Part A – Browse by Topic
CGS-MolDx
Articles
- CGS Administrators Announces MolDx Expansion to J15 (Vol 4)
- Part A MolDX Claim Submission Instructions
General
- MolDX: Pharmacogenomics Testing Policy Article Update
- CGS-MolDX Molecular Test Registration and Claims Submission (CM00003, Vol. 8) V2
- Laboratory Service Provider Alert (CM00004) V2
- MolDX Claim Submission Instructions
- MolDX Manual
- Part A MolDX Claim Submission Instructions (CM00098, V2)
MolDX Local Coverage Determinations (LCDs)
Technical Assessment
General
- AAPC (American Academy of Professional Coders)
- Accelerated and Advance Payments
- AHIMA (American Health Information Management Association)
- Audit and Reimbursement Related Correspondence
- Checking Claims Status
- HIMSS (Health Information and Management Systems Society)
- Incarcerated Beneficiary Claim Denial FAQs (Last Updated 11/27/13): CMS has issued a list of Frequently Asked Questions (FAQs) about the claim denials associated with a beneficiary's incarceration status
- Medical Record Requests: Keys to Success
- Medicare Bad Debts
- Medicare Fee-for-Service Provider Resources
- MLN6922507 – Medicare Payment Systems
- MolDX: Coverage, Coding, and Pricing Standards and Requirements
- Molecular Test Registration Requirement for Hospital Laboratories (CM00101)
- Physicians! Are You Ordering Oxygen for Your Patient?
- Physicians! Your Medical Records Play a Vital Role in Ordering and Providing DMEPOS to Your Patients!
- Provider Resources
- Top Billing Errors
- UB-04 Discharge Status Codes
- WEDI (Workgroup for Electronic Data Interchange)
- WHO (World Health Organization)
ICD-10
For dates of service on or after October 1, 2015, Medicare providers are required to report ICD-10 codes on their claims. The ICD-10 codes sets contain more than 155,000 codes and accommodate a host of new diagnoses and procedures. The Centers for Medicare & Medicaid Services (CMS) website provides a dedicated ICD-10 web page offering a variety of resources to assist providers with the ICD-10 implementation.
Helpful Resources Regarding ICD-10
CMS ICD-10-CM/PCS Resources
- Medicare Fee-for-Service Provider Resources
- MLN Web-Based Training
- Provider Resources
- Talking to Your Customers About ICD-10 and Version 5010: Tips for Software Vendors
- The ICD-10 Transition: An Introduction
ICD-10-CM/PCS Resources Offered By Other Organizations
Incentive Programs
Find helpful information on incentive programs using these resources on the CMS website:
- Electronic Health Record (EHR) Incentive Program (applies to eligible hospitals and Critical Access Hospitals)
- Hospital Value-Based Purchasing Program: CMS Hospital Quality Initiative Web page and Hospital Value-Based Purchasing Web page
- Post-Acute Care Quality Initiatives
- HSAG Can Help You Use Your QRUR to Identify Opportunities to Improve Care – For Ohio Providers
- Medicare Incentive Programs At a Glance
Injections & Drugs
Access guidance regarding injections & drugs (including biologicals) through the following links:
Reimbursement
- Average Sales Price (ASP) and Not Otherwise Classified (NOC) Pricing Files
- Drug reimbursement for inpatient hospital and inpatient Skilled Nursing Facility (SNF) beneficiaries is included in the prospective payment system (PPS) rates for each facility type (except for hemophilia clotting factors for hospital inpatients under Part A). More information: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17, section 10.
- General guidance regarding payment rules for drugs and biologicals: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17
Coverage and Claim Submission
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17:
- Jurisdiction for oral cancer and oral anti-emetic drugs: section 80.2.2
- Immunosuppressive drugs: section 80.3.1 (see also: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 50.5.1)
- Hemophilia clotting factors: section 80.4
- Hospital outpatient setting (including radiopharmaceuticals): section 90.2
- General guidance regarding coverage of drugs and biologicals: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 50 and subsequent sections
Articles
Medicare Diabetes Prevention Program (MDPP)
CMS Resources
MSP
Medicare is a secondary payer when the beneficiary is covered by group insurance, Workers' Compensation, or if other third-party liability (no-fault, liability, Federal Black Lung Program) applies. Refer to the following resources for additional information.
- Medicare Secondary Payer (MSP) Overview
- CMS Guidelines and Resources for Medicare Secondary Payer (MSP)
- Submitting Medicare Secondary Payer (MSP) Claims and Adjustments
- Billing MSP Claims With Value Code 44
- Federal Black Lung (BL) Program
- Medicare Payment for MSP Claims
- Medicare Secondary Payer (MSP) Billing & Adjustments quick resource tool
- Medicare Secondary Payer (MSP) Billing & Adjustments Online tool
For more information about Medicare Secondary Payer (MSP) provisions and billing requirements, refer to the following CMS and CGS resources:
CMS Resources
- Medicare Secondary Payer Web page
- Medicare Secondary Payer Fact Sheet
- Other Insurer Intake Tool
- MLN7748519 – Medicare Secondary Payer: Don't Deny Services & Bill Correctly
- Contact the Benefits Coordination & Recovery Center (BCRC)
- MSP provisions (including information about situations in which Medicare pays as secondary): CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 2
- MSP billing/claim submission requirements: CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 3
- Processing MSP Claims Related or Unrelated to an Accident or Injury for Non-GHP Claims with ICD-9-CM Diagnosis Codes 500-508 and 800-999 or Related ICD-10-CM Diagnosis Codes – Medicare Secondary Payer (MSP) Manual (Pub 100-05, Ch. 6, Section 40.10
- Coordination of benefits: CMS Benefits Coordination & Recovery Center (BCRC) web page
Opioid Treatment Program Services
Section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act established a Medicare Part B benefit for opioid use disorder (OUD) treatment services, including medications for medication-assisted treatment (MAT), furnished by opioid treatment programs (OTPs).
REMINDER: OTPs should not bill more than once in a 7-day period, except in limited situations, such as a beneficiary starting treatment at the OTP in the middle of the OTP’s standard weekly billing cycle. Please reference the resources below for additional information.
CMS Resources
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 17
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 39
- COVID-19: CMS Allowing Audio-Only Calls for OTP Therapy, Counseling, and Periodic Assessments
- Opioid Treatment Programs (OTP) CMS Web Page
- Opioid Treatment Programs (OTP) Billing/Payment CMS Web Page
- Opioid Treatment Programs (OTPs) Medicare Billing and Payment Fact Sheet
- Opioid Treatment Programs (OTPs) Medicare Enrollment Fact Sheet
Outpatient Therapy
Access guidance regarding outpatient therapy services submitted to Medicare Part A on a UB-04 form (including "Part B of A" therapy services) through these CMS resources:
Resources
- CMS website, Therapy Services
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 12: Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, sections 220 and 230
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 5: Part B Outpatient Rehabilitation and CORF/OPT Services
- Skilled therapy services provided to patients in Skilled Nursing Facilities:
- CMS website, Therapy Cap
- CMS website, Functional Reporting
Articles
Patient Driven Payment Model (PDPM)
Access these helpful resources for more information regarding PDPM:
CMS Resources
- CMS Patient Driven Payment Model
- CMS Presentation: SNF PPS: Patient Driven Payment Model
- CMS Patient Driven Payment Model (PDPM) Frequently Asked Questions
- Videos: PDPM: What Is Changing (and What Is Not) and Integrated Coding & PDPM Case Study
CGS Resources
- Implementation of the SNF PDPM (MLN Matters MM11152)
- New Medicare Webpage on Patient Driven Payment Model (MLN Matters SE18026)
- SNF PPS PDPM: Patient Driven Payment Model
Preventive Services
Medicare pays for many preventive services that can help prevent illness from occurring or determine if a person is at risk for certain conditions so he or she can take steps to prevent them.
Use the resources below to find more information about the preventive services that Medicare covers and offer them to your patients.
CMS Resources
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 18
- Medicare Preventive Services CMS MLN Educational Tool
- Preventive Services CMS Web page