Modifier GJ (2021)

Modifier GJ (2021)

GJ Modifier Opt-out physician/practitioner EMERGENCY OR URGENT SERVICES In an emergency or urgent care situation, a provider may treat a Medicare beneficiary with whom he or she does not have a private contract and bill Medicare for such treatment. The provider may not charge the beneficiary more than the limiting charge and must submit a…

Medicare will Automatically Convert Format 4010A1 Electronic Remittance Advice (835) to X12 Version 5010

Medicare will Automatically Convert Format 4010A1 Electronic Remittance Advice (835) to X12 Version 5010

Effective August 1, 2012, if you have not yet converted from the 4010A1 format of the electronic remittance advice, the Medicare Fee-For-Service (FFS) program will automatically convert your electronic remittance advice to the X12 Version 5010 format. If the computer software you use to open/translate the electronic remittance advice X12 Version 5010 format is not…

Drugs that are Covered Under Original Medicare Part B

Drugs that are Covered Under Original Medicare Part B

The term “drug” means “drug or biological.” Drugs that are covered under Medicare Part B are governed by the Original Medicare regulations and local coverage decisions. For more coverage details, see the Medicare Benefits Policy Manual Publication 100-02, Chapter 15, Section 50 “Drugs and Biologicals” and the Medicare Claims Processing Manual, Publication 100-04, Chapter 17,…

Non-Covered Surgical Dressings

Non-Covered Surgical Dressings

The following are the examples of situations in which dressings are noncovered under the Surgical Dressings benefit are: Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or A Stage I pressure ulcer; or A first degree burn; or Wounds caused by trauma which do not require…

Medicare Timely Filing Exceptions

Medicare Timely Filing Exceptions

The Medicare regulations at 42 Code of Federal Regulations (CFR), Section 424.44, specify the time limits for filing Part A and Part B Fee-For-Service claims. Section 424.44 also identifies certain exceptions to the claims filing time limit. If the requirements for satisfying a timely filing exception are met, an extension to file the claims may…

Date of service (DOS) for Care Plan Oversight services (CPO) – G0181

Date of service (DOS) for Care Plan Oversight services (CPO) – G0181

The CPO code, G0181 descriptor reads as follows: Physician Supervision of a patient under care of Medicare covered home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development, and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone…

What is limiting charge with Medicare?

What is limiting charge with Medicare?

Limiting charges were established by CMS to limit the amount a non-participating provider can charge a beneficiary for a non-assigned service. In other words, this is the maximum amount that non-participating providers may bill their Medicare patients on non-assigned claims. The limiting charge is equal to 115 percent of the non-participating allowance. Limiting charges only apply…

What is ‘Incident To’?

What is ‘Incident To’?

“Incident to” is a benefit category that allows Medicare to reimburse physicians for physician services as though the physician personally performed the service, when the service was actually performed by someone other than the physician. All of the requirements for “incident to” services are encompassed in the following broad statements: 1) The reporting physician must have had…

Seasonal Influenza Virus, Pneumococcal and Hepatitis B – FAQs

Seasonal Influenza Virus, Pneumococcal and Hepatitis B – FAQs

Does a Part B deductible or coinsurance apply to adult immunizations covered by Medicare? Neither a Part B deductible nor coinsurance applies to the seasonal influenza virus or pneumococcal vaccines and their administration. The Part B deductible, plus the 20 percent Medicare coinsurance amount, applies to the hepatitis B vaccine for all dates of service…