Category: Medicare
Superior: Appeal Submissions
IMPORTANT: Post-Service Medical Necessity Appeal Submissions
Superior HealthPlan would like to remind providers that post-service Medical Necessity Appeals must be mailed or faxed using the submission information below. Submissions must include the reason for appeal and any additional clinical information for appeal review..
Centene Management Company
ATTN: Medical Management Appeals
5900 E. Ben White Blvd
Austin, Texas 78741
Fax number: 1-866-918-2266
Post-service appeals for reconsideration of a Medical Necessity Denial on behalf of a member should not be sent to the Claims Appeal address.
For questions about post-service Medical Necessity Appeals, providers can contact 1-877-398-9461.
Submit 2024 MIPS Data by April 14th
The data submission period for Medicare’s 2024 Merit-Based Incentive Payment System (MIPS) performance yeard has been extended to April 14th at 7 pm CT.
At Stake is a pay cut of up to 9% in the 2026 payment year.
Cigna Medicare Business Acquisition Completed
Well, it is final. As of today, March 19, 2025 Health Care Service Corporation
(HCSC) has acquired Cigna’s Medicare operations.
HCSC has acquired Cigna’s Medicare businesses, including Medicare Advantage, Cigna Supplemental Benefits, Medicare Part D, and CareAllies.
It has been stated:
- Members will have the same plan, member ID, benefits, and network structure.
- No changes are expected for 2025
- You should not expect any changes in coverage levels or out-of-pocket cost.
- And the one we all hoped would change, BCBS says we can still expect the same level of service.
Humana’s Contract Numbers
Knowing the Medicare Advantage (MA) Contract number of the plans your office has opt’ed into can be a big help.
Some may say what is a MA contract number? Or you may have heard it called an H number.
The Centers for Medicare and Medicaid Services (CMS) is responsible for identifying each Medicare Advantage C plan with a unique contract number. This number is assigned to the insurance company during the approval process. For local managed care contracts, the number begins with an ‘H’ or a ‘9″.
Below are your H numbers for the Humana-POET contract.
The next time you are in doubt about a Humana Card, look for one of these numbers on the front of the card.
Humana Gold Plus H0028-041 (HMO)
HumanaChoice Giveback H5216-358 (PPO)
Humana USAA Honor Giveback H5216-348-000-2025 (PP0) This is the only Humana Military card under the POET Contract.
This isn’t the best example of a Humana card, but you can see the H number in the bottom right hand corner.
Aetna Reverses NPP Payment Reduction
By: Hannah Wisterman ~ 2/12/25
On January 31st, InK reported Aetna was changing it’s policy on billing for Non-Physician Providers (NPP). As of February 10th Aetna has changed their stand. Please Read!
Aetna’s Feb. 10 reversal preserves NPPs’ ability to fully bill under a supervising physician’s name and National Provider Identifier (NPI) for services “incidental to” the physician’s diagnosis and treatment of an injury or illness. Services billed incident-to must be conducted in the same office suite where the physician is present and available to intervene if needed.
HS Connect Issues
You may have been experiencing issues with HS Connect. One office reported to POET (thank you) they had been in contact with HS Connect. And was told that on January 1, 2025 HS Connect had a major update. You may already guessed, it failed (Majorly in Texas). Our source was told that HS Connect is having to enter Texas Data by hand. What you are seeing when you pull up the screen is 2024 data.
For more information call: HS Connect Help Desk (866) 952-7596 , option 2 or email [email protected]
Modifier 25 Fact Sheet from Novitas
Modifier 25 Fact Sheet
Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.
Physicians of the same specialty in the same group practice are considered the same physician; therefore, they must bill and be paid as though they were a single physician.
Appropriate Use
Use modifier 25 with the appropriate level of E/M service.
- Modifier 25 indicates on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-operative care associated with the procedure or service performed.
- E/M service may occur on the same day as a procedure. Medicare allows payment when the documentation supports modifier 25.
- A minor surgical procedure performed has a global period of 0-day or 10-day listed on the Medicare physician fee schedule (JH) (JL) and meets the definition of modifier 25.
Global Surgery
Global surgery is defined as all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.
Do not use modifier 25 when billing for services performed during a post-operative period if related to the previous surgery. Related follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure’s global surgical package.
- For an unrelated E/M service during the global period of a previous procedure, you may be able to report an appropriate E/M code with modifier 24 (unrelated evaluation and management service by the same physician during a postoperative period) appended.
- The E/M is for a new problem not related to the patient’s previous complaint or procedure.
- Append modifier 57 (decision for surgery), rather than modifier 25, if the E/M service prompts the decision to render a major procedure within 24 hours of the E/M service. Major procedure is defined as one with a 90-day global period.
National Correct Coding Initiative (NCCI) Procedure-to-procedure (PTP) edits
The NCCI promotes national correct coding methodologies and controls improper coding leading to inappropriate payment. The PTP code pair edits are automated prepayment edits preventing improper payment when reporting certain codes together for Part B-covered services on the same day by the same physician.
When both correct coding and global surgery edits apply to the same claim by the same physician, we’ll first apply the correct coding edits. Then, we’ll apply the global surgery edits to the correctly coded services
References:
E/M visit complexity add-on HCPS code G2211,
Effective for dates of service on and after January 1, 2025:
HCPCS code G2211 is payable when an associated office and outpatient (O/O) E/M base code (CPT codes 99202-99205 or 99211-99215) is reported with modifier 25 for the same patient by the same provider and a Part B preventive service, immunization administration, or annual wellness visit service identified in attachment 1 in Change Request (CR) 13705 is also present for the same date of service.
For claims not containing one of the identified services above or dates or service prior to January 1, 2025:
- Claims will deny when HCPCS code G2211 and an associated office and outpatient (O/O) E/M visit (CPT codes 99202-99205 or 99211-99215) is reported with modifier 25 for the same patient by the same provider on the same date of service:
- Separately identifiable visits occurring on the same day as minor procedures (such as 0 or 10-day global procedures) have resources sufficiently distinct from costs associated with furnishing stand-alone O/O E/M visits to justify different payment.
References:
- Change Request 13705 – Allow Payment for Healthcare Common Procedure Coding System (HCPCS) Code G2211 when Certain Part B Preventive Services are Provided on the Same Day
- MLN Matters article MM13473 – How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on-Code G2211
- MLN Matters article MM13272 – Edits to Prevent Payment of G2211 with Office/Outpatient Evaluation and Management Visit and Modifier 25c
Inappropriate use
Avoid denials of claims with an appropriate use of modifier 25
- Do not report HCPCS code G2211 when modifier 25 is reported on an associated E/M visit (CPT codes 99202-99205 and 99211-99215) for claims not containing a Part B preventive service, immunization administration, or annual wellness visit service or dates of service prior to January 1, 2025.
- Do not use modifier 25 on HCPCS code G2211.
- Do not use modifier 25 on CPT code 99211
- Do not use modifier 25 by a physician other than the physician performing the procedure or physician of the same specialty in the same group practice.
- Do not use modifier 25 when documentation does not support a significant, separately identifiable E/M service.
References:
- CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 40.2-40.5
- CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 23, section 30.2
- E/M Service-specific coding instructions
- Frequently Asked Questions: Evaluation and management services
- Global Surgery Fact Sheet
- Global surgery & related services
- Global surgery calculator (JH) (JL)
- Local contractor pricing references
- MLN Matters article MM13452 – Medicare Physician Fee Schedule Final Rule Summary: CY 2024
- Modifier 25 tip sheet
Telehealth Breaking News
The below information was received today 12/26/2024, from Betsy Nicoletti
Medicare practitioners and patients can continue to perform/receive telehealth services as they have since the start of the pandemic for the next three months.
The first keep-the-government-open bill from Dec. 20 extended Medicare telehealth for two years. It didn’t pass. The bill that passed and was signed into law extends telehealth for Medicare patients as we know it now until March 31, 2025. Then, Congress must ACT again or we have the return to the pre-pandemic rules
Does this mean we can use the new CPT telehealth codes 98000-98015?
NOT FOR MEDICARE PATIENTS
98000-98015 have a status indicator of INVALID
Continue to use office visit codes with POS 02 or POS 10
And Other Payers?
Sadly, each payer can make their own telehealth rules.
2025 Medicare Outlook
1st Come, 1st Served
POET will host MGMA’s 2025 Medicare Outlook Web Event
Date: December 10, 2024
Time: 12 o’clock, noon
Where: POET Office 111 Gaslight Blvd. Ste.B, Lufkin, TX 75949
Lunch will be provided
Limited Seating Available
Call or Email to reserve your place.
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