CMS Guidelines

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ABN form – From CMS, the most up-to-date version can be downloaded directly from CMS. Renewed ABN is MANDATORY for 2021 due to Covid.

Ambulatory Surgical Center (ASC) – Medicare approved HCPCS/CPT codes and payment rates thru 2021. See Addendum AA, BB, DD1, DD2 and EE

Ambulatory Surgical Center (ASC) Payment System Update CMS Transmittal #R10702CP 4/1/2021

Amendments, Corrections and Delayed Entries in Medical Documentation – CMS IOM Pub 100-08; Medicare Program Integrity; See Item

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

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

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. Click “Accept” at the bottom & you’re in.

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 Dec 4, 2020. You may need to scroll down a bit or do a CTRL + F search, but the Status Indicator meanings for all the categories are here.

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

Complying With Signature Requirements – CMS MLN Matters, April 2022

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.

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

NCCI Policy Manual – for Medicare Services – Current year. No need to download the entire zipped file with all the chapters; a single chapter can be downloaded on its own. These PDF documents 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 Practitioners – 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 has 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. Not all HCPCS/CPT codes 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. Be sure to read the Approved RAC Topics and Proposed RAC Topics to be prepared.