Saturday, April 30, 2016

Medicare Appeal time limit - Five level of appeal

When to file an appeal

Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.

Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

The five levels of appeals, listed in order, are:

Appeal level Time limit for filing request Where to file an appeal

First level: Redetermination 120 days from the initial claim determination Medicare administrative contractor (MAC

Second level: Reconsideration 180 days from the redetermination decision Qualified independent contractor (QIC)

Third level: Administrative law judge hearing (ALJ) 60 days from the date of the reconsideration decision Office of Medicare Hearings and Appeals

Fourth level: Medicare Appeals Council 60 days from the date of the ALJ decision Departmental Appeals Board

Fifth level: Judicial review: 60 days from the date of the Medicare Federal District Court

Submit request by:

Monetary threshold for requests made on or after January 1, 2015: $1,460. For requests made on or after January 1, 2016, the threshold is $1,500.

Federal District Court

Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

Monday, April 25, 2016

Common reason for adjusting and reopening claims FAQ

Q: What are some common situations when I can or cannot adjust or reopen claims?

A: Providers are responsible in determining when it is appropriate to make corrections to paid (status/location P/B9997) or rejected (status/location R/B9997) claims. Listed below are some helpful hints in determining when you can or cannot correct

Clerical or minor claim error corrections

• Mathematical or computational mistakes
• Transposed providers or diagnostic codes
• Inaccurate data entry
• Misapplication of fee schedule
• Computer errors
Denial of clams as duplicates which the party believes were incorrectly identified as a duplicate
• Incorrect data items, such as provider number, use of a modifier or date of service

Tolerance guidelines for adjusting hospitals and skilled nursing facilities (SNF) claims

• Number of inpatient days (including a change in the length of stay, or a different allocation of covered/non-covered days)
• Blood deductible
• Change in the Part B cash deductible of more than $1.00
• Inpatient hospital cash deductible of more than $1.00
• Servicing hospital or SNF provider number
• Hospital outlier payment
• Discharge status

Adding charges or services

• Providers may adjust claims (TOB xx7) to add charges or services when the claim is within the timely filing period.
• Providers are not permitted to add charges or services on an initial bill after the expiration of the time limitation for filing a claim.
• Click here for additional information on the timely filing guidelines.

Hospital diagnosis related group (DRG) claim adjustments
• Hospital adjustments to correct the diagnostic and procedure coding on their claim to a higher weighted DRG must be submitted within 60 days of the paid remittance.

• Claim adjustments that result in a lower weighted DRG are not subject to the 60 days requirement.
Skilled nursing facility (SNF) health insurance prospective payment system (HIPPS) code adjustments

• SNF adjustments to change in HIPPS code due to a minimum data set (MDS) correction must be completed within 120 days of the through date on the claim.

Medically denied claim

• It is not appropriate to adjust claims that have medical review (MR) denials (status/location D/B9997), or paid claims with line item(s) denials.
• Medicare administrator contractors (MACs) will not allow claim lines that have been denied through a MR process (for example, MR, recovery audit contractor (RAC), comprehensive error rate testing (CERT), office inspector general (OIG), quality improvement organization (QIO), etc.) to be reopened.
• Click here to review the process on how to determine when a claim was medically reviewed and how to make changes.
• Providers must submit appeal request for claim denials based on medical records, including failure to respond to medical record requests.

Additional reminders
• Do not adjust claims in status/location P/B9996 (payment floor) until they have reached final disposition.
• Claims in status/location P/B7516 or R/B7516 (Medicare secondary payer post pay) will be held for at least 75 days (CMS cost avoidance savings), and cannot be adjusted until they have reached final disposition.
• Third party payer error in making primary payment does not constitute “good cause” for the purpose of reopening a claim beyond one year of the initial determination.
• A contractor’s decision to reopen or not reopen a claim, regardless of the reason for the decision, is not subject to an appeal.
• A reopening will not be granted if an appeal decision is pending or in process.

Wednesday, April 20, 2016

How much payment would get Assitant Surgeon, Co- Surgery and Team surgery

Assistant Surgeon Services

Harvard Pilgrim reimburses assistant surgeon services when the assistant at surgery is a physician, a physician assistant, or a nurse practitioner consistent with CMS’ determination of approved procedure codes payable to an assistant surgeon.

• Assistant surgeon services are reimbursed at 16% of the fee schedule/allowable amount.
• Secondary surgical procedures are reimbursed at 8% of the fee schedule/allowable amount.

Assistant Surgeon Services (in Maine only)
Registered nurse/first assistants and physician assistants are reimbursed as assistant surgeons at a rate equal to 85% of the assistant surgeon 16% allowable rate.

Co-surgery is reimbursed at 62.5% of the fee schedule/allowable amount.

Team Surgery
Team surgery is reimbursed after individual consideration and review of operative notes according to the percentage of surgery performed by each respective surgeon.

Attempted Service (discontinued procedure)
Attempted inpatient surgery is reimbursed at 50% of the fee schedule/allowable amount.

Reduced Services
Reduced services are reimbursed at 50% of the fee schedule/allowable amount.


Kyphoplasty, vertebroplasty, and radiologic supervision and interpretation, vertebroplasty for multiple myeloma, monostatic and solitary myeloma, spinal cord hemangioma, secondary malignant neoplasm bone and bone marrow, osteoporotic
vertebral collapse and vertebral hemangioma.

Sunday, April 17, 2016

Claim reopening Guidelines

Q: What is the difference between a claim reopening and an adjustment?

A: Reopening’s are different from adjustment bills based on the following rules:
• Adjustment bills are subject to normal claims processing timely filing requirements (that is, filed within one year of the date of service).

• Reopenings are subject to timeframes associated with administrative finality and are intended to fix an error on a claim for services previously billed (for example, claim determinations may be reopened within one year of the date of receipt of the initial determination for any reason, or within one to four years of the date of receipt of the initial determination upon a showing of good cause). Reopening’s are only allowed after the normal timely filing period has expired.

Providers that need to correct or supplement information on paid (status/location P/B9997) and/or rejected (status/location R/B9997) claims may refer to the following:

Claim adjustment guidelines

• Providers may submit adjustment claims (type of bill (TOB) xx7) to correct errors or supplement a claim when the claim remains within the timely filing limits.
• Click here for additional information on the timely filing guidelines.
• Click here to review the claim data elements required for adjusting and/or canceling claims.

Claim reopening guidelines
• Prior to January 1, 2016, providers submitted the timely filing exception form for preapproval on claim(s) requiring correction that were beyond the timely filing limit.

• Effective on/after January 1, 2016, providers must utilize the new reopening process (TOB xxQ) when the need for correction is discovered beyond the claim timely filing limit; an adjustment bill is not allowed.

• CMS released special edition MLN Matters® article SE1426 external pdf file, to assist providers with coding instructions and billing scenarios for submitting requests to reopen claims that are beyond the claim filing timeframe.

Examples of timelines for filing adjustments and reopenings:

Timely filing period – Use TOB xx7

Thursday, April 14, 2016

CPT CODE G0102, G0103, G0101 - covered ICD 10 codes

Prostate Cancer Screening


G0102 – Digital Rectal Exam (DRE)
G0103 – Prostate Specific Antigen Test (PSA)

ICD-10-CM Codes

Who Is Covered
All male Medicare beneficiaries aged 50 and older (coverage begins the day after their 50th birthday)

Annually for covered beneficiaries

Beneficiary Pays


Copayment/coinsurance applies

• Deductible applies
• Copayment/coinsurance waived
• Deductible waived

Screening Pelvic Examinations (includes a clinical breast examination)


G0101 – Cervical or vaginal cancer screening; pelvic and clinical breast examination

ICD-10-CM Codes

High risk – Z77.22, Z77.9, Z91.89, Z72.89,
Z72.51, Z72.52, AND Z72.53

Low risk – Z01.411, Z01.419, Z12.4, Z12.72,
Z12.79, and Z12.89

Who Is Covered

All female Medicare beneficiaries


• Annually if at high risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within past 3 years; or

• Every 2 years for women at normal risk

Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived