CMS Guidelines

This page reviewed and updated 1/25/2019.

ABN form - From CMS, the most up-to-date version can be downloaded directly from CMS.

Ambulatory Surgical Center (ASC) - Medicare approved HCPCS/CPT codes and payment rates, 2013, 2014, 2015 and 2016. Addendum AA, BB, DD1, DD2 and EE

Amendments, Corrections and Delayed Entries in Medical Documentation - CMS Transmittal 615, Pub 100-08 Medicare Program Integrity; Revised & Implemented 11/2/2015. See Item on pg 4

CMS Internet Only Manuals (IOMs) - 100-04 is the Medicare Claims Processing Manual but there are many here that are equally worthwhile for reading.

CMS Lab Fee Schedule for dates of service 2009 to current year.

CMS MLN Matters Articles - All of them from 2004 to current year.

CMS MLN Matters Q&A regarding the use of -AI modifier to indicate "Principal Physician of Record"

CMS National Correct Coding Initiative (NCCI) - Bundling Edits and Medically Unlikely Edits table in .xls format for physician coding and hospital/facility coding for the current year.

CMS PFS Relative Value Files - This link goes back to 2003 RVU files to current year.

CMS Physician Fee Schedule (PFS) Look-up Tool When pricing a procedure, finding RVU information or Status Indicators on a particular CPT code this is a fast and easy lookup tool.

CMS Physician Fee Schedule (PFS) Status Indicators - for the PFS Fee Schedule Relative Value Files, found in Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements, revised in 11/2015. You may need to scroll down a bit, but the Status Indicator meanings are here.

CMS Signature Requirements for Diagnostic Tests - CMS MLN Matters, Revised Jan 17, 2018, with links to original transmittals and guidance.

CMS Transmittals - Did you miss the latest CMS Transmittal? Go here and see what the latest information is from CMS.

CMS Web-based Training CEUs - Associations Offering Credit for MLN Events & Training - Including AAPC, AHIMA and AMBA

CMS Web-based Training CEUs - AAPC - Details on How to submit CEUs to AAPC - An Academy of Professional Coders

CMS Web-based Training CEUs - AHIMA - Details on How to submit CEUs to AHIMA - A Health Information Management Association

CMS Web-based Training CEUs - AMBA - Details on How to submit CEUs to AMBA - American Medical Billing Association

Complying With Signature Requirements - CMS MLN Matters Fact Sheet, May 2018

Drug Prices - Average Sale Price (ASP) for Drugs - click on the link on the left hand side for the year that's needed to find the Pricing Files.

CLIA- and Non-CLIA Waived Lab Tests - From CMS to Current Year.

Electronic Health Records Fact Sheet - from CMS, an excellent definition of "cloning" and altering entry dates and more cautions regarding the EHR. Providers should read this.

HCPCS codes Table of Drugs and the Alpha-Numeric HPCS codes from CMS with descriptions to current year.

Medicare Coverage Database Good search tool to find an NCD or LCD for all the states/regions.

MLN re: Signature Stamps - "With few exceptions, stamped signatures are not acceptable" from CMS, with links to original guidance.

Modifier 59 Replacement Modifiers CMS Transmittal 1422 regarding the "new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”

NCCI Policy Manual - for Medicare Services - Effective January 1, 2019 This is a direct link to the zipped file that has PDF documents that address NCCI bundling logic and information for each chapter of the CPT book. This is the Medicare "Bible" for bundling edits - a must have/read and referral source for coding and denials management.

NCCI PTP Edits for Hospitals and Practioners - for Medicare Services - Effective current year. These are the Excel files that contains the Column 1/Column 2 NCCI Edits. The above link gives the logic behind the edits; this link IS the edits.

MUE Edits - for Part B Medicare Services - Effective current year. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE. Find Practitioner, Facility Outpatient and DME tables in Excel format for the current year & the previous year.

Nurse Practitioners and Clinical Nurse Specialists - What CMS says they can do. CMS Transmittal 75 from IOM 100-02 Medicare Benefit Policy: Nurse Practitioner (NP) Services and Clinical Nurse Specialist (CNS) Services

Principal Physician of Record - 2010 Transmittal introducing the use of -A1 modifier to indicate "Principal Physician of Record"

Recovery Auditor Contractors (RACs) - Recent updates on what CMS states that a RAC can and cannot do. Good reading.

RSS AAPC E/M Discussion Forum

  • In E/M level coding Medical necessity is moderate but problem related HPI elements is not there, can we give level 4.Thanks December 5, 2019
    Patient is established came with headache and fatigue with 1 week.patient had hypertension, Physician said continue medication.But in assessment Allergic rhinitis is there he treated with RX.Allergic rhinitis HPI elements is not there,but elements is there which related to HTN. So please can you suggest the appropriate level ?Thanks
  • Need coding help please 44120? Hernia? December 5, 2019
    Hi All, Can I get a little help please. Getting 44120 but can I get anything for the hernia ? Thanks so much! midline incision was then made and carried through the subcutaneous tissue to the fascia. The fascia was incised and the abdomen opened. There was significant adhesive disease to the midline. There was […]
  • Hair tourniquet of penis December 5, 2019
    Could someone help me with getting a for hair tourniquet of penis CPT code? The code that my provider used is 54115; which I do not agree with. See op note for details. I was wondering for this patient that I would use an unlisted procedure code. OP note: This is a 7-year-old child with […]
  • Chronic Patellar dislocation December 4, 2019
    Need help coding this OP report. 29870, 27422, 27350, 27428, 27350, 20680? A knee scope was inserted through the superolateral patellar portal to evaluate the joint and pictures were obtained showing the diseased lateral patellar facet and lateral femoral condyle. A longitudinal midline knee incision as such would be used for a total knee replacement […]
  • 27427 for MPFL pants-over-vest repair? December 4, 2019
    I'm wondering if this is the correct code for a MPFL pants over vest repair. "Made an incision over the medial patella. Blunt dissection was taken (down to) MPFL. I did a pants-over-vest repair using vicryl suture with three sutures placed trying not to over-tighten..." Patient has recurrent patella dislocations. My doc is submitting this […]
  • Palliative Care Coding-Symptoms or conditions? December 4, 2019
    Hi Everyone, I need input on a specific topic regarding Palliative care coding. I've read many articles online and read through forums to try to obtain these answers and I feel that they are all over the place. When coding for Palliative care, I was told that symptoms are coded over definitive conditions, and I've […]