Part B – Browse by Specialty
Ambulance
Access guidance for ambulance services through the CMS website:
- CMS Ambulance Services Web page
- Ambulance Fee Schedule
- Ambulance Fee Schedule and Medicare Transports
- Ambulance and Advance Beneficiary Notices of Noncoverage (ABNs)
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 10
- CMS Ambulance Open Door Forums
Ambulatory Surgery Center
Access these resources for CMS-level guidance regarding coverage and claim submission guidelines for Ambulatory Surgical Centers (ASCs):
- Ambulatory Surgical Center Quality Reporting (ASCQR) Program
- ASC Quality Reporting
- CMS Ambulatory Surgical Center Web page
- CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 14 – Ambulatory Surgical Centers
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 260 – and subsequent sections
Anesthesia & Pain Management
Access these resources for CMS-level guidance regarding coverage and claim submission guidelines regarding anesthesia and pain management services:
- CMS Anesthesiologists Center Web page
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12
- Qualified non-physician anesthetists: section 140
- Calculating anesthesia time and units: section 140.3.2
- Supervision and multiple anesthetists: section 140.4
Chiropractic Medicine
Access these resources for CMS-level guidance regarding coverage and claim submission guidelines for chiropractic services:
- Advance Beneficiary Notice of Non-Coverage (ABN) for Chiropractic Services
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 240 and subsequent sections
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 220
- Educational Resources to Assist Chiropractors with Medicare Billing
- Medicare Coverage for Chiropractic Services – Medical Record Documentation Requirements for Initial and Subsequent Visits
- Medicare Documentation Job Aid For Doctors Of Chiropractic
- Use of the AT modifier for Chiropractic Billing
Hematology/Oncology
Helpful resources for hematology/oncology practices:
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17
- Payment for drugs and biologicals: sections 10-30
- Discarded drugs: section 40
- Self-administered drugs: section 80.5, and refer to the CMS Medicare Coverage Database for the list of drugs CGS has deemed to be "usually self-administered"
- Requirements for Erythropoiesis Stimulating Agents, including required modifiers: sections 80.8-80.12
- CMS Medicare Claims Processing Manual (Pub. 100-04) chapter 13
- Radiation Oncology: section 70
- CMS Medicare Benefit Policy (Pub. 100-02), chapter 15
- Unlabeled use for Anti-Cancer Drugs: section 50.4.5
- Immunosuppressive Drugs: 50.5.1
- Erythropoietin (EPO): 50.5.2
- CMS Drug & Biological Fee Schedules
- Medicare Program (cms.gov) - JW and JZ-Modifier-FAQs
- Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy (cms.gov)
IDTF
Access these CMS resources for additional information for IDTFs:
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 35
- Physician supervision requirements for diagnostic tests:
- Levels of supervision are defined by CMS, in the Medicare Physician Fee Schedule Database (MPFSDB). For definitions of the levels, refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 23, in the Addendum-MPFSDB Record Layouts (see field 31A)
- Access the CMS Physician Fee Schedule look-up tool to identify the supervision indicator for specific CPT and HCPCS codes
- Independent Diagnostic Testing Facility (IDTF) Performance Standards
New to Medicare?
Welcome to Medicare! In addition to the resources below, here are some key resources from the CMS website to help you get started:
- CMS Physician Center Web page
- Medicare Program: General Information
- Complying with Medicare Signature Requirements
Are you a new Medicare Part B provider or staff member? CGS is here to help, and we welcome you to the Medicare program. Please take a tour of the New Provider Resource Center. CGS developed this page with you providers in mind and compiled resources from far and wide. Given these resources, your journey through the Medicare Part B world is sure to be simplified!
We encourage all providers to become familiar with the Centers for Medicare & Medicaid Services (CMS) website and the CGS website to find answers and resources relevant to your Medicare needs.
Education
The primary goal of the Provider Outreach & Education (POE) program is to reduce the Comprehensive Error Rate Testing (CERT) error rate by giving Medicare providers timely and accurate information they need to understand the Medicare program, be informed about changes, and submit accurate claims. Take advantage of Webinars, Ask-the-Contractor Teleconferences (ACTs), Face-to-Face Training, self-paced Online Education Courses (OECs) and more to stay abreast of Medicare changes and updates.
CMS hosts regular and ongoing teleconference calls for the provider community on various topics. Calls are free. We encourage providers to take advantage of these educational opportunities to receive Medicare information from CMS Subject Matter Experts. Register to receive notices about upcoming Open Door Forums on the CMS website.
Join the Electronic Mailing List
By taking a few simple steps you can register to receive immediate updates on all Medicare information including Medicare publications, important updates, educational opportunities and so much more. The electronic mailing is a free service that guarantees receipt of the latest Medicare news and other time-sensitive information.
Sign up for the topics and categories of interest to you.
Self-Service Technology- myCGS, IVR, and Customer Service
There are instances when a Customer Service Representative may not be available to assist with your inquiry. CGS requires providers to use Self-Service Technology for simple transactions, such as eligibility, deductible, Medicare Secondary Payer information, claims status, and outstanding check information. This allows our Customer Service Staff to be available when you need dedicated assistance for your complex issues. If your inquiry cannot be resolved through self-service technology, you may reach a customer service representative during normal business hours.
myCGS is the latest in self-service technology, offering the providers the ability to check claim status, eligibility, Medicare Secondary Payer information, Part B Deductible/Therapy Cap limitations, remittance notices, and financial information.
To register for this free web portal, please see:
The IVR is the telephone information system, and is available during and outside normal customer service hours, with brief periods of downtime for system maintenance and mainframe availability. Use the IVR to order duplicate remittance notices, as well as obtain the Medicare Part B deductible status, eligibility, Medicare Secondary Payer information, fee schedule information, denial reasons, outstanding check amounts, National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) validation and other claim processing information.
Please Note: You will need your billing NPI, PTAN, and the last five digits of your company's tax identification number (TIN) in order to utilize myCGS, the IVR, or when speaking to a Customer Service Representative.
For complex inquires that cannot be handled via the IVR and require the assistance of a Customer Service Representative, providers may call our Provider Contact Center.
- 1-866-276-9558
The Online Help Center allows you to submit inquires electronically to our customer service staff. It is important to note that you should not submit inquiries or comments through this system that contain sensitive personal information (e.g., social security numbers, tax ID numbers, beneficiary numbers, claim information, etc.) as this method of submitting an inquiry is unsecured and unencrypted. In addition, also note that it may take up to 45 days to respond to your electronic inquiry.
Part B Online Help Center
Electronic Data Interchange (EDI)
Requirement for Electronic Claim Submission
Submitting claims electronically reduces the reimbursement time by half and improves cash flow. For electronic claims, the minimum amount of time Medicare Contractors must hold claims before releasing payments is only 14 days. Paper claims have a 29-day payment floor from the date of receipt. We encourage all providers to take advantage of the benefits of EDI.
The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be submitted electronically. There are a few exceptions to this requirement. Please complete the Self-Assessment for ASCA in order to determine your qualifications.
Free software
We offer free software in order to submit your Medicare Claims electronically. PC-ACE Pro32 allows you to enter patient information, claim information, procedure file information, and create summary reports from submissions of electronic claims. Details of the software, including download information, are available at the following links:
Printing Remittance Advices (RAs)
Medicare Remit Easy Print (MREP) software is free and allows you to view and print HIPAA-compliant Remittance Advices (RAs). You may view and print as many or as few claims from each RA as you like. This will be especially helpful when you need to print only one claim from the remittance advice when forwarding the claim to a secondary payer. This software can save you time resolving Medicare claim issues.
More Information about EDI
These benefits and other valuable resources such as EDI contact information are available at the following links:
Forms
In an effort to simplify your transactions with Medicare, CGS offers the convenience of a one-stop shop for all the Part B Forms. Forms available from this link include the Reopening Adjustment Request Form, Redetermination Request Form, Offset Request Form, Overpayment Refund, a link to all CMS Forms and more.
Frequently Asked Questions (FAQs)
You have questions; CGS has answers! Choose from a variety of topics, including Electronic Data Interchange, Medicare Secondary Payer, CMS FAQs and more.
Claim Submission
Our goal is to help you submit claims correctly the first time. We are continually adding resources and educational opportunities geared toward identifying common claim submission errors and resolving such issues. Refer to these helpful tools for more information, and remember to check "Browse by Specialty" and "Browse by Topic" for more specialized assistance:
Modifier Finder Tool
We often receive inquiries from providers about claim denials and proper modifier usage. To better assist with these types of inquiries, CGS designed the Part B Modifier Finder tool to aid Medicare providers in using modifiers correctly. You may search this database by modifier, keyword, or, if you wish, you may also view the entire listing of modifiers, their definitions, and additional billing information by selecting the "Show all Modifiers" option.
Give the Modifier Finder Tool a try
Medicare Claim Review Programs and Bundling Edits
National Correct Coding Initiative (NCCI) edits, Medically Unlikely Edits (MUEs), Comprehensive Error Rate Testing (CERT) program, Recovery Audit Contractor (RAC), and the CGS Medical Review (MR) Department: CGS encourages providers to become familiar with these review programs as all claims are subject to review by at least one or more of these programs.
National Correct Coding Initiative (NCCI) & Medically Unlikely Edits (MUEs):
National Correct Coding Initiative (NCCI) edits are designed to promote correct coding by identifying CPT and HCPCS codes that have component parts (other CPT and HCPCS codes) and code combinations that are mutually exclusive. NCCI is a national initiative, and code pairs associated with NCCI edits are available on the CMS website. Edits are updated as often as quarterly, and there are exceptions allowed for some code pairs.
- Column I codes identify the major procedure ("parent codes"), and the associated Column II codes are the component codes.
- Code pairs with indicator "0" may not be reimbursed separately.
- Code pairs with indicator "1" may be reimbursed separately if documentation supports that the service is separately identifiable and medically necessary. For exceptions to NCCI edits: submit the appropriate modifier and maintain supporting documentation. Refer to the CGS Modifier Lookup tool for more information.
Medically Unlikely Edits (MUEs) are also a national initiative and were designed to reduce errors on submitted claims. MUEs set the maximum units of service providers would report in most circumstances for a single beneficiary on the same date of service. Not all codes have MUEs. Most MUEs are published; however, CMS does not publish all MUE values.
More information about NCCI and MUE, and the edits associated with both programs, is available on the CMS website.
Comprehensive Error Rate Testing (CERT) Program
The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to produce national, contractor-specific, and service-specific paid claim error rates. Find CERT information and resources here.
The CERT Claim Identifier Tool allows you to obtain the results of their CERT review for your office or practice. You may search this database by using the Claim Identifier (CID).
Medical Review
Do you have questions about the Medical Review process, how to contact the Medical Director, where to find your Local Coverage Determinations (LCDs), or documentation tips and guidelines? Check out the Medical Review link for more information.
Recovery Auditor (RA)
The Medicare Modernization Act of 2003 (MMA) mandated that the Centers for Medicare & Medicaid Services (CMS) establish the Recovery Audit Contractor (RAC) program as a three-year demonstration. The demonstration began March 2005 in California, Florida, and New York. In 2007, the program expanded to include Massachusetts, Arizona, and South Carolina before ending on March 27, 2008. The success of the demonstration resulted in the passage of legislation in the Tax Relief and Healthcare Act of 2006, Section 302, which required CMS to establish a National RAC Program by January 1, 2010.
The Medicare Fee for Service (FFS) Recovery Audit Program's mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers, so that the CMS can implement actions that will prevent future improper payments in all 50 states. Recovery Audit Contractors are known as Recovery Auditors (RAs). The RA for each jurisdiction (state) is determined based on where the services were rendered.
Region 1
States – Ohio, Kentucky, Indiana, Michigan, New York, Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut
Performant Contact Information
Telephone number: 1.866.201.0580
Performant website
E-mail address: info@performantrac.com
Remittance Advices and Payments
Remittance Advices: At first, you may wish you had a secret decoder ring to decipher your Medicare Remittance Advices (RAs).
- Codes on your RAs are the keys to deciphering payments, denials, and other important information about your submitted claims. RAs include two types of codes that explain how your claims were processed: Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs). Access the Washington Publishing Company's websitefor a complete list of CARC and RARC codes.
Payments
Medicare reimburses many (but not all) types of services based on fee schedules.
- The Medicare Physician Fee Schedule (MPFS) is the basis for reimbursement for many services.
- Look up the MPFS amounts and other helpful reimbursement information for specific CPT and HCPCS codes on the CGS website (using our helpful tool) or directly from the CMS website.
- Other fee schedules used to calculate reimbursement for Medicare claims include:
- Ambulance Fee Schedule
- Ambulatory Surgical Center Fee Schedule
- Clinical Laboratory Fee Schedule
- Reimbursement for drugs & biologicals: Average Sales Price (ASP)
Ophthalmology & Optometry
Access guidance for optometry and ophthalmology professionals through these links:
- CGS Local Coverage Determination L33944, "Blepharoplasty"
- CMS Medicare Benefit Policy Manual (Pub, 100-02), Chapter 15, Section 30.4 and Section 280.1
- MLN Products – Medicare Vision Services
- Office of Inspector General Report: Medicare Payments for Drugs Used to Treat Wet Age-related Macular Degeneration
Other Specialty
Find a variety of resources on this web page that apply to multiple specialties or specialties other than those listed in the "browse by" section of our website. General resources include:
- Payment methodology for nonphysician practitioners: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12
- Physician assistants: section 110
- Nurse Practitioners and Clinical Nurse Specialists: section 120
- Nurse-Midwife services: section 130
- Clinical Social Workers: section 150
- Psychologists: sections 160 and 170
Podiatry
Access guidance for podiatric services through the CMS website:
- Guidelines for "foot care": Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 290 and subsequent sections
- National Coverage Determination: "Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS) (aka Diabetic Peripheral Neuropathy"
Radiation Oncology
Access guidance for radiation oncology services through the CMS website:
Radiology
Access guidance for radiology services through the CMS website:
- Multiple interpretations of the same X-ray or EKG, and multiple X-rays or EKGs furnished on the same date of service: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 13, section 100.1
- Multiple Procedure Payment Reduction (MPPR) on the Professional Component (PC) of Certain Diagnostic Imaging Procedures
- Payment Reduction for Computed Tomography (CT) Diagnostic Imaging Services
- Payment Reduction for X-Rays Taken Using Film
- Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)
- Physician supervision requirements for diagnostic tests:1
- Levels of supervision are defined by CMS, in the Medicare Physician Fee Schedule Database (MPFSDB). For definitions of the levels, refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 23, in the Addendum-MPFSDB Record Layouts (see field 31A)
- Access the CMS Physician Fee Schedule look-up toolto identify the supervision indicator for specific CPT and HCPCS codes