Frequently Asked Questions - Top 10 Written Inquiries
WPS Medicare is pleased to publish FAQs based upon topics we have identified as those generating a high volume of written inquiries to Customer Service. The following table lists ten reasons (by topic) our Medicare providers and their agents sent in a written inquiry during the first quarter of Fiscal Year (FY) 2010.
Top 10 Written Inquiries
First Quarter FY10 (October, November, December 2009)
(Excluding Claim Status and Eligibility Issues)
| Description | Occurrences |
| Appeals, Process Rights | 947 |
| Remittance Advice, Duplicate Remittance Notice | 767 |
| General Information, Misrouted Telephone Call/Written Correspondence | 346 |
| Appeals, Status/Explanation/Resolution | 219 |
| Policy/Coverage Rules, Benefits/Exclusion/Coverage Criteria/Rules | 85 |
| Policy/Coverage Rules, Statutes and Regulations | 49 |
| Policy/Coverage Rules, Local Coverage Determination | 42 |
| Policy/Coverage Rules, Pre-authorization | 39 |
| Administrative Billing Issues, Filing/Billing Instructions | 32 |
| General Information, Issue Not Identified/Incomplete Information Provided | 30 |
1. Medicare deactivated my Provider Transaction Access Number (PTAN) because I haven't submitted any claims for more than 12 months. When I submitted a new CMS-855 enrollment application to have my PTAN reactivated, the provider enrollment unit didn't make my billing effective date retroactive. Why not?
Although the Centers for Medicare & Medicaid Services (CMS) allows Medicare contractors to backdate the effective date of PTANs for new enrollments for up to 30 days prior to the filing date of the application, the same is not true for reactivated PTANs. The CMS does not permit Medicare contractors to backdate the effective date of most PTAN reactivations.
For Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Certified Nurse Midwives, Clinical Social Workers, Clinical Psychologists, and Registered Dietitians/Nutrition Professionals:
The CMS Internet Only Manuals (IOM), Publication 100-08, Chapter 10, section 13.1.B., indicates that the effective billing date for reactivation for physicians, designated non-physician practitioners, and group practices of these individuals is either: (a) the date of filing of the CMS-855 enrollment application, or (b) the date they first began furnishing services at a new practice location (unless the provider has at least one other actively-billing Medicare-enrolled practice location under the same tax identification number), whichever is later. This means WPS Medicare generally establishes the provider's billing effective date based on the date we receive the provider's new CMS-855 enrollment application. You can locate this section of the IOM on the CMS Website 
.
If a physician, designated nonphysician practitioner, or a group practice of these individuals has at least one other enrolled practice location under the same tax identification number (TIN), the reactivation effective date is either: (a) the date the supplier first saw a Medicare patient at the location indicated on the new CMS-855 enrollment application, or (b) the same date as the non-billing end-date in Medicare's claims processing system, whichever is later.
All Other Individuals and Organizations:
For individuals and organizations other than those described above, the effective billing date for reactivation is the later of the date the provider first saw a Medicare patient at the location or the same date as the non-billing end date.
Note: In all cases, a new PTAN is assigned for reactivation. Dates of service prior to the effective date of the new PTAN are not payable.
If you have any questions, please contact the provider enrollment department at the applicable phone number:
877-908-8476: Wisconsin, Illinois, and Michigan providers
866-564-0315: Minnesota providers
2. How do I bill for a Health Care Procedure Coding System (HCPCS) drug injection code using a valid or a not otherwise classified (NOC) code?
Valid HCPCS code
Providers should report the dosage/strength (strength of dosage, if appropriate), and method of administration. Please remember this information does NOT apply to oral drugs/medications.
Not Otherwise Classified (NOC) HCPCS code such as J3490
When billing for a drug injection using a HCPCS NOC code such as J3490, the provider must report the description of the drug, including the name of the drug, dosage/strength (strength of dosage, if appropriate), and method of administration or Medicare will reject the claim. Providers should always bill J3490 with one unit of service. Please remember this information does NOT apply to oral drugs/medications.
The provider should also indicate "ADDITIONAL DOCUMENTATION AVAILABLE UPON REQUEST" in Item 19 of the CMS-1500 claim form or in the NTE02 segment of the electronic claim.
WPS Medicare reimburses most NOC HCPCS drug injections based on the drug invoice from the supplier. By indicating "additional documentation available upon request," WPS Medicare sends a development letter asking for the invoice of the drug billed. If the NTE02 segment does not indicate the availability of the additional documentation, or if you do not return the information in a timely manner, WPS Medicare rejects the claim as unprocessable.
For information on how to submit this information electronically, visit the WPS Medicare Website's electronic claim submission requirements .
3. Does WPS Medicare require the National Drug Code (NDC) number when a provider submits a claim for the generic drug code J3490, unclassified drug?
The NDC was developed by the Food and Drug Administration (FDA) to serve as a universal product identifier for human drugs. WPS Medicare does not recognize the use of the NDC on Medicare claims submitted for code J3490. However, providers should include the name of the drug, the total dosage (plus strength of dosage, if appropriate), and the method of administration. Providers should always bill J3490 with one unit of service. Please remember this information does NOT apply to oral drugs/medications.
Providers can refer to the article on the WPS Medicare Website for information on claims submitted with procedure code J3490.
4. Is it necessary to have a physician's office on the same floor as the patient in order to meet Medicare's "incident to" guidelines?
The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Chapter 15, section 60, discusses incident to a physician's professional service in the office or clinic setting. Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of non-enrolled non-physician practitioners (NPPs) or auxiliary personnel. Direct supervision means the billing provider must be in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services. Direct supervision does not mean that the physician must be present in the same room with his or her aide. However, a provider on a separate floor does not meet this requirement.
It is the responsibility of the provider of the service to determine whether or not they meet the "immediately available" provision in the "incident to" guidelines. It is also important to note that the "incident to" guidelines (as a whole) do not apply in a hospital/facility setting.
Additional information for incident to a physician's professional service in the office or clinic setting is available on the Centers for Medicare & Medicaid Services (CMS) Website .
5. What sections of the Advance Beneficiary Notice of Noncoverage (ABN) do I need to complete, if I think an otherwise covered service may be denied as not reasonable or medically necessary?
To be a valid ABN, the provider must complete sections A, B, C, D, E, and F before presenting the ABN to the beneficiary for signature. If a valid ABN is not given, and the item or service is denied as not reasonable and necessary, the provider may not shift financial liability to the beneficiary. Comprehensive instructions for completing the ABN are available on the Centers for Medicare & Medicaid Services (CMS) Website .
6. Why do my chiropractic claims deny for the x-ray date not being valid?
A subluxation may be demonstrated by an x-ray or by physical examination.
Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation.
Please be aware that if providers do submit on the claim an x-ray date and the x-ray date is not in the required time frame, Medicare will deny the claim.
An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary's health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.
Page Last Updated: Thursday, 18-Mar-2010 05:55:53 CDT
