Specialties / Services FAQs

Yes, air ambulance services are payable from hospital to hospital, if it meets medical appropriateness criteria and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. We, at First Coast, will only reimburse to the nearest available medically appropriate facility.

Reference

• CMS IOM Pub. 100-02, Benefit Policy Manual, Chapter 10, section 10.4.4 

No, however OPTs and CORFs are different provider types and submit claims on different types of bills. In addition, they are not part of an outpatient hospital therapy department. 

An OPT is defined as a provider of service with an agreement to furnish outpatient therapy services to beneficiaries. The services must be reasonable and necessary with a potential for improvement. Only restoration therapy is covered. The beneficiary must be under the care of a physician. The facility agrees that they will not charge the beneficiary for covered services that Medicare should pay. OPTs use a 74x type of bill when submitting claims to Medicare. 

A CORF is a facility that is primarily engaged in providing diagnostic, therapeutic and restorative services to outpatients for the rehabilitation of the injured and disabled or patients recovering from an illness. The CORF must provide a comprehensive, coordinated skilled rehabilitation program for its patients that include, at minimum, CORF physicians’ services, physical therapy services, and social or psychological services. The facility must have adequate space and equipment necessary for any of the services provided. In general, all services must be furnished on the premises of the CORF. The only exception is home evaluations. CORFs use a 75x type of bill when submitting claims to Medicare. 

Another difference between CORFs and OPTs

For a CORF, the referring physician must review the plan of treatment every 60 days. However, an OPT must have the physician certify the plan of care every 90 days. For outpatient hospital-based therapy departments, re-certification for therapy should be performed every 90 days; however, it is acceptable for re-certification to be performed every 60 days.

References

• CMS certification and compliance, outpatient rehabilitation providers
• CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, sections 220.1.3 A-D
• CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 12, section 30E

Yes. Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare. The IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, section 20.1.2 lists multiple options relating to how and when authorization can be obtained and submitted.

Reference

• CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 10

Yes. Eligible FFS Medicare patients can enroll with any MDPP supplier offering MDPP sessions via distance learning, regardless of where the patient and supplier are located.

Yes, you can bill for a round trip ambulance service as long as it meets all requirements for a medically necessary ambulance service. If the point of pickup (POP) zip code is the same then the round trip can be billed on the same claim, if not two separate claims must be submitted.

Example (same POP zip code; same claim):

If you transport a Medicare patient from their residence (R) to hospital (H), report the appropriate ambulance transport Healthcare Common Procedure Coding System (HCPCS) code (AXXXX) and mileage code A0425 with modifiers RH (residence to hospital) appended to each code. The number of loaded miles is reported with the mileage code.

The return trip is reported with the appropriate HCPCS ambulance code and mileage code A0425 with modifiers HR (hospital to residence) appended to each code. The number of loaded miles is reported with the mileage code.

There will be a total of four lines billed.

Example (different POP zip codes; two separate claims):

If you transport a Medicare patient from their residence to hospital, report the appropriate ambulance transport HCPCS code and mileage code A0425 with modifiers RH appended to each code. The number of loaded miles is reported with the mileage code.

The return trip is billed on the second claim. Report the appropriate HCPCS ambulance code and mileage code A0425 with modifiers HR appended to each code. The number of loaded miles is reported with the mileage code.

Reference:

• CMS IOM Pub. 100-04, Claims Processing Manual, Chapter 15, sections 30.1 & 30.2

  Note: Part B ambulance suppliers follow instructions in section 30.1; Part A providers billing Part B ambulance services follow instructions in section 30.2.

No, hospitals are required to notify patients who have used or will use 90 days of benefits that they can choose not to use their reserve days for all or part of a stay. The hospital notice should be given when the beneficiary has five regular coinsurance days left and is expected to be hospitalized beyond that period. If the hospital discovers the patient has fewer than five regular coinsurance days left, it should immediately notify the patient of this option. The hospital should notate when it informed the patient of this option.

Reference

• CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 5, section 30

Yes. 

Please note, suppliers must ensure all patients are eligible for MDPP under FFS Medicare and follow all Centers for Disease Control and Prevention (CDC) Diabetes Prevention Recognition Program (DPRP) standards for distance learning delivery. All MDPP suppliers must maintain the capacity to offer MDPP services in person, even if they are currently delivering most or all MDPP sessions via distance learning.
 

CMS clarified in the Calendar Year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Final Rule that Medicare covers partial hospitalization program (PHP) services for the treatment of substance use disorders (SUDs). Specifically, notwithstanding the requirement that PHP services are provided in lieu of inpatient hospitalization, CMS considers services for the treatment of SUD and behavioral health to be consistent with the statutory and regulatory definitions of PHP services.

References

• CMS IOM Pub. 100-02, Chapter 6, Section 70.3
• CY 2024 OPPS ASC final rule

MDPP suppliers need to complete the CMS-20134 application. 

References 

• Completing the Medicare enrollment application - Medicare Diabetes Prevention Program (MDPP) suppliers (CMS-20134) application
• MDPP enrollment tutorial (PECOS) (cms.gov) 
   

MDPP suppliers must update changes to the coach roster in PECOS within 30 calendar days to avoid claims being rejected or denied. 

Reference

• MDPP coach eligibility fact sheet

MDPP suppliers submit all claims for MDPP services to their MAC, regardless of where the patient is located. 

The claims submission process will be the same for MDPP sessions delivered via distance learning as for MDPP sessions delivered in-person.

MDPP suppliers will use “Other” (99) as their place of service (POS) code for sessions delivered via distance learning and HCPCS code G9887. 

For MDPP billing, claims may list the currently enrolled practice location (not the coach’s home address) as the POS.

References

• Medicare diabetes prevention program (MDPP) - frequently asked questions
• Provider specialty: Medicare diabetes prevention program (MDPP)
   

Beginning with dates of service on and after January 1, 2011:

• For trips totaling up to 100 covered miles, suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage. The decimal must be used in the appropriate place (e.g., 99.9).
• For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 998.5 miles should be reported as 999).
• For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9).
• For mileage HCPCS billed on the ASC X12 837 professional transaction or the CMS-1500 paper form only, contractors shall automatically default to “0.1” units when the total mileage units are missing. 

Reference 

• CMS IOM Pub 100-04 Medicare Claims Processing Manual, Chapter 15

A therapist may bill for more than one therapy service that was furnished within the same 15-minute time period when "supervised modalities" have been defined by the American Medical Association (AMA) as “untimed and unattended and not requiring the presence of the therapist” (CPT codes 97010 to 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist. 

Reference

• CMS IOM Pub. 100-04, Chapter 5, sections 20.2 B-D and 20.3

One of the provisions of the Balanced Budget Act (BBA) of 1997 (Section 4432b) requires consolidated billing for SNFs. The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care residents receive during a covered Part A SNF stay, as well as physical, occupational, and speech therapy services received during a non-covered stay.

A limited number of services are specifically excluded from consolidated billing and therefore separately payable under Part B. These exceptions, as well as additional information concerning SNF consolidated billing, can be found on the CMS website at the CMS SNF consolidated billing webpage.

See additional information in our SNF overlap FAQ.

Reference 

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 6, Section 10.1

(Additionally, when the physician decides the patient should be in observation without prompting by the utilization review (UR) committee or case management and prior to the discharge of the patient and submission of the claim.)

No. When a physician orders a patient to be placed under observation, the patient's status is outpatient. The purpose of observation is to determine the need for further treatment or for inpatient admission.

Condition code 44 is used when an inpatient admission is being changed to outpatient. According to the CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 1 -- General Billing Requirements, condition code 44 is:

• For use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined the services did not meet its inpatient criteria.
• Note: For Medicare, the change in patient status from inpatient to outpatient is made prior to discharge or release while the patient is still a patient of the hospital.
• Additionally, concurrence of the UR committee and the physician must be documented in the medical record.

Reference

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, section 50.3 and Chapter 4

The CMS Medicare Claims Processing Manual states:

Ambulance transports

Emergency or urgent situations: In general, a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress. Forcing delivery of an ABN during an emergency may be considered coercive. ABN usage in the ER may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues.

Non-emergent / urgent ambulance transport: If the provider or supplier wants to transfer liability to the beneficiary, issuance of the ABN is mandatory for ambulance transport services if all of the following three criteria are met: 

1. The service being provided is a Medicare covered ambulance benefit under §1861(s)(7) of the SSA and regulations under this section as stipulated in 42 CFR §410.40 -.41
2. The health care provider or supplier believes that the service may be denied, in part or in full, as “not reasonable and necessary” under §1862(a)(1)(A) for the beneficiary on that occasion; and
3. The ambulance service is being provided in a non-emergency situation. (The patient is not under duress.) 

ABN issuance is mandatory only when a beneficiary’s covered ambulance transport is modified to a level that is not medically reasonable and necessary and will incur additional costs. If an ambulance transport is statutorily excluded from coverage because it fails to meet Medicare’s definition of the ambulance benefit, a voluntary ABN may be issued to notify the beneficiary of his/her financial liability as a courtesy.

Reference

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 30, section 50.17

CMS has developed billing and coding cheat sheets to assist with reporting. See the 2024 MDPP billing and claims cheat sheet for the list of current codes.

Reference 

• 2024 MDPP billing and claims cheat sheet 

If there is no MDPP supplier in the new location, the beneficiary can attend virtual sessions through distance learning (e.g., a live virtual classroom), if offered. The beneficiary may also identify other MDPP suppliers that offer distance learning delivery of MDPP services.

Electronic claims, 14 days; paper would be 29. Best practice is to wait 30 days for claim finalization prior to resubmitting.

CMS is responsible for sending the deactivation lists to the MAC. They could request for a provider to be deactivated for not billing any claims for six months or longer. 

There are several ways to capture, and document loaded ambulance mileage, including:

• Odometer reading
• Trip odometer readings
• Global Positioning System (GPS)
• Navigation computers
• Mapping programs (e.g., MapQuest)

These are all acceptable forms of documentation and must be kept in the patient’s record and made available to Medicare upon request.

Note: Documentation must include the name and address of the origin and destination in the trip report completed by the ambulance supplier.

Details are available in the ambulance physician certification statement article. Additional ambulance-related resources are available on the ambulance page. 

CMS offers an Ambulance Services Center where you can find information on the ground ambulance date collection system and more. 

View these pages to locate additional ambulance-related information:

• Modifiers
• Prior authorization process

Use the following resources to locate beneficiary signature requirements, including lifetime signature guidelines: 

• CMS IOM Pub.100-02 Medicare Benefit Policy Manual, Chapter 10, section 20.1.2
• 42 CFR § 424.40 - Request for payment effective for more than one claim
• Guidance on Beneficiary Signature Requirements for Ambulance Claims
• CMS-1500 (02/12) data element requirements

The information is located under Compliance & Review Programs, Prior Authorization (PA) Ambulance RSNAT and the Ambulance Specialty page. Review the Understanding Repetitive Scheduled Non-Emergent Ambulance Transports for questions concerning the RSNAT process. 

MDPP suppliers should report Demonstration Code "82" in Item 19 on the CMS-1500 claim form or in the EDI equivalent 2300 REF01 P4 and 2300 REF02 82.