Wednesday, May 27, 2015

Medicare non covered items and services - part 1


The following four categories of items and services that are not covered under the Medicare Program are discussed in this publication:
1)Services and supplies that are not medically reasonable and necessary;
2)Non-covered items and services;
3)Services and supplies that have been denied as bundled or included in the basic allowance of
another service; and
4) Items and services reimbursable by other organizations or furnished without charge.
Where applicable, exceptions (items and services that may be covered) are also included in this discussion.

1)    Services and Supplies That Are Not MedicallyReasonable and Necessary

Services and supplies that are not medically reasonable and necessary to the overall diagnosis and treatment of the beneficiary’s condition will not be covered. Some examples include:
• Services furnished in a hospital that, based on the beneficiary’s condition, could have been
furnished in a lower-cost setting (for example, the beneficiary’s home or a nursing home);
• Hospital services that exceed Medicare length of stay limitations;

• Evaluation and management services that exceed those considered medically reasonable and
• Therapy or diagnostic procedures that exceed Medicare usage limits;
• Screening tests, examinations, and therapies for which the beneficiary has no symptoms or documented conditions,with the exception of certain screening tests, examinations, and therapies as described under Exceptions;
• Services not warranted based on the diagnosis of the beneficiary (for example, acupuncture and
transcendental meditation); and
• Items and services administered to a beneficiary for the purpose of causing or assisting in causing death (assisted suicide).
In general, Medicare-covered services are those services considered medically reasonable and necessary to the overall diagnosis or treatment of the beneficiary’s condition or to improve the functioning of a malformed body member. Services or supplies are considered medically necessary if they meet the standards of good medical practice and are:
• Proper and needed for the diagnosis or treatment of the beneficiary’s medical condition;
• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition; and
• Not mainly for the convenience of the beneficiary, provider, or supplier.

Services must also meet specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations. For every service billed, you must indicate the specific sign, symptom, or beneficiary complaint necessitating the service. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment
for services without beneficiary symptoms or complaints or specific documentation.


• Annual Wellness Visit;
• Initial Preventive Physical Examination (also known as the “Welcome to Medicare Preventive
• Colorectal cancer screening;
• Screening mammography;
• Clinical breast examinations;
• Screening Pap tests;
• Screening pelvic examinations;
• Prostate cancer screening;
• Cardiovascular disease screenings;
• Diabetes screening tests;
• Glaucoma screening;
• Human Immunodeficiency Virus (HIV) screening;
• Bone mass measurements;
• Medical nutrition therapy (for certain beneficiaries diagnosed with diabetes, renal disease, or who
have received a kidney transplant within the last 3 years);
• Diabetes Self-Management Training (for beneficiaries diagnosed with diabetes);
• Vaccines;
• Ultrasound screening for abdominal aortic aneurysm;
• Intensive behavioral therapy for cardiovascular disease;
• Intensive behavioral therapy for obesity;
• Counseling to prevent tobacco use for asymptomatic beneficiaries;
• Screening for depression;
• Screening and behavioral counseling interventions in primary care to reduce alcohol misuse; and
• Screening for sexually transmitted infections (STI) and high intensity behavioral counseling
to prevent STIs. Items and services  administered for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, may be covered provided they are not furnished for the specific purpose of causing death.

Monday, May 18, 2015

Medicare Preventive Visit, the Annual Wellness Visit and Routine Physical Exams: Three Different Services, Only Two Are Covered by Medicare

When you go to the doctor for a once-a year examination, it’s important that both you and your doctor know what kind of exam you are there for.

Medicare pays for a one-time ‘Welcome to Medicare’ preventive visit within the first 12 months you have Part B coverage. During this visit (also called the ‘Initial Preventive Physical Exam’), your doctor will obtain information on your medical and social history related to your health. ‘Social history’ can mean any history of alcohol, tobacco or other drug use, and your diet and physical activities. Your doctor will measure your blood pressure, weight, height, body mass index, and screen your vision. Your doctor will also give you guidance or advice on preventive services you may wish to consider including certain screenings, shots, and referrals for other care, if needed. You should receive a brief written plan or checklist for the Medicare-covered screenings that you are eligible for.

For this visit, bring your medical records (if your doctor doesn’t have them), including immunization records. Also bring a record of the prescription drugs you are taking, as well as any over-the-counter medications and vitamins you use. If you are new to the doctor conducting this exam, he or she is going to want to know why you were prescribed these medications or take the over-the-counter medicines and vitamins.

When we say ‘doctor’ for the ‘Welcome to Medicare’ visit, we mean a physician (doctor of medicine or osteopathy) or a qualified non-physician (such as a physician assistant, nurse practitioner, or certified clinical nurse specialist).

While you are not required to have this examination, you pay nothing for this visit if your doctor accepts assignment, and the Part B deductible doesn’t apply. This is one preventive service that’s too good to pass up! When you make your appointment, let your doctor’s office know that you would like to schedule your “Welcome to Medicare” preventive visit.

Twelve months after the ‘Welcome to Medicare’ visit, you are eligible for an ‘Annual Wellness Visit’. Or, if you did not have the ‘Welcome to Medicare’ service, you can have the ‘Annual Wellness Visit’ once you have had Part B Medicare coverage for longer than 12 months. 

The Annual Wellness Visit can be performed by a ‘health professional’, including a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a health educator, registered dietician, nutrition professional, or other licensed practitioner. This would include a team of medical professionals working under the direct supervision of a physician.
During your first wellness visit, your provider will develop or update a personalized prevention plan based on your current health and risk factors. They will inquire or ask you to update your medical and family history. They will also check your blood pressure, measure your height and weight, and conduct other routine measurements.

They will review any potential risk factors for depression, your ability to function, as well as other mental attributes.
Other components of this visit: developing a written schedule or checklist for the next five to 10 years, discussing any risk factors and giving health advice or referrals for health education.

After your first Annual Wellness Visit, you are eligible for future wellness visits once every 12 months. You don’t need to wait until the exact date each year to have the exam; you only have to wait until the same month every year.
Like the ‘Welcome to Medicare’ visit, you pay nothing for the ‘Annual Wellness Visit’ if your doctor accepts assignment, and the Part B deductible doesn’t apply. When you make your appointment, let your doctor’s office know that you would like to schedule your “Annual Wellness” visit.

During both the ‘Welcome to Medicare’ visit and the “Annual Wellness” visit, your doctor may order tests or make referrals for other services based on your general health and medical history. Payments for other services you receive from your doctor or based on a referral from your doctor, including laboratory tests and EKGs, are not included in the payment for visit and will be billed separately. You may have to pay coinsurance, and the Part B deductible may apply, to those services.

While both the ‘Welcome to Medicare’ preventive visit and the ‘Annual Wellness Visit’ are covered by Medicare, routine physical examinations or yearly check-ups are not covered by Medicare. The Medicare-covered preventive visits include specific components that your doctor must perform to be able to bill for the covered service. That is why it is important that your doctor and your doctor’s staff know what type of visit you are scheduled for. If your doctor is not aware that you are there for one of the Medicare-covered preventive visits, he or she may conduct a routine physical exam instead.

Tuesday, May 5, 2015

Don't Forget Covered Medicare Preventive Services

It’s time to take care of you. You can do this by taking advantage of the preventive and screening services that Medicare covers. These services can help keep you healthy. Ask your doctor which of these services is right for you.

As part of the Affordable Care Act, Medicare now covers many preventive and screening services at no cost to you (waived deductible and coinsurance/copayment) if your doctor accepts assignment, including the following:

Your first 'Welcome to Medicare' visit, also known as the Initial Preventive Physical Examination (IPPE)
Annual Wellness Visit
Abdominal Aortic Aneurysm (AAA) Screening
Colorectal Cancer Screening (Fecal Occult Blood Test (FOBT), flexible sigmoidoscopy and colonoscopy)
Bone Mass Measurement
Cardiovascular Disease Screening
Diabetes Screening Tests
Hepatitis B Virus (HBV) Vaccination
Human Immunodeficiency Virus (HIV) Screening
Medical Nutrition Therapy
Pneumococcal Vaccination
Prostate Specific Antigen (PSA) blood test
Pelvic Examination (including a clinical breast examination)
Screening Mammogram
Screening Pap Test
Screening Pelvic Exam
Seasonal Influenza Virus Vaccination
Smoking and Tobacco-Use Cessation Counseling Services and Counseling to Prevent Tobacco Use (for symptomatic beneficiaries)
Ultrasound Screening for Abdominal Aortic Aneurysm
Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
Intensive Behavioral Therapy (IBT) for Obesity
Screening for Depression
Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse
Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
For some preventive services, coinsurance or copayment and the Medicare Part B deductible apply:
Diabetes Self-Management Training
Glaucoma Screening
Prostate Cancer Screening - Digital Rectal Examination
For Colorectal Cancer Screening (Barium Enema), the coinsurance or copayment applies, and the Medicare Part B deductible is waived.

Wednesday, April 29, 2015

Railroad Medicare Beneficiaries to the Flu Season

It’s that time – time to get your flu vaccination. Medicare Part B (Including Railroad Medicare) normally pays for one flu vaccination per flu season (can be in the winter or in the fall). The flu season typically starts in October and can continue through late May. The Centers for Disease Control and Prevention (CDC) has found that most flu activity hits in the January/February time frame.

As always, this year’s flu vaccine is designed to protect against the types of the flu that research shows are more common during the season. It’s anticipated that 135 million to 139 million vaccination doses will be available in the United States.

There are different ways of receiving the vaccine (shot or nasal spray), and there are also different types of vaccination options. Traditional vaccines protect against three to four different kinds of flu viruses, two that are influenza A and one or two that are influenza B. Several of the vaccines are egg-based, meaning they are either manufactured in eggs or with egg protein. If you are sensitive to, or are allergic to eggs, you should discuss with your doctor which type of vaccine would be best for you.

The CDC recommends that everyone at least six months of age or older should get the flu vaccine. Individuals fitting the following characteristics are highly encouraged to have the vaccination:
1. Adults 50 years or older
2. Children younger than five years but older than six months
3. People at high risk of developing complications from the flu, such as pneumonia
4. Those with asthma, diabetes or chronic lung disease or other conditions, etc.
5. Pregnant women
6. Residents of nursing homes
7. People who are caregivers to individuals with illnesses listed above

You can receive a vaccination in many locations, such as clinics, local pharmacies, health departments, college health centers, as well as your doctor’s office. Most locations participate in Medicare, and you do not need to file a claim to Railroad Medicare if they participate in the Medicare Program.

Wednesday, April 15, 2015

Medicare Participating Provider versus Non-Participating Provider

Key Points/Instruction/What you need to know

Participating Provider Non-Participating Provider
A participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis. A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims.
Agrees to accept Medicare-approved amount as payment in full. Can elect to accept assignment or not accept assignment on a claim-by-claim basis.
May not collect more than applicable deductible and coinsurance for covered services from patient. Payment for non-covered services may also be collected. If the provider performs elective surgery costing more than $500, the beneficiary must be notified in writing of the expected financial responsibility.
Charges are not subject to limiting charge. Cannot bill the patient more than the limiting charge on non-assigned claims. (DC, DE, MD, NJ, City of Alexandria, VA, Counties of Arlington and Fairfax in VA)
Medicare payment paid directly to the provider. Pennsylvania’s Medicare Overcharge Measure prevents non-participating physicians from charging patients more than the Medicare allowance. Therefore, PA providers cannot bill the patient more than the Medicare approved amount on non-assigned claims.
Mandatory claims submission applies. Beneficiary receives payment on non-assigned claims.
Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD). Mandatory claims submission applies.
Reimbursement is 5 percent higher than the non-participating amount. Clinical laboratory services and drugs and biologicals must be billed as assigned.
Medigap information is transferred. Approved amount is 5 percent less than participating — even if assignment is accepted on the claim.
Patient referral service by hospital. Medigap information is not transferred.

To be a participating provider under Medicare, you must be in compliance with the applicable provisions of title VI of the Civil Rights Act of 1964 and must enter into an agreement under §1866 of the Act which provides that you: (1) will not charge any individual or other person for items and services covered by the health insurance program other than allowable charges and deductibles and coinsurance amounts; and (2) will return any money incorrectly collected from the beneficiary or other person on their behalf or make such other disposition that would cause a termination of your agreement.

Toward the end of each calendar year there is an open enrollment period. The open enrollment period generally is from mid-November through December 31. During this period, if you are enrolled in the Medicare Program, you can change your current participation status beginning the next calendar year on January 1. This is the only time you have the opportunity to change your participation status.
New physicians, practitioners, and suppliers can sign the participation agreement and become a Medicare participant at the time of enrollment into the Medicare Program. The participation agreement will become effective on the date of filing; i.e., the date the participant mails (post-mark date) the agreement to the Medicare Administrative Contractor (MAC) or delivers it to the MAC.

If you choose to participate:
•    Do nothing if you are currently participating, or
•    If you are not currently a Medicare participant, complete the blank agreement (CMS-460) and mail it (or a copy) to each MAC to which you submit Part B claims. (On the form show the name(s) and identification number(s) under which you bill.)
If you decide not to participate:
•    Do nothing if you are currently not participating, or
•    If you are currently a participant, write to each MAC to which you submit claims, advising of your termination effective the first day of the next calendar year. This written notice must be postmarked prior to the end of the current calendar year.

If you choose to participate:
•    Complete the blank agreement (CMS-460) and submit it with your Medicare enrollment application.
•    If you have already enrolled in the Medicare program, you have 90 days from when you are enrolled to decide if you want to participate. If you decide to participate within this 90-day timeframe, complete and submit the CMS-460.

If you decide not to participate:

•    Do nothing. All new physicians, practitioners, and suppliers that are newly enrolled are automatically non-participating. You are not considered to be participating unless you submit the CMS-460 form.

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.

Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)

Medicare Physician Fee Schedule Payment Rates Formula

The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +

Medicare fee schedule download