General

Palmetto GBA is publishing the following FAQ based upon data analytics identifying topics generating a high volume of telephone inquiries between April 1, 2022, through June 30, 2022. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).

1. Question: My facility is seeing an increasing number of claims rejecting with indication of having an ongoing responsibility to medicals (ORM). Where can I find information regarding this topic?

Answer: ORM reporting is a mandatory requirement for liability insurers, no-fault insurers, and workers’ compensation plans and insurers due to the implementation of Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). These entities are often identified as Responsible Reporting Entities (RREs). ORM information is reported so that claims for the same incident or injury are checked and not paid primary by Medicare if there is other insurance that should pay first.

Once ORM is indicated on a beneficiary’s record it will always remain unless proof is submitted to indicate an error has occurred. RRE’s are required to report that an ORM period has ended however, which will assign a termination date but will not remove that there is an ORM record.

If the beneficiary’s record contains a termination date any future claims after termination date will not be affected. If no termination date has been indicated claims will continue to be checked for potential same incident or injury information to determine if payment should be processed or rejected.

It is important to note that ORM indication on a beneficiary record does not automatically mean that payments for medicals have been made. The ORM means that the RRE has made a determination that they are assuming responsibility. For more information on ORM please see the resources below:

• Mandatory Insurer Reporting (NGHP) 
• Ongoing Responsibility for Medicals (ORM) 
   

2. Question: My claims are returning stating the procedure codes being used are invalid based on the date of service billed. Where can lists be found that has the timeframe where codes are valid?

Answer: It is imperative that information billed on claims are accurate for the dates of service(s) to ensure claims are processed accurately. CMS has created a web page that has the codes listed by effective date ranges. This list is updated annually. Please use the link below to access the code information: List of CPT/HCPCS Codes.

3. Question: My facility is struggling with the SNF Interrupted Stay Policy. How can it be explained in simple terms?

Answer: The SNF interrupted stay policy exists to ensure that beneficiaries are not being frequently discharged and readmitted a facility to obtain a new discharge payment.

PDPM includes an interrupted stay policy, which combines multiple SNF stays into a single stay when the patient’s discharge and readmission occurs within a prescribed window.

If a patient is discharged from a SNF and readmitted to the same SNF no more than three (3) consecutive calendar days after discharge, then the subsequent stay is considered a continuation of the previous stay.

If patient is discharged from SNF and readmitted more than three (3) consecutive calendar days after discharge, or admitted to a different SNF, then the subsequent stay is considered a new stay.

4. Question: Why are my SNF claims being rejected with a benefits exhaust reason code if they were submitted with the condition code DR as instructed?

Answer: CMS utilized its authority under section 1812(f) of the Social Security Act to waive certain Medicare requirements under the SNF PPS due to the COVID-19 pandemic. Specifically, for patients who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period. This waiver applies only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances. If those conditions are not applicable claims will be rejected. This also applies if the beneficiary has already utilized the additional days granted under the waiver.

5. Question: When value codes Q0 and Q1 are on my remittance advice, what does that indicate?

Answer: If the remittance advice information for a particular claim contains value code Q0 and/or Q1 it indicates Accountable Care Organization (ACO) involvement. The value code Q0 indicates Accountable Care Organization reduction. The value code Q1 indicates an Accountable Care Organization Payment Reduction. These value codes indicate the amount in which payment has been reduced based on provider’s agreement with an ACO. CMS has detailed information regarding ACO’s using the following link: Accountable Care Organizations (ACOs). 

6. Question: My facility receives beneficiaries from SNFs where they receive occupational therapy OT. We are not receiving payment from Medicare for those services. Please advise why.

Answer: Therapies such as OT, physical therapy (PT), and speech-language pathology (SLP) must be billed by the SNF in which the beneficiary is located. These services are included in SNF Consolidated billing. As a part of SNF Consolidated billing the service must be billed by the SNF for beneficiaries that are in a Medicare-certified bed. The facility has to have an agreement with the SNF. According to Medicare regulations the SNF must pay the rendering provider for services included in consolidated billing. More information on SNF Consolidated Billing can be found using the following link: SNF Consolidated Billing. 

7. Question: My claims are editing for ESRD Consolidated Billing Services. What services are included under that policy?

Answer: Under the ESRD Prospective Payment System (ESRD PPS) certain laboratory services, drugs and biologicals, equipment, and supplies are subject to consolidated billing and are not separately payable when provided to ESRD beneficiaries by providers other than the ESRD facility. Under consolidated billing, ESRD facilities are expected to furnish services, either directly, or under an arrangement with an outside supplier. The items and services subject to ESRD Consolidated billing are updated yearly and can be found using the following link: ESRD PPS Consolidated Billing 

8. Question: The number of claim rejections are increasing for my facility related to preventive services being provided by the facility for frequency. Is there a tool that can be used to prevent this from continuing?

Answer: CMS has developed a preventive services chart to assist facilities with information such as frequency requirements for related services. The information is listed by service type and can be found using the following link: Preventive Services Chart. 

9. Question: My claims are editing for procedure-to-procedure edits. How do I find those?

Answer: CMS has developed a Medicare NCCI FAQ library that contains the links to important information such as the Medicare NCCI Procedure to Procedure (PTP) Edits Medicare NCCI FAQ Library The information is updated quarterly and contains addition and deletion information.

10. Question: Where can I locate the most recent list of changes to the Inpatient Only List for device codes?

Answer: The January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS) implemented January 3, 2022, contains the most recent information regarding device codes. This notification contains information regarding the inpatient only device codes. Please refer to the information link before for additional information and attachments: January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS).

Last Reviewed: 09/23/2024

Palmetto GBA is publishing the following FAQ based upon data analytics identifying topics generating a high volume of telephone inquiries between January 1, 2022, through March 31, 2022. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).

1. Question: Why are my previously processed 131 claims being adjusted with a 13G claim and rejecting with Reason code C7252?

Answer: Outpatient claims (13X/85X) receive edit C7252 when services reported are within the admission and discharge dates of a SNF inpatient Part A claim for non-therapy services.

Skilled Nursing Facility (SNF) Consolidated Billing (CB) requires the SNF to bill all services for Part A residents receiving skilled care with the exception of excluded services.

Prior to billing the claim, verify whether the patient is in a covered Part A SNF stay. If so, then you must determine if the services are subject to SNF CB.

Instructions for SNF CB

• Go to the CMS SNF CB website
• Click on the Part A MAC update for the year in question
• Scroll to downloads, then click on the annual SNF consolidated billing HCPCS updates
• You will get a question to "open" or "save" the file; click "open"
• Then double-click to open the excel (xlsx) file
• Once you open the excel file, you can perform a search for the service provided by either the CPT®/HCPCS code or description of the service
• If the service appears on the annual SNF consolidated billing HCPCS updates file, it is excluded from SNF CB (unless the word "inclusion" appears in the "Major Category" column) and may be billed separately on the 13X or 85X claim
• If the service does not appear on the annual SNF consolidated billing HCPCS updates file, it is included in SNF CB and must be included on the SNF inpatient Part A claim. Contact the SNF to discuss services "under arrangement"
• When outpatient Part B claims include services subject to SNF CB, the Common Working File (CWF) rejects the claim with reason code C7252. This edit reads only the first line of the claim. If that service is part of SNF CB, the entire claim rejects even if other services on the claim are not part of SNF CB.
• As a result, you must split your claim. Submit a claim for services not subject to SNF CB first. Once that claim processes, submit a no-pay claim for services subject to SNF CB.
   

2. Question: I have researched the Palmetto GBA website searching for the 2022 Wage Index information and cannot locate any current information. Where is this information located?

Answer: Fiscal Year (FY) 2022 Wage Index information can be located on the CMS website under the FY 2022 Wage Index Home Page. Frequently calls to the Provider Contact Center (PCC) includes questions regarding Core-Based Statistical Areas (CBSA). The latest information regarding that topic as well as many other wage indices related topics can be found utilizing this invaluable resource.

3. Question: My claims are returning to provider (RTP) with Reason Code 15202? What can I do to avoid receiving this error?

Answer: Description — On inpatient hospital or inpatient SNF bills with covered days greater than zero, the accommodation days shown with revenue codes 10x–21x must be equal to the cost report days. Outpatient claims should not be billed with covered days.

Resolution

**Always verify patients’ available benefits before filing claims. **

• Verify the dates of service and patient status
• Verify the number of covered (Value Code (VC) 80) and non-covered days (VC 81)
  • Note reviewing the patient status is crucial in this step to ensure accuracy of day count (example: If the patient status is a 30 the day is included in the day count)
• Verify the number of units shown with the accommodation revenue codes (010X–021X). Verify the dates shown with occurrence span codes.
• When billing condition code 04 and 69 charges should be submitted as covered
• When billing occurrence span code 77 charges should be submitted as covered
• If your claim is an adjustment; please ensure all lines are covered when resubmitting your claim
• If billing SNF and occurrence code 22 is present, you may bill covered up to the occurrence code 22. Then you should bill 210 until discharge.
  • Note when billing occurrence span code 74 it must be billed with rev code 180 and there should be no money associated with this line on your claim.
• Condition code 04 is informational only and should always be billed with covered charges, units and days
• When billing occurrence code M1 claim days and units should be non-covered
• When billing condition code 21 days and units should be submitted as non-covered

Resource: CMS Internet Only Manual (IOM), Publication 100-4 Chapter 3 Section 40.2, Medicare Claims Processing Manual.

4. Question: What could cause my financial account to be put on a hold?

Answer: There are a few reasons why the financial holds could have been put in place. The two most common reasons are late/unfiled credit balance and cost reports. The resources below are helpful tools that can provide resolutions related to the two most common reasons as well as other situations.

JM Part A Resources

• Credit Balance Reporting (CMS-838)
• Submitting the Credit Balance (838) Report and Due Dates
• Using Medicare's Online Credit Balance Report Lookup Tool 
• Credit Balance Report 
• Cost Report Filing Information 
• Cost Report Status Tool
•  How to Change Your Cost Reporting Period

CMS Resources

• Medicare Financial Management Manual, IOM 100-06, Chapter 12 (PDF)
• Contractor Desk Review and Audit, IOM 100-06, Chapter 9, PS&R (PDF) 
• Medicare Financial Management Manual, IOM 100-06, Chapter 5,Section 240 (PDF)
   

5. Question: My staff has issues with getting claims that contain a device-intensive procedure code to process. What is the best method of handling these types of claims?

Answer: Device-intensive procedure codes billed without at least one device code required for the procedure on the same claim with the same date of service or a device code billed without the device-intensive procedure code that is necessary for the device to have therapeutic benefit to the patient on the same claim with the same date of service will not complete processing.

To avoid this from occurring the provider must verify the following:

• Ensure that the procedure and device code(s) reported on the claim are correct
• Ensure that the procedure/device code(s) are submitted on the same claim with the same date of service

Once the information is verified and everything is correct , providers must check the codes in the I/OCE Quarterly Release Files relevant to the date of service on the claim to determine if a code is applicable. 

If the Device-intensive procedure was discontinued Medicare Claims Processing Manual Publication 100-04 Chapter 4 Section 61.2 (PDF) states that the following modifiers can be reported with the procedure codes:

• 52 (Reduced services)
• 73 (Discontinued outpatient procedure prior to anesthesia administration)
• 74 (Discontinued outpatient procedure after anesthesia administration)

If there is no applicable HCPCS code for the device the provider may report HCPCS Code C1889.

For certain device-intensive procedures, providers may bypass the device edit requiring at least one device HCPCS code for the procedure. For situations where no device was performed with certain device-intensive procedures, providers may bypass the edit by reporting modifier CG per information found in Medicare Claims Processing Manual Publication 100-04 Chapter 4 Section 61.3.5 (PDF).

6. Question: My facility has a numerous claim that are in a suspended status on FISS. Is there a problem with my claims that are in suspended locations? Is there anything that can be done to make my suspended claims process quicker?

Answer: All Medicare billing transactions will temporarily suspend (“S”) in different status and locations (S/LOCs) as they process through FISS. Once a claim is submitted to Medicare, assuming that it has no errors and meets medical necessity requirements, it will remain in a suspended status until it is ready to be paid. The Medicare Claims Processing Manual Publication 100-04 Chapter 1 Section 80.2.1 (PDF) states that Medicare contractors have 30 days to process clean claims. While the typical timeframe to process claims is less than this, contractors have the full 30 days from the receipt date of a clean claim to process it. There is no provider action needed during this timeframe unless otherwise notified.

Claims may also suspend due to system issues that prevent Medicare billing transactions from processing appropriately. Billing transactions impacted by these issues may be suspended for more than 30 days. The first course of action for the provider should be to check the Claims Payment Issues Log (CPIL) on the Palmetto GBA website based on the jurisdiction.

Select Claims Payment Issues Log to view the current and resolved CPILs.

Claims that are suspended in ST/LOC’s SB6001 can be in the location up to 45 days awaiting the return of documentation that has been requested from the provider as part of the Additional Documentation Request process (ADR).

Please review the Medical Review Part A Fact Sheet for additional information regarding ADR process.

7. Question: How does a facility determine whether its is going through a change of ownership versus a reorganization?

Answer: The CMS Regional Office (RO) makes the determination of whether a particular circumstance constitutes, for Medicare purposes, a change of ownership or a reorganization. Prior to submitting the CMS-855A, contact your CMS RO. CMS has made the Contacts Database available to providers to assist in determining who should be contacted. To utilize the database please follow the steps below:

• Select Organization Type
  • CMS RO — Center for Medicare & Medicaid Services Regional Office
• Select Contact Type
  • Any
• Select a Region or State Territory
  • Select appropriate region or state
• Select Show Contacts to display the list of regional offices based on your selection
• Select See Details to obtain necessary details to complete search
   

8. Question: Our facility has had to contact the Provider Contact Center (PCC) constantly regarding what has been described as known system issues what can we do to find out automatically what is causing issues?

Answer: The provider community is given the option to sign up for article update notifications via email. To sign up for email updates provider must choose the Subscribe to Email Updates link based on jurisdiction.

The Claims Payment Issues Log is also available to the provider community. The CPIL allows facilities to see detailed information regarding identified problems which includes such information as:

• Issue description
• Date CPIL opened
• Action required from the provider if applicable
• Resolution date once resolved
   

9. Question: I am a new Skilled Nursing Facility (SNF) and am questioning whether my facility needed to participate in the SNF Value-Based Purchasing Program (SNF VBP). Does my facility have to?

Answer: The SNF VBP Program is not optional. All SNFs paid under Medicare’s SNF Perspective Payment System (PPS) are required to participate in the SNF VBP Program. The types of SNFs paid under the SNF PPS include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities. Participation in the SNF VBP Program does not require any action on the part of SNFs to enroll, nor does it require any additional data collection burden.

CMS has developed the Skilled Nursing Facility Value-Based Purchasing Program: Frequently Asked Questions (PDF) to assist providers with questions surrounding SNF VBP.

Last Reviewed: 09/23/2024

More Background to Question
A PIP hospital provider received a demand letter requesting payment on a RAC DRG change that resulted in an overpayment. The provider agrees with the findings and will not appeal. Because the provider receives no monetary payments on inpatient claims individually (bi-weekly PIP payments occur), it is the providers belief that any adjustments to inpatient claims result in updating the Provider Statistical and Reimbursement (PS&R) and then the overpayment will be accounted for at the time of cost report settlement. If the provider issues a check to Palmetto GBA and the claim is also adjusted in the FISS system, will we not be repaying the amount twice, both in the check issued and then upon cost report settlement?

Answer
According to Change Request (CR) 7601, the PS&R is supposed to segregate and exclude RAC-initiated adjustments to PIP claims. Therefore, the provider may send in payment for the demanded overpayment. They will not get hit twice when the cost report is settled, since it will be excluded from the settlement calculation. If the provider does not want to send in a check, an accounts receivable (AR) will be created and Palmetto GBA will send a demand letter for RAC adjustments. In this case, we would offset against the PIP payment to collect the debt. Providers need to be aware that if the offset collection isn’t enough to fully collect the debt, interest could accrue.

There is also the option of requesting an immediate offset on all future ARs or specific ARs. If providers select this option, they will still receive the demand letter to let them know a debt has been incurred; Palmetto GBA will then offset the debt from future PIP payments.

Last Reviewed: 09/23/2024

Answer: Yes, you may use the therapist intervention notes to help support your codes. You are allowed to do that for Medicare purposes. Make sure that the physician is informed on the therapist activities and you will still need to forward those notes to the physician at some point.

Last Reviewed: 09/23/2024

Answer: A PHE declaration lasts until the Secretary of Health and Human Services declares that the PHE no longer exists or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary may extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist and may terminate the declaration whenever the Secretary determines that the PHE has ceased to exist. The declaration was most recently extended on July 15, 2022.

Palmetto GBA provides directions received from CMS on the Palmetto GBA website and through email update messaging. More questions and answers regarding the PHE are available on the U.S. Department of Health and Human Services Public Health Emergency Declaration Q&A web page.

Last Reviewed: 09/23/2024

Answer: You can’t adjust a claim to correct a medically denied line. You must submit a Redetermination: 1st Level Appeal form along with a corrected claim.

Last Reviewed: 09/23/2024

Answer: "Forwarding balance" means that a negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous Remittance Advice (RA). A reference number (the original ICN and the patient's Medicare ID number) is applied for tracking purposes.

What Does That Mean?

• A negative value represents a balance that will be moved forward to a future remittance payment advice. This means that an overpayment for a specific claim or claims (on this remittance) has been created because Medicare has paid for a service that should not have been allowed or has paid too much for a service. Your remittance notice will show the corrected allowed amounts for the adjusted claim(s).
• A positive value represents a balance that is being applied from a previous remittance advice. This means we are notifying you that we have completed an adjustment on a claim or claims (included in this remittance) and we have determined that an additional payment is due in part or in full for a previously processed service(s). Your remittance notice will show the corrected allowed amounts for the adjusted claim(s). A reference number (the original ICN and the patient's Medicare ID number) will be provided for tracking purposes.

Last Reviewed: 09/23/2024

Answer: A PTAN is the Provider Transaction Access Number, which is also known as the six-digit provider number, OSCAR number or legacy number. Providers will be asked for their PTAN when calling the provider contact center (PCC).

Last Reviewed: 09/23/2024