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Medicare’s payment for surgery includes all the services connected to the surgery. This includes pre-, intra, and post-operative services provided by the surgeon or a member of the same group with the same specialty. Instructions are in the CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40. The Medicare Physician Fee Schedule Relative Value File includes column “O.” This column shows the number of days included in the payment. If the column contains 000, it means payment for the surgery includes all services provided on the same calendar date of the surgery and Medicare includes services provided by the surgeon as part of the global surgery package. If you feel the subsequent procedure should be paid separately, documentation must support an exception for Medicare to allow separate payment for other services that would otherwise be included in the global surgery package. Modifiers appended to the claim show the specific exceptions.

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The follow-up colonoscopy should be billed with the correct HCPCS codes, G0105 or G0121, along with the KX modifier. The correct diagnosis code for a follow-up colonoscopy after a positive Cologuard test with no abnormal findings would typically be Z12.11 (encounter for screening for malignant neoplasm of the colon) if the colonoscopy is considered a screening procedure following the positive test.

@@wpspoe Thank you. Should Z12.11 always be the primary DX code for qualifying High-Risk and Average-Risk screening colonoscopy encounters?

Z12.11 is the primary diagnosis for all screening colonoscopies, whether high-risk or average-risk, regardless of findings. Any polyps or abnormalities found are coded as secondary diagnoses.

The KX modifier would be appended to all outpatient lines of service when the beneficiary has met or exceeded the therapy threshold limit. In addition to the KX modifier, the GO modifier shall continue to be used. Use of the KX modifier in therapy billing is only necessary for outpatient services, so place of service 21 (Inpatient Hospital) would not require use of this modifier. For more information on the use of the KX modifier, visit the Medicare Claims Processing Manual, Chapter 5, Section 10.3.3: www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c05.pdf

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An initiating visit is for new patients or for those not seen within the previous 12 months. You would need to discuss CCM during that visit. Medicare does not require any particular level of service. For patients seen within the previous 12 months, you do not need to have discussed CCM during that visit. You can have a separate discussion on starting CCM with that patient.

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Thanks for watching our video. Each secondary insurance has their own coverage criteria so we would not be able to comment on their possible decisions.

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An annual wellness visit (AWV) can be provided in a patient's home when all requirements are met. Services must be provided by a health professional as described in the Medicare Benefits Policy Manual, Chapter 15, Section 280.5. (www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf).

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Thank you for your question! Licensure varies by state and must be provided if required for the organization to perform services. It does not determine the application that needs to be submitted. An IDTF is a facility that is performing diagnostic services and is independent of a clinic, physicians office or hospital. and IDTF may perform both the technical and professional component of the diagnostic service. You can find more information in the Program Integrity Manual (PIM), chapter 10, § 10.2.2.4 - Independent Diagnostic Testing Facilities (IDTFs). CMS has also published a National Coverage Determination (NCD) you may find helpful: Billing and Coding: Independent Diagnostic Testing Facility (IDTF): www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57807&ver=105&

Thank you for your question. Once the site visit is completed by the National Site Visit Contractor (NSVC), The NSVC shares their findings with the MAC. The MAC uses that information to make the enrollment determination and continue processing. Timelines for processing, including applications that require a site visit, are outlined in the Program Integrity Manual (PIM), chapter 10 § 10.5. WPS also has a resource available on our website to assist you med.wpsgha.com/guides-resources/view/529.

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Medicare eligible medical services must occur in the USA or it's territories. Providers outside the USA or it's territories do not need to enroll or opt out of Medicare.

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If your appeal is at level 4, you will need to reach out to the Departmental Appeals Board. CMS offers information on their website at www.hhs.gov/about/agencies/dab/index.html If you need general help or information on a level 1 appeal, contact our customer service area. This link will take you to our contact page. You can use the drop-down to locate the contact information. med.wpsgha.com/contact

A medical professional use the provider enrollment process. The process involves completing an application. For more information, view the CMS web page Become a Medicare Provider or Supplier at www.cms.gov/medicare/enrollment-renewal/providers-suppliers.

All ambulance claims require the Point of Pickup (POP) ZIP Code. The denial CO 284 is related to prior authorization. You will want to contact customer service for assistance with your claim.

Yes. The swing bed in considered part of a hospital not a skilled nursing facility.

CMS instructions are silent on whether time spent in gathering the patient consent would or would not be part of the monthly chronic care management (CCM) time-based billing. This would be a business decision as to whether you would include this in the initiating visit, the comprehensive assessment and care planning (if provided), or in the monthly CCM service.

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You can send an email to wps.gha.education@wpsic.com and request a copy of the power point.

The practitioner can develop the care plan. The practitioner can also work with the clinical staff to develop the care plan. You can find additional information in the resource we have available on our website. Chronic Care Management: med.wpsgha.com/guides-resources/view/856

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We are not the contractor handling second level appeals. We recommend checking the CMS Website for more information. www.cms.gov/medicare/appeals-grievances/fee-for-service/second-level-appeal The website provides a list of the contractors handling this level of an appeal.

The condition code 02 shows the claim is related to employment. The lack of condition code 02 should indicate the claim is not related. For specifics on your claim, contact our customer service area.

The condition code 02 shows the claim is related to employment. The lack of condition code 02 should indicate the claim is not related. For specifics on your claim, contact our customer service area.

Hello. You will need to complete the 855I to enroll the LLC and the 460. The new 460 is required because you are no longed under a group. You will also need to complete the CMS 588 for electronic funds transfer.

@@wpspoeThanks - this is very helpful. When I fill out 588, should I also delete the group I am leaving in the reassignment section or should I assume that the group will update the 588 on their end. and remove me when I leave the group?

@@mrt3511 Yes, that is the best practice.

@@wpspoeAonther question- do I need to fill out the 460 BOTH for myself (provider) as well as my LLC ?

@@mrt3511 You will one. The form will cover your practice locations.

Hi, you can select Medicare Nutrition Therapist or Technician. If you do no have these options, you would report "other" on the drop-down. There will be a free-text field, and you enter your specialty.

You will need to enroll with electronically in Medicare Provider Enrollment, Chain, and Ownership System (PECOS) at pecos.cms.hhs.gov/pecos/login.do#headingLv1. You may also complete the paper enrollment form and send the form to the Home Health and Hospice MAC for Texas. To view the MAC, visit CMS's web page www.cms.gov/medicare/medicare-contracting/medicare-administrative-contractors/who-are-the-macs-a-b-mac-jurisdiction-m-jm for JM.

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Hello, to answer your question I need to confirm if the information showing incorrectly in Provider Enrollment Chain and Ownership System (PECOS) with a Provider Transaction Access Number (PTAN) assigned or the National Plan and Enumeration System (NPPES)? If it is in NPPES it can be changed inside the providers NPPES record. If the provider has a Sole Owner PTAN that is no longer needed an application would need to be submitted to deactivate either through PECOS or on paper using a CMS 855I.

Hello. Thanks for the suggestion. We will look into this.

Billing will depend on the units of service as described by the procedure code. For example, the procedure code indicates one unit of service is 50 units. In the example, you would have one line with the procedure code, and 11 units of service with Modifier JZ. You would then have one line of service with one unit with Modifier JW. Another example, the procedure code indicates the units of service is 100 units. In the example given, you would have one line of service with six units and Modifier JZ.

Hello. Yes, this type of bill is possible. The transport must be medically necessary and the patient cannot be inpatient in either hospital for Medicare to consider the claim.

The unit of service is .09 mg. Use Modifier JZ. The amount available in the single-dose package does not show an additional unit of service.

Good afternoon. Thank you for the comments. I am not sure which source documents you may be referring to. Note that there are several URLs included in the PowerPoint to the various CRs, etc. If you are not currently on the mailing list for the webinar you can email me at Audit.Advisement@wpsic.com and I can send that to you so that you can access the links. Regarding the audio, it appears those cutouts were in the recording itself, since nothing was brought up during the live session that this is a recording of. Unfortunately, there are some instances where the webinar recording tool that we use drops a few seconds here and there. We have expanded to two sessions to allow for more flexibility for people to attend live, which may be better quality. We still load the recording of the webinar, in lieu of this being a live only event. Hopefully you were able to at least get most of the information out of the recording. I can add you to that webinar mailing list if you send me an email to the above. Hope this helps!

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The upload can occur in a variety of formats. The way you create the files is not something we can help with. We are not sure what features your printer has available or if it is also a scanner.

Hi, we ask that all questions be sent to wps.gha.education@wpsic.com. In the subject line include the name of the video. After receiving the question, one of our team will provide an answer.

Hi, we ask that all questions be sent to wps.gha.education@wpsic.com. In the subject line include the name of the video. After receiving the question, one of our team will provide an answer.

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