Finding Answers on the CGS Website – Ask-the-Contractor Teleconference (ACT) – March 7, 2023
Click on a question to expand or Show All / Close All
- Where can I find RVU values for Status C codes on your website? I can find the reimbursement for these codes, but I have not been able to find RVU values.
-
Status C codes are not listed on the MPFS since pricing has not been established. CGS does not routinely publish payment rates for these codes because many of them require review of medical records for evaluation and pricing.
C = MACs priced code. MACs will establish RVUs and payment amounts for these services, generally on an individual case-by-case basis following review of documentation such as an operative report.
Reference How to Use the MPFS Look-Up Tool page 23 of 33
For CGS to establish RVUs and payment amounts for status C codes the following is required:
- The status C CPT Code(s)
- Documentation identifying what was provided, this can be an operative report or the patient's medical record for the date of service the procedure was performed
This information can be provided during the submittal of the claim and identified by PWK process.
Once this information is provided, we will be able to identify RVUs and payment amounts for the Status C code(s).
Published: 03.22.23
-
- Can you describe the level of patient assessment needed that can only be provided in general inpatient hospice level of care, example; patient with malignant bowel obstruction, or patient with malignancy related bowel to cutaneous fistula, pleural effusion and pericardial effusion, both patients requiring medication titration and PRN symptom control medication administration?
-
The general rule of thumb to follow when you're looking at GIP Services are services that can't be provided in any other setting.
General inpatient care is allowed when the patient's medical condition warrants a short term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings.
General inpatient care (GIP) is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting.
GIP is not intended to be custodial or residential. Once a beneficiary's symptoms are stabilized, or pain is managed, he/she must return to a routine level of care. The beneficiary may remain in a facility due to safety, but Medicare will not pay for GIP unless the beneficiary is in need of this level of care, and it is clearly documented in the medical records.
Supportive Documentation for GIP
Upon transfer to GIP level of care, documentation should include both:
- A precipitating event (onset of uncontrolled symptoms or pain)
- The interventions tried in the home that have been unsuccessful at controlling the symptoms
Supporting documentation for pain control may include:
- Frequent evaluation by a doctor or nurse
- Frequent medication adjustment
- IVs that cannot be administered at home
- Aggressive pain management
- Complicated technical delivery of medication
Supporting documentation for symptom control may include:
- Sudden deterioration requiring intensive nursing intervention
- Uncontrolled nausea or vomiting
- Pathological fractures
- Open wounds requiring frequent skilled care
- Unmanageable respiratory distress
- New or worsening delirium
The POC should reflect the change in the level of care, the beneficiary's response, and the collaboration with the facility staff.
Published: 03.22.23
-
- In myCGS, is there a way to look up the letters by the appeal number or claim number?
-
As far as searching the actual letters, you can filter them by date and submission ID. The myCGS team is working on an update that will allow you to search by other filter options. Please stay tuned for those changes.
Published: 03.22.23
-
- As a Part B provider treating a hospice patient, how do we find the primary diagnosis for hospice?
-
Please reach out to the patient's hospice for this information. It is not provided in myCGS.
Published: 03.22.23
-
- What is the proper claim formatting when Medicare is the secondary payer, but the primary payment has been accepted as payment in full?
-
Use the 111 bill type with the charges as covered and the 77 condition code.
Published: 03.22.23
-
- Does Medicare require submission of claims for late charges, or is that based on provider discretion?
-
There are only certain situations where providers are required to adjust their claim and make changes. This includes changes to procedure codes on inpatient claims that will result in a change to the DRG. Also, providers usually cannot add charges not included on the original claim after timely filing expires. This information is in the Claims Processing Manual, Chapter 1, Sections 130.1- 130.2.
Published: 03.22.23
-