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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medicare Updates

  • 3 Jul 2019 3:38 PM | Zachary Edgar (Administrator)

    Related CR Release Date: July 3, 2019

    Effective Date: October 1, 2019

    MLN Matters Number: MM11230

    Providers Affected

    Providers and suppliers who serve Qualified Medicare Beneficiaries (QMBs).


    Modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.

    The MSN generated for all QMB individuals includes information regarding their QMB status and lack of liability for Medicare cost-sharing amounts for covered Parts A and B items and services However, CMS has recently learned that the claims processing systems do not differentiate between paid and fully denied claims or denied service lines, and initiate the changes whenever an individual is enrolled in QMB.

    MSNs with QMB claims that are paid:

    • If an MSN includes at least one detail line for a QMB that contains an allowed amount greater than zero, page one (the summary page), will use MSN Message 62.0 to briefly explain the QMB billing protections (in the "Be Informed!" section).
    • Also, on page one, the patient’s total liability amount (in the “Total You May Be billed” field) will omit the deductible and coinsurance amounts for details lines that are for a QMB and include an allowed amount greater than zero.
    • Further, in the claims detail section of the MSN, if the detail line is for a QMB and includes an allowed amount greater than zero, such detail line will reflect $0 (in the “Maximum You May Be Billed” field) and include message 62.1 that informs the beneficiary of her/his QMB status and billing protections.

    MSNs with QMB claims that are denied

    •  In the claim detail pages of the MSN, if a detail line is for a QMB and contains an allowed amount of zero, the MSN:
      • Will reflect the beneficiary's total liability amount in the “Maximum You May Be Billed” field and
      • Include new MSN 11.21 message to inform the beneficiary that even though Medicare has denied the claim, Medicaid may pay for the care.
    • Since most QMBs also have full Medicaid coverage, it’s important to convey that their full Medicaid coverage may cover care that Medicare has denied.

  • 10 May 2019 3:41 PM | Zachary Edgar (Administrator)

    Related CR Release Date: May 10, 2019

    Effective Date: January 1, 2018

    Implementation Date: August 12, 2019

    MLN Matters Number: MM11259

    Providers Affected

    Physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

    Changes Made

    During this initial period of implementation, reporting of the PRC on claims is voluntary. In the future, it will be mandatory and tied to cost measures preceded by rulemaking. As of January 1, 2018, Medicare Part B Merit-Based Incentive Payment System (MIPS)-eligible clinicians may now report their patient relationships on Medicare claims using the PRC codes.

    Below is the description of the PRC Code Modifiers X1, X2, X3, X4 and X5:

    • X1 - Continuous/Broad services = For reporting services by clinicians who provide the principal care for a patient, with no planned endpoint of the relationship
    • X2- Continuous/Focused services = For reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed for a long time.
    • X3 -Episodic/Broad services = For reporting services by clinicians who have broad responsibility for the comprehensive needs of the patients, that is limited to a defined period and circumstance, such as a hospitalization.
    • X4 - Episodic/Focused services = For reporting services by specialty focused clinicians who provide time-limited care. The patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention.
    •  X5 - Only as Ordered by Another Clinician = For reporting services by a clinician who furnishes care to the patient only as ordered by another clinician. This patient relationship category is reported for patient relationships that may not be adequately captured in the four categories described above.

    The Centers for Medicare & Medicaid Services (CMS) has several goals for the voluntary reporting period:

    • For clinicians to gain familiarity with the categories and experience submitting the codes
    • To collect data on the use and submission of the codes for analyses to inform the potential future use of these codes in cost measure attribution methodology in the Quality Payment Program.

    The codes are currently in a voluntary reporting period. Whether and how the codes are reported on claims will not affect Medicare reimbursement. For now, the modifiers have no impact on beneficiaries.

  • 26 Apr 2019 3:37 PM | Zachary Edgar (Administrator)

    Related CR Release Date: April 26, 2019

    Effective Date: January 1, 2019

    MLN Matters Number: MM11171

    Providers Affected

    Teaching physicians billing Medicare Administrative Contractors (MACs) for Evaluation and Management (E/M) services provided to Medicare beneficiaries.

    Changes Made

    It clarifies existing language in the Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 100.1.1 (Evaluation and Management (E/M) Services) to bring it in line with current documentation policy for teaching physicians and E/M services.

    The following provides these policy clarifications:

    For the purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate: 1) that the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and 2) the participation of the teaching physician in the management of the patient.

    The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurse

    Note that MACs will not search their files to reprocess claims impacted by this change. However, they will adjust such claims that you bring to their attention.

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