Common Reasons For Denial
- No Response to the Documentation Request
- CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
What Are The Most Important Chapters
The Medicare Benefit Policy Manual comprises 17 chapters and covers program guidelines for multiple health care settings.
Hospitals, doctors offices, rehabilitation clinics, skilled nursing facilities, home health care companies and others use this information to navigate complex Medicare rules.
The manual largely focuses on the Medicare Part A benefit, with chapters on inpatient hospital coverage, skilled nursing facilities, hospice care, ambulance services, lifetime reserve days, inpatient psychiatric care and home health services.
Theres also guidance on more specific topics, including end-stage renal disease, medical devices and coverage exclusions.
Chapter 17 is the manuals newest addition. It covers opioid treatment programs.
Medicare Benefit Policy Manual Chapters
Medicare rules and regulation are specific to each practice setting. Providers should consult the chapter that corresponds to their health care facilities.
For example, Chapter 7 is specific to home health services covered under Medicare Part A. If a home health care agency provides services under Part B, they should refer to chapter 15, which governs all outpatient therapy services.
Need FREE Medicare Help?
Direct Billing/payment For Npp Services Furnished To Inpatients And Outpatients
NPs, CNS and PAs are authorized to bill Medicare carriers directly for their professional services when furnished to hospital patients, both inpatients and outpatients. The employer of a PA, rather than the hospital, must bill the carrier for their professional services when furnished to hospital patients. Hospitals should not bill for the professional services of a PA, unless the PA is employed by the hospital.
The professional services of NPs and CNSs furnished to hospital inpatients and outpatients may be billed directly by the NP or CNS to the carrier under their respective NPI.
The employer of a PA may bill the carrier directly for the professional services of the PA furnished to hospital inpatients and outpatients under the PAs NPI number.
Hospitals may bill the carrier for the professional services of an NP or a CNS furnished to hospital inpatients and outpatients when payment for the NP and CNS services has been reassigned to the hospital and when the hospital bills for these services under the NPs or CNSs NPI number.
You May Like: How Much Is My Social Security Retirement Benefit
Ama Disclaimer Of Warranties And Liabilities
CPT is provided as is without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. The AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with Palmetto GBA or CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
CMS Disclaimer
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled I Accept.
End User Point And Click Agreement
CPT codes, descriptions and other data only are copyright 2012 American Medical Association . All Rights Reserved. Applicable FARS/DFARS Clauses Apply.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services . You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA Web site, .
Applicable FARS/DFARS restrictions apply to government use.
U.S. Government Rights
Also Check: Ssi Versus Social Security Benefits
Denial Reasons And Prevention Recommendations
5D165/5H165 No Physician Certification/Recertification
Reason for DenialFor outpatient therapy services to be covered by the Medicare program, the plan of care must be certified by the physician or nonphysician practitioner . Certification means that the physician or NPP has signed and dated the plan of care or some other document that indicates approval of the plan of care. No valid physician certification or recertification was submitted.
How to Avoid This Denial
- The plan of care must be complete and valid for the certification to be valid
- The physician/NPP signature on the certification must be legible
- The initial certification should be signed/dated within 30 days of the first day of treatment
- The recertification must occur at least every 90 calendar days
- The physician/NPP signature on the certification must be legible for the certification to be valid
- If certification is provided on a separate document other than the actual plan of care, there must be documentation to support the certifying physician/NPP had access to the plan of care for review. This can be a statement on the document for the physician/NPP, a fax log showing where the plan of care was forwarded to the physician/NPP, or a note in the therapy record indicating the plan of care was forwarded to the physician /NPP.
More Information
How to Avoid This Denial
More Information
Who Is The Medicare Benefit Policy Manual For
The Medicare Benefit Policy Manual is one of several internet-only manuals published by the U.S. Centers for Medicare & Medicaid Services, or CMS.
Health care providers, contractors, Medicare Advantage companies and state survey agencies use the Benefit Policy Manual and other publications as a guide to administer Medicare coverage.
The manual includes detailed information regarding day-to-day operating instructions, policies and procedures, all of which are based on government statutes, regulations, guidelines and directives.
While the manual is intended for health care professionals, it can also serve as a rich source of information for members of the general public and Medicare beneficiaries.
Also Check: Social Security Benefits At 62
What Is The Medicare Benefit Policy Manual Used For
While the Medicare Benefit Policy Manual has some use to Medicare beneficiaries and to general members of the public, the document is most often primarily used by health care professionals.
The manual includes information related to day-to-day Medicare operating instructions, policies and procedures, government statutes, regulations, guidelines and directives that all combine to shape how Medicare coverage is administered to millions of Americans.
What Does The Medicare Benefit Policy Manual Include
The Medicare Benefit Policy Manual covers program guidelines for hospitals, doctors offices, rehabilitation clinics, skilled nursing facilities, home health care companies and other health care providers who treat Medicare patients and accept Medicare coverage.
The manual also includes information for private insurance companies who sell Medicare Advantage plans, Medicare Part D prescription drug plans and Medicare Supplement Insurance plans related to how Medicare plan benefits may and may not be covered, packaged, marketed, sold and administered.
The manual mostly focuses on Medicare Part A, which covers hospital benefits and other inpatient care. There is also information about more specific topics like end-stage renal disease, opioid treatment programs, medical equipment and devices and coverage exclusions and exceptions.
There are 17 chapters in the manual:
Recommended Reading: Retirement Age For Full Social Security Benefits
Chapter 1: Covered Medical And Other Health Services
This is the Chapter that encompasses all therapy services covered under the category outpatient. Outpatient refers to physical, occupational and speech therapy services provided and paid utilizing the Physician Fee Schedule . The title, outpatient, may be misleading, as residents of a SNF are included, as are home care residents and hospital residents in an observation stay. Traditional therapy outpatient settings are also in this category. This Chapter is, by far, the most detailed Chapter of the MBPM when it comes to laying out rules and requirements for therapy services, including documentation, supervision and coverage. Here is the link to Chapter 15.
Something To Think About
Medicare has recently recouped millions of dollars from skilled nursing facility providers and hospital systems across the country for therapy services billed that were not supported by documentation or deemed necessary. Ironically, the therapy services were often provided by an outsourced rehab company, therefore the penalty went to the providerthe facilitythe one with the Medicare Provider Numberthe one who submitted a false claim likely without knowing it was false.
There is quite a ruffle out there in long term care with stories of therapists working for rehab companies who may be feeling uncomfortable with the day to day expectations.minutes and more minutes laid out for them to provide with minimal clinical input as to why. Therapists are assigned a schedule of treatments to follow with the total expected treatment minutes predetermined. The APTA Center for Integrity in Practice web site has resources to help clinicians sort through issues such as these, as well as examples of fraud, abuse and waste that may be surprising to some.
Today, I urge you to do just 1 thing. I urge you to read the attached 2 page document from APTA, AOTA and ASHA entitled Consensus Statement on Clinical Judgement in Health Care Settings. Print it. Post it. Keep it.
We all want to do the right thingand it is NEVER too late to start reading the Manual!
As always, if you have any questions, submit them to our Q& A Forum, JustAsk!
In Your Corner,
You May Like: Eligible For Social Security Benefits
The Medicare Benefit Policy Manual
The Medicare Benefit Policy Manual is otherwise known as Publication 100-02. It is made up of 16 Chapters and covers Medicare guidelines for multiple settings, including: Inpatient Rehab Hospitals, Home Care, Skilled Nursing Facilities and Outpatient Therapy. A list of the 16 Chapters can be found here.
In general, the MBPM guidelines discuss Medicare coverage in the above settings from a Part A perspective. The only Chapter that is dedicated to Part B covered therapy services is Chapter 15. The Medicare rules and specifications are different for each practice setting . When referring to the regulations you are looking for, it is important that you are pulling them from the correct Chapter of the Manual, or you may be applying the wrong rules to your setting. Based on your practice setting, these are the Chapters that may interest you:
The Medicare Benefit Policy Manual For Medicare Part A And B
The Medicare Benefit Policy Manual is one of many on the list of Internet-Only Manuals provided by the Center for Medicare and Medicaid Services . The Manuals are CMS day-to-day operating instructions, policies and procedures. They are based on statutes, regulations, guidelines, models, and directives. The CMS program components, providers, contractors, Medicare Advantage organizations and state survey agencies use the IOMs to administer CMS programs. They are also a good source of Medicare and Medicaid information for the general public .
A list of all the IOMs with links to each can be found here.
Don’t Miss: Ernst & Young Retirement Benefits Plan
Where Can I Find The Medicare Benefits Policy Manual
The Medicare Benefit Policy Manual is available on the CMS website.
The manual isnt a single document. Rather, each chapter is a separate, hyperlinked PDF.
for a full list of all the chapters.
For a list of all CMS internet-only manuals, including National Coverage Determinations and the claims processing manual, .
New Medicare beneficiaries and their families may find the Medicare & You Handbook more informative and user-friendly than the Medicare Benefit Policy Manual. This comprehensive guide to coverage, benefits and enrollment is updated annually and highlights new policy changes at the beginning of the document.
Home For The Holidays
Late November begins a time for gatherings with family and friends Thanksgiving, soon followed by the December holidays. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. In past years, the Center for Medicare Advocacy has advised residents and their families and friends to put their minds at ease. According to Medicare law, nursing home residents may leave their facility for family events without losing their Medicare coverage. The issue of concern, in the past, was whether residents would have to pay the facility. The answer depended on the length of their absence. Under certain circumstances, beneficiaries could be charged a bed hold fee by their skilled nursing facility .
On November 12, the Centers for Medicare & Medicaid Services issued guidance for state survey agencies on visitation rules. While not specifically addressing the holidays, as last years Alert for families did, the November 2021 surveyor guidance recognizes residents right to leave their facilities and includes recommendations for when they return. This CMA Alert discusses the new CMS guidance and then longstanding provisions in the Medicare Manuals that govern Medicare coverage.
CMS Alert during the Coronavirus Pandemic
Residents absent for 24 hours or more should generally be managed as a new admission or readmission, as recommended by the Centers for Disease Control and Prevention.
Don’t Miss: Federal Government Employee Retirement Benefits
Chapter : Extended Care Services Under Hospital Insurance
This is the Chapter pertaining to Medicare Part A covered services in a skilled nursing facility . Residents covered under Part A in a SNF follow the Prospective Payment System Minimum Data Set schedule. Reimbursement is allocated based on the Resource Utilization Group a resident is infor therapy, this is determined by the total number of days and minutes listed on the MDS during any given MDS cycle. Here is the link to Chapter 8.
What Medicare Covers In The Dsmt Benefit
Medicare Part B covers both initial and subsequent year outpatient diabetes self-management training .
Initial DSMT
This is a once-in-a-lifetime Medicare benefit. A properly executed written or e-referral from the beneficiarys treating diabetes provider is required.
Prior to the delivery of the initial DSMT, it is important to verify that the beneficiary has not received any initial DSMT in the past. This is because once the initial benefit is started, the 10 hours must be furnished within 12 consecutive months starting with the first date of service after this time, any hours not furnished cannot be billed for Medicare payment.
If the beneficiary has received initial DSMT paid by another health insurance company, he/she is still eligible to receive the 10 hours of initial DSMT as a Medicare benefit.
One hour of individual DSMT is payable in the initial episode of care, but the remaining 9 hours must be furnished as group services unless one of three specific conditions are met, which allows all 10 hours to be furnished individually. These conditions are:
DSMT Follow-Up
Read Also: Are Medicare Benefits The Same In Every State
Medicare Reimbursement Guidelines For Dsmt
The Centers for Medicare & Medicaid Services provides reimbursement for Medicare beneficiaries for diabetes self-management training , under certain conditions. Becoming familiar with the Medicare DSMT reimbursement guidelines can help increase a DSMES services financial sustainability. Reimbursement guidelines change often, so visit the Centers for Medicare & Medicaid Services resources listed below to ensure access to the most up to date information.
CMS Resources for DSMT
The following is a brief overview of the Medicare Part B DSMT benefit reimbursement rules, also known as the benefits coverage guidelines. The rules are very detailed and have been modified several times over the years they may or may not change in the future.
DSMT providers must follow all CMS requirements to ensure legitimate payment and should always verify information before proceeding. In addition, the provider should verify that the patient has Medicare Part B insurance before furnishing the benefit and submitting a claim. Click here pdf icon for a link to a table that outlines the specific reimbursement rules. The table is provided courtesy of Mary Ann Hodorowicz Consulting, LLC.