It seems not a day goes by that I do not receive a phone call regarding a Medicare regulatory issue. I would like to review a few frequently discussed topics, along with tips and reminders, that you might find helpful, whether you are a new or seasoned Medicare provider.
Revalidation: Once you are enrolled as a Medicare provider for orthotics and prosthetics, the Centers for Medicare & Medicaid Services (CMS) mandates that your practice is revalidated every three years (from the date of initial enrollment or your last revalidation). The National Supplier Clearinghouse (NSC) will notify you by mail two to three months before your revalidation is due. You should be aware of the due date to ensure you do not miss this notice when it arrives. If you do not complete the revalidation on time, your Medicare payments will be placed on hold and/or your Medicare number will be deactivated. I am surprised by the number of calls I get stating the notification for revalidation was never opened or was lost, and the provider only realized it once his or her provider number was deactivated.
Please note that NSC revised the enrollment application for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers, Form CMS-855S, earlier this year. The new Form CMS-855S (05/16) must be used beginning January 1, 2017. This form is available on the NCS website, www.palmettogba.com/nsc.
Provider Transaction Number (PTAN): Each physical location of your practice must have its own PTAN number. If your practice has multiple locations where patients are seen, but only one location is used as your central billing location, you will want to review how your Health Insurance Claim Form, CMS-1500, is being generated.
Box 32 on CMS-1500 identifies the location where the services were rendered, and box 33 identifies the billing provider information or the provider name and address where the payment should be sent. Medicare regulation states that a PTAN is considered inactive if it has not been used in billing for four consecutive quarters. You will want to ensure each PTAN is used at least once per year. I recommend you use each PTAN at least once per quarter to avoid an unnecessary deactivation.
Administrative Simplification and Compliance Act (ASCA): The ASCA prohibits payment for services to a provider if the claim was not billed to Medicare electronically, except in specific situations. To maintain efficient billing practices, it is always recommended that you submit claims electronically.
Following are a few circumstances in which Medicare will allow paper claim submissions:
- If a practice has fewer than ten full-time employees
- If a practice submits fewer than ten Medicare claims per month
- If the claim is submitted directly by the beneficiary
If a practice does not meet the requirements, there are still some instances when a claim must be submitted with certain accompanying paperwork, and will require an ASCA waiver. For example, one of my clients provides lymphedema pumps. Each of these claims requires that a Certificate of Medical Necessity be attached, which needs to be submitted via paper claim form. If you need to submit claims to Medicare via paper submission, you must complete an ASCA waiver or your claim will be denied.
For a complete list of circumstances for billing via paper claims without the need for an ASCA waiver, visit www.oandp.com/link/341.
Erin Cammarata is president and owner of CBS Medical Billing and Consulting. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact .
