LOD - Basics of billing and appealing

Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.

To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:

Select which best describes you: Health Care Professional Person(s) with Medicare

Select your location: Florida Puerto Rico U.S. Virgin Islands

Select your line of business: Part A Part B

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website. Applicable FARS/DFARS restrictions apply to government use.

AMA Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.

CMS Disclaimer: The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

AMA - U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright © 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

End Disclaimer

This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.

Home ► Online learning ► LOD - Basics of billing and appealing

Last Modified: 12/6/2024 Location: FL, PR, USVI Business: Part A, Part B

Learning On Demand – Basics of billing and appealing

Join our live training events

Want to participate in one of our live educational events?

Check out our events calendar

View our YouTube channel

Title	Line of Business	Description	Format	Duration
Medicare Part A Updates – October 2024	Part A	This course is a review of the most recent Medicare updates and typically contains a wide variety of topics which include, but are not limited to, MAC initiatives, CMS initiatives, quarterly and annual updates, as well as preventative service reminders.	Webinar	Self-paced
Medicare Part B Updates – October 2024	Part B	This course is a review of the most recent Medicare updates and typically contains a wide variety of topics which include, but are not limited to, MAC initiatives, CMS initiatives, quarterly and annual updates, as well as preventative service reminders.	Webinar	Self-paced
Modifier of the Month: Repeat Procedures: 76, 77 and 91	Part B	Claims for repeat services can deny as duplicate claims if submitted without differentiating the services with proper modifiers. We'll provide guidance on submitting claims with modifiers 76, 77 and 91 to demonstrate repeat services and required supporting documentation.	Webinar	Self-paced
Medicare Part A Updates – July 2024	Part A	This course is a review of the most recent Medicare updates and typically contains a wide variety of topics which include, but are not limited to, MAC initiatives, CMS initiatives, quarterly and annual updates, as well as preventative service reminders.	Webinar	Self-paced
Modifier of the Month: 50 Versus Anatomical Modifiers	Part B	When submitting claims for procedures performed unilaterally or bilaterally during the same operative session, the proper modifier(s) should be applied to your claim lines. This course will demonstrate how to differentiate between using anatomical modifiers or modifier 50. We'll review appropriate use of these modifiers using relative claims and appeals examples.	Webinar	Self-paced
Medicare Part B Updates - July 2024	Part B	This course is a review of the most recent Medicare updates and typically contains a wide variety of topics which include, but are not limited to, MAC initiatives, CMS initiatives, quarterly and annual updates, as well as preventative service reminders.	Webinar	Self-paced
Modifiers of the Month: 22, 52 and 53	Part B	Claims for increased procedural services, reduced services and discontinued procedures should have supporting documentation to avoid claim denials and future appeals. With this course, we'll provide guidance on properly submitting claims with documentation when applying modifiers 22, 52 and 53.	Webinar	Self-paced
StayConnected: When and How to Submit Part B Appeals	Part B	Stay connected with Medicare Part B by attending the Part B Post-pay Workshop series. This webinar will provide an overview of the Part B appeals process including the different levels of appeal and submission timeframes, clarification of non-appealable claims, and appeal status.	Webinar	Self-paced
StayConnected: What Happens After the Claim is Submitted	Part B	Stay connected with Medicare Part B by attending the Part B Post-pay Workshop series. This webinar will review the stages of the Part B financial process after claims are submitted to Medicare, including claim processing and adjudication. We'll outline how to identify claim status, define the fields on the Medicare remittance advice (RA) and demonstrate how to successfully use this resource to monitor claims processing outcomes to reconcile patient accounts.	Webinar	Self-paced
Modifier of the Month: NCCI Modifiers 59, XE, XS, XU and XP	Part B	For non-evaluation and management services, modifiers 59 & X{EPSU} are used to identify distinct procedures or services not normally reported together when performed on the same day. As these modifiers are often used incorrectly, we'll explore the proper use of these modifiers, common scenarios, and supporting documentation requirements.	Webinar	Self-paced
Medicare Secondary Payer (MSP) Series: Preparing and Submitting Part B Claims	Part B	This Part B provider course in our Medicare secondary payer (MSP) series will begin with a brief overview of the MSP program provisions and how to identify patient eligibility. We will progress to step-by-step guidance on claim completion and submission and conclude with interactive billing scenarios.	Webinar	Self-paced
StayConnected: Monitoring the Processing Status of Part A Claims	Part A	Stay connected with Part A Medicare billing by attending the Part A Post Payment Workshop series. This webinar will review the various stages of the Part A financial process after claims are submitted to Medicare, including claim processing and finalization. We will outline how to identify claim status, define the various fields on the Medicare remittance advice (RA) and demonstrate how to successfully use this resource to monitor claims processing outcomes to reconcile accounts and receivables.	Webinar	Self-paced
Reporting the Correct Place of Service	Part B	This course will focus on reporting the correct place of service (POS) codes on your Medicare claims to ensure appropriate reimbursement amounts are issued. We define the most commonly used codes and review how to use them.	Webinar	Self-paced
Medicare Covered Dermatology Services	Part A and Part B	Medicare covers medically necessary dermatology services for the prevention, diagnosis, and treatment of certain skin conditions. Join this session to review the Medicare coverage, billing and documentation requirements of services provided by dermatologists. We will conclude with an overview of recent medical review findings and identify resources to assist in preventing improper payment errors.	Webinar	Self-paced
Modifier of the Month: AS, 80, 81, 82 and 62 (Assistant-at-Surgery and Co-Surgeons)	Part B	The Office of Inspector General (OIG) released a report indicating Medicare improperly paid physicians for co-surgery and assistant-at-surgery services were billed without the appropriate payment modifiers. Medicare makes a reduced payment to physicians who work together to perform a surgical procedure on the same patient during the same operative session. This course will explore the co-surgeon and surgical assistance modifiers (62, AS, 80, 82), and review the documentation requirements and various scenarios when these modifiers should be used	Webinar	Self-paced
Medicare Secondary Payer (MSP) Series: Identifying the Primary Payer	Part A and Part B	The second course in our Medicare secondary payer (MSP) series navigates how to identify the primary payer. We will explore the role of the MSP Contractor. We will examine the MSP resources and self-service tools available.	Webinar	Self-paced
Medicare Secondary Payer (MSP) Series: Fundamentals	Part A and Part B	This first course in our Medicare secondary payer (MSP) series provides the definition and purpose of the MSP program. We will review the MSP provisions including Group Health Plans (GHPs) and Non-group Health Plans (NGHPs). We will explore MSP resources and self-service tools available.	Webinar	Self-paced
Understanding the PWK Segment	Part A and Part B	Description: The paperwork segment of an electronic claim submission is commonly known as PWK. The PWK process allows you to utilize the cost-effective electronic data interchange technology and if you choose to submit paper documentation at the time of the claim submission. This video will give you a brief demonstration about the PWK segment. Please share your feedback about this webinar.	Video	0:03:50
Electronic transactions in the Medicare program (Spanish)	Part A and Part B	View this video for more information about the electronic transactions, your requirements for billing electronically, and the free software available for you. Please share your feedback about this webinar.	Video	0:09:10
Electronic transactions in the Medicare program	Part A and Part B	View this video for more information about the electronic transactions, your requirements for billing electronically, and the free software available for you. Please share your feedback about this webinar.	Video	0:06:56
Documenting and billing Medicare orders and referrals (Spanish)	Part B	Learn about enrollment and documentation requirements for providers ordering or referring services and claim requirements for providers performing and billing for services. Please share your feedback about this video.	Video	0:08:10
Documenting and billing Medicare orders and referrals	Part B	Learn about enrollment and documentation requirements for providers ordering or referring services and claim requirements for providers performing and billing for services. Please share your feedback about this video.	Video	0:05:38
Identifying if your Medicare claim Is eligible for an appeal	Part A and Part B	Before submitting an appeal on a Medicare claim, you first want to make sure that a claim determination, or decision, was made of either paid or denied. We often see providers incorrectly appealing a claim returned to provider for correction. This video covers how you can identify when a claim is eligible for an appeal. Please share your feedback about this video.	Video	00:02:51
Understanding the Medicare overpayment process	Part A and Part B	This video will help you understand the overpayment process, your responsibilities to pay the money back money, and what to do if you disagree with an overpayment decision. Please share your feedback about this video.	Video	00:10:47

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.