Quarterly Frequently Asked Questions (FAQs): March 2019

Question: Why do I have to appeal a claim denied with Claim Adjustment Reason Code (CARC) B20 (procedure/service was partially or fully furnished by another provider) when I am the provider that rendered the service and someone else billed the same service in error? 

Answer: When a claim is submitted to Medicare, the claim is processed with the assumption the billing provider has the necessary documentation to support the service billed along with the medical necessity of any service billed. If when processing a claim it is determined that another provider has already billed and been paid for the same service, the claim is denied. The provider may exercise their appeal rights and provide supporting documentation to support the service they billed. If Medicare determines that a claim paid in error, Medicare will request a refund of the incorrectly paid services.

In many cases it is determined that two providers in the same group billed for the same service. Providers are encouraged to look at all services billed by all providers in their group for a given patient before requesting an appeal.

Question: My claim is denying with claim adjustment reason code (CARC) 236 (This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements). What can I do when I believe both codes in my coding pair should be allowed and I do not agree with the CMS National Correct Coding Initiative?

Answer: The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. Each NCCI procedure-to-procedure (PTP) edit has an assigned modifier indicator which indicates whether an NCCI-associated modifier(s) may be used to bypass an edit under appropriate circumstances. The NCCI Policy Manual (located under the download section) outlines NCCI modifier indicators as well as other factors related to NCCI edits. All Medicare Administrative Contractors must implement the NCCI edits within the claims processing systems. Providers with concerns about specific NCCI edits or coding pairs may submit comments in writing to:

National Correct Coding Initiative
Capitol Bridge LLC
P.O. Box 907
Carmel, IN 46082–0907
Fax Number: (317) 571–1745

More information about the NCCI is available on the CMS National Correct Coding Initiative Webpage.

Question: How do I bill correctly when using HCPCs code J3490 and how is the drug priced?

Answer: Palmetto GBA’s article, Unclassified or Not Otherwise Classified (NOC) Drug Codes: Rejected if Not Submitted Correctly, provides guidance on billing and pricing for drugs billed with the unclassified or NOC codes. Additional resources are also available to assist providers.

Question: How do I know if I should bill my supply to Palmetto GBA or the Durable Medicare Equipment Medicare Administrative Contractor (DME MAC) and if I need to bill the DME MAC, how do I know which DME MAC to bill?

Answer: CMS annually updates a spreadsheet that contains a list of the HCPCS codes for DME MAC and Part B MAC jurisdictions. 2019 Jurisdiction List for DMEPOS HCPCS Codes (PDF, 121 KB).

There are four DME MACs should a service indicate it needs to be billed to the DME MAC.
Noridian DME MAC- Jurisdiction A  
CGS DME MAC- Jurisdiction B  
CGS DME MAC- Jurisdiction C
Noridian DME MAC- Jurisdiction D  

Question: What is the process for asking for a reconsideration of a local coverage determination (LCD) if I disagree with the LCD or believe a modification is necessary?

Answer: The LCD Reconsideration process is a method by which interested parties can request a revision to an active LCD. Palmetto GBA follows the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-Only Manual 100-08), Chapter 13 process for LCD Reconsiderations. The reconsideration process is available for final, effective LCDs only. The process for LCD Reconsideration is outlined on the Palmetto GBA Jurisdiction J and M websites. Jurisdiction M LCD Reconsideration Process
Question: Can Palmetto GBA change a National Coverage Determination (NCD)?

Answer: No. CMS is responsible for actions related to NCDs. The process is outlined in the Federal Register Notice: Medicare Program; Revised Process for Making National Coverage Determinations 8/7/2013 (PDF, 205 KB).

Question: Where can I find information on how to use the claim status feature of the Palmetto GBA eServices portal?

Answer: Section 4.0 of the eServices User Manual (PDF, 8.02 MB) outlines how to use the claim status feature.

Question: Can I submit a claim through eServices if I need to submit additional documentation?

Answer: Jurisdiction J and M providers may use eServices to submit a claim. At this time only Jurisdiction J providers may submit additional documentation through eServices to support a claim whether the Jurisdiction J claim is submitted through eServices or electronically. Palmetto GBA is working to make this feature available to Jurisdiction M providers.

Jurisdiction J providers should review section 4.6 of the eServices User Manual (PDF, 8.02 MB) for details regarding the submission of a claim and attach additional documentation (when needed) through the eServices tool.

Question: If I submit my claim electronically can I use eServices to submit my additional documentation and do I still need to submit the PWK form?

Answer: Jurisdiction J providers can use Palmetto GBA’s eServices to submit required additional documentation for your electronic claim. You would use the additional documentation form within eServices instead of the PWK form in this scenario. Section 4.9 of the eServices User Manual (PDF, 8.02 MB) outlines how to submit additional documentation. It is important to follow the necessary instructions to indicate on your electronic claim that you have submitted additional documentation for your claim. Submitting Additional Documentation.

Question: I am receiving Smart Edits on my electronic 277CA report. What are Smart Edits and what do I do with them?

Answer: Palmetto GBA’s Advanced Communication Engine (ACE) Smart Edits are available to all direct submitters as well as those who transmit claims via clearinghouses/billing services. Smart edits will appear on claim rejection reports (277CA). The 277CA reports are sent to the direct submitter. Learn more about ACE Smart Edits on the Palmetto GBA websites.

Question: The call center stated that my claim was not in the system but I know that it was submitted electronically. Why can’t the call center representative see my claim?

Answer: Claims failing the pre-adjudication editing process (Smart Edits) are not forwarded to the claims adjudication system and therefore are not visible to the Customer Service Advocate (CSA). After you have reviewed the ACE Smart Edit, you must either make any necessary changes to the claim and resubmit the claim or, if you choose not to change the claims, you must resubmit the claim in its original format and it will pass to the MCS claims adjudication system for processing after which the CSA will be able to see the claim in the processing system.

More information is available on the Palmetto GBA websites.

Question: What happens if I do not review my 277CA reports and work the Smart Edits I receive?

Answer: Claims failing the pre-adjudication editing process are not forwarded to the claims adjudication system. After you have reviewed the ACE Smart Edit, you must make any necessary changes to the claim and resubmit the claim or, if you choose not to change the claims, you must resubmit the claim in its original format and it will pass to the MCS claims adjudication system for processing.
Question: What can I use the PECOS system for?

Answer: The Internet-based Provider Enrollment, Chain and Ownership System (Internet-based PECOS) can be used in lieu of the Medicare enrollment application (i.e., paper CMS-855) to electronically:

  • Submit an initial Medicare enrollment application
  • View or change your enrollment information
  • Track your enrollment application through the web submission process
  • Add or change a reassignment of benefits
  • Submit changes to existing Medicare enrollment information
  • Reactivate an existing enrollment record
  • Withdraw from the Medicare program
  • Submit a Change of Ownership (CHOW) of the Medicare-enrolled provider

More about the Internet-based PECOS System is available on the CMS website.

Question: My Healthcare Common Procedure Coding System (HCPCS) code has a status indicator of X listed in the Medicare Physician Fee Schedule (MPFS). Does that mean the code is not covered?

Answer: A MPFS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid under or excluded from the Medicare Physician Fee Schedule payment methodology, if the service is covered. 

Status X Descriptor
Statutory exclusion. These codes represent an item or service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No relative value units (RVUs) or payment amounts are shown for these codes and no payment may be made under the physician fee schedule. (Examples are ambulance services and clinical diagnostic laboratory services.)

CMS has several payment methodologies Medicare Administrative Contractors (MACs) use when pricing HCPCS codes. In addition to MPFS, which is reimbursement for services that fall under the definition of physician services, some claims are paid under the CMS Average Sales Price (ASP) fee schedule and others may be carrier priced.
You can troubleshoot why your HCPCS code may not be listed on the Medicare Physician Fee Schedule.

For a full listing of the current Medicare Physician Fee Schedule (MPFS) Indicator Descriptors is available on the Palmetto GBA website.

Question: How do I know Medicare coverage for CPT code 64566?

Answer: Palmetto GBA has a local coverage determination (LCD) that includes this CPT code.
Posterior Tibial Nerve Stimulation (PTNS) for Urinary Control (L33443)

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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