Customer Service FAQs

In an effort to provide our customers with self-service tools and up-to-date information on calls we receive in our Customer Service Department, we will periodically place Q&As on our Website. We hope you will find this information useful.

1. What are the financial limits on outpatient therapy services for a date of service of March 1, 2008?
2. What is the Ambulance Inflation Factor (AIF) for Calendar Year 2008?
3. Under the hospital outpatient Prospective Payment System (PPS), how should a provider report more than one EKG performed in the same day?
4. What is the date of service that should be used on a claim for a laboratory test on a specimen for which the collection period spanned two calendar days?
5. In order for providers to properly claim a bad debt and be reimbursed under the Medicare Program, providers must follow all of the Criteria for Allowable Bad Debt. Where can providers locate this information?
6. What procedure code is used when a patient is admitted to inpatient hospital care for less than 8 hours on the same calendar date?
7. What is the definition of the Present on Admission (POA) Indicator? When are hospitals required to report POA information?
8. For a date of service on or after January 1, 2009, how would a provider bill for an implanted prosthetic device that is furnished to a Medicare beneficiary who is a hospital inpatient, but does not have Part A coverage?
9. When the Medicare contractor has revoked a provider's billing privileges, how long must the provider wait before re-applying for participation in the Medicare program?
10. What authentication elements must be present on a provider inquiry on letterhead?
11. Are skilled nursing facilities (SNFs) subject to SNF consolidated billing as it relates to telehealth services?
12. What condition code should be used for services for billing periods after the therapy cap has been exceeded which are not eligible for exceptions?
13. For beneficiaries located at qualifying originating sites which require consultative input of physicians who are not available for a face-to-face encounter, what follow-up inpatient telehealth Healthcare Common Procedure Coding System (HCPCS) codes should be used?
14. What are the Medicare Part B payment allowances for influenza and pneumococcal vaccines?
15. If an Inpatient Psychiatric Facility (IPF) must send a patient to another facility for care or treatment (e.g., dialysis), how does the IPF get reimbursed?
16. How should hospitals identify the emergency room (ER) encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A Skilled Nursing Facility (SNF) stays?
17. What criteria must be met to use condition code 44 to report a change in status from inpatient to outpatient?
18. How are inpatient hospital or skilled nursing facility days counted?
19. Are HIPAA covered entities protected from complaints when they make disclosures to Quality Improvement Organizations (QIOs)?
20. How should hospitals identify the emergency room (ER) encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A skilled nursing facility (SNF) stays?
21. If a hospital bills for three sessions of cardiac rehabilitation services for a patient on a given day, must they each be a minimum of 60 minutes? Please elaborate.
22. What claim adjustment reason code do you use when claims are denied for failure to have the appropriate diagnosis code? Please elaborate.
23. Under what conditions will Medicare not cover a particular surgical or other invasive procedure to treat a particular medical condition?
24. When will Medicare pay for the services of co-surgeons?

1. What are the financial limits on outpatient therapy services for a date of service of March 1, 2008?
The financial limits on outpatient therapy services are $1,810 for combined physical therapy and speech-language pathology services; and $1,810 for occupational therapy services.

2. What is the Ambulance Inflation Factor (AIF) for Calendar Year 2008?
The Ambulance Inflation Factor (AIF) for Calendar Year 2008 is 2.7%.

3. Under the hospital outpatient Prospective Payment System (PPS), how should a provider report more than one EKG performed in the same day?
Report the first EKG without a modifier. Any additional EKGs performed in the same day are reported with modifier -76 appended to the Current Procedural Terminology (CPT) code.

4. What is the date of service that should be used on a claim for a laboratory test on a specimen for which the collection period spanned two calendar days?
If a specimen is collected over a period that spans two calendar days, then the date of service must be the date that the collection period ended.

5. In order for providers to properly claim a bad debt and be reimbursed under the Medicare Program, providers must follow all of the Criteria for Allowable Bad Debt. Where can providers locate this information?
Sections 308 and 310 of the Provider Reimbursement Manual (CMS Publication 15-1), available at http://www.cms.hhs.gov/Manuals/PBM/list.asp .

6. What procedure code is used when a patient is admitted to inpatient hospital care for less than 8 hours on the same calendar date?
When a patient is admitted to inpatient hospital care for less than 8 hours on the same calendar date, you shall report the Initial Hospital Care using a code from CPT code range 99221-99223. In this scenario, do not use the Hospital Discharge Day Management Service CPT code 99238 or 99239.

7. What is the definition of the Present on Admission (POA) Indicator? When are hospitals required to report POA information?
POA is defined as present at the time an order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA. Hospitals are required to report POA information for both primary and secondary diagnoses when submitting claims for discharges.

8. For a date of service on or after January 1, 2009, how would a provider bill for an implanted prosthetic device that is furnished to a Medicare beneficiary who is a hospital inpatient, but does not have Part A coverage?
Hospitals may submit these services on a 12X type of bill, reporting a new C-code that will be effective for services furnished on and after January 1, 2009, when they furnish an implanted prosthetic device to a Medicare beneficiary who has Part B coverage but does not have Medicare coverage of inpatient hospital services on the date that the device is furnished.

9. When the Medicare contractor has revoked a provider's billing privileges, how long must the provider wait before re-applying for participation in the Medicare program?
The enrollment bar will require that providers and suppliers whose billing privileges are revoked to wait from one to three years before reapplying to participate in the Medicare program.

10. What authentication elements must be present on a provider inquiry on letterhead?
The letterhead, if it contains a verifiable provider name and address, must also contain one of the following three elements: 1) NPI; 2) PTAN; or 3) last 5 digits of the tax identification number.

11. Are skilled nursing facilities (SNFs) subject to SNF consolidated billing as it relates to telehealth services?
No. The originating site facility fee is outside the SNF prospective payment system bundle and, as such, is not subject to SNF consolidated billing. The originating site facility fee is a separately billable Part B payment.

12. What condition code should be used for services for billing periods after the therapy cap has been exceeded which are not eligible for exceptions?
Services for billing periods after the cap has been exceeded, which are not eligible for exceptions, may be billed for denial using condition code 21.

13. For beneficiaries located at qualifying originating sites which require consultative input of physicians who are not available for a face-to-face encounter, what follow-up inpatient telehealth Healthcare Common Procedure Coding System (HCPCS) codes should be used?
HCPCS Code Descriptor
G0406 Follow-up inpatient telehealth consultation, limited
G0407 Follow-up inpatient telehealth consultation, intermediate
G0408 Follow-up inpatient telehealth consultation, complex

14. What are the Medicare Part B payment allowances for influenza and pneumococcal vaccines?
The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the average wholesale price as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department, rural health clinic, or federally qualified health center, in which cases, payments for the vaccines are based on reasonable cost.

15. If an Inpatient Psychiatric Facility (IPF) must send a patient to another facility for care or treatment (e.g., dialysis), how does the IPF get reimbursed?
The Inpatient Psychiatric Facility (IPF) will continue to be paid the per diem rate with any applicable adjustments for the days when the patient is temporarily transferred to a different facility for treatment and it would in turn pay the receiving facility for the services provided, as long as the patient is still an inpatient of the IPF (i.e., the patient has not been discharged).

16. How should hospitals identify the emergency room (ER) encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A Skilled Nursing Facility (SNF) stays?
In order to bypass the ER encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A SNF stays, hospitals should identify those services by appending the modifier ET (Emergency Services) to line item date of service on their outpatient bill types 13x and 85x when revenue code 045x (Emergency Room) is present on the claims. The reporting of the ET modifier will alert common working file (CWF) that these are related ER services performed on subsequent dates so that it will bypass the SNF consolidated billing (CB) edits.

17. What criteria must be met to use condition code 44 to report a change in status from inpatient to outpatient?
Condition code 44 may be reported on a hospital outpatient claim to indicate that a patient was initially admitted to inpatient care but that the patient's status was changed to that of a registered outpatient only if each of the following criteria are met:

1. The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
2. The hospital has not submitted a claim to Medicare for the inpatient admission;
3. A physician concurs with the utilization review committee's decision; and
4. The physician's concurrence with the utilization review committee's decision is documented in the patient's medical record.

18. How are inpatient hospital or skilled nursing facility days counted?
The number of days of care charged to a beneficiary for inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to midnight method is to be used in counting days of care for Medicare reporting purposes even if the hospital or SNF uses a different definition of day for statistical or other purposes. A part of a day, including the day of admission and day on which a patient returns from leave of absence, counts as a full day. However, the day of discharge, death, or a day on which a patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of admission. If admission and discharge or death occur on the same day, the day is considered a day of admission and counts as one inpatient day. Charges for ancillary services on the day of discharge or death or the day on which a patient begins a leave of absence are covered.

19. Are HIPAA covered entities protected from complaints when they make disclosures to Quality Improvement Organizations (QIOs)?
The Social Security Act provides certain protections to those who disclose information to the QIOs, as described in §1157 of the Act. Under §1157, no person providing information to a QIO will be held, by reason of having provided such information, to have violated any criminal law or to be civilly liable under any State or Federal law, unless the information provided is unrelated to the performance of the contract of the QIO or the information is false and the individual knew or had reason to believe that the information was false.

20. How should hospitals identify the emergency room (ER) encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A skilled nursing facility (SNF) stays?
In order to bypass the ER encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A SNF stays, hospitals should identify those services by appending the modifier ET (Emergency Services) to line item date of service on their outpatient bill types 13x and 85x when revenue code 045x (Emergency Room) is present on the claims. The reporting of the ET modifier will alert common working file (CWF) that these are related ER services performed on subsequent dates so that it will bypass the SNF consolidated billing (CB) edits.

21. If a hospital bills for three sessions of cardiac rehabilitation services for a patient on a given day, must they each be a minimum of 60 minutes? Please elaborate.
As stated in Transmittal 1417/ CR 5912, in order to report more than one session for a given date of service, each session must last a minimum of 60 minutes. For example, if the services provided on a given day total 1 hour and 50 minutes, then only one session should be billed to report the cardiac rehabilitation services provided on that day. Medicare only covers a limited number of sessions.

22. What claim adjustment reason code do you use when claims are denied for failure to have the appropriate diagnosis code? Please elaborate.
Use claims adjustment reason code #167 to denote "This/these diagnosis(es) is (are) not covered" when claims are denied for inappropriate diagnosis codes.

23. Under what conditions will Medicare not cover a particular surgical or other invasive procedure to treat a particular medical condition?
Medicare will not cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs:
1) a different procedure altogether;
2) the correct procedure, but the wrong body part: or
3) the correct procedure, but the wrong patient.

24. When will Medicare pay for the services of co-surgeons?
Medicare will only pay for the services of co-surgeons when the services are rendered by two surgeons, each with a different specialty, and the claim carries modifier 62 to show there were two surgeons for co-surgery.

Page Last Updated: Thursday, 25-Feb-2010 08:07:08 CST