Medicare Updates Part B Claims Address

by | Dec 1, 2019 | Medicare

Part B Claims

Novitas Solutions Attn: Part B Claims PO Box XXXX (replace the Xs with the PO Box number from the table below) Mechanicsburg, PA 17055-XXXX (fill in the +4 from the table below)

Part B Claims CMS 1500 Claim Form (08/05) PO Box Zip +4
Arkansas P.O. Box 3098 17055-1816
Colorado P.O. Box 3107 17055-1823
DCMA P.O. Box 3396 17055-1841
Delaware P.O. Box 3397 17055-1842
Indian Health Services P.O. Box 3111 17055-1857
Influenza/Flu Claims/Roster Billings P.O. Box 3112 17055-1827
Louisiana P.O. Box 3097 17055-1815
Maryland P.O. Box 3398 17055-1843
Mississippi P.O. Box 3129 17055-1834
New Jersey P.O. Box 3030 17055-1802
New Mexico P.O. Box 3107 17055-1823
Oklahoma P.O. Box 3107 17055-1823
Pennsylvania P.O. Box 3418 17055-1854
Texas P.O. Box 3108 17055-1824

Medicare Therapy Cap and Threshold 2013

by | Nov 28, 2019 | Medicare

Update to Medicare Therapy Cap and Threshold 2013

January 1, 2013 through March 31, 2013

-Annual per beneficiary therapy cap amount is $1900 for physical therapy and speech language pathology services combined and there is a separate $1900 amount allotted for occupational therapy services.

-Providers may utilize the automatic process for exception for any diagnosis for which they can justify se…rvices exceeding the cap. Therapists may request an automatic exception for claims that are between $1900 and $3700 in expenditures. When the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy procedure code subject to the cap limits.

-Manual Medical reviews-completed on every claim at and after the beneficiary’s services exceed $3700.00

April 1, 2013 through December 31, 2013

-Annual per beneficiary therapy cap amount is $1900 for physical therapy and speech language pathology services combined and there is a separate $1900 amount allotted for occupational therapy services.

-Providers may utilize the automatic process for exception for any diagnosis for which they can justify services exceeding the cap. Therapists may request an automatic exception for claims that are between $1900 and $3700 in expenditures. When the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy procedure code subject to the cap limits.

-Recovery Auditors will conduct prepayment manual medical review in 11 demonstration states:

CA, FL, IL, LA, MI, MO, NC, NY, TX, OH, PA

-CMS will grant an exception to all claims with a KX modifier at and after the beneficiary’s services exceed $3700.00 and Recovery Auditors will conduct post payment review on all claims in the remaining states.

In the non-Demonstration states, the Recovery auditors will conduct immediate post-payment review.  All claims will continue to go the MAC and once received the MAC will pay claim.  The Recovery Auditor will then issue an Additional Documentation Request letter to the provider.  The Recovery Auditor will complete manual medical review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.  If services are denied, the MAC will retract the payment.

Medicare Functional Limitation Requirements

by | Nov 27, 2019 | Medicare

What are the Functional Limitation G- Codes?

Beginning on January 1, 2013 in a testing phase and required as of July 1, 2013, therapists are required to report new G-Codes to report the functional limitation of their patients. This new set of G-Codes will move therapists closer to incorporating function and functional progress with treatments. There are a total of 42 new non-payable G-Codes and 7 new modifiers for use on claims for Physical Therapy, Occupational Therapy, and Speech-Language Pathology services.

**Beginning July 1, 2013, Medicare will begin returning and rejecting claims for therapy services that do not contain the required functional G-Code information.**

 Required Reporting of Functional G-Codes and Severity Modifiers

The functional G-Codes and corresponding severity modifiers are used in the required reporting on specified therapy claims for certain Dates of Service. Only one functional limitation shall be reported at a given time for each related therapy plan of care.

Functional reporting is required on therapy claims as shown below:

  • At the outset of a therapy episode      of care (initial date of service).
  • At least once every 10 treatment      days.
  • The same Date of Service that an      evaluative procedure is submitted (Codes 97001, 97002, 97003, 94004)
  • At the time of discharge from the      therapy episode of care
  • On the same Date of  Service      the reporting of a particular limitation is ended, in cases where the need      for further therapy is needed

 What are the Functional Limitation G-Codes?Below are some of the functional limitation G-Codes that are to be used by Physical Therapists. They are organized in related sets. Please note: this is not a complete list. Mobility Set

  • G8978 -Mobility:      walking and moving around functional limitation, current status, at      episode outset and reporting intervals
  • G8979 –      Mobility: walking and moving around functional limitation, projected goal      status, at episode outset, at reporting intervals, and at discharge or to      end reporting
  • G8980 –      Mobility: walking and moving around functional limitation, discharge      status, at discharge from therapy or to end reporting

Changing and Maintaining Body Position Set

  • G8981 – Changing      and Maintaining Body Position functional limitation, current status, at      episode outset and at reporting intervals
  • G8982      – Changing and Maintaining Body Position functional limitation,      projected goal status, at episode outset, at reporting intervals, and at      discharge or to end reporting
  • G8983      – Changing and Maintaining Body Position functional limitation,      discharge status, at discharge or to end reporting

Carrying, Moving and Handling Objects Set

  • G8984 –      Carrying, Moving and Handling Objects functional limitation, current      status, at episode outset and at reporting intervals
  • G8985 –      Carrying, Moving and Handling Objects functional limitation,      projected goal status, at episode outset, at reporting intervals, and at      discharge or to end reporting
  • G8986 –      Carrying, Moving and Handling Objects functional limitation,      discharge status, at discharge or to end reporting.

 Self Care Set

  • G8987 – Self      Care functional limitation, current status, at episode outset and at      reporting intervals
  • G8988 – Self      Care functional limitation, projected goal status, at episode outset,      at reporting intervals, and at discharge or to end reporting
  • G8989 – Self      Care functional limitation, discharge status, at discharge or to end      reporting.

Other PT/OT Primary Set

  • G8990      –      Other PT/OT Primary functional limitation, current status, at episode      outset and at reporting intervals
  • G8991 – Other      PT/OT Primary functional limitation, projected goal status, at      episode outset, at reporting intervals, and at discharge or to end      reporting
  • G8992 – Other      PT/OT Primary functional limitation, discharge status, at discharge      or to end reporting.

 Other PT/OT Subsequent Set

  • G8993 – Other      PT/OT Subsequent functional limitation, current status, at episode outset      and at reporting intervals
  • G8994      – Other      PT/OT Subsequent functional limitation, projected goal status, at      episode outset, at reporting intervals, and at discharge or to end      reporting
  • G8995      – Other PT/OT Subsequent functional limitation, discharge      status, at discharge or to end reporting.

Severity/Complexity ModifiersFor each non-payable G-Code used, a modifier must be used to report the severity/complexity for that functional measure. The severity modifiers reflect the patient’s percentage of functional impairment as determined by the therapist furnishing the therapy services. The seven modifiers include:.

  • CH – 0 %      impaired, limited or restricted
  • CI – At least      1 % but less than 20 % impaired, limited, or restricted
  • CJ – At least      20 % but less than 40 % impaired, limited, or restricted
  • CK – At least      40 % but less than 60 %impaired, limited, or restricted
  • CL – At least      60 % but less than 80 %impaired, limited, or restricted
  • CM – At least      80 %but less than 100 % impaired, limited, or restricted
  • CN – 100 %      impaired, limited, or restricted