q. Where can I find Medicare updates? A. There are several resources available to check for Medicare Part A updates. First, Medicare Part A provider bulletins are sent out to providers weekly. The bulletins contain new Medicare Part A updates and regulation changes. Providers may access provider bulletins through our web site at www.marylandmedicare.com. All provider bulletins issued after October 1, 1999 are available at no cost from our web site. Another important web site is the Centers for Medicare and Medicaid Services site, which is www.hcfa.gov. Providers may access this web site to obtain fee schedules, program memorandums and also to download manuals such as the Medicare, hospital, skilled nursing facility, etc. manuals. Providers may also visit www.lmrp.net. This web site is dedicated solely to Local Medical Review Policies (LMRP). Local policies outline how contractors will review claims to ensure that they meet Medicare coverage requirements.
Q. Why did my claim deny for sequential billing? A. Your inpatient claim was submitted out of sequence. You must verify all prior bills from the 'admit date' of this claim to the 'statement from date' of this claim. If any claims between that period of time have not been submitted or paid, you must hold your current claim until the prior claims pay. If all claims have been submitted in date of service order, please verify that the correct type of bill, patient status code, and admit date have been used. If any prior claims have paid with an incorrect type of bill, patient status, or admit date, please adjust those claims and after payment has been received on those adjustments, resubmit your current claim.
Q. Is there any special method for sending in medical records in response to an ADR request? A. When compiling medical records in response to an ADR request, attach a copy of the ADR to the set of medical records that correspond to that ADR letter. We often receive records with several ADR's attached. We also receive records bunched together that are for different beneficiaries. We log only one ADR, for the claim listed on the top ADR, according to the DCN on the front of the first ADR letter. Due to the volume of claims we receive, we log only one ADR for records that are bunched together. If additional claims are with the ADR and found later upon review, the claims may be automatically denied due to exceeding the 45-day time allowed to return records for the ADR request. This results in unnecessary denials for failure to return documentation. Multiple claims may be submitted in the same envelope, but only one ADR should be attached to one set of medical records (by rubber band, staple, paper clip, etc.) - the medical records that correspond to each ADR letter.
When an ADR request is sent, your claim will appear in a SB6001 location on your claims count summary screen. Do not wait to receive the paper copy of the ADR request. You can begin to pull medical records together immediately when your claim appears in SB6001. Remember, you are responsible for submitting medical records within 45 days from the time your claim hits this location, even if you do not receive the paper copy of the ADR request. If medical records are not received within 45 days, your claim will deny. When your medical records are received by the medical review department, your claim will be moved to SM5014 and remain there until the records are reviewed.
Q. What is the appropriate billing for services provided when an Advance Beneficiary Notice(ABN) is given to the beneficiary? A no-pay bill is used when an MSN showing denial of a claim is needed (i.e., to file a secondary payer). Charges must be billed as non-covered with Condition Code 21. The claim will be denied and is not subject to medical review. A demand bill is used when the provider informs the beneficiary that Medicare will not cover one or more services and the patient requests a claim be billed to Medicare. All non-covered services and non-covered charges must be submitted on a separate no pay type of bill with Condition Code 20. The claim will be subject to medical review. Medical review will request medical records and a copy of the Advanced Beneficiary Notice (ABN) or a similar form (signed by the beneficiary) must be included. The ABN states the beneficiary was informed the service(s) are not covered by Medicare and agreed to be responsible for payment if Medicare denies payment.
Q. What is the 72-hour rule? A. Diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned and operated by the hospital, within three days prior to the date of the beneficiary’s admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage. This rule also includes non-diagnostic outpatient services that are related to a patient’s hospital admission. Reference: Hospital Manual, section 415.6
Q. How can I update a beneficiary’s insurance information on the Common Working File (CWF)? A. Providers must call the Coordination of Benefits (COB) contractor at 1-800-999-1118 to ask that the beneficiary’s CWF record be updated. They should not request that the COB reprocess any denied claims. Once they see that CWF has been updated, the provider may adjust their claim or call our Customer Service Line at 1-866-488-0545.
Q. Why do I have a Hemophilia add-on payment on my remittance advice? A. The add-on payment is for the cost of administering blood-clotting factor to Medicare hemophiliacs. Three separate add-on amounts have been set, one for each of the three basic types of clotting factor – Factor VIII, Factor IX and other factors which are given to the patients with inhibitors to Factors VIII and IX. In order to qualify for the add-on payment, the claim must contain a hemophilia diagnosis code, either as the principal or secondary diagnosis. Final rule states that payment will be made for blood clotting factor only if there is an ICD-9-CM diagnosis code for hemophilia included on the claim, since blood clotting factors are only covered for beneficiaries with hemophilia. Reference: Hospital Manual, Section 460.1
Q. When is it appropriate to use modifier 25 on an outpatient claim? A. Modifier 25 is used when a significant and separately identifiable evaluation and management (E&M) service is performed by the same physician on the same day of a procedure or other service. Use the 25 modifier for an E&M service:
That is above and beyond the original procedure performed.
That is beyond the usual pre-operative and post-operative care associated with the original procedure.
When a separate history was taken, a separate physical was performed and a separate medical decision was made.
Q. What is CMS's policy with respect to giving ABNs to Medicare beneficiaries seeking emergency services? A. An ABN should not be given to a beneficiary in any case in which EMTALA applies, until the hospital has met its obligations under EMTALA (section 1876 of the Social Security Act), which includes completion of a medical screening examination (MSE) to determine the presence or absence of an emergency medical condition, or until an emergency medical condition has bee stabilized. CMS has published this policy in the November 10, 1999 OIG/HCFA Special Advisory Bulletin on the Patient Anti-Dumping Statute: "A hospital would violate the Patient Anti-Dumping Statute if it delayed a medical screening examination or necessary stabilizing treatment in order to prepare an ABN and obtain a beneficiary signature. The best practice would be for a hospital not to give financial responsibility forms or notices to an individual, or otherwise attempt to obtain the individual's agreement to pay for services before the individual is stabilized. This is because the circumstances surrounding the need for such services, and the individual's
limited information about his or her medical condition, may not permit an individual to make a rational, informed consumer decision." This policy applies in any case in which EMTALA applies, not only to EMTALA cases seen in emergency rooms. (8/30/2001)
Q. What is CMS' rationale for its policy with respect to giving ABNs to Medicare beneficiaries in emergency care settings? A. An ABN should not be obtained from a beneficiary in a medical emergency since that individual cannot be expected to make a reasoned informed consumer decision. In genuine emergencies, the patient/victim and his or her family/friends (representative) are under great duress, by the emergency circumstances, and may sign anything in order to obtain help. On the other hand, there is a risk that patients might actually forego needed emergency services if faced with a financial burden which they believe they cannot bear. (8/30/2001)
Q. Has CMS published its policy regarding ABNs in emergency care settings? A. Yes. In Program Memorandum A-00-43, Advance Beneficiary Notices (ABNs) for Services for Which Institutional Part B Claims Will be Processed by Fiscal Intermediaries, dated July 27, 2000, the following instruction, at section I.B.4.c., was published: "c. A requirement for delivery of a notice is that the beneficiary, or authorized representative, must be able to comprehend the notice (i.e., they must be capable of receiving notice)…a person under great duress (for example, in a medical emergency) is not able to understand and act on his/her rights. If the beneficiary is not capable of receiving the notice, then the beneficiary has not received proper notice and cannot be held liable where the LOL [Limitation On Liability, section 1879 of the Act] provisions apply and you may be held liable." Note that this policy applies more widely than just emergency room visits. Giving ABNs to patients under great duress is not permitted, regardless of the particular treatment setting or location. (8/30/2001)
Q. So CMS's policy applies to situations involving patient duress other than patients seeking emergency services? A. Yes. The same policy applies in any case in which a beneficiary is under great duress and cannot make an informed consumer decision about purchasing items or services out-of-pocket or through other insurance when Medicare denial of payment is likely or certain. We would consider any ABN given in any kind of coercive circumstances, including medical emergencies, to be defective, that is, they would not protect the provider from liability, For example, in PM A-00-43, at section I.B.4.e., the following instruction is premised on the same underlying policy: "e. A patient must be notified well enough in advance of receiving a medical service so that the patient can make a rational, informed consumer decision. For example, do not give an ABN to a patient as s/he is connected to a test device or after s/he is already on the table for a MRI. Such last moment delivery of notice can be considered to be coercive, regardless of the provider's intentions. In such a case, the delivery of the ABN may not be considered timely and the beneficiary may not be held liable." (8/30/2001)
Q. Is it ever appropriate to ask a Medicare Beneficiary to complete an ABN while being seen in the ER? A. Yes. An ABN that is otherwise appropriate may be given to a Medicare beneficiary who is seen in the ER after completion of a medical screening examination (MSE) to determine the presence or absence of an emergency medical condition and after any emergency medical condition has been stabilized. (8/30/2001)
Q. Some physicians still are concerned that it is difficult to determine under what circumstances an ABN should be completed. A. ABNs are designed to be given when the physician expects (or is certain) that Medicare will deny payment for an item or service, either on the basis of the exclusion for lack of medical necessity (section 1862 (a) (1) of the Act) or on one of the few other statutory bases that trigger ABNs (viz., custodial care, a hospice patient determined not to be terminally ill, a home health patient who is not homebound or requiring intermittent skilled nursing care, and DMEPOS in the case of unsolicited telephone calls, lack of a supplier number and failure to get an advance determination of non-coverage.) Physicians are expected to be knowledgeable about Medicare coverage rules on the basis of Medicare publications and professional relation's activities as well as on the bases of their experience with the Medicare program and their local medical standards of practice Note: CMS Ruling 95-1, section IV.B.2., Criteria For Determining Practitioner and Other Supplier Knowledge, provides that: "In accordance with 42 411.406
(Criteria for determining that a provider, practitioner, or other supplier knew that items or services were excluded from coverage as custodial care or as not reasonable and necessary) and 7300.5 of the Medicare Carriers Manual, evidence that the practitioner or other supplier did, in fact, know or should have known that Medicare would not pay for a service or item includes: o A Medicare contractor's prior written notice to the practitioner or other supplier of Medicare denial of payment for similar or reasonably comparable services or items; o Our general notices to the medical community of Medicare payment/denial of services and items under all or certain circumstances. (Our notices include, but are not limited to manual instructions, bulletins, carriers' written guides, and directives); and o Provision of the services and items was inconsistent with acceptable standards of practice in the local medical community (refer to section V. of this Ruling). If any of the circumstances described above exists, a practitioner or other supplier is held to have knowledge." (8/30/2001)
Q. Some physicians would argue that Medicare rules are too complex for them to know them all. What happens if a physician makes a mistake and does not give an ABN to a beneficiary and then the Medicare contractor denies the claim? A. There are other protections for physicians under the Limitation On Liability provision (1879 of the Act) besides the use of ABNs. In any denial for medical necessity (or one of the other statutory bases that trigger ABNs), the physician may appeal the denial on the basis that the service should be covered and, if the physician prevails, the claim will be paid as covered. Additional physician documentation of the medical necessity of the service for the individual patient may result in a reversal of a denial. The physician also can appeal on the basis that the physician did not know and could not reasonably have been expected to know that payment would be denied by Medicare. If the physician is found not liable on the basis that s/he did not know of the likelihood of a Medicare denial, the clam may be paid under 1879 as if it were covered. (8/30/2001)
Q. Can a RT bill a "G" code for the 6-minute walk test? A. No, G0238 and G0239 could include educational activities as therapeutic procedures to improve respiratory function. The 6-minute walk test is not therapeutic and should not be billed with these codes.
Q. Can I use a V-code as a primary diagnosis when coding a claim? A. No. Refer to the "V" codes section of the ICD-9-CM book, which states that this is a supplementary classification of factors influencing health status. As this is a supplementary code, it should not be the one selected for use as the primary or admitting diagnosis.
Q. The claims/service area receives a request for hard-copy adjustment to a previously medically denied claim. Included in the request is a statement regarding "changing diagnosis" on the original claim. How should this be handled? A. The Fiscal Intermediary cannot accept hard-copy records for adjustments to MR denials. If the provider wishes to appeal, the request must be in writing to the MR department. A letter requesting the appeal and the supporting medical records should be mailed to the Appeals Coordinator. The request must be timely (At the present time, the request for outpatient The request must be timely (At the present time, the request for outpatient original denial.). Requests for hard-copy adjustments on previously medically reviewed claims should be returned to the provider. In addition, changing the original diagnosis could be perceived as fraudulent activity. Adding to the original diagnosis (es) on a claim would be acceptable, along with documentation to support the medical necessity of the additional diagnosis (es).
