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TABLE OF CONTENTS CHAPTER ONE- INTRODUCTION TO THE MEDICARE PROGRAM ................ 6 CENTERS FOR MEDICARE & MEDICAID SERVICES ............................................... 7 THE MEDICARE PROGRAM ...................................................................................... 8 Part A and Part B Enrollment Periods ...................................................................... 8 Part A – Hospital Insurance ..................................................................................... 9 Part B – Medical Insurance .................................................................................... 12 Part C – Medicare Advantage ................................................................................ 13 Part D – Prescription Drug Plan ............................................................................. 14 ORGANIZATIONS THAT IMPACT THE MEDICARE PROGRAM .............................. 15 CHAPTER TWO - BECOMING A MEDICARE PROVIDER OR SUPPLIER ..... 17 MEDICARE PROVIDERS AND SUPPLIERS ............................................................. 18 Part A Providers and Suppliers .............................................................................. 18 Part B Providers and Suppliers .............................................................................. 18 Physicians .............................................................................................................. 19 Interns and Residents ............................................................................................ 19 Teaching Physicians .............................................................................................. 20 Practitioners ........................................................................................................... 20 ENROLLING IN THE MEDICARE PROGRAM ........................................................... 20 National Provider Identifier ..................................................................................... 20 Medicare Enrollment Application ............................................................................ 21 Participating and Nonparticipating Providers and Suppliers ................................... 23 PRIVATE CONTRACTS WITH MEDICARE BENEFICIARIES ................................... 26 PROMOTING CULTURAL COMPETENCY IN YOUR PRACTICE ............................. 27 CHAPTER THREE - MEDICARE REIMBURSEMENT ...................................... 29 MEDICARE CLAIMS .................................................................................................. 30 Exceptions to Mandatory Filing .............................................................................. 30 Electronic Claims ................................................................................................... 31 Electronic Media Claims Submissions ................................................................... 31 Electronic Media Claims Submission Alternatives.................................................. 31 Paper Claims.......................................................................................................... 32 Durable Medical Equipment, Prosthetics and Orthotics, and Parenteral and Enteral Nutrition Claims ...................................................................................................... 32 DEDUCTIBLES, COINSURANCE, AND COPAYMENTS .......................................... 33 COORDINATION OF BENEFITS ............................................................................... 33 Medicare Secondary Payer Program ..................................................................... 33 Coordination of Benefits Contractor ....................................................................... 35 INCENTIVE PAYMENTS ........................................................................................... 37 Health Professional Shortage Area Incentive Payment .......................................... 37 Physician Quality Reporting Initiative Incentive Payment ....................................... 38 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 3
MEDICARE PHYSICIAN FEE SCHEDULE ................................................................ 38 MEDICARE NOTICES ............................................................................................... 40 Advance Beneficiary Notice ................................................................................... 40 Certificate of Medical Necessity and Durable Medical Equipment Medicare Administrative Contractor Information Forms ......................................................... 40 Remittance Advice ................................................................................................. 41 Medicare Summary Notice ..................................................................................... 41 OTHER HEALTH INSURANCE PLANS ..................................................................... 42 Medicare Advantage .............................................................................................. 42 Medicaid ................................................................................................................. 42 Medigap ................................................................................................................. 43 Railroad Retirement ............................................................................................... 43 United Mine Workers of America ............................................................................ 44 CHAPTER FOUR - MEDICARE PAYMENT POLICIES .................................... 45 MEDICARE COVERED SERVICES .......................................................................... 46 Part A Inpatient Hospital Services .......................................................................... 46 Part B Services ...................................................................................................... 49 INCIDENT TO PROVISION ....................................................................................... 49 SERVICES NOT COVERED BY MEDICARE ............................................................ 51 CHAPTER FIVE - EVALUATION AND MANAGEMENT SERVICES ................ 53 COMMON SETS OF CODES..................................................................................... 54 Evaluation and Management Services ................................................................... 54 International Classification of Diseases, 10 th Edition, Clinical Modification/ ........... 56 Procedure Coding System ..................................................................................... 56 EVALUATION AND MANAGEMENT DOCUMENTATION ......................................... 56 CHAPTER SIX - PROTECTING THE MEDICARE TRUST FUND .................... 58 MEDICAL REVIEW PROGRAM................................................................................. 59 COVERAGE DETERMINATIONS .............................................................................. 59 HEALTH CARE FRAUD AND PROGRAM ABUSE .................................................... 61 Significant Medicare Fraud and Abuse Provisions ................................................. 62 Potential Legal Actions ........................................................................................... 63 Sanctioned and Reinstated Provider and Supplier Lists ........................................ 66 Incentive Reward Program ..................................................................................... 66 Whistle Blower Provision ........................................................................................ 66 CHAPTER SEVEN - INQUIRIES, OVERPAYMENTS, AND FEE-FOR-SERVICE APPEALS .......................................................................................................... 68 INQUIRIES ................................................................................................................ 69 OVERPAYMENTS ..................................................................................................... 69 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 4
Page 1 and 2: Medicare Physician Guide A Resource
Page 3: ICD-9-CM Notice The International C
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 and 28: Below is an illustration of the pay
Page 29 and 30: cultural background, or ability to
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
Page 51 and 52: 2) Furnished by the physician or au
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
Page 61 and 62:
codes that describe what is and is
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
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CHAPTER SEVEN INQUIRIES, OVERPAYMEN
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If Medicare pays more than the corr
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It contains the name, telephone num
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filed), the time limit will be exte
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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
Page 93 and 94:
Electronic Billing & EDI Transactio
Page 95 and 96:
National Provider Identifier Standa
Page 97 and 98:
United Mine Workers of America Elec
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1995 DOCUMENTATION GUIDELINES FOR E
Page 101 and 102:
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
Page 117 and 118:
I. INTRODUCTION WHAT IS DOCUMENTATI
Page 119 and 120:
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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Physician

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