2016 Medicare Physician Fee Schedules Available
On January 20, 2016, Palmetto GBA posted the updated 2016 Medicare Part B Physician Fee Schedules (MPFS) on their webiste,
. under the Medicare Physician Fee Schedule tool. The files can also be downloaded in Excel or a CSV format.
The previously posted codes were incorrect, which caused CMS to remove all fee schedules from their MACs' websites. This caused an emergency update to the CY 2016 Medicare Physician Fee Schedule Database (MPFSDB)
MLN Change Request (CR) 9495 amends payment files that were issued to contractors based on the CY 2016 Medicare Physician Fee Schedule (MPFS) Final Rule. The Centers for Medicare & Medicaid Services (CMS) amended these payment files in order to correct technical errors to the MPFS update files, and to include corrections described in the CY 2016 MPFS Final Rule Correction Notice.
New Place Of Services Codes
Effective January 1, 2016, there are two possible place of service codes to choose from for outpatient hospital settings: new place of service code 19 and revised place of service code 22.
Place of Service 19
Off Campus-Outpatient Hospital
A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
Place of Service 22
On Campus-Outpatient Hospital
A portion of a hospital's main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
Reporting outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the Physician Fee Schedule (PFS) when services are provided to a registered outpatient. Therefore, you should use POS code 19 or POS code 22 when you furnish services to a hospital outpatient regardless of where the face-to-face encounter occurs.
The payment policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19 unless otherwise stated in Change Request (CR) 9231.
Clarifying the Medical Necessity Component for Critical Care Services
Critical care services must be medically necessary and reasonable. Critical care is defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. In some instances, the patient may require critical care for the first day, but not on subsequent days as their condition has stabilized.
Save Time and Assure Accuracy: Use the Most current Redetermination Request Form
Palmetto GBA is committed to making it easy for you to submit requests for a redetermination. They have changed the Redetermination First Level Appeal form to allow the information you type onto this form to be captured automatically by their system. This allows your request to process more quickly and accurately. The form can be completed online and printed and signed for submission. The most current Redetermination 1st Level Appeal form includes the form number, Revision Date of 11/2105 and a Barcode date of 12/15/2015.
eServices: Fast and Secure Medicare Information
Palmetto GBA offers secure and fast access to your Medicare information through their eServices. Through this system, you can securely submit forms, documents and payments, receive print material/letters electronically via eDelivery, view beneficiary eligibility, claims status, online remittances and financial information and much more. For more information, visit
The CERT Contractor Differs from the Medicare Contractor
Palmetto GBA is the Jurisdiction M contractor who CMS employs to provide claims processing for the states of SC, NC, VA and WV. Services provided by Palmetto GBA include processing claims for Medicare Part A, Part B and sixteen states that provide Home Health and Hospice (HHH) services.
The CERT contractor is a totally separate contractor who contracts with CMS.
Compliance officers at each medical practice are encouraged to ensure that the CERT contractor's database stays updated with the correct contact information.
Please verify or change the CERT contact information for your facility at the CERT Provider website. You will need your Contractor ID, so please select the line of business and the number by your state.
The West Virginia number is 11402.
Palmetto GBA continues to see a problem regarding the absence of a physician signature on medical records reviewed by the CERT contractor. Once the provider receives a response from CERT, the provider will then submit an appeal to Palmetto and will send a copy of the record that has been signed after the CERT review. The important tip here is to
ensure medical records are signed prior to submitting the records to the CERT contractor.
Submitting Complete and Legible Medical Records is Key!
When submitting medical records to the CERT contractor, be sure the medical record submitted is complete and legible. Documentation must support the level of care and treatment and must be reasonable and necessary. Codes documented on the claim must be reflected in the medical record. Coders should ensure they use the correct code when coding services on the claim.
E/M Tip: Discharge Services-Patient Expired
Only the physician who personally performs the pronouncement of death may bill for the face-to-face hospital discharge service. The date of the pronouncement must reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date.
E/M Tip: Documentation Requirements for Teaching Physicians
E/M services billed by teaching physicians require that they personally document at least the following:
That they performed the service or were physically present during the key or critical portions of the service when performed by the resident
The participation of the teaching physician in the management of the patient
When assigning codes to services billed by teaching physicians, reviewers will combine the documentation of both the resident and the teaching physician.
Automated Calls to Physicians with Eligible Overpayments
Effective Monday, January 11, 2016, Jurisdiction M Medicare implemented automated calls to providers with eligible overpayments in an effort to increase timely responses to eligible outstanding overpayments.
An automated courtesy call will be made when the debt remains open in a collections status and ages to at least 67 days old. This call will be a reminder to any provider who has not responded to a first demand letter either with payment in full, by submitting an appeal, or by submitting an acceptable request for an extended repayment schedule.
These calls will provide basic information about the pending overpayment, including the date of the first demand letter and the outstanding balance.
To avoid further collection action, providers can submit payment electronically using the Palmetto GBA eServices link at
, submit a check to the address listed on the demand letter, submit a request for an extended repayment schedule, or file an appeal in accordance with the rights provided to you in the demand letter.
Medicare Secondary Payer Inquiry Form
Palmetto GBA has added a Medicare Secondary Payer Inquiry Form in the Finance forms section of our website. This form should be used for any Medicare Secondary Payer (MSP) request pertaining to Primary or Secondary payment of claims.
Please forward all inquiries for MSP Recovery to the Benefits Coordination & Recovery Center (BCRC)
Do not include a refund check with the new form
If you are sending a refund check, please use the Medicare Secondary Payer Refund Overpayment Check Enclosed form
Do not use this form if you are requesting a Redetermination on a MSP claim that is not MSP related
Do not use this form for new claim submissions
Do not use this form for situations that involve the Veteran's Administration. Use the Reopening form instead.