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Cardiology / Cardiovascular CPT Code Changes and Updates 2015

<div dir="ltr" style="text-align: left;" trbidi="on">Get Cardiology CPT Code Changes 2015 and latest Cardiovascular Coding Updates.<br />
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More than 500 CPT Code Changes are being implemented in 2015. Cardiovascular CPT Code Changes in 2015 includes 33 new codes, 23 revised codes and 6 deleted codes.<br />
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Current Procedural Terminology (CPT) is a system that codes the existing medical procedures, treatments, and services. The CPT codes are essential for the documentation and discussions of medical procedures and services among healthcare providers such as medical practitioners (general physicians, cardiologists, dermatologists, and other specialists), nurse practitioners (nurse anesthetist, nurse midwife), patients, medical technicians, insurance companies, hospital administrators as well as medical billers and codes. <br />
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Use of CPT Codes is essential in US healthcare system, to reduce the possibility of miscommunication. For that reason also, it is important that the CPT Codes are kept up to date to keep up with the latest developments in medical field. That's why, Medical Billing and Coding professional in United States are required to keep updated with the revised CPT Code Changes, every year by American Medical Association (AMA).<br />
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Cardiology CPT Code Changes 2015 are important to be reviewed particularly by medical people who work in cardiology. CPT Codes are divided into 3 categories. Category I CPT Codes are further divided into 6 main sections, including Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. Category II CPT Codes are intended for performance measurement, and therefore, is not for reimbursement. Category III CPT Codes are about Emerging Technology. <br />
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<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2015/03/cardiology-cardiovascular-cptcodechangesupdates.html"><img alt="Cardiology / Cardiovascular CPT Code Changes and Updates 2015" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwj4kV7fLosICIB3iPT-ZVUyvlAesBQ5ANVcAPGcIilq9WA_F3AwhB9YeGUDfaUyBjK379lQQZBrwHRCFG0P6mtheJUe27twmjzvnUQQGAQhJLw6L4eoqM8CAgsgQlvzNCoLpkcpI9m7CF/s1600/cardiology-medical-billing.png" /></a></div><br />
Each year, CPT Codes are discussed and, if necessary, revised by CPT Editorial Panel, a panel in AMA that is responsible for managing and revising CPT Codes each year. In fact, CPT Editorial Panel holds three meetings every year to review and discuss what needs to be changed in CPT Codes based on the new developments in medical technologies, procedures, and techniques. Likewise, Cardiology CPT Code Changes 2015 are also based on the new developments in technologies, procedures, and techniques concerning cardiology. CPT Editorial Panel establishes and publishes the new CPT Codes, usually in the fall (around October), each year. The new CPT Codes are started to be officially used in the beginning of the next year (January, 1st). Although CPT Codes are renewed every year, the revision is kept to minimum to avoid massive confusion, especially among people who work in medical field, and to make it easier for them to adapt to the new CPT Codes. <br />
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Below we are summary and list of Cardiology CPT Codes Changes in 2015:<br />
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<h2>Cardiology / Cardiovascular CPT Code Changes and Updates 2015</h2>Cardiology CPT Code Changes 2015 can obviously be found under sections about Cardiovascular such as CPT Codes 92950 - 93799  (under medicine section in Category I), CPT Codes 33010 - 37799 (under surgery section in Category I), and also in other sections and categories. <br />
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CPT Editorial Panel only made a few changes in CPT Codes about cardiology. The changes in Cardiovascular CPT Codes aincludes several procedures such as TEE, FEVAR, ECMO, Stent and Complex Chronic Care. <br />
<ol><li><h3>New Interventional TEE CPT Codes for Transesophageal Echocardiography</h3>The Cardiology CPT Code Changes 2015 about TEE may include the addition of new codes that describe specific types of TEE. When you use the previous CPT Codes, you might use one CPT Code for more than one type of TEE. This is because in the previous CPT Codes, one code may be used for more than one type of TEE. The 2015 CPT Codes, however, break down a clump of TEE in one code into several different codes. <br />
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</li><li><h3>New FEVAR CPT Codes 2015</h3>Another change in Cardiology CPT Code Changes 2015 is about FEVAR (Fenestrated Endovascular Aortic Aneurysm Repair) procedures. Similar to the changes in Cardiology CPT Codes about TEE, the changes in Cardiology CPT Codes about FEVAR also include the addition of new codes that can specify FEVAR procedures. In other words, it is no longer clumped in one code. <br />
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</li><li><h3>ECMO CPT Code Changes 2015</h3>The previous CPT Codes for ECMO (Extracorporeal Membrane Oxygenation) are deleted and replaced by many more codes to specify the procedures. <br />
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</li><li><h3>TMVR new CPT codes for Transcatheter Mitral Valve Repair</h3>New coding notes pertaining to transcatheter mitral valve repair (TMVR) were added for the subheading Mitral Valve. These notes pertain exclusively to the two new CPT codes added for TMVR, 33418, and add-on code for additional prosthesis during the same session, 33419.<br />
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</li><li><h3>25 ECMO/ECLS new CPT Codes Changes for Cardiac Support</h3>Twenty-five new codes were added to the new subheading of Extracorporeal Membrane Oxygenation (ECMO) or Extracorporeal Life Support Services (ECLS). These procedures provide cardiac and/or respiratory support to the heart and lungs. The codes represent the services directly related to the cannulation, initiation, management, and discontinuation of the ECMO/ECLS (33946-33989).<br />
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</li><li><h3>Stent Procedures CPT Codes Changes</h3>2015 CPT Codes also get a new code related to Stent procedures. <br />
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</li><li><h3>Pacemaker or Pacing Cardioverter-Defrillator</h3>The 2014 subheading of Pacemaker or Pacing Cardioverter-Defrillator was replaced by Pacemaker and Implantable Defibrillator. There are extensive new and revised notes which include updated definitions as well as additions to the table for Pacemaker and Implantable Defibrillator code selections. A new code has been added for the insertion of an implantable defibrillator system, 33270, and one for electrode insertion, 33271. Two new codes were added for the removal (33272) and repositioning (33273) of the electrodes.<br />
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</li><li><h3>Complex Chronic Care for Cardiology</h3>Complex Chronic Care for Cardiology is also put into a new code in 2015 Cardiology CPT Codes. <br />
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</li><li><h3>Cardiology Emerging Technology</h3>Aside from those additional new codes for various cardiology procedures and treatments, there are also some Cardiology CPT Code Changes 2015 concerning the new technologies in Cardiology. Many new technologies in Cardiology that had been previously coded in Category III Emerging Technology are now finally moved to Category I in 2015 CPT Codes; that means, there are more awesome, better, and safer advanced medical options now when it comes to cardiology.</li>
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<tr><td colspan="2" width="100%"><h4>Revised CPT Codes- acemaker/Implantable Defibrillator</h4></td></tr>
<tr><td width="9%">33215</td><td width="91%">Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode</td></tr>
<tr><td width="9%">33216</td><td width="91%">Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator</td></tr>
<tr><td width="9%">33217</td><td width="91%">Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator</td></tr>
<tr><td width="9%">33218</td><td width="91%">Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator</td></tr>
<tr><td width="9%">33220</td><td width="91%">Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator</td></tr>
<tr><td width="9%">33223</td><td width="91%">Relocation of skin pocket for implantable defibrillator</td></tr>
<tr><td width="9%">33224</td><td width="91%">Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)</td></tr>
<tr><td colspan="2" width="100%"><h4>Revised CPT Codes- acemaker/Implantable Defibrillator</h4></td></tr>
<tr><td width="9%">33225</td><td width="91%">Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)</td></tr>
<tr><td width="9%">33230</td><td width="91%">Insertion of implantable defibrillator pulse generator only; with existing dual leads</td></tr>
<tr><td width="9%">33231</td><td width="91%">Insertion of implantable defibrillator pulse generator only; with existing multiple leads</td></tr>
<tr><td width="9%">33240</td><td width="91%">Insertion of implantable defibrillator pulse generator only; with existing single lead</td></tr>
<tr><td width="9%">33241</td><td width="91%">Removal of implantable defibrillator pulse generator only</td></tr>
<tr><td width="9%">33243</td><td width="91%">Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy</td></tr>
<tr><td width="9%">33244</td><td width="91%">Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction</td></tr>
<tr><td colspan="2" width="100%"><h4>Revised CPT Codes- acemaker/Implantable Defibrillator</h4></td></tr>
<tr><td width="9%">33249</td><td width="91%">Insertion or replacement of permanent implantable defibrillator system with transvenous lead(s), single or dual chamber</td></tr>
<tr><td width="9%">33262</td><td width="91%">Removal of implantable  defibrillator pulse generator with replacement of implantable  defibrillator pulse generator; single lead system</td></tr>
<tr><td width="9%">33263</td><td width="91%">Removal of implantable  defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system</td></tr>
<tr><td width="9%">33264</td><td width="91%">Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system</td></tr>
<tr><td colspan="2" width="100%"><h4>New CPT Codes- Pacemaker/Implantable Defibrillator</h4></td></tr>
<tr><td width="9%">33270</td><td width="91%">Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed</td></tr>
<tr><td width="9%">33271</td><td width="91%">Insertion of subcutaneous implantable defibrillator electrode</td></tr>
<tr><td width="9%">33272</td><td width="91%">Removal of subcutaneous implantable defibrillator electrode</td></tr>
<tr><td width="9%">33273</td><td width="91%">Repositioning of previously implanted subcutaneous implantable defibrillator electrode</td></tr>
<tr><td colspan="2" width="100%"><h4>Deleted CPT Code- Aorta and Great Vessels</h4></td></tr>
<tr><td width="9%">33332</td><td width="91%">Insertion of graft, aorta or great vessels; with shunt bypass</td></tr>
<tr><td colspan="2" width="100%"><h4>New CPT Code- Aorta and Great Vessels</h4></td></tr>
<tr><td width="9%">33418</td><td width="91%">Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis</td></tr>
<tr><td width="9%">+33419</td><td width="91%">; additional prosthesis(es) during same session</td></tr>
<tr><td colspan="2" width="100%"><h4>Deleted CPT Code- Pulmonary Valvotomy</h4></td></tr>
<tr><td width="9%">33472</td><td width="91%">Valvotomy, pulmonary valve, open heart; with inflow occlusion</td></tr>
<tr><td colspan="2" width="100%"><h4>New CPT Codes- Extracorporeal membrane oxygenation (ECMO) /extracorporeal life support (ECLS)</h4></td></tr>
<tr><td width="9%">33946</td><td width="91%">Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous</td></tr>
<tr><td width="9%">33947</td><td width="91%">initiation, veno-arterial</td></tr>
<tr><td width="9%">33948</td><td width="91%">daily management, each day, veno-venous</td></tr>
<tr><td width="9%">33949</td><td width="91%">daily management, each day, veno-arterial</td></tr>
<tr><td width="9%">33951</td><td width="91%">insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)</td></tr>
<tr><td width="9%">33952</td><td width="91%">6 years and older ></td></tr>
<tr><td width="9%">33953</td><td width="91%">insertion of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age</td></tr>
<tr><td width="9%">33954</td><td width="91%">6 years and older</td></tr>
<tr><td width="9%">33955</td><td width="91%">insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age</td></tr>
<tr><td width="9%">33956</td><td width="91%">6 years and older</td></tr>
<tr><td width="9%">33957</td><td width="91%">reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)</td></tr>
<tr><td width="9%">33958</td><td width="91%">6 years and older</td></tr>
<tr><td width="9%">33959</td><td width="91%">reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age ></td></tr>
<tr><td width="9%">33962</td><td width="91%">6 years and older</td></tr>
<tr><td width="9%">33963</td><td width="91%">reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age</td></tr>
<tr><td width="9%">33964</td><td width="91%"> 6 years and older</td></tr>
<tr><td width="9%">33965</td><td width="91%">removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age</td></tr>
<tr><td width="9%">33966</td><td width="91%">6 years and older</td></tr>
<tr><td width="9%">33969</td><td width="91%">removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age</td></tr>
<tr><td width="9%">33984</td><td width="91%"> > 6 years and older</td></tr>
<tr><td width="9%">33985</td><td width="91%">removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age</td></tr>
<tr><td width="9%">33986</td><td width="91%">6 years and older</td></tr>
<tr><td width="9%">33987</td><td width="91%">Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS</td></tr>
<tr><td width="9%">33988</td><td width="91%">Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS</td></tr>
<tr><td width="9%">33989</td><td width="91%">Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS</td></tr>
<tr><td colspan="2" width="100%"><h4>Deleted CPT Codes- ECMO</h4></td></tr>
<tr><td width="9%">33960</td><td width="91%">Prolonged extracorporeal circulation for cardiopulmonary insufficiency; initial day</td></tr>
<tr><td width="9%">33961</td><td width="91%">each subsequent day</td></tr>
<tr><td width="9%">36822</td><td width="91%">Insertion of cannula(s) for prolonged extracorporeal circulation for cardiopulmonary insufficiency (ECMO) (separate procedure)</td></tr>
<tr><td colspan="2" width="100%"><h4>Deleted CPT Codes- Destruction of Vein</h4></td></tr>
<tr><td width="9%">36469</td><td width="91%">Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face</td></tr>
<tr><td colspan="2" width="100%"><h4>Revised CPT Codes - Stenting</h4></td></tr>
<tr><td width="9%">37215</td><td width="91%">Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection</td></tr>
<tr><td width="9%">37216</td><td width="91%">without distal embolic protection</td></tr>
<tr><td width="9%">37217</td><td width="91%">Transcatheter placement of an intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation</td></tr>
<tr><td width="9%">37236</td><td width="91%">Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery</td></tr>
<tr><td width="9%">37237</td><td width="91%">each additional artery (List separately in addition to code for primary procedure)</td></tr>
<tr><td colspan="2" width="100%"><h4>New CPT Code- Stenting</h4></td></tr>
<tr><td width="9%">37218</td><td width="91%">Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation</td></tr>
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The new Cardiology and Cardiovascular CPT changes in 2015 are likely to make the things more better for useful Cardiologists, Medical Billers and Insurances. The additions and reorganizations in Cardiology CPT Codes will reducing further the chance of error and miscommunication while documenting and discussing cardiology procedure or treatment among healthcare providers, patients, insurance companies, hospital administrators, medical technicians, and all parties concerned.<br />
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Cardiology / Cardiovascular CPT Code Changes and Updates 2015

Get Cardiology CPT Code Changes 2015 and latest Cardiovascular Coding Updates. More than 500 CPT Code Changes are being implemented in 2015. Cardiovascular CPT Code Changes in 2015 includes 33 new cod…

Medicare Benefits: Worker Compensation, Veterans Administration, Automobile Accident

<div dir="ltr" style="text-align: justify;" trbidi="on">Learn how Medicare Benefits apply in case of Worker Compensation, Veterans Administration (VA) and Automobile Accident.<br />
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Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare. <br />
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When Medicare began in 1966, it was the primary payer for all claims except for those covered by Workers' Compensation, Federal Black Lung benefits, and Veteran’s Administration (VA) benefits.<br />
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In 1980, Congress passed legislation that made Medicare the secondary payer to certain primary plans in an effort to shift costs from Medicare to the appropriate private sources of payment. Primary payers are those that have the primary responsibility for paying a claim. <br />
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Medicare remains the primary payer for beneficiaries who are not covered by other types of health insurance or coverage. Medicare is also the primary payer in certain instances, provided several conditions are met.<br />
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<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2015/03/medicare-benefits-workercompensation-va-accident.html"><img alt="Medicare Benefit: Worker Compensation, Veterans Administration, Automobile Accident" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHtRqqp6H5kiz9T2BYwNoj7OhexTRVhZc7O6QYxdaMjvv6emc_mPVqbMgDbYVJQBf-e7yu4CbXofpPHJUm3yn4r7R9H9YgrNI0B7AiNDTqAV_Rmh5jdpeKs56wpL0Mb2fGhmc83DfJ7ZQ/s1600/Medicare-Tax-New.jpeg" /></a></div><br />
<h2>Medicare Worker Compensation, Veterans Administration, Automobile Accident</h2>Following are some common situations to help your Medical Billing and Coding needs, when Medicare and other health insurance or coverage may be present, and which entity will be the primary or secondary payer when patient has Worker Compensation, Veterans Administration and Automobile Accident:<br />
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<h3>Medicare Worker's Compensation</h3>Medicare is secondary to Worker's Compensation benefits if the patient is being treated for a work related illness or injury. If the claim is contested, pending the Worker's Compensation Board decision, the physician/supplier may bill Medicare first. A statement should be included on the claim form indicating that the worker's compensation claim is being contested.<br />
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Claims for beneficiaries who may have worker's compensation insurance will suspend for manual review to determine whether the services are related to a work illness or injury. If the services are obviously not related to a work illness or injury, the claim will be released for final processing.<br />
Physicians/suppliers should complete item 10a of the CMS 1500 claim form if the services are not provided for diagnosis and treatment of a work related illness or injury.<br />
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<h3>Medicare Veterans Administration</h3>Veterans entitled to Medicare may choose one of the programs to be responsible for payment of services covered by both programs. If the veteran elects Medicare coverage, it is not necessary to submit a claim to the Veterans Administration (VA) for a denial before submitting the claim to Medicare. Claims submitted to Medicare will be processed without development, assuming that Medicare coverage and eligibility requirements are met.<br />
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Claims cannot be submitted to both programs for the same dates and types of treatment. If a veteran elects Medicare coverage, a claim should not be submitted to the VA for the Medicare deductible or co-insurance.<br />
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<h4>Veterans (VA) Claim Submission</h4>When hospital care was authorized by the VA in advance, or within 72 hours of admission. When outpatient medical services were authorized by the VA in advance. (NOTE: a VA Fee Basis ID card is not considered by Medicare to be an authorization, and the veteran retains his or her right to elect VA or Medicare coverage.)<br />
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When care was not authorized by the VA in advance, the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.<br />
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<h4>Medicare Claim Submission</h4>When a veteran is eligible for Medicare benefits and hospital care was not authorized by the VA in advance, or within 72 hours of admission. (For services billable on Form 1450, the Medicare provider should enter condition code 26 in field locator 35-39)<br />
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When a veteran is eligible for Medicare benefits, has a VA Fee Basis ID card and elects Medicare coverage over VA.<br />
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When a veteran is eligible for Medicare benefits and has no prior authorization from the VA for care—unless the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.<br />
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When a veteran is eligible for Medicare benefits, and the VA has authorized care for only a part of the hospital treatment period. A denial from the VA is not needed prior to submitting a claim to Medicare.<br />
VA advance authorization for care will be via sharing agreement, contract, or written communication. Telephone authorization may be granted in emergency situations. All telephone authorizations are documented by the VA at the time the authorization is granted.<br />
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Any VA authorization for an inpatient is terminated when the veteran is determined by VA to be stable for transfer to a VA facility, or the veteran states that he or she is not willing to be transferred to a VA facility for continued treatment upon stabilization.<br />
Medicare and VA will be performing periodic computer data matches to assure that instances of duplicate payment are identified. When duplicate payments are found, Medicare will pursue recovery of its payment, and will develop information for potential referral to the Internal Revenue Service or the Office of Inspector General.<br />
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<h4>Incarcerated Beneficiaries</h4>Medicare is secondary payer for services furnished to individuals in the custody of penal authorities. The state (or other government component which operates the prison) in which the beneficiary resides is responsible for all medical costs incurred. Medicare is primary only if the following conditions are met:<br />
State or local requires those individuals or groups of individuals to repay the cost of the medical care incurred while in custody.<br />
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The state or local government entity enforces the requirement to pay by billing the incarcerated individual, whether or not covered by Medicare or any other health insurance.<br />
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<h3>Medicare Automobile Accident</h3>Medicare is secondary to all accident related claims. Beneficiaries may not choose which of these claims will be paid by the automobile insurance and which claims will be paid by Medicare. Providers should submit all accident related claims to the automobile insurance before submitting them to Medicare. To avoid late claim filing, claims may be submitted to Medicare even though payment has not been received from the automobile insurer. In addition, conditional payment can be made by Medicare if 1) the automobile insurance will not pay promptly (within 120 days); or 2) due to physical or mental incapacity, the beneficiary fails to meet the claim filing requirements of the automobile insurer. Conditional payments are made on the condition that the beneficiary will reimburse Medicare if payment is later made by the automobile insurer.<br />
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If the automobile insurance benefits are exhausted, Medicare requires a statement of exhaustion from the automobile insurer. The itemized statement must include: the dates of service paid and the actual provider who was reimbursed. Note: Claim processing will be denied without this information.<br />
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Providers should complete item 10 of the CMS 1500 claim form if the services are related to an automobile accident. If there is information on our files which indicates that a beneficiary has been involved in an automobile accident, the claim will suspend for manual review. If the details referenced on the claim are not sufficient information to process the claim, a questionnaire will be sent to the beneficiary. If a response is not received from the beneficiary within 45 days, the claim will be denied.<br />
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<h4>No-Fault Insurance</h4>Medicare is secondary to all types of insurance that pay for medical expenses for injuries sustained on the property or premises of the insured, regardless of who caused the accident. This type of insurance includes homeowners and commercial plans. It may also be referred to as medical payments coverage, personal injury protection (PIP), or medical expense coverage.<br />
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Providers should follow the claims submission guidelines described in the automobile accident section in this chapter. The exhaustion of benefits and conditional payment rules also apply to no-fault insurance.<br />
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Medicare does not pay for services paid for or authorized by governmental entities.<br />
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<h4>Liability Insurance</h4>Liability insurance is insurance (including a self-insured plan) that provides payment based upon legally established responsibility for injury, illness or damage to property. It includes, but is not limited to automobile liability and general casualty insurance. It includes payments under State "wrongful death" statues that provide payment for medical damages.<br />
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Providers are required to ask Medicare patients, or their representatives, if the services are for treatment of an injury or illness that resulted from an automobile accident or other incident for which the patient holds another party responsible. The provider should obtain the name, address, and policy number of any automobile or non-automobile liability insurance, no fault insurance, or any other party that may be responsible for payment of medical expenses that result from an accident or injury.<br />
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Where a provider has reason to believe that he/she provided services to a Medicare beneficiary for whom payment under liability insurance may be available, the provider may:<br />
Within the 120 day promptly period, the provider must bill only the liability insurer unless there is evidence that the liability insurer will not pay within the 120 day promptly period. If the provider has such evidence, he/she may bill Medicare for conditional payment, provided that documentation is supplied to support the fact that payment will not be made promptly; or<br />
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After the 120 day promptly period has ended, the provider may, but is not required to, bill Medicare for conditional payment if the liability insurance claim is not finally resolved. If the provider chooses to bill Medicare, he/she must withdraw claims against the liability insurer or a claim against the beneficiary's settlement. If the provider chooses to continue with a claim against the liability settlement, the provider may not bill Medicare.<br />
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<b>Provider participates in Medicare Program</b>: in this case provider bills Medicare - The provider must accept the Medicare approved amount as payment in full and may charge beneficiaries only for deductible and coinsurance; or Provider pursues liability insurance - The provider may charge the beneficiaries actual charges up to the amount of the proceeds of the liability settlement, but he/she may not collect payment from the beneficiary until after the proceeds of the liability insurance are available to the beneficiary.<br />
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<b>Provider not Participate in Medicare Program</b>: in this case Provider bills Medicare accepting assignment - The provider may accept the Medicare approved amount as payment in full and may charge the beneficiaries only for deductible and coinsurance; or<br />
Provider bills Medicare not accepting assignment - The provider may charge beneficiaries no more than the limiting charge and may collect without regard to whether the liability insurance is available to the beneficiary.<br />
For services for which there is no Medicare coverage available regardless of whom furnishes them, the provider may charge and collect actual charges from beneficiaries without regard to whether the proceeds of liability insurance are available to the beneficiary.<br />
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<h4>Black Lung Benefits</h4>Medicare is secondary for beneficiaries who have medical benefits under the Federal Black Lung Program. Medicare is secondary only for services provided for the treatment of lung conditions caused by mining. Claims for beneficiaries entitled to benefits under the Federal Black Lung Program may suspend for manual review. If the diagnosis or services reported on the claim are not related to the black lung condition, Medicare is primary and the claim will be released for final processing.<br />
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For some beneficiaries entitled to the Federal Black Lung Program, the coal mine operator is responsible for medical benefits. In these cases, providers should submit the claims to the coal mine operator or its Workers' Compensation plan for processing.<br />
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<h4>Primary Insolvency</h4>In accordance with the Centers for Medicare & Medicaid Services (CMS) requirements, when a primary payer becomes insolvent, Medicare payments will not be made unless the claim is accompanied by an Explanation of Benefits from the receiver (substitute primary payer decided on by the courts) and the court order of payment.<br />
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Physicians and suppliers who accept assignment may not collect or seek payment from the beneficiary or their estate for any Medicare covered service(s) during the primary insurer's insolvency process. Providers should file their claims with the primary insurer or the receiver if they have not already done so.<br />
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The receiver will determine the full primary payment to be made. Once you have been paid by the receiver, you may bill Medicare for secondary payments, if appropriate. You will have six (6) months from the date of the receiver's Explanation of Benefits to file a claim for secondary payments with Medicare. If the claim is received after the six month filing limit, it will be processed as untimely.<br />
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In order for Medicare to process these claims for secondary payment, please provide the following:<br />
<ul><li>A hard copy of the claim;</li>
<li>An Explanation of Benefits from the receiver;</li>
<li>A copy of the court order that addresses this issue.</li>
</ul><br />
<h4>Employer Plan HMO Coverage</h4>The Centers for Medicare & Medicaid Services has clarified that providers are responsible for submitting claims to Medicare for secondary payment consideration when the primary insurer is a Health Maintenance Organization (HMO). Medicare may consider secondary payment for all or part of an employer-sponsored HMO's copayment.<br />
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An HMO pays providers a monthly capitation fee to care for its members. Because of this reimbursement, there are no billed charges for the rendered services. Medicare will consider the Medicare fee schedule amount as the billed charge. This amount will also be considered the primary insurer's allowed amount in calculating Medicare liability. The Medicare claim form submitted for the HMO copayment can be completed with standard information:<br />
<br />
<h4>Item 24F Charges</h4>Item 28 (total charge) – Enter total charges for the services (i.e., total of all charges in item 24f)<br />
Since providers collect HMO copayments at the time of service, a copayment receipt signed by the beneficiary must be submitted with the claim. The receipt will be accepted in lieu of the primary benefits statement or explanation of benefits (EOB) required in all other Medicare secondary payer situations. The receipt must clearly indicate "HMO copayment." To assist you with this requirement, you may copy the form shown below and use it for this purpose.<br />
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When an acceptable co-payment receipt is not submitted with a claim, payment for these services may be delayed or could result in a denial of the claims. HMO co-payment receipts submitted with Medicare Secondary Payer claims should meet certain requirements.<br />
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The original co-payment receipt, signed by the beneficiary on the date they were seen should be attached to the claim form.<br />
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should be one receipt for each date of service submitted on the claim form.<br />
If the patient did not pay the co-pay at the time of the service, a co-pay receipt should not have been submitted with the claim. A receipt should only be issued to the patient if the patient paid the co-pay at the time of their service.<br />
Medicare will send any reimbursement for non-assigned claims submitted for HMO copayment to the beneficiary. For assigned claims submitted for HMO copayment, Medicare's payment will be sent to the provider who in turn must reimburse the beneficiary.<br />
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<h4>Services Obtained Outside the HMO Plan</h4>Generally, Medicare will not pay for services obtained from a source outside the HMO plan. If a beneficiary wants or needs to go to a provider outside the plan, an authorization must be obtained from the HMO plan. If authorization is not obtained, the HMO will not make payment. If the beneficiary has not been notified in writing of this rule and the HMO will not make payment, Medicare will process the claim for payment. Once the beneficiary has been notified, Medicare payment will not be made for future services obtained outside the plan.<br />
</div>

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