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Find helpful resources regarding CRD- and ESRD-related services on the CMS website:
- Update to Pub. 100-02, Chapter 11 End-Stage Renal Disease (ESRD) for Calendar Year (CY) 2017
- ESRD Monthly Capitation: Claim Submission, Documentation, and Payment – pending/26401
- Evaluation & Management (E/M) services on the same date as dialysis services: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 40.2.A.8
- National Coverage Determination: Laboratory Tests – CRD Patients
- Items and services included in ESRD Consolidated Billing(see document under Downloads)
- Kidney transplant information: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 11, section 140
- Kidney disease patient education information: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 310
- Payment for immunosuppressive management: CMS Medicare Claims Processing Manual, chapter 12, section 30.6.3
- Requirements for Erythropoiesis Stimulating Agents, including required modifiers: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17, sections 80.8-80.12
- Determining the 30 Month Coordination Period: CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 2, section 20.1
- Documentation Fact Sheet: Outpatient Physician Dialysis
Access these CMS resources for additional information regarding diagnostic tests:
Find helpful resources regarding claim submission and information
- 2017 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List
- DMEPOS Video Education
- Calendar Year (CY) 2015 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Crossover Claims Rejecting Due to Unnecessary Billing of Discharge Date
- Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856) - MLN Matters PDF Document SE1305
- July Quarterly Update for 2013 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule - MLN Matters PDF Document MM8325
- DMEPOS Contract Suppliers Announced
- Payment Related to Prior Authorization for Power Mobility Devices (PMD) - MLN Matters PDF Document MM8056
- Medicare DMEPOS Competitive Bidding Program: Quick Reference Article - MLN Matters PDF Document SE1244
- Humanitarian Use Device (HUD) Coverage
- CGS Information Regarding HUD Approvals
- CGS IDE Submission Requirements
- Calendar Year (CY) 2014 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Change to the Reasonable Charge Update for 2014 for Splints, Casts, and Certain Intraocular Lenses
- Dear Physician – Nebulizers – Coverage Criteria and Physician Documentation Requirements
- Dear Physician - Enteral Nutrition, Coverage and Physician Documentation Requirements
- Glucose Monitors and Supplies
- Calendar Year (CY) 2013 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Dear Physician - Home Oxygen Initial Qualification Testing
- Dear Physician - CERT/Therapeutic Shoes for Persons with Diabetes
- Supplies and Durable Medical Equipment (DME): Which Contractor Processes the Claim?
- Dear Physician - Face-to-Face and Written Order Requirements for High Cost DME
- Spiracur SNAP Wound Care System
Evaluation & Management (E/M)
Refer to these helpful resources for CMS-level information regarding E/M services:
Access the articles listed below for more information about topics and programs that are of general interest to Medicare providers. You may also find the following additional resources helpful:
Home Health & Hospice
Find helpful resources regarding Medicare's home health and hospice benefits, including required documentation from certifying physicians:
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. Below are just some of the resources available on the CMS ICD-10 website.
If you will not be able to complete the necessary system changes to submit claims with ICD-10 codes by October 1, 2015, or find that you are unable to submit claims on or after October 1, 2015, due to issues with your billing software, vendor or clearinghouse, ICD-10 claims submission alternatives are available.
CMS ICD-10-CM/PCS Resources
Medicare Learning Network (MLN) Matters Articles
ICD-10-CM/PCS Resources Offered By Other Organizations
Medicare providers (including physicians and, in some cases, nonphysician practitioners) may be eligible for and participate in a variety of incentive programs. Find out more about these programs:
Medicare providers (including physicians and, in some cases, nonphysician practitioners) may be eligible for and participate in a variety of incentive programs. Details about each program are included in this web article. Refer to the CGS Incentive Programs Job Aid for concise descriptions and comparisons of these programs.
Health Professional Shortage Area (HPSA)
Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the Health Resources and Services Administration (HRSA) as primary medical care HPSAs. In addition, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. If a ZIP code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.
- Find out if the service location qualifies for one of these incentives. Access the list of ZIP codes in HPSAs for which automatic incentive payments can be made from the CMS Physician Bonuses web page. (Select the file you want under Downloads; there are separate files for primary care and mental health HPSAs for each calendar year). If the ZIP code where the service was furnished IS on this list, the applicable HPSA bonus payment will be calculated automatically. Use this handy CMS Guideto help you determine if the service is eligible for the automated HPSA bonus.
- If the ZIP code where the service was furnished is in a HPSA but is not on the list of ZIP codes for which automatic payments can be made, verify that the ZIP code is in a HPSA:
- If you determine that the ZIP code where the service was rendered IS in a HPSA based on one of these sources, submit HCPCS modifier AQ with:
- Physicians' professional services rendered in a designated HPSA, when the ZIP code where the services were furnished is in a HPSA but is not on the list of ZIP codes for which automatic HPSA payments can be made.
- Services furnished by psychiatrists in designated Mental Health HPSAs, when the ZIP code where the services were furnished is in a HPSA but is not on the list of ZIP codes for which automatic HPSA payments can be made.
HPSA Surgical Incentive Payment (HSIP) Program
Effective for dates of service January 1, 2011 through December 31, 2015, general surgeons serving in designated HPSAs will receive an additional 10% bonus for major surgical procedures with a 10- or 90-day global period, as defined in the Medicare Physician Fee Schedule Database (MPFSDB). This additional payment, referred to as the HPSA Surgical Incentive Payment (HSIP) will be paid on a quarterly basis in addition to the original HPSA payment. The bonus payment is applicable to surgeries that have 10 or 90 global days, as defined in the Medicare Physician Fee Schedule Database (MPFSDB).
Primary Care Incentive Program (PCIP)
For primary care services furnished on or after January 1, 2011 through December 31, 2015, a 10% incentive payment will be provided to primary care practitioners who render primary care services. CMS has provided CGS with a list of the National Provider Identifiers (NPIs) of the primary care practitioners eligible to receive the incentive payments. Learn more:
Electronic Health Record (EHR) Incentive Program
The Medicare EHR Incentive Program will provide incentive payments to eligible professionals, eligible hospitals, and CAHs that demonstrate meaningful use of certified EHR technology. Eligible professionals can receive up to $44,000 over five years under the Medicare EHR Incentive Program. There is an additional incentive for eligible professionals who provide services in a Health Professional Shortage Area (HSPA). Beginning in 2015, the program also applies a negative payment adjustment to eligible professionals who are not ";meaningful users" in 2014. Find out more on the CMS Electronic Health Records (EHR) web page.
Physician Quality Reporting System (PQRS)
The CMS Physician Quality Reporting System (PQRS) provides incentives to eligible health care providers who report quality measures. Beginning in 2015, the program also applies a negative payment adjustment to eligible professionals who do not ";satisfactorily" report certain quality data. Refer to CMS Physician Quality Reporting System (PQRS) web pagefor more information.
Injections & Drugs
Find helpful resources regarding payment, claim submission requirements, and coverage under Medicare Part B for injections and drugs:
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 Databasefor 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
Mental Health Services
Access helpful resources regarding coverage, claim submission requirements, and payment information related to mental health services:
The determination as to whether Medicare pays as primary or secondary is based on various laws. For more information about Medicare Secondary Payer (MSP) provisions and billing requirements, refer to the following CMS resources:
Physical & Occupational Therapy
Find information regarding claim submission and documentation requirements for physical and occupational therapy, including therapy caps and functional reporting, through these CMS resources:
Find more information regarding preventive services through these CMS resources:
Access guidance for teaching physicians through these CMS resources:
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