Billing / Coding FAQs
FAQ Categories
Billing
99211 is an established patient office or other outpatient visit that may not require the presence of a physician. To bill incident-to, the incident-to rules must be met. To ensure the services meet those requirements, utilize the incident-to tool on our website. This applies to E/M services prior to 2021 and after.
Reference
The “incident to” provisions do not apply to hospital settings.
The only exception to this is when the physician establishes an office within a nursing home or other institution. Where a physician establishes an office within a nursing home or other institution, coverage of services and supplies furnished in the office must be determined in accordance with the “incident to a physician’s professional service” provision as in any physician’s office. A physician’s office within an institution must be confined to a separately identified part of the facility which is used solely as the physician’s office and cannot be construed to extend throughout the entire institution. Thus, services performed outside the office area would be subject to the coverage rules applicable to services furnished outside the office setting.
Reference
The incident-to provisions do not apply to hospital settings.
The only exception to this is when the physician establishes an office within a nursing home or other institution. Where a physician establishes an office within a nursing home or other institution, coverage of services and supplies furnished in the office must be determined in accordance with the incident-to a physician’s professional service provision as in any physician’s office. A physician’s office within an institution must be confined to a separately identified part of the facility which is used solely as the physician’s office and cannot be construed to extend throughout the entire institution. Thus, services performed outside the office area would be subject to the coverage rules applicable to services furnished outside the office setting.
We do not issue benefit exhaust letters. This information will appear on your remittance advice. We’ve included the link to X12, which contains links to various code lists, including claim adjustment reason codes (CARCs); remittance advice remark codes (RARCs); provider adjustment reason codes; claim status codes; and much more.
Examples of what you may see on the remittance advice for benefits exhaust are listed below:
- Claim status code: 432 - Date benefits exhausted
- CARC 78 - Non-covered days/Room charge adjustment.
- RARC N374 - Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.
- RARC N587 - Policy benefits have been exhausted.
- CARC 119 - Benefit maximum for this time period or occurrence has been reached.
Reference
No. The services provided by physical therapist assistants (PTAs) cannot be billed incident to a physician/non-physician practitioner’s (NPP), because PTAs do not meet the qualifications of a therapist. Only the services of a licensed/registered physical therapist can be billed “incident to” a physician service. PTAs may not provide evaluation services, make clinical judgments or decisions, or take responsibility for the service. PTAs act at the direction and under the supervision of the treating physical therapist and in accordance with state laws. The services of the PTA are only billable when provided under the direct supervision of the physical therapist and under their NPI number.
Reference
No. The services provided by physical therapist assistants (PTAs) cannot be billed incident-to a physician/non-physician practitioner’s (NPP), because PTAs do not meet the qualifications of a therapist. Only the services of a licensed/registered physical therapist can be billed incident-to a physician service. PTAs may not provide evaluation services, make clinical judgments or decisions, or take responsibility for the service. PTAs act at the direction and under the supervision of the treating physical therapist and in accordance with state laws. The services of the PTA are only billable when provided under the direct supervision of the physical therapist and under their NPI number.
Reference
An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:
- A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility; Note: No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services;
- A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
- An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.
Reference:
Any visit provided during a hospitalization with a surgery (except critical care and emergency room visits) by the physician who performed the surgery would not be separately billable, as they would be considered part of the global care (including post-op) of the patient. Other providers involved can bill for appropriate visits.
When a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the surgical procedure. When critical care is unrelated to the surgical procedure, append the modifier -FT (unrelated E/M visit during a postoperative period, or on the same day as a procedure or another E/M visit) to the critical care service. For more information, see our article on critical care services.
However, after the hospitalization, if the patient sees the same physician outside the hospital and during the global period, modifier 24 rules would apply to any potentially separately billable visits.
References
Fees for fee schedule services paid under the Medicare Physician Fee Schedule (MPFS), for Part A as well as Part B available from the fees page. On the fees page, you'll also have access to:
- The latest news and information about fee schedules in the “News” information box
- Location-specific fee information for Part A and Part B for most Medicare-covered procedure codes with First Coast’s easy-to-use, interactive look-up tool.
- Printable Part B portable document format (PDF) fee schedules and text-only fee schedule data files that can be imported into a spreadsheet or database.
- Fee schedules and fee schedule-related information from previous payment years in First Coast’s comprehensive archive.
- A link to the CMS National physician fee schedule database tool to find fee and policy information based upon a single, list, or a range of HCPCS criteria.
Note: There are four payment localities in Florida. If you do not know your locality, click here. Puerto Rico and the U.S. Virgin Islands are each comprised of a single locality.
Additional information and specific fee schedules may be found on the CMS website.
Providers are responsible to collect patient data, asking questions related to employment and liability insurance, to identify payers other than Medicare. This action minimizes incorrect billing and Medicare overpayments. Providers must determine if Medicare is the primary or secondary payer by obtaining MSP information such as group health coverage through employment or non-group health coverage resulting from an injury or illness. Patients should be questioned at each visit to determine if there have been changes in insurance coverage or if there may be other insurer liability. Refer to CMS’ Part B Other Insurer Intake Tool: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-recovery/ProviderServices/Downloads/pro_othertool.pdf
The Medicare secondary payment is determined by a series of calculations and comparisons. The primary insurer’s claim processing details on their explanation of benefits (EOB) is needed to determine the secondary payment amount.
Three calculations are made per procedure. The lowest of the three is the secondary payment.
Calculation 1
If the Obligated to Accept payment in Full (OTAF) amount is present,
- Determine the lowest amount between the OTAF amounts vs. the billed amount of the service.
- Use the lowest amount listed above minus the primary paid amount.
If the OTAF amount is not present,
- Use the billed amount of the service minus the primary paid amount.
Calculation 2
Determine Medicare's primary payment would be:
- Note the Medicare allowed amount for the procedure.
- If applicable, subtract Medicare's deductible indicated in the DEDCT column.
- Multiply the difference by the appropriate percentage: 62.5 percent, 80 percent, or 100 percent, depending on the procedure code.
Calculation 3
Compare the Medicare allowed amount to the primary insurer's allowed amount and select the higher allowed amount.
Using the higher allowed amount from listed above, subtract from the primary insurer's paid amount.
- The Medicare secondary payment is equal to the lowest payment amount resulting from calculation #1, #2 or #3 above.
Note: You may also utilize the Medicare secondary payer (MSP) calculator.
For each calendar year, a certain cash deductible exists that must be met before payment may be made by Medicare.
- The deductible for 2025 is $257.00.
Patient expenses are applied toward the deductible based on incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible.
If an individual does not have Part B benefits for an entire calendar year (i.e., insurance coverage begins after the first month of the year), he or she is still subject to the full deductible for the calendar year. Medical expenses they incurred during the year, but before they are actually entitled to Medicare, cannot be applied to the deductible.
Although the date of service generally determines when expenses were incurred, the order in which expenses are applied to the deductible is based on when the bills are actually received.
- Note: Services not subject to the deductible cannot be used to satisfy the deductible.
Reference
No. In order for the service to qualify as "incident to," an initial encounter must have occurred between the physician and the patient, and a course of treatment established by the physician. In this situation, services performed by the PA do not meet the “incident to’” requirement and would not qualify because this is a new patient. The claim would be billed listing the PA as the performing provider.
Reference
No. In order for the service to qualify as incident-to, an initial encounter must have occurred between the physician and the patient, and a course of treatment established by the physician. In this situation, services performed by the PA do not meet the incident-to requirement and would not qualify because this is a new patient. The claim would be billed listing the PA as the performing provider.
Cancel the original claim and submit the claim to the VA. Once the canceled claim has processed, the Fiscal Intermediary Standard System (FISS) will automatically recoup the money you were paid.
Where the VA authorized services, Medicare does not make payment for items or services furnished by a non-Federal provider pursuant to such an authorization. Although certain MSP billing procedures apply, VA is not an MSP provision.
Reference
As explained by CMS in the calendar year (CY) 2025 final rule:
Under Medicare Part B, certain types of services, including services incident to physicians’ or practitioners’ professional services, are required to be furnished under specific minimum levels of supervision by a physician or practitioner. For most services furnished by auxiliary personnel incident to the services of the billing physician or practitioner, direct supervision is required.
Outside the circumstances of the PHE, direct supervision requires the immediate availability of the supervising physician or other practitioner, but the professional need not be present in the same room during the service.
We have established this “immediate availability” requirement to mean in-person, physical, not virtual, availability. Through the March 31, 2020, COVID-19 interim final rule with comment period (IFC), we changed the definition of “direct supervision” during the PHE for COVID-19 as it pertains to supervision of diagnostic tests, physicians' services, and some hospital outpatient services, to allow the supervising professional to be immediately available through virtual presence using two-way, real-time audio/video technology, instead of requiring their physical presence.
For 2025, we will continue to continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through December 31, 2025.
Reference
If a provider receives a Medicare demand letter, refer to the appeal rights section of the demand letter for specific instruction on how to file an appeal and stop recoupment of the accounts receivable if applicable.
When a provider determines that a Medicare overpayment exists, the following steps must occur.
Complete the Return of Monies Voluntary Refund Form
- Provide a refund check
- List all Medicare claim numbers included in the overpayment or a copy of the Medicare remittance notices with detailed claim information (Name, Medicare ID #, date of service, procedure code and billed amount)
- Include the other insurer’s Explanation of Benefits (EOB) and/or payment information for every claim involved. The other insurer’s EOB must have the insurer’s name and address.
There are potential civil monetary penalties for violating the Medicare limiting charge. The limiting charge applies to non-participating providers in the Medicare Part B program when they do not accept assignment and the beneficiary is not responsible for any billed amounts in excess of the limiting charge for a covered service.
The Social Security Act Amendments of 1994 state that non-participating physicians, other practitioners, or suppliers are held liable for charges that exceed the Federal limiting charge on services to which they apply. If such a physician, other practitioner, or supplier willfully, knowingly, and repeatedly exceeds the limiting charge, then they may be subject to a civil monetary penalty of up to $10,000 per violation, plus three times the amount of the charges claimed for each violation. In addition, the physician, other practitioner, or supplier may be excluded from the Medicare program for up to five years. This amendment is effective for services rendered on or after January 1, 1997.
Reference
CMS IOM Pub. 100-04 Medicare Claims Processing Manual Chapter 1, section 30.3.12.3
In order to ensure the MSP refund is properly processed, a copy of the other insurer’s EOB and/or payment information (i.e., a copy of the check) is required to calculate the Medicare Secondary payment. When the Medicare Secondary payment is calculated, it will determine if the refund amount is correct or there is an additional balance due.
However, if the other insurer’s EOB is not received or information on the primary does not match all the detail line on the Medicare claim, the entire claim and/or detail line will be processed as a full denial. This could result in a balance due to Medicare, demandable debt, with no Medicare secondary consideration.
Providers are required to pay Medicare within 60 days from the date a payment is received from another payer (primary to Medicare) for the same service for which Medicare paid.
However, if a demand letter is needed by the provider’s accounting department, submit the MSP Overpayment Refund form and the other insurer’s EOB and/or payment information (e.g., a copy of the check) to Medicare.
If the other insurer’s EOB is not received or information does not match all the detail line on the Medicare claim, the entire claim and/or detail line will be processed as a full denial. This could result in a balance due to Medicare, demandable debt with no Medicare Secondary consideration.
Medicare secondary payer is used when another insurer is responsible for paying insurance benefits first for Medicare beneficiaries. Medicare may be responsible to make a secondary payment; however, the law provides many different coverage scenarios so each one must be reviewed individually. MSP information may be found on the CMS website.
- https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Medicare-Secondary-Payer/Medicare-Secondary-Payer
- https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Overview
Reference
Learn information on evaluation and management (E/M) services including what modifiers to apply by viewing the following article: Evaluation and management FAQs.
Medicare evaluation and management (E/M) guidelines are now in effect regarding split or shared services. The CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6.18 includes a detailed breakdown of the split or shared guidelines.
Please read the following article for a summary of these changes: Split or shared E/M guidelines: Medicare Claims Processing Manual updates.
Payment for ASCs are made under a separate payment system. As such, certain modifiers are specific to ASCs. View the following article to learn more: Modifiers applicable to ASCs.
Learn which modifier to use when you expect Medicare will deny a claim that does not meet medical necessity criteria and whether you have or do not have an advanced beneficiary notice (ABN) signed by the beneficiary by viewing the following article: How to use modifiers to indicate the status of an ABN.
When a provider receives primary payments from Medicare and another insurer for the same service billed, provider must repay the overpayment within 60 days of the receipt of the duplicate payment.
The following steps will ensure proper correction to Medicare records and calculation of secondary payment is made.
- Determine if an overpayment exists by calculating the Medicare secondary payment. The difference of what Medicare paid and the Medicare secondary payment amount is the overpayment amount. See How is a Medicare secondary payment determined?
- Complete and submit the Medicare secondary payer overpayment refund form (see below), indicating all appropriate MSP information. Attach copies of the related remittances or list all claim information for multiple on a separate sheet or CD.
- Send a refund check for the overpaid amount within 60 days of the date the duplicate payment was received
- Send the other insurer’s explanation of benefits (EOB) and/or payment information. This EOB must contain claim and detail level data, such as the date of service, procedure code or HCPCS descriptor, billed amount, paid amount, deductible applied and processing remarks. (Contact the other insurer for a breakdown if these are not on the EOB received.)
- Mail ALL of these to:
Florida providers:
JN Part B Florida Debt Recovery and Check Mail
P. O. Box 3092
Mechanicsburg, PA 17055-1810
Puerto Rico and U.S. Virgin Islands providers:
JN Part B Puerto Rico and Virgin Islands Debt Recovery and Check Mail
P. O. Box 3121
Mechanicsburg, PA 17055-1831
References
No. Although the injections are billed under the supervising physician’s NPI, he or she is not required to see the patient or document any notes in the patient’s medical record.
A service that is billed as “incident to” is one that is furnished as an incidental but integral part of the physician’s professional services in the course of the diagnosis or treatment of the patient’s injury or illness.
Therefore, in order to bill for injections provided “incident to” by an NP or NPP, the following criteria must be met:
- Supervising physician must be in the office at the time the injection is given by the NP or NPP
- Supervising physician must have established a treatment plan for the condition for which the injection is provided
- Documentation contained within the patient’s medical record should demonstrate the “link” between the non-physician’s service and the precedent physician’s service to which it is incidental
Note: If the NP is billing under his or her own NPI, the supervising physician is not required to be in the office -- unless the physician’s presence is required by state law.
Reference
No. Although the injections are billed under the supervising physician’s NPI, he or she is not required to see the patient or document any notes in the patient’s medical record.
A service that is billed as incident-to is one that is furnished as an incidental but integral part of the physician’s professional services in the course of the diagnosis or treatment of the patient’s injury or illness.
Therefore, in order to bill for injections provided incident-to by an NP or NPP, the following criteria must be met:
- Supervising physician must be in the office at the time the injection is given by the NP or NPP
- Supervising physician must have established a treatment plan for the condition for which the injection is provided
- Documentation contained within the patient’s medical record should demonstrate the link between the non-physician’s service and the precedent physician’s service to which it is incidental
Note: If the NP is billing under his or her own NPI, the supervising physician is not required to be in the office -- unless the physician’s presence is required by state law.
Reference
When assignment is accepted, Medicare Part B recommends:
- Since it is difficult to predict when deductible/coinsurance amounts will be applicable - and over-collection is considered program abuse - do not collect these amounts until you receive Medicare Part B payment.
- If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. (We do not recommend that you collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse and can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.)
- Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.
Reference
View our modifiers page for tips, decision flowcharts, and more.
Learn information on the appropriate use of modifiers to report assistant at surgery services and how payment is determined under the Medicare physician fee schedule (MPFS) by viewing the following article: Appropriate use of assistant at surgery modifiers and payment indicators.
View the following list of codes that may not be corrected using the reopening process in SPOT.
The MSP Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The purpose of the COB program is to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken Medicare payment. The MSP Contractor does not process claims or claim-specific inquiries. The MACs are responsible for processing claims submitted for primary or secondary payment and resolving situations where a provider receives a mistaken payment of Medicare benefits.
All Medicare Secondary Payer (MSP) claims investigations are initiated from and researched by the MSP Contractor and is not a function of the local Medicare claims paying office. This single-source development approach greatly reduces the number of duplicate MSP investigations. This also offers a centralized, one-stop customer service approach for all MSP-related inquiries, including those seeking general MSP information. The MSP Contractor provides customer service to all callers from any source, including, but not limited to, beneficiaries, attorneys/other beneficiary representatives, employers, insurers, providers, and suppliers.
Contact the MSP Contractor for the following:
- Report employment changes or any other insurance coverage information
- Report a liability, auto/no-fault or workers compensation case
- Ask questions regarding a COB MSP claims investigation
- Ask general MSP questions
- How to obtain conditional payment information
- How to obtain Medicare’s final recovery claim amount
- Ask questions regarding MSP recovery demand letters
- Ask questions regarding repayment of recovery claims
MSP information may be found on the CMS website.
- https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/index
- https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Overview
The BCRC customer service department can be reached at 1-855-798-2627 or 1-855-797-2627 for the hearing and speech impaired.