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

  • What does c/f mean? May 24, 2019
    I can't seem to get the answer to this one no matter how hard I google. The example is "... c/f copd exacerbation..." Is c/f the same as "consistent with"? Thank you!
  • Auditing Fee May 23, 2019
    I've been asked to do a coding audit but I'm unsure of what to charge. I've been a coder for 7 years (actually doing coding on/off during these years), but I've never done an audit. I was hoping some of you who have performed audits could share what you charge? Per hour? Per chart? Thank […]
  • IUD attemt May 23, 2019
    good morning if provider attempted to remove an IUD but was unsuccessful, can I use 58301 with modifier 52?
  • Is it proper to bill 31233 (approach) with CPT 31267 (Cyst removal)? May 23, 2019
    The physician performed an antral puncture with removal of cyst from the left maxillary sinus. Attempts were unsuccessful through the nose. The canine fossa using a scalpel and a inch drill punch was performed through the anterior wall of the left maxillary sinus. This allowed the endoscope to be passed through the front of the […]
  • PRP injections where Provider is only doing the injection portion? May 23, 2019
    I have a provider that just started doing PRP injections in clinic and the machine and kits are supplied by a vendor. From the information I gathered from the clinic manager, the patient pays the vendor upfront for the treatment. The vendor company is then doing all the harvesting and processing of the blood. The […]
  • Maximus Gluteus repair CPT code? May 23, 2019
    Does any one know what CPT code to use for this? Thank you