Physician

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This chapter provides information about the Centers for Medicare & Medicaid Services (CMS), the Medicare Program, and organizations that impact the Medicare Program. CENTERS FOR MEDICARE & MEDICAID SERVICES CMS is a Federal agency within the U.S. Department of Health and Human Services (HHS) that administers and oversees the Medicare Program and a portion of the Medicaid Program. CMS also regulates laboratory testing and surveys and certifies Rural Health Clinics, Federally Qualified Health Centers, Critical Access Hospitals, nursing homes, health care agencies, intermediate care facilities for the mentally retarded, and hospitals. CMS consists of a Central Office and 10 Regional Offices (RO). The Central Office is located in Baltimore, Maryland, and provides operational direction and policy guidance for the nationwide administration of the above programs. The ROs are located in major cities throughout the U.S. and support the health care provider community by: Conducting outreach activities; Establishing relationships with local and regional provider associations; and Helping providers and suppliers resolve disputes they may have with Contractors. Where to Find Additional Information About the Centers For Medicare & Medicaid Services To find additional information about CMS, visit http://www.cms.hhs.gov/home/aboutcms.asp on the CMS website. CMS awards contracts to organizations called Medicare Contractors who perform claims processing and related administrative functions. Beginning in 2006, all Original Medicare Plan claims processing Contractors (Fiscal Intermediaries, Carriers, and Durable Medical Equipment Carriers) will be transitioned into Medicare Administrative Contractors. Medicare Contractor Contact Information The Provider Call Center Toll-Free Numbers Directory, which contains Medicare Contractor contact information, can be accessed in the Downloads Section at http://www.cms.hhs.gov/MLNGenInfo/30_contactus.asp on the CMS website. Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 7
THE MEDICARE PROGRAM The Medicare Program was established by Title XVIII of the Social Security Act (the Act) on July 1, 1966. Medicare consists of the following four parts: Part A, hospital insurance; Part B, medical insurance; Part C, Medicare Advantage (MA); and Part D, prescription drug plan (PDP). Part A and Part B are available to: Individuals who are age 65 or older; Individuals who are under age 65 with certain disabilities; and Individuals with End-Stage Renal Disease (ESRD). When an individual becomes entitled to Medicare, CMS or the Railroad Retirement Board (RRB) will issue a health insurance card. The following information can be found on the health insurance card: Name; Sex; Medicare Health Insurance Claim (HIC) number; and Effective date of entitlement to Part A and/or Part B. The HIC number on the health insurance card issued by CMS has an alpha or alphanumeric suffix and the Social Security Number (SSN), which is usually either the SSN of the insured or the spouse of the insured (depending on whose earnings eligibility is based). The HIC number on the health insurance card issued by the RRB has an alpha prefix and one or more characters and the insured’s SSN, a six-digit number, or a nine-digit number. Office staff should regularly request the beneficiary’s health insurance card and picture identification to verify that services are furnished only to individuals eligible to receive Medicare benefits. Copies of the health insurance card and picture identification should be made for the beneficiary’s medical file. Part A and Part B Enrollment Periods Individuals who want premium Part A and/or Part B may only enroll during one of the following prescribed enrollment periods: The Initial Enrollment Period (IEP) begins with the first day of the third month before the month premium Part A or Part B eligibility requirements are first met and ends seven months later (e.g., the IEP for the aged begins three months before the individual attains age 65 years and ends the third month after the month age 65 years is attained). Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 8
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: CHAPTER ONE INTRODUCTION TO THE MED
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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
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Page 43 and 44: OTHER HEALTH INSURANCE PLANS Medica
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CHAPTER SIX PROTECTING THE MEDICARE
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codes that describe what is and is
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Consistently using billing or reven
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Investigations A Program Safeguard
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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
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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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Physician

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