Sunday, March 21, 2021

CPT Ferrlecit J code - j2916, J1756, Venofer

 

HCPCS Code Description


J1756 Injection, Iron Sucrose, 1 mg (Venofer®)

J2916 Injection, Sodium Ferric Gluconate Complex in Sucrose Injection, 12.5 mg (Ferrlecit®)


Description

Sodium ferric gluconate complex in sucrose (Ferrlecit®) injection is an iron replacement product.


FDA Approved Indication(s)


Ferrlecit is indicated for the treatment of iron deficiency anemia (IDA) in adult patients and in pediatric patients with chronic kidney disease (CKD) receiving hemodialysis who are receiving supplemental epoetin therapy.


Overview


Iron is a critical structural component of hemoglobin, a key protein found in normal red blood cells (RBCs) which transport oxygen. Without this important building block, anemic patients experience difficulty in restoring adequate, healthy RBCs that improve hematocrit levels. Iron deficiency is a common condition in end stage renal disease (ESRD) patients undergoing hemodialysis. Clinical management of iron deficiency involves treating patients with iron replacement products while they undergo hemodialysis. The available evidence suggests that the mode of intravenous administration is perhaps the most effective treatment for iron deficiency in hemodialysis patients. Unlike oral iron products, which must be absorbed through the GI tract, IV iron products are infused directly into the bloodstream in a form that is readily available to the bone marrow for RBC synthesis, resulting in an earlier correction of iron deficiency and anemia.

Coverage also includes the medically necessary and reasonable use of parenteral iron preparations in non-dialysis related clinical conditions.



Guidelines


Medicare covers Sodium Ferric Gluconate Complex in Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Medicare also covers Iron Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Coverage also includes for parenteral iron in iron deficiency anemia:

• For patients with iron deficiency anemia who do not respond to oral iron supplementation due to malabsorption disorders or patients who have documented intolerance to oral iron supplementation.

• For anemia related to chronic kidney disease.

• Initial treatment of absolute iron deficiency in patients receiving myelosuppressive chemotherapy who have asymptomatic anemia and risk factors for the development of symptomatic anemia requiring transfusion. 

For the pregnant beneficiary when iron stores are depleted such that the mother and/or the fetus are at risk of adverse outcomes and oral iron replenishment is either not tolerated or the anemia is of such severity as to require more immediate replenishment. Additionally, use in the peripartum period may be indicated when intra/post-partum hemorrhage is severe and by administering parenteral iron a transfusion may be avoided. This indication does not replace the strong consideration for transfusions when the hemorrhage is potentially life threatening.


PURPOSE


The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services.


The document can be used as a guide to help determine applicable:

• Medicare coding or billing requirements, and/or

• Medical necessity coverage guidelines; including documentation requirements.

UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.


Policy


*Pleasesee amendment forPennsylvaniaMedicaidattheend ofthis CPB.

I. Aetna considers intravenous iron therapy medically necessary for any of the following indications:

A. For members needing iron supplementation who are unable to tolerate compounds given orally; or

B. For members who are losing iron (blood) at a rate too rapid for oral intake to compensate for the loss; or

C. For members with a disorder of the gastrointestinal tract, such as inflammatory bowel disease (ulcerative colitis and Crohn's disease), in which symptoms may be aggravated by oral iron therapy; or

D. For members who are unable to maintain iron balance on treatment with hemodialysis (Note: Venofer, an iron sucrose injection, and Ferrlecit, a sodium ferric gluconate complex in sucrose injection, are indicated for the treatment of iron deficiency* anema in members undergoing chronic hemodialysis who are receiving supplemental erythropoietin/epoetin therapy; or

E. For members with iron deficiency* anemia associated with peritoneal dialysis and non-dialysis-dependent (NDD) chronic kidney disease (Note: Venofer [iron sucrose] and Feraheme [ferumoxytol] are indicated for such use, not Ferrlecit ([sodium ferric gluconate]); or

F. For members who are donating large amounts of blood for autologous programs; or

G. For members who repeatedly fail to heed instructions for oral iron supplementation or are incapable of accepting or following them; or

H. For members with chemotherapy-induced anemia; or

I. For members with heart failure and iron deficiency*, with or without anemia; or

J. For members with iron deficiency* anemia due to heavy uterine bleeding; or

K. For members with iron deficiency* following gastric bypass surgery and/or subtotal gastric resection and who exhibited decreased absorption of oral iron.


Dosing of Parentaral Iron Preparations:


Iron Dextran is available as Dexferrum in 50 mg and 100 mg Single-Dose Vials and Infed in 100 mg Single-Dose Vials. Iron dextran preparations contain 50 mg of elemental iron/ml, and are approved for iron deficiency anemia not amenable to oral iron therapy. High molecular weight (HMW) iron dextran preparations (Dexferrum) are now rarely used because they are associated with a considerably higher incidence of adverse events than are the low molecular weight (LMW) preparations (INFeD).

LMW preparations have a maximum daily dose 100 mg of elemental iron (2 ml). The recommended dosing in chronic kidney disease is elemental iron 50 to 100 mg once-weekly. There is no evidence that doses of LMW iron dextran larger than 1,000 mg are clinically useful. Once transferrin saturation greater than or equal to 20 % or serum ferritin greater than or equal to 100 ng/ml (224.7 pmol/L), IV iron therapy should be continued at lowest dose needed to maintain target hematocrit/hemoglobin levels and iron stores.


Sodium Ferric Gluconate Complex is available as Ferrlecit in 62.5 mg Single-Dose Ampules/Vials and Nulecit in 62.5 mg Single-Dose Vials. Ferric gluconate complex contains 12.5 mg/ml elemental iron. Ferrlecit (sodium ferric gluconate complex in sucrose injection) is approved for the treatment of iron defiency anemia in adult patients and pediatric patients age 6 years and older with chronic kidney disease receiving hemodialysis who are receiving supplemental epoetin therapy. Nulecit (sodium ferric gluconate complex in sucrose injection) is approved for treatment of iron deficiency anemia in adult patients and in pediatric patients age 6 years and older undergoing chronic hemodialysis who are receiving supplemental epoetin therapy. Ferric gluconate is approved for a maximum single dose of 125 mg, although  published evidence suggests that a dose of 250 mg is well- tolerated. The adult dose 125 mg IV at or during dialysis session, and most patients require cumulative dose greater than or equal to 1,000 mg over 8 sessions. Once transferrin saturation greater than or equal to 20 % and serum ferritin level greater than or equal to 100 ng/ml achieved, ferric gluconate should be continued at the lowest dose needed to maintain hemoglobulin/hematocrit levels (for example, 25 to 100 mg elemental iron weekly for 10 weeks). 



Anemia in Pregnancy & Parenteral Iron Therapy

Abstract

Anemia is common in pregnancy and iron deficiency is the most common cause. Oral iron is the standard therapy, but there is a problem of adherence due the gastrointestinal side effects. Intravenous iron therapy has more advantages, therefore, intravenous iron therapy is the best treatment for pregnant women during the third trimester. We reviewed the statistics of deliveries of the fiscal year 2012, the cases of anemia in pregnancy as in patients provided by Record Room from the calendar year 2012 and the patient cases that used sodium ferric gluconate complex in sucrose injection (FERRLECIT) from the Obstetrics/Gynecology Ward from the fiscal year 2012 provided by the Department of Pharmacy of the Ashford Presbyterian Community Hospital (APCH). A review of the records of pregnant women receiving iron dextran injection (INFeD) intravenously in our ambulatory infusion center was also performed. Our data confirmed that either presentations elevated the hemoglobin and they were well tolerable. Iron sucrose is the preferred and it has demonstrated a high success rate.

I recommend considering this alternative earlier at the third trimester and establishing guidelines using parenteral iron and erythropoietin in combination in refractory cases. 

Keywords: Anemia; Pregnancy; Parenteral; Iron



Sodium Ferric Gluconate Complex in Sucrose (Ferrlecit) HCPCS code J2916: Billing Guidelines

Effective with the date of service of April 30, 2018, the North Carolina Medicaid and Health Choice (NCHC) programs will be terminating Clinical Policy 1B-3, Intravenous Iron Therapy, within the Physician Drug Program (PDP). Requirements, indications, and all other information of the policy are indicated below. From the perspective of the providers, all things associated with the process of submitting claims regarding the IV Iron agents will remain unchanged.


See prescribing information for details.


Below is information regarding Ferrlecit.

Medicaid and NCHC cover sodium ferric gluconate complex in sucrose for beneficiaries aged 6 years and older for the following FDA approved indications:

a. Iron deficiency anemia in beneficiaries undergoing chronic hemodialysis (HDD-CKD) who are receiving epoetin therapy

Medicaid and NCHC covers sodium ferric gluconate complex in sucrose for beneficiaries aged 6 years and older for the following off-label indications:

a. Iron deficiency anemia in beneficiaries with chronic kidney disease who are on peritoneal dialysis (pddckd)

b. Iron deficiency anemia in beneficiaries who are non-dialysis dependent with chronic kidney disease (nddckd)

c. Iron deficiency anemia of excessive uterine blood loss or pregnancy

d. Iron deficiency anemia in beneficiaries with cancer or who have chemotherapy- associated anemia

e. Iron deficiency anemia with comorbid heart failure

f. Iron repletion for autologous blood transfusion;

g. Gastrointestinal (gi) blood loss with iron deficiency (such as gastric bypass surgery, celiac disease, inflammatory bowel disease)

h. Disorders of iron metabolism

i. Iron deficiency where oral treatment is ineffective or infeasible

j. Iron deficiency due to intravascular hemolysis (such as paroxysmal nocturnal hemoglobinuria, valvular heart disease and malfunctioning prosthetic valves), and

k. Iron deficiency due to achlorhydria (including pernicious anemia or medication induced).


 


Thursday, March 18, 2021

CPT code 49505, 49507, 49520, 49521, 49525

Procedure code and Description

49505  - Repair initial inguinal hernia, age 5 years or older; reducible

49507 - Repair initial inguinal hernia, age 5 years or older; incarcerated

49520 - Repair recurrent inguinal hernia, any age; reducible

49521 - Repair recurrent inguinal hernia, any age; incarcerated

49525 - Repair inguinal hernia, sliding, any age


For example, the CPT Manual instruction above CPT code 49491 states: “With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other

prostheses is not separately reported.” Therefore, CPT code 49568 (mesh implantation) should not be reported separately with CPT code 49505 (inguinal hernia repair).


REPAIR HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY


The hernia repair codes in this section are categorized primarily by the type of hernia (inguinal, femoral, incisional, etc.). Some types of hernias are further categorized as "initial" or "recurrent" based on whether or not the hernia has required previous repair(s). Additional variables accounted for by some of the codes include patient age and clinical presentation (reducible vs. incarcerated or strangulated).

With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prosthesis is not separately reported.

(Codes 49491-49651 are unilateral procedures. To report bilateral procedures, report modifier -50 with the appropriate procedure code)


(Do not report modifier -63 in conjunction with 49491, 49492, 49495, 49496, 49600, 49605, 49606, 49610, 49611)


49505 Repair initial inguinal hernia, age 5 years or over; reducible


49505-LT


RATIONALE: In the CPT® Index, look up Hernia Repair/Inguinal/Initial, Child 5 Years or Older. You are referred to 49491, 49495–49500, and 49505 and 49507. Review the codes to choose the appropriate service. 49505 is the correct code. The repair was through an incision (not by laparoscopy) on an initial inguinal hernia on a patient over five years of age and the hernia was not incarcerated or strangulated. According to CPT® guidelines, “With the exception of the incisional hernia repairs (49560–49566), the use of mesh or other prosthesis is not separately reported.” It would be inappropriate to code the mesh in this scenario.



Hernia Type Inguinal Hernia

Types of Hernia

• Incarcerated Hernia- hernia that is trapped in the abdominal wall.

• Strangulated Hernia- An incarcerated hernia that becomes strangulated cutting the blood flow. Symptoms of this include nausea, high fever, sharp pains and swelling


 Type Description

Occurs when tissue protrudes through a weak spot in the abdominal muscles/groin area.


 Diagnosis

Physical exam, ultrasound, CT Scan or MRI


Cause & Symptoms

Common causes: Increased pressure w/in the abdomen, pregnancy, chronic coughing or sneezing, or strenuous activity. Symptoms can include: Stomach muscle weakness,sharp pain, swelling in scrotum, or bulge in groin.


Measures of Inguinal Hernia Repair Surgeries by Setting


For each hospital and year in our sample, we construct separate counts of inguinal hernia repair surgeries performed in the outpatient setting and in the inpatient setting; both counts are done for discharges where the primary payer was fee-for-service Medicare. We identify outpatient hernia repair surgeries from CPT codes and inpatient surgeries from ICD-9-CM procedure codes. To select the relevant procedure codes, we used the Clinical Classification Software (CCS) developed by the Agency for Healthcare Quality and Research (AHRQ 2012a,b).


The CCS assigns multiple CPT and ICD-9 procedure codes to CCS 85 (inguinal and femoral hernia repair). Of the 19 CPTs codes in CCS 85, we eliminated four procedures pertaining to femoral hernia and six procedures used to treat children. As the clinical studies cited earlier showed comparable patient outcomes following open inguinal hernia repair, we excluded four CPTs used for laparoscopic hernia repair. Payment rate data for one open inguinal hernia repair procedure (CPT 49521) are not available for a large share of hospitals in our sample. Our analysis thus includes four procedures used in the open repair of inguinal hernia (CPTs 49505, 49507, 49520, and 49525). For each procedure, we count the times the CPT was recorded as the principal procedure or as one of up to nine other procedures on outpatient discharge records, by hospital and year. Of the ICD-9-CM procedures in CCS 85, we excluded codes for femoral hernia repair and laparoscopic repair of inguinal hernia, and included 14 procedures used in the open repair of inguinal hernia (5300–5305 and 5310–5317).10 We count the times any of these 14 procedures appear as the principal procedure or as one of up to nine other procedures on inpatient discharge records, by hospital and year.

1598 HSR: Health Services Research 48:5 (October 2013) Table 1 reports descriptive statistics for open inguinal hernia repair surgeries by setting in our sample hospitals in 1999. Sample sizes vary by procedure (based on the availability of payment rate data) and by setting (based on the availability of discharge records).11 Panel A reports the mean number of times the procedure was performed in the outpatient setting as the principal procedure and as either the principal or other procedure. CPT 49505 is the most commonly used of the four outpatient procedures; the average hospital performed 24.6 surgeries involving that procedure in that year. Panel B reports the mean count of hernia procedures in the inpatient setting. There were 8.2 inpatient open inguinal hernia repair surgeries performed as the principal or other procedure per hospital in 1999.


Payment Rate Measures


We next construct hospital-specific Medicare payment rates to outpatient departments for each of the open inguinal hernia repair procedures described

above (CPTs 49505, 49507, 49520, and 49525). For the post-OPPS years, we obtain quarterly CMS publications reporting payments by ambulatory payment classification (APC) along with quarterly crosswalks from CPT to APC.12 We create hospital-specific measures by adjusting APC payment rates using the hospital wage index and we create annual measures by averaging the quarterly data.


To obtain hospital- and procedure-specific payments in the pre-OPPS years, we follow the algorithm developed in He and Mellor (2012) to impute hospital- and procedure-specific charges from the total charge field on the discharge record. The algorithm identifies CPT-specific charges for 58–94 percent of the hospitals in our sample depending on the CPT.13 Once we obtain procedure- and hospital-specific charges, we apply hospital-specific outpatient surgery payment-to-charge ratios imputed from 1997 to 1999 annual Medicare cost reports. 


Figure 1 illustrates median Medicare payment rates (in 2008 dollars) over time for each of the four procedures. Median payment rates decreased by 4–10 percent between 1999 and 2004 (before and after the full phase-in of OPPS), and the majority of hospitals (51–60 percent, depending on the procedure) experienced a decrease in payment rate in this time period. About 40–45 percent of the procedure-specific within-hospital variation in payment rates over the 12 years in our sample occurs in the years around the implementation of OPPS, and a large portion (between 80–88 percent) of the 1999– 2004 payment variation represents decreases in payments from the prior year.


Indications for Use


Gentrix® Surgical Matrix Thin (3-layer) are intended for implantation to reinforce soft tissue where weakness exists in patients requiring urological, gastroenterological, or plastic & reconstructive surgery. Reinforcement of soft tissue within urological, gastroenterological, and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia and body wall repair, colon and rectal prolapse repair, tissue

repair, and esophageal repair. The Gentrix Surgical Matrix Thin minimizes tissue attachment to the device in case of direct contact with viscera.


Gentrix® Surgical Matrix (6-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia (e.g.: hiatal/diaphragmatic) and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair. The

Gentrix Surgical Matrix minimizes tissue attachment to the device in case of direct contact with viscera.


Gentrix® Surgical Matrix Plus (8-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia (e.g.: hiatal/diaphragmatic) and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair. The Gentrix Surgical Matrix Plus minimizes tissue attachment to the device in case of direct contact with viscera.


Gentrix® Surgical Matrix Thick (8-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following procedures: hernia and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair.


Procedures: CPT Codes and Medicare Payments


Physician and Outpatient Facility


The following table contains CPT codes that may be utilized when reporting surgical procedures. Please check the current CPT manual for other codes that may be applicable. The table also includes the 2020 Medicare national unadjusted payment rates. Check with your MAC for payment rates specific to your region. 


Correct Coding Initiative (CCI) Edits

Empire is increasing its compliance with industry standards by adopting the following code combinations from the Center for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (CCI) into our payment policy.

The National Correct Coding Initiative is a collection of bundling edits that are separated into two major categories: Comprehensive/Component Procedure Code edits and Mutually Exclusive Procedure Code edits.

Comprehensive/Component Procedure Code edits

Codes that are considered "Components" are incidental to the codes considered to be "Comprehensive" and will be denied as such. The table below lists the procedure that will be denied—"Deny Procedure"—as incidental to the corresponding "When Billed with Procedure."


Mutually Exclusive Procedure Code edits

Mutually Exclusive Procedures are procedures that cannot be reasonably done in the same session. To be consistent with existing payment policy, when Mutually Exclusive procedures are billed for the same date of service, only the procedure with the highest relative value ("When Billed with Procedure") will be allowed and the procedure with the lower relative value ("Deny Procedure") will be denied as Mutually Exclusive of the other procedure.

In some situations, according to CMS, certain modifiers may be allowed to bypass these edits. 


Deny Procedure When Billed with Procedure


38500 49505 

49568         49505 



Modifier 73 – Discontinued Outpatient Hospital Surgical Procedure/Service Prior to Anesthesia Administration


Used for surgical or radiological procedures in ASC.  Due to extenuating circumstances or those that threaten the well‐ being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided and being taken to the room where the procedure is to be performed), but prior to the administration of the anesthesia.



** Used for procedures that require anesthesia.


** Used for an outpatient hospital procedure discontinued before the patient has been prepared for the procedure and/or before the induction of anesthesia whether local regional block(s) or general anesthesia.


** If none of the procedures were completed, report the first planned procedure with modifier 73. Patient must be wheeled to the room where the procedure is to be performed in order to report modifier.


** Do not use this modifier for the elective cancellation of a procedure.


** Do not use this modifier if the surgeon cancels or postpones the scheduled surgery because of a patient complaint such as a cold or flu upon intake.


** The physician should not use this modifier. This is only appropriate for use by the ASC.


Example: A 65‐year old male was brought to the OR for repair of a recurrent inguinal hernia.  The patient was prepped and draped and positioning was carried out.  Before the administration of anesthesia, the patient complained of chest pain.  A cardiac monitor revealed ST segment changes.  The procedure was cancelled and the reported CPT 49520‐73:   Repair recurrent inguinal hernia, any age, reducible

Tuesday, February 9, 2021

CPT CODE 30801, 30802, 30930, 30130, 30140

Procedure code and Description


 * 30801: cautery and/or ablation, mucosa of inferior turbinates, unilat or bilat, any method; superficial (3.4 rvu)

* 30802: intramural (4.92 rvu) (this includes radiofrequency procedures)

* 30930: fracture inferior turbinates, therapeutic (3.02 rvu)

* 30130: excision inferior turbinate, partial or complete (7.15 rvu)

* 30140: submucous resection of inferior turbinate, partial or complete, any method (7.68 rvu)


INFERIOR TURBINOPLASTY

Coding for turbinoplasty procedures centers on whether bone was removed during procedure. Soft tissue reduction of turbinates, without removal of bone, is reported with code 30802. If bone is removed, it is reported with 30140

HOSPITAL OUTPATIENT CODING AND PAYMENT

Hospitals use CPT codes to report outpatient services. Payment shown is for Medicare’s APC hospital outpatient prospective payment system and is the Medicare national average without geographical adjustment. Status Indicator “T” = significant procedure, multiple reduction applies. Payment for each code is made at 100% of the rate when it is the only significant procedure billed. When billed with another status T procedure with higher weight, payment for lower weighted procedures is reduced to 50% of the rate.


CPT code 30802 is used for both unilateral or bilateral procedures and may be reported only once per operative session. Use of the phrase “any method” in the code definition indicates that the specific instruments and techniques used to accomplish the reduction do not alter the code assignment. Intramural ablation of the turbinates includes any ablation of the superficial tissues so the code for superficial ablation (30801) is not assigned separately with 30802. CPT code 30140 is considered to be unilateral and would be billed with bilateral modifier-50.


INFERIOR TURBINOPLASTY WITH OUTFRACTURE

Turbinoplasty and outfracture are sometimes performed together. According to NCCI edits or CPT descriptions, CPT code 30930 should not be billed with 30140. If CPT codes code 30802 and 30930 are reported together, only one code is paid unless procedures are performed independently on opposite sides.


b. Resection Inferior Turbinate (CPT code 30140)

CMS finalized the RUC recommended value of 3.00 RVUs for this code. One notable comment received related to this code included a request that CMS add a new supply named the “turbinate reduction wand” to the supply inputs associated with this procedure when performed in the physician office setting. The commenter stated that this device is designed to ablate, coagulate, and remove a core of tissue that provides the desired volumetric reduction of the anatomy, and supplied several invoices for use in pricing the new supply.


CMS responded stating the suggested turbinate reduction wand has a price of nearly $200, which would add substantially to the costs of CPT code 30140. Before including such significant resource costs in the code, they requested input from the physician community such as the RUC. At present, they do not have any information to suggest that the use of this new supply is typical for CPT code 30140, and the RUC did not recommend the inclusion of this supply on either of the two occasions when this code was reviewed in CY 2017. For these reasons, CMS did not believe that it would be appropriate to add the turbinate reduction wand to CPT code 30140 at this time, but welcomed the submission of additional information regarding this use of this supply from stakeholders.



Thursday, November 26, 2020

CPT 97110, 97112, 97113, 97116, 97124, 97139 - Therapeutic procedure codes

 Billing Coding/Physician Documentation Information


97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112  Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises

97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)

97124    Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

97139 Unlisted therapeutic procedure (specify)


Counting Minutes for Timed Codes in 15 Minute Units


When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes, through and including 37 minutes, then 2 units should be billed. Time intervals for 1 through 8 units are as follows:


Units Number of Minutes


1 unit: = 8 minutes through 22 minutes

2 units: = 23 minutes through 37 minutes

3 units: = 38 minutes through 52 minutes

4 units: = 53 minutes through 67 minutes

5 units: = 68 minutes through 82 minutes

6 units: = 83 minutes through 97 minutes

7 units: = 98 minutes through 112 minutes

8 units: = 113 minutes through 127 minutes


The pattern remains the same for treatment times in excess of 2 hours.


If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit. If the service is performed for at least 30 minutes, that service shall be billed for at least two units, etc. It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. See examples 2 and 3 below.


When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed. See example 1 below.


If any 15 minute timed service that is performed for 7 minutes or less than 7 minutes on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit for the service performed for the most minutes. This is correct because the total time is greater than the minimum time for one unit. The same logic is applied when three or more different services are provided for 7 minutes or less than 7 minutes. See example 5 below.


The expectation (based on the work values for these codes) is that a provider’s direct patient contact time for each unit will average 15 minutes in length. If a provider has a consistent practice of billing less than 15 minutes for a unit, these situations should be highlighted for review.


If more than one 15 minute timed CPT code is billed during a single calendar day, then the total number of timed units that can be billed is constrained by the total treatment minutes for that day. See all examples below.


Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3B, Documentation Requirements for Therapy Services, indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units for the total therapy minutes provided.


Example 1 –

24 minutes of neuromuscular reeducation, code 97112,

23 minutes of therapeutic exercise, code 97110,

Total timed code treatment time was 47 minutes.


See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.


Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.


Example 2 –

20 minutes of neuromuscular reeducation (97112)

20 minutes therapeutic exercise (97110),

40 Total timed code minutes.

Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes and should be billed

for at least one unit, but the total allows 3 units. Since the time for each service is the same, choose either

code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes.

Example 3 –

33 minutes of therapeutic exercise (97110),

7 minutes of manual therapy (97140),

40 Total timed minutes


Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.


Example 4 –

18 minutes of therapeutic exercise (97110),

13 minutes of manual therapy (97140),

10 minutes of gait training (97116),

 8 minutes of ultrasound (97035),

49 Total timed minutes


Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less

than 53 minutes regardless of how many services were performed). You would still document the ultrasound in the treatment notes.


Example 5 –

7 minutes of neuromuscular reeducation (97112)

7 minutes therapeutic exercise (97110)

7 minutes manual therapy (97140)

 21 Total timed minutes


Appropriate billing is for one unit. The qualified professional (See definition in Pub. 100-02, chapter 15, section 220) shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.


NOTE: The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the eighth should be excluded from the total count. The total minutes of active treatment counted for all 15 minute timed codes includes all direct treatment time for

the timed codes. Total treatment minutes - including minutes spent providing services represented by untimed codes - are also documented. For documentation in the medical record of the services provided see Pub. 100-02, chapter 15, section 220.3.



Therapeutic Procedures


Therapeutic Procedures (codes 97110-97546) were added to CPT® in 1995 to clarify the differences between Therapeutic Procedures, Modalities, and Tests and Measurements. A Therapeutic Procedure is defined as “a manner of effecting change through the application of clinical skills and/or services that attempt to improve function.” These procedures require direct one-on-one patient contact by a physician or therapist. The descriptions for most of these codes reflect 15-minute intervals.


Common components included as part of Therapeutic Procedures include chart reviews for treatment, setup of activities and the equipment area, and review of previous documentation as needed. Subsequent to providing the therapeutic service, the treatment is recorded, and the patient’s progress is documented. The patient health record should list the duration of the procedure time.


Therapeutic Procedures are intended to be performed with one-on-one patient contact. If a provider is performing Therapeutic Procedures in a group of two or more individuals, CPT® code 97150 should be reported. Time and/or the number of Therapeutic Procedures are not specified in this code so it should only be billed once per patient per visit.


To illustrate, a practitioner spends 10 minutes working with patient X on therapeutic exercises to develop strength and endurance. The practitioner instructs patient X to continue the exercises for 5 or more minutes and attends to another patient, patient Y, during this time, while continuing to supervise patient X. The practitioner returns to patient X and spends another 5 minutes directly working with him, and once again instructs patient X to continue a particular exercise for 5 minutes. The practitioner again attends to patient Y during this time, and then returns to patient X to work directly with him for another 5 minutes. Should code 97150 be reported, or should code 97110 be reported twice**


From a CPT coding perspective, code 97110 requires the practitioner to maintain direct patient contact (i.e., visual, verbal, and/or manual contact) during provision of the service, so 97110 should only be reported when the practitioner is providing therapy to one patient alone. When the practitioner is working with several patients at the same time, then CPT code 97150 should be reported. The specific type of therapy provided (e.g., 97110) to the group therapy code.


What is considered a unit of time when reporting time based codes**


 A Review of Reporting Time-Based Codes:


“According to the codebook's instruction, a unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes) When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used (CPT 2014; page xv).Therefore …based on the time guidelines provided in the CPT code set, it is not appropriate to append modifier 52, Reduced Services, to codes 97110-97546. Services of less than eight minutes would not be reported. To illustrate further, when reporting Physical Medicine and Rehabilitation code 97110, a time-based code can be reported for each 15-minute unit. Multiple units can be reported on a date of service for one or more

procedures based on the aggregate amount of time spent by a qualified health care professional in direct contact with the patient. As with any 15-minute time based code, it is important to recognize that a substantial portion of the 15 minutes must be spent in performing the pre-, intra-, and post service work in order to report the time-based code. If only five minutes are spent performing the physical medicine service, the code should not be reported. A minimum of eight minutes of therapeutic exercises is required to report code 97110.” 



Medicare Guidelines for Timed Codes:


Medicare guidelines are different from the above in that providers should report the code for the time actually spent in delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as “intraservice care” begins when the therapist, physician, or assistant under the supervision of a physician, is delivering treatment services. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.


The time counted is the time the patient is treated. For example, if gait training for a patient with a recent stroke requires both a therapist and an assistant, or even two therapists to manage the patient on the parallel bars, each 15 minutes the patient is being treated counts as one unit of 97116. The time the patient spends not being treated because of the need for toileting or resting should not be billed. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time.


For any single CPT® code, providers would bill Medicare a single 15-minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes. If the duration of a single modality or procedure is greater than or equal to 23 minutes to less than 38 minutes, then 2 units should be billed. Time intervals for larger numbers of units are as follows:


3 units > 38 minutes to < 53 minutes

4 units > 53 minutes to < 68 minutes

5 units > 68 minutes to < 83 minutes

6 units > 83 minutes to < 98 minutes

7 units > 98 minutes to < 113 minutes

8 units > 113 minutes to < 128 minutes


The pattern remains the same for treatment times in excess of 2 hours. Providers should not bill for services performed for less than 8 minutes. The expectation (based on the work values for these codes) is that a provider’s time for each unit will average 15 minutes in length. If a provider has a practice of billing less than 15 minutes for a unit, these situations should be highlighted for review.


The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the 8th should be excluded from the total count as the timing of active treatment counted includes all time.


It is advisable that the beginning and ending time of the treatment should be recorded in the patient’s medical record along with the note describing the treatment and patient’s progress. If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time, see examples below.


Example 1: If 24 minutes of 97112 and 23 minutes of 97110 were furnished, then the total treatment time was 47 minutes, so only 3 units can be billed for the treatment. The correct coding is 2 units of 97112 and one unit of 97110, assigning more units to the service that took more time.


Example 2: If a therapist delivers 5 minutes of 97035 (ultrasound), 6 minutes of 97140 (manual techniques), and 10 minutes of 97110 (therapeutic exercise), then the total minutes are 21 and only one unit can be paid. Bill one unit of 97110 (the service with the longest time) and the clinical record will serve as documentation that the other two services were also performed.


QUICK GUIDE TO USING THE PTA MODIFIER with therapy procedures


Beginning January 1, 2020, CMS requires the use of the CQ modifier to denote outpatient therapy services furnished in whole or in part by a physical therapist assistant (PTA) in physical therapist (PT) private practices, skilled nursing facilities, home health agencies, outpatient hospitals, rehabilitation agencies, and comprehensive outpatient rehabilitation facilities. (A similar modifier, identified as CO, is required for services furnished by an occupational therapy assistant.)


Beginning January 1, 2022, these services will be paid at 85% of the Medicare physician fee schedule amount that is otherwise applicable.


Note: Check the policies for all your non-Medicare fee-for-service payers to determine if they will adopt use of the PTA modifier.


How to Use This Guide:

Use this guide to help you identify when you must apply the CQ modifier. When billing timed treatment codes, first determine the total number of units that can be billed based on the 8-minute rule. Then determine, for each unit, whether the PTA furnished more than 10% of each unit independent of the physical therapist. This is the de minimis standard that was established for determining “in part” services.


Only the minutes the PTA spends independent of the PT count toward the 10% de minimis standard.

The 10% de minimis standard is applied to untimed codes, and is applied to each billed unit of a timed code rather than to all billed units of a timed code.

If a PTA’s time spent furnishing care exceeds 10% of the total time spent furnishing an untimed code, apply the CQ modifier.

If a PTA’s time spent furnishing care exceeds 10% of a unit of service, apply the CQ modifier to the unit.

If a PTA’s time spent furnishing care is 10% or less of a unit of the service, do not apply the CQ modifier.


DEFINITIONS

In whole: The entire service or procedure, or 100% of the total treatment time.


In part: Exceeds the de minimis portion of the therapy service, meaning more than 10% of the total service or procedure time when an untimed code. When a timed code, exceeds the de minimis standard of 10% of each billed unit.



DOCUMENTATION


CMS is not establishing any new documentation requirements to accompany the new CQ modifier. Current requirements for each treatment include all of the following:

Date of treatment.

Identification of each specific intervention provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding. You must record each service that is represented by a timed code, regardless of whether or not it is billed, because the unbilled timed services may impact the billing.

Total timed code treatment minutes and total treatment time in minutes. Total treatment time includes the minutes for both timed and untimed code treatment; it does not include time for services that are not billable, such as rest periods. Medicare does not require recording of services that are neither billable nor part of the total treatment minutes, but you may choose to include them to provide an accurate description of the treatment, show consistency with the plan, or comply with state or local policies. You also may voluntarily record the amount of time for each specific intervention, but it isn’t required because it is indicated in the billing. The billing minutes must be consistent with the total timed code treatment minutes. (More: Medicare Claims Processing Manual, Pub 100-04, Chapter 5, Section 20.2)

Signature and professional identification of the qualified provider(s) who furnished or supervised the services and a list of each person who contributed to that treatment—for example: signature of Kathleen Smith, PTA, with notation of phone consultation with Judy Jones, PT, supervisor [when such remote supervision is permitted by state and local law]. The supervisor’s signature and identification need not be on each treatment note unless the supervisor actively participated in the treatment. (More: Medicare Benefit Policy Manual Chapter 15, Section 220.3(E))


EXAMPLES

A. The PT and PTA each individually and exclusively furnish minutes of the same therapeutic exercise service (CPT 97110) in different time frames: The PT furnishes 7 minutes and the PTA furnishes 7 minutes, for a total of 14 minutes. One 15-minute unit is billed based on the total time range of at least 8 minutes and up to 22 minutes.


Billing:


Report 1 unit of 97110 with the CQ modifier to signal that the PTA’s 7 minutes of furnished services exceeded 10% of the 1 unit of service, described in a 15-minute increment (1.5 rounded to 2 minutes, so the modifier would apply if the PTA had furnished 3 or more minutes of the service).

The 7 minutes of 97110 furnished by the PT do not result in billable service. However, document them within the total treatment time.


NOTE: This results from a combination of factors: the same procedure is equally split between the 2 providers, only 1 unit can be billed, and the PTA has exceeded the de minimis standard.


B. The PT and PTA each individually and exclusively furnish minutes of the same therapeutic exercise service (CPT 97110) in different time frames: The PT furnishes 20 minutes and the PTA furnishes 25 minutes, for a total of 45 minutes. Three 15-minute units are billed based on the total time range of at least 38 minutes and up to 52 minutes.


Billing:

Report 1 unit of 97110 without the CQ modifier, because the PT wholly furnished 1 unit of 97110 (20 minutes; within the 8-22 minute time range for a single unit).

Report 2 units with CQ modifier, because the PTA wholly furnished 2 units of 97110 (25 minutes; within the 23-37 minute time range for 2 units).


C. The PTA and PT work concurrently as a team to furnish the same neuromuscular reeducation service (CPT 97112) for a 30-minute session. Two 15-minute units are billed based on the total time range of at least 23 minutes and up to 37 minutes.


Billing:

Report 2 units of 97112 without the CQ modifier, because the PT furnished both units in whole while assisted by the PTA. The PTA’s time is irrelevant to billing.


D. The PT independently furnishes 15 minutes of manual therapy (CPT 97140), and then the PTA independently furnishes 7 minutes of therapeutic exercise (CPT 97110). One 15-minute unit of 97140 is billed based on the time range of at least 8 minutes and up to 22 minutes.


Billing:

Report 1 unit of 97140 without the CQ modifier, because the PT furnished that service in whole.

The 7 minutes of 97110 furnished by the PTA do not result in billable service. However, document them within the total treatment time.


E. Similar to Example D, but instead the PT independently furnishes 7 minutes of 97140, and the PTA independently furnishes 15 minutes of 97110. One 15-minute unit of 97110 is billed based on the time range of at least 8 minutes and up to 22 minutes.


Billing:

Report 1 unit of 97110 with the CQ modifier, because the PTA furnished that service in whole.

The 7 minutes of 97140 furnished by the PT do not result in billable service. However, document them within the total treatment time; and document the minutes for both codes and count them toward the total time of the timed code services furnished to the patient on the date of service. 


F. Similar to Example D again, but instead the PT independently furnishes 7 minutes of 97140, and the PTA independently furnishes 7 minutes of 97110, for a total of less than a full 15 minutes. One 15-minute of service is billed based on the time range of at least 8 minutes and up to 22 minutes.


Billing:

Report 1 unit of 97140 without the CQ modifier, because the PT furnished that service independently of the PTA; this is the “tie-breaker” when each provider furnishes the same number of minutes. The 7 minutes of 97110 furnished by the PTA do not result in billable service. However, document them within the total treatment time.


G. Similar to Example D again, but instead the PT furnishes 8 minutes of 97140, and the PTA furnishes 13  minutes of 97110. One 15-minute unit is billed based on the time range of at least 8 minutes and up to 22 minutes.


Billing:

Report 1 unit of 97110 with the CQ modifier, consistent with CMS policy to bill the service with the greater time, and applying the modifier because the PTA furnished the service independently.

The 8 minutes of 97140 furnished by the PT do not result in billable service. However, document them within the total treatment time.


H. The PT furnishes 20 minutes of neuromuscular reeducation (CPT 97112), and the PTA furnishes 8 minutes of 97110, for a total of 28 minutes. Two 15-minute units are billed based on the time range of at least 23 minutes and up to 37 minutes.


Billing:

Report 1 unit of each procedure code, following the usual process for billing based on services furnished with the most minutes:

Report 1 unit of 97112 without the CQ modifier.

Report 1 unit of 97110 with the CQ modifier.


Note: This is because the 2 billable units of timed codes are allocated among procedure codes by assigning the first 15 minutes of service to 97112 (the code with the highest number of minutes), leaving 13 minutes of timed services: 5 minutes of 97112 (20 minus 15) and 8 minutes of 97110. Since the 8 minutes of 97110 is longer than the remaining 5 minutes of 97112, the second billable unit of service is assigned to 97110. The CQ modifier doesn’t apply to 97112 because the PT furnished all minutes of that service independently. The CQ modifier does apply to 97110 because the PTA furnished all minutes of that service independently. 


I. The PT furnishes 32 minutes of 97112, the PT and PTA each separately furnish a combined 26 minutes of 97110 (12 minutes for the PT and 14 minutes for the PTA), and the PTA independently furnishes 12 minutes of self-care (CPT 97535), for a total of 70 minutes of timed code services. Five 15-minute units are billed based on the time range of at least 68 minutes and up to 82 minutes.


Billing:

Report 2 units of 97112 without the CQ modifier, because the PT furnished the service in whole.

Report 1 unit of 97110 without the CQ modifier, because the PT furnished 12 minutes independently.

Report 1 unit of 97110 with the CQ modifier, because the PTA furnished 14 minutes independently.

Report 1 unit of 97535 with the CQ modifier, because the PTA furnished the service in whole.


J. The PT independently furnishes 12 minutes of 97112, and the PTA independently furnishes 8 minutes of 97535 and 7 minutes of 97110, for a total time of 27 minutes. Two 15-minute units, 1 each of 97112 and 97535, are billed based on the time range of at least 23 minutes and up to 37 minutes.


Billing:

Report 1 unit of 97112 without the CQ modifier, because the PT furnished it independently in whole.

Report 1 unit of 97535 with the CQ modifier, because the PTA furnished it independently.

The 7 minutes of 97110 do not result in billable service. However, document the minutes for all 3 codes and count them toward the total time of the timed code services furnished to the patient on the date of service.


K. The PT furnishes 15 minutes each of 97112 and 97535, and is assisted by the PTA, who furnishes 3 minutes of each service concurrently with the PT for a total time of 30 minutes. Two 15-minute units are billed based on the time range of at least 23 minutes and up to 37 minutes.


Billing:

Report 1 unit of 97112 and 1 unit of 97535, both without the CQ modifier, because the PT furnished both units in whole while assisted by the PTA. The PTA’s time is irrelevant to billing. However, document that the PTA furnished 3 minutes of care alongside the therapist under 97112 and 3 minutes of care alongside the therapist under 97535. The time is not added to the total time.

Thursday, June 11, 2020

Medicare Credit balance report - General overview


MEDICARE CREDIT BALANCE REPORT 

CERTIFICATION PAGE

The Medicare Credit Balance Report is required under the authority of sections 1815(a), 1833(e), 1886(a)(1)(C) and related provisions of the Social Security Act. Failure to submit this report may result in a suspension of payments under the Medicare program and may affect your eligibility to participate in the Medicare program.

ANYONE WHO MISREPRESENTS, FALSIFIES, CONCEALS OR OMITS ANY ESSENTIAL INFORMATION MAY BE SUBJECT TO FINE, IMPRISONMENT OR CIVIL MONEY PENALTIES UNDER APPLICABLE FEDERAL LAWS.

CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER

I HEREBY CERTIFY that I have read the above statements and that I have examined the accompanying credit balance report prepared by



Medicare Credit Balance Report – Provider Instructions

General

The Paperwork Burden Reduction Act of 1995 was enacted to inform you about why the Government collects information and how it uses the information. In accordance with sections 1815(a) and 1833(e) of the Social Security Act (the Act), the Secretary is authorized to request information from participating providers that is necessary to properly administer the Medicare program. In addition, section 1866(a)(1)(C) of the Act requires participating providers to furnish information about payments made to them, and to refund any monies incorrectly paid. In accordance with these provisions, all providers participating in the Medicare program are to complete a Medicare Credit Balance Report (CMS-838) to help ensure that monies owed to Medicare are repaid in a timely manner.

The CMS-838 is specifically used to monitor identification and recovery of “credit balances” owed to Medicare. A credit balance is an improper or excess payment made to a provider as the result of patient billing or claims processing errors. Examples of Medicare credit balances include instances where a provider is:

• Paid twice for the same service either by Medicare or by Medicare and another insurer;

• Paid for services planned but not performed or for non-covered services;

• Overpaid because of errors made in calculating beneficiary deductible and/or coinsurance amounts; or

• A hospital that bills and is paid for outpatient services included in a beneficiary’s inpatient claim. Credit balances would not include proper payments made by Medicare in excess of a provider’s charges such as DRG payments made to hospitals under the Medicare prospective payment system.

For purposes of completing the CMS-838, a Medicare credit balance is an amount determined to be refundable to Medicare. Generally, when a provider receives an improper or excess payment for a claim, it is reflected in their accounting records (patient accounts receivable) as a “credit.” However, Medicare credit balances include monies due the program regardless of its classification in a provider’s accounting records. For example, if a provider maintains credit balance accounts for a stipulated period; e.g., 90 days, and then transfers the accounts or writes them off to a holding account, this does not relieve the provider of its liability to the program. In these instances, the provider must identify and repay all monies due the Medicare program.

Only Medicare credit balances are reported on the CMS-838.

To help determine whether a refund is due to Medicare, another insurer, the patient, or beneficiary, refer to the sections of the manual [each provider manual will have the appropriate cite for that manual] that pertain to eligibility and Medicare Secondary Payer (MSP) admissions procedures.

Submitting the CMS-838

Submit a completed CMS-838 to your fiscal intermediary (FI) within 30 days after the close of each calendar quarter. Include in the report all Medicare credit balances shown in your accounting records (including transfer, holding or other general accounts used to accumulate credit balance funds) as of the last day of the reporting quarter.

Report all Medicare credit balances shown in your records regardless of when they occurred. You are responsible for reporting and repaying all improper or excess payments you have received from the time you began participating in the Medicare program. Once you identify and report a credit balance on the CMS-838 report, do not report the same credit balance on subsequent CMS-838 reports.



Completing the CMS-838

The CMS-838 consists of a certification page and a detail page. An officer (the Chief Financial Officer or Chief Executive Officer) or the Administrator of your facility must sign and date the certification page. Even if no Medicare credit balances are shown in your records for the reporting quarter, you must still have the form signed and submitted to your FI in attestation of this fact. Only a signed certification page needs to be submitted if your facility has no Medicare credit balances as of the last day of the reporting quarter. An electronic file (or hard copy) of the certification page is available from your FI.

The detail page requires specific information on each credit balance on a claim-by-claim basis. This page provides space to address 17 claims, but you may add additional lines or reproduce the form as many times as necessary to accommodate all of the credit balances that you have reported. An electronic file (or hard copy) of the detail page is available from your FI.

You may submit the detail page(s) on a diskette furnished by your contractor or by a secure electronic transmission as long as the transmission method and format are acceptable to your FI. Segregate Part A credit balances from Part B credit balances by reporting them on separate detail pages. NOTE: Part B pertains only to services you provide which are billed to your FI. It does not pertain to physician and supplier services billed to carriers.

Begin completing the CMS-838 by providing the information required in the heading area of the detail page(s) as follows:

• The full name of the facility;

• The facility’s provider number. If there are multiple provider numbers for dedicated units within the facility (e.g., psychiatric, physical medicine and rehabilitation), complete a separate Medicare Credit Balance Report for each provider number;

• The month, day and year of the reporting quarter; e.g., 12/31/02;

• An “A” if the report page(s) reflects Medicare Part A credit balances, or a “B” if it reflects Part B credit balances;

• The number of the current detail page and the total number of pages forwarded, excluding the certification page (e.g., Page 1 of 3); and

• The name and telephone number of the individual who may be contacted regarding any questions that may arise with respect to the credit balance data. Complete the data fields for each Medicare credit balance by providing the following information (when a credit balance is the result of a duplicate Medicare primary payment, report the data pertaining to the most recently paid claim):

Column 1 - The last name and first initial of the Medicare Beneficiary, (e.g., Doe, J.).

Column 2 - The Medicare Health Insurance Claim Number (HICN) of the Medicare Beneficiary.

Column 3 - The multiple-digit Internal Control Number (ICN) assigned by Medicare when the claim is processed.



Column 4 - The 3-digit number explaining the type of bill; e.g., 111 - inpatient, 131 - outpatient, 831 - same day surgery. (See the Uniform Billing instructions, [each provider manual has the appropriate cite for the manual].)

Columns 5/6 - The month, day and year the beneficiary was admitted and discharged, if an inpatient claim; or “From” and “Through” dates (date service(s) were rendered), if an outpatient service. Numerically indicate the admission (From) and discharge (Through) date (e.g., 01/01/02).

Column 7 - The month, day and year (e.g., 01/01/02) the claim was paid. If a credit balance is caused by a duplicate Medicare payment, ensure the paid date and ICN number correspond to the most recent payment.

Column 8 - An “O” if the claim is for an open Medicare cost reporting period, or a “C” if the claim pertains to a closed cost reporting period. (An open cost report is one where an NPR has not yet been issued. Do not consider a cost report open if it was reopened for a specific issue such as graduate medical education or malpractice insurance.)

Column 9 - The amount of the Medicare credit balance that was determined from your patient/ accounting records.

Column 10 - The amount of the Medicare credit balance identified in column 9 being repaid with the submission of the report. (As discussed below, repay Medicare credit balances at the time you submit the CMS-838 to your FI.)

Column 11 - A “C” when you submit a check with the CMS-838 to repay the credit balance amount shown in column 9, an “A” if a claim adjustment is being submitted in hard copy (e.g., adjustment bill in UB-92 format) with the CMS-838, and a “Z” if payment is being made by a combination of check and adjustment bill with the CMS-838. Use an “X” if an adjustment bill has already been submitted electronically or by hard copy.

Column 12 - The amount of the Medicare credit balance that remains outstanding (column 9 minus column 10). Show a zero (“0”) if you made full payment with the CMS-838 or a claim adjustment had been submitted previously, including electronically.

Column 13 - The reason for the Medicare credit balance by entering a “1” if it is the result of duplicateMedicare payments, a “2” for a primary payment by another insurer, or a “3” for “other reasons.” Provide an explanation on the detail page for each credit balance with a “3.”

Column 14 - The Value Code to which the primary payment relates, using the appropriate two digit code as follows: (This column is completed only if the credit balance was caused by a payment when Medicare was not the primary payer. If more than one code applies, enter the code applicable to the payer with the largest liability. For code description, see [each provider manual has the appropriate cite for that manual].)

12 – Working Aged

13 – End Stage Renal Disease

14 – Auto/No Fault


15 – Workers’ Compensation

16 – Other Government Program

41 – Black Lung

42 – Department of Veterans Affairs (VA)

43 – Disability

44 – Conditional Payment

47 – Liability

Column 15 - The name and billing address of the primary insurer identified in column 14.

NOTE: Once a credit balance is reported on the CMS-838, it is not to be reported on a subsequent  period report.

Payment of Amounts Owed Medicare

Providers must pay all amounts owed (column 9 of the report) at the time the credit balance report is submitted. Providers must submit payment, by check or adjustment bill.

• Payments by check must also be accompanied by a separate adjustment bill, electronic or hard copy, for all individual credit balances that pertain to open cost reporting periods. The FI will ensure that the monies are not collected twice.

• Submission of the detail information on the CMS-838 will not be accepted by the FI as an  adjustment bill.

• Claim adjustments, whether as payment or in connection with a check, must be submitted as adjustment bills (electronic or hard copy). If the claim adjustment was submitted electronically, this must be shown on the CMS-838 (see instructions for column 11).

• There is a limited exception for MSP credit balances. Federal regulations at 42 CFR 489.20(h) state that “if a provider receives payment for the same services from Medicare and another payer that is primary to Medicare…” the provider must identify MSP related credit balances in the report for the quarter in which the credit balance was identified, even if repayment is not required until after the date the report is due. If the provider is not submitting a payment (by check or adjustment bill) for an MSP credit balance with the CMS-838 because of the 60-day rule, the provider must furnish the date thecredit balance was received. Otherwise, the FI must assume that the payment is due and will issue a recovery demand letter and accrue interest without taking this 60-day period into consideration.

• If the amount owed Medicare is so large that immediate repayment would cause financial hardship, you may contact your FI regarding an extended repayment schedule.

Records Supporting CMS-838 Data

Develop and maintain documentation that shows that each patient record with a credit balance (e.g., transfer, holding account) was reviewed to determine credit balances attributable to Medicare and the  amount owed, for the preparation of the CMS-838. At a minimum, your procedures should:

• Identify whether the patient is an eligible Medicare beneficiary;
• Identify other liable insurers and the primary payer;
• Adhere to applicable Medicare payment rules; and
• Ensure that the credit balance is due and refundable to Medicare.

NOTE: A suspension of Medicare payments may be imposed and your eligibility to participate in the Medicare program may be affected for failing to submit the CMS-838 or for not maintaining documentation that adequately supports the credit balance data reported to CMS. Your FI will review your documentation during audits/reviews performed for cost report settlement purposes.

Provider Based Home Health Agencies (HHAs)

Provider-based HHAs are to submit their CMS-838 to their Regional Home Health Intermediary even though it may be different from the FI servicing the parent facility.

Exception for Low Utilization Providers

Providers with extremely low Medicare utilization do not have to submit a CMS-838. A low utilization provider is defined as a facility that files a low utilization Medicare cost report as specified in PRM-I, section 2414.4.B, or files less than 25 Medicare claims per year.

Compliance with MSP RegulationsMSP regulations at 42 CFR 489.20(h) require you to pay Medicare within 60 days from the date you receive payment from another payer (primary to Medicare) for the same service. Submission of the CMS-838 and adherence to CMS’ instructions do not interfere with this rule. You must repay credit balances resulting from MSP payments within the 60-day period.

Report credit balances resulting from MSP payments on the CMS-838 if they have not been repaid by the last day of the reporting quarter. If you identify and repay an MSP credit balance within a reporting quarter, in accordance with the 60-day requirement, do not include it on the CMS-838; i.e., once payment is made, a credit balance would no longer be reflected in your records.

If an MSP credit balance occurs late in a reporting quarter, and the CMS-838 is due prior to expiration of the 60-day requirement, include it in the credit balance report. However, payment of the credit balance does not have to be made at the time you submit the CMS-838, but within the 60 days allowed.




Instructions to Fiscal Intermediaries (FIs) for the Medicare Credit Balance Report

General In accordance with section §1815(a) and §1833(e) of the Social Security Act (the Act), the Secretary is authorized to request information from participating providers that is necessary to properly administer the Medicare program. In addition, §1866(a) (1) (C) of the Act requires participating providers to furnish information about payments made to them and to refund any monies incorrectly paid. In accordance with these provisions, providers are to complete a Medicare Credit Balance Report (CMS-838) to ensure that monies owed to Medicare are repaid in a timely manner.

Fiscal intermediaries (FIs) are responsible for monitoring and ensuring provider compliance with the credit balance reporting process. This responsibility includes the following activities: ensure that providers submit properly completed CMS-838 reports on time, claims adjustments to Medicare credit balances are properly made, payments to providers are suspended for untimely submission of CMS-838 reports, demand letters are appropriately issued to providers that have not repaid their Medicare credit balances, and outstanding Medicare credit balances are included in Medicare financial reports.

Medicare Credit Balance Report (CMS-838)

Providers use the quarterly CMS-838 report to disclose Medicare credit balances. They determine the number and amount of these balances for refunding the Medicare program. Generally, when a provider  receives an improper or excess payment for a claim, it is reflected in their accounting records (patientaccounts receivable) as a “credit.” However, Medicare credit balances include money due to the program regardless of its classification in a provider’s accounting records. For example, if a provider maintains credit balance accounts for a stipulated period such as 90 days, and then transfers the accounts or writes them off to a holding account, this does not relieve the provider of its liability to the program. In these instances, the provider is responsible for identifying and repaying all of the monies from these credit balance accounts to the Medicare program.

The current version of the Medicare Credit Balance Report (Certification Page and Detail Page) and instructions for its completion are available at www.cms.hhs.gov/forms. This report is identified as CMS Form 838 on the CMS Web site, and a replica of this form is in section 20 of this chapter.FIs are charged with the responsibility for performing all necessary activities to implement these instructions.

Providers must pay all amounts owed (column 9 of the Detail Page) at the time the credit balance report is submitted. Payment must be submitted with the report and may be made by check or adjustment bill.

• Submission of the completed Detail Page by itself does not constitute a claim adjustment. The claim adjustment (i.e., adjustment bill) must be submitted separately, either electronically or by hard copy (e.g., UB-92). The instructions for column 11 of the Detail Page reflect the type of payment made.

• If the credit balances are repaid by check, the provider must still submit adjustment bills for any individual credit balances. (The FI will ensure that the monies for these balances are not collected twice.)

FI Internal Controls

The FI’s Chief Financial Officer for Medicare Operations shall ensure that all FI credit balance reporting related processes and activities are completed timely and accurately.


Minimum Requirements for Internal Controls


A. A designated centralized area to receive Medicare credit balance reports.

B. FIs shall have all CMS-838 reports and accompanying documents retained in the centralized area. The sole exceptions are the originals of the accompanying check and/or accompanying claim adjustment bill.

• A copy of any accompanying check or accompanying claim adjustment bills must be retained with the other original documents.

• All other documents must be copied if the information they contain is needed by another area for the resolution of any matter involving provider credit balance reports.

• The envelopes shall be retained or copied to substantiate the date of receipt of the CMS-838 report.

NOTE: FIs may convert these materials into image files (e.g., PDF files) for electronic storage and archival purposes.

C. Faxed credit balance reports that are within 30 calendar days of the close of each calendar quarter should be accepted as timely.

• Retain the coversheet to substantiate the date of receipt of the CMS-838 report.

NOTE: When the FI accepts faxes, the FI shall ensure that these faxes are received over electronically secure transmission lines, and placed in a limited access work area.

D. The FI shall designate a point of contact for receipt and the resolution of credit balance reporting related issues. This individual is to verify that all FI activities related to credit balance reporting are completed timely and accurately in all areas of the FI.

E. The FI shall have a listing of all providers required for submitting the CMS-838. FIs shall have written procedures to ensure this listing is reviewed and updated each calendar year quarter.

F. Written policies and procedures for monitoring and validating receipt of timely, accurate, and complete CMS-838s from all providers.

For example:

• Is the name and title of the certifying officer or administrator of the provider on the Certification Page, and are all data fields completed for Medicare credit balances on the Detail Page? Did the Detail Page come with an accompanying check and/or appropriate hard copy or electronic adjustment bills?

• Were the monies for the reported credit balances timely recouped to the Medicare Trust Fund?

G. FIs shall have appropriate tracking and/or reports for provider credit balances reporting related activities.

For example:

• Such as related claims adjustments, Suspension Warning Letters and suspensions, verification of low Medicare utilization providers with claims data, demand letters, financial reporting, credit balance summary reports, etc., that have been performed with respect to credit balance reports due or received for a given calendar year quarter.


H. The FI shall have internal controls in place to ensure the accurate and timely processing and reporting of credit balances.

• The time frame for processing claims adjustments for Medicare credit balances from start to finish is 90 days from the receipt date of acceptable credit balance reports. (Contact your RO if you need additional time.)

I. A desk guide or manual with published internal control policies and standard operating procedures for implementing the credit balance reporting process.Suspension Warning Letter (FI Action if a Credit Balance Report is not Submitted)


A. The FI shall issue a Suspension Warning Letter if it does not receive a credit balance report from a provider by the 15th calendar day after 30 calendar days from the end of each calendar year quarter (45 calendar days from the end of each calendar year quarter).

• The Suspension Warning Letter shall state that the FI will suspend all claims payments at 100% in 15 calendar days from the date of issuance of this letter if the credit balance report is not received during this time period.

• This suspension will continue until the FI receives a credit balance report.

• The FI shall ensure that any necessary suspensions are implemented timely and maintained, as appropriate. (Refer to Pub. 100-06, Chapter 4, §§40 - 40.2). In addition, Federal regulations at 42 CFR §405.372 require that the provider be notified of the intention to suspend payment and the reasons for the suspension.

B. The FI shall have the responsibility to ensure that if providers change from submitting a low utilization cost report to a full cost report, then they shall comply with all credit balance reporting requirements. NOTE: A provider with extremely low Medicare utilization does not have to submit the CMS-838 form. A low utilization provider is defined as a facility that files a low utilization Medicare cost report or files less than 25 Medicare claims per year.


Issuance of a Notification/Rejection Letter to Providers Regarding Non-Payment of Medicare Credit Balances or Missing/Inaccurate Information on the CMS-838 Report


A. The FI shall have a process in place to resolve non-payment of Medicare credit balances or missing/ inaccurate information on received CMS-838 reports.

For example:

• Review each credit balance entry individually on the CMS-838 report to determine whether it is missing information such as: is it being repaid by check or hardcopy adjustment bill?

• Contacting the provider via telephone, to obtain missing information on the CMS-838 report. (Phone calls should be documented).

• If the FI is successful at reaching the provider, the provider may fax over the requested information at the FI’s discretion.

B. If the FI is unsuccessful in reaching the provider within 30 calendar days from the due date of the CMS838 report, the FI should issue a letter on the thirtieth day after the due date of the CMS-838 report.

• This letter shall state that the FI will place the provider on 100% withhold up to the total amount owed if the provider does not send a check or adjustment bills for these balances in 15 calendar days from the date of this letter.

• After the Notification/Rejection letter has been sent and the provider is placed on 100% withhold up to the total amount owed and a balance remains outstanding 60 days after the due date of the CMS838, the FI must issue a demand letter to the provider. Refer to Section 10.6 - FI Issuance of a Credit Balance Demand Letter.



FI Issuance of a Credit Balance Demand Letter 

When a Medicare credit balance is not fully recovered to the Medicare Trust Fund through the adjustment bill process (or through check submission) and this balance remains outstanding 60 days after the due date of the CMS-838, the FI shall issue a demand letter to the provider.

• The FI shall issue demand letters within 60 calendar days from the due date of the CMS-838 report.

• If a full payment is not received 15 days after the date of the first demand letter, the FI shall start the 100% withholding of claims payment up to the total amount owed on day 16, (if they haven’t already placed providers on 100% from their 1st Notification/Rejection letter) Refer to Pub. 100-06, Chapter 4, §§40 and 40.1.

• If no response is received from the provider within 30 days after the date of the first demand letter, follow the existing instructions in Pub. 100-06, Chapter 4, §§10 and 20.

• If the provider believes that prompt repayment of the amount owed Medicare is so large that it will cause financial hardship, the provider may complete a request for an extended repayment schedule in accordance with Pub. 100-06, Chapter 4, §50.

• Contact your Regional Office (RO) for guidance on specific provider issues as needed. Refer to Pub. 100-06, Chapter 3, §40.2 for sample Demand Letter for Claims Accounts Receivables. For MSP, refer to Pub. 100-05, Chapter 7, §60.10.1 “Intent to Refer” letter.

10.7 - Interest Assessment for Non-MSP and MSP Medicare Credit Balances (Rev. 99, Issued: 06-30-06; Effective/Implementation Dates: 10-02-06) Calculation of Interest on Medicare Credit Balances Effective October 1, 2004, 42 CFR § 405.378 and 411.24 (m) (l) was amended to change how interest is calculated on Non-MSP/MSP recoveries. Section 1862(b)(2)(B)(i) of the Act provides express authority to assess interest on MSP debts. Under this new rule, interest is assessed for each full 30-day period thatpayment is not made on time. This change applies to debts established on or after October 1, 2004.

A. Assessment of Interest on Non-MSP Credit Balances Interest on Non-MSP debts established prior to October 1, 2004 will continue to be assessed under the former method, until the debt is recovered in full. NOTE: Refer to Pub. 100-06, Chapter 4, §30.3 – Non-MSP (Debt Collection).

B. Assessment of Interest on MSP Credit Balances Refer to Pub. 100-05, Chapter 7, revised §30.1.5- “Interest on MSP Recovery Claims” for information on the calculation of interest.




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