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AAs, CNMs, CNSs, CPs, CRNAs, CSWs, and PAs who are legally authorized to practice by the State and otherwise meet Medicare requirements may also opt-out of Medicare and privately contract with beneficiaries for the purpose of furnishing items or services that would otherwise be covered. The opt-out period is for two years unless it is terminated early or the physician or practitioner fails to maintain opt-out. Opt-outs may be renewed for subsequent two-year periods. The physician or practitioner must opt-out of Medicare for all beneficiaries and all items or services, with the exception of emergency or urgent care situations, in which case the physician or practitioner may treat a beneficiary with whom he or she does not have a private contract and bill Medicare for the treatment. Claims for emergency or urgent care require modifier GJ, "OPT-OUT physician or practitioner emergency or urgent service.” Medicare will make payment for covered medically necessary items or services that are ordered by a physician or practitioner who has opted-out of Medicare if: He or she has acquired a provider identifier; and The items or services are not furnished by a physician or practitioner who has also opted-out of Medicare. Where to Find Additional Information About Becoming a Medicare Provider or Supplier Additional information about how to become a Medicare provider or supplier is available as follows: At http://www.cms.hhs.gov/medicareprovidersupenroll on the CMS website; and In the Medicare General Information, Eligibility, and Entitlement Manual (Pub. 100-1) located at http://www.cms.hhs.gov/Manuals on the CMS website. PROMOTING CULTURAL COMPETENCY IN YOUR PRACTICE Racial and ethnic minorities are expected to make up approximately 40 percent of the population by 2030. With the increasing diversity of the U.S. population, providers and suppliers are more and more likely to encounter situations that require the delivery of culturally competent care, access to a vast array of language services, and supportive health care organizations. Addressing a patient’s social and cultural background will assist providers in delivering high quality, effective health care and increase patient satisfaction, improve patient compliance, and reduce racial and ethnic health disparities. The U.S. Department of Health and Human Services Office of Minority Health and Science Applications International Corporation have developed a free interactive webbased training cultural competency course titled A Physician’s Practical Guide to Culturally Competent Care. The course assists physicians, PAs, NPs, and other health care professionals in preparing for the increasingly diverse patient population and furnishing the highest quality of care to every patient regardless of race, ethnicity, Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 27
cultural background, or ability to speak English as their primary language. The course offers a variety of continuing education credit types. The course and information about cultural competency are available at http://thinkculturalhealth.org on the Web. Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 28
Page 1 and 2: Medicare Physician Guide A Resource
Page 3 and 4: ICD-9-CM Notice The International C
Page 5 and 6: MEDICARE PHYSICIAN FEE SCHEDULE ...
Page 7 and 8: CHAPTER ONE INTRODUCTION TO THE MED
Page 9 and 10: THE MEDICARE PROGRAM The Medicare P
Page 11 and 12: worker must have a specified number
Page 13 and 14: Part B - Medical Insurance Some of
Page 15 and 16: Where to Find Additional Informatio
Page 17 and 18: CMS contracts with one Quality Impr
Page 19 and 20: This chapter discusses Medicare pro
Page 21 and 22: staff or faculty appointments, part
Page 23 and 24: The following forms are often requi
Page 25 and 26: Accept the Medicare allowed amount
Page 27: Below is an illustration of the pay
Page 31 and 32: This chapter provides information a
Page 33 and 34: suppliers can obtain a list of elec
Page 35 and 36: Insurer information (name, group nu
Page 37 and 38: Coordination of Benefits Contractor
Page 39 and 40: In these situations, the physician
Page 41 and 42: Where to Find Additional Informatio
Page 43 and 44: OTHER HEALTH INSURANCE PLANS Medica
Page 45 and 46: Part B Railroad Retirement Benefits
Page 47 and 48: This chapter discusses Medicare cov
Page 49 and 50: 2) Renal dialysis treatments Renal
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Page 53 and 54: Services that are considered not me
Page 55 and 56: This chapter discusses common sets
Page 57 and 58: International Classification of Dis
Page 59 and 60: CHAPTER SIX PROTECTING THE MEDICARE
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Page 63 and 64: Consistently using billing or reven
Page 65 and 66: Investigations A Program Safeguard
Page 67 and 68: Sanctioned and Reinstated Provider
Page 69 and 70: CHAPTER SEVEN INQUIRIES, OVERPAYMEN
Page 71 and 72: If Medicare pays more than the corr
Page 73 and 74: It contains the name, telephone num
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Page 77 and 78: Liability and Appeal Decisions Liab
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REFERENCE SECTION Medicare Physicia
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Coinsurance Under the Original Medi
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Medically Necessary Services or sup
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Participating Provider or Supplier
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ACRONYMS AA ABN AEP AIC ALJ ASC CAH
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HIC HIPAA HPSA ICD-9-CM ICD-10-CM/P
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RRB RVU SA SEP SGR SHIP SLP SNF SSA
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Electronic Billing & EDI Transactio
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National Provider Identifier Standa
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United Mine Workers of America Elec
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1995 DOCUMENTATION GUIDELINES FOR E
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II. DOCUMENTATION OF E/M SERVICES T
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DG: The CC, ROS and PFSH may be lis
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For purposes of ROS, the following
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DG: At least one specific item from
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C. DOCUMENTATION OF THE COMPLEXITY
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occasion the physician who ordered
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Table of Risk Level of Risk Present
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1997 DOCUMENTATION GUIDELINES FOR E
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I. INTRODUCTION WHAT IS DOCUMENTATI
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III. DOCUMENTATION OF E/M SERVICES
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DG: The CC, ROS and PFSH may be lis
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REVIEW OF SYSTEMS (ROS) A ROS is an
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DG: At least one specific item from
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Problem Focused Examination - shoul
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System/Body Area Respiratory Elemen
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System/Body Area Musculoskeletal Ex
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Cardiovascular Examination System/B
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Ear, Nose and Throat Examination Sy
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Content and Documentation Requireme
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System/Body Area Elements of Examin
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System/Body Area Musculoskeletal Ex
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Neurological Examination System/Bod
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System/Body Area Psychiatric Elemen
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System/Body Area Gastrointestinal (
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System/Body Area Skin Elements of E
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NUMBER OF DIAGNOSES OR MANAGEMENT O
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RISK OF SIGNIFICANT COMPLICATIONS,
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D. DOCUMENTATION OF AN ENCOUNTER DO
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