Six Medicare Tips: New and Notable

Claims, coverage, coding, and more: Here are some Medicare changes and reminders that might affect your practice.

1. Claims containing invalid values in the prior authorization (PA) fields are subject to rejection. Whenever a prior authorization is needed for a service, you report the PA number in the electronic claim file in loop 2300 in the REF segment with a G1 qualifier. The Centers for Medicare & Medicaid Services (CMS) has not required this field in the past but recently made changes to allow the use of the PA field in unique circumstances in the future. Claims containing invalid values in the PA field are subject to rejection. If your claim is rejected for this reason, remove the invalid value and resubmit the claim.

2. Novitas will return claims with invalid modifiers/combos. As of Nov. 17, 2014, Novitas will no longer accept Medicare claims submitted with an invalid modifier or an invalid procedure code/modifier combination. Novitas will return the claim as unprocessable, and you'll have to correct and resubmit the claim for it to be processed.

For current coding rules, refer to CPT coding guidelines and National Correct Coding Initiative edits, and watch for upcoming modifier education from Novitas. See also Notivas' Reference Manual Chapter 29 on correcting coding combination edits. And, mark your calendar for a free Dec. 12 webinar from Novitas on modifier 59 changes. You can register now

3. A revised Reassignment of Benefits application form will become available in December. A revised Reassignment of Benefits application, CMS 855R (11/12), will be available for use on the CMS website as of Dec. 29, 2014. Novitas will accept both the current version of CMS 855R (07/11) and the revised version through May 31, 2015. After May 31, only the revised version will be in effect. Remember, however, that the most efficient way to submit any Medicare enrollment application is through Medicare's Provider Enrollment Chain and Ownership System (PECOS). Applications submitted via PECOS are processed more quickly than paper applications. 

The revised CMS 855R has been streamlined, with some sections reordered for clarity. It includes an optional section for primary practice location address. This information is shared with other programs, such as Physician Compare, to help beneficiaries identify where their physicians are primarily practicing and must be an address affiliated with the group/organization where the benefits are being reassigned.

4. Medicare covers a new colorectal cancer screening test. CMS has finalized its National Coverage Decision for Cologuard, a new colorectal screening test. Medicare covers the Cologuard test once every three years for Medicare beneficiaries who are 50-85 years old, show no signs or symptoms of colorectal disease, and are at average risk of developing colorectal cancer. Cologuard is the first product reviewed through a joint Food and Drug Administration-CMS pilot program where the agencies concurrently review medical devices to help reduce the time between FDA's approval of a device and Medicare coverage.

5. Update on polysomnography claims: In June, Medicare administrative contractors began to demand and recover what CMS initially considered to be overpayments associated with an Office of Inspector General (OIG) study on polysomnography claims. In August, this activity was suspended, and all claim denials will be reversed. Any recouped money will be refunded, including interest. No action is required by you.

6. Reminder: A Medicare program safeguard contractor has reported an increase in venipuncture coding errors. Read this TMA e-tip to review correct coding.

TMA can help you keep up with what's new and notable in Medicare. Medicare Update: 2014 OIG Work Plan is a 43-minute webinar that tells where OIG is focusing its review activities. Looking ahead, plan to attend TMA's popular live Medicare update seminar. It will be offered around the state in February 2015.

Published Nov. 11, 2014

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Last Updated On

December 20, 2016

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