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NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.
RAILROAD MEDICARE ADVISORY October 2021
Volume 2021, Issue 10
Latest Part B News for Railroad Medicare
What’s Inside...
Administration
Help Us to Help You: Have Your Provider and Patient Information Ready When You
Call Customer Service ............................................................................................................. 3
Provider Customer Service Center Training and Closure Dates ................................................. 4
“PTAN Lookup and Request Tool”............................................................................................. 6
Unsolicited Voluntary Refunds ................................................................................................... 6
Tell Us What You Think of Our Service ..................................................................................... 7
eServices and Google Authenticator ........................................................................................... 8
Get Your Railroad Medicare News Electronically .................................................................... 10
Medicare Learning Network® (MLN) ..................................................................................... 11
ePass is Now Available in the Railroad Medicare Interactive Voice Response
(IVR) Unit .......................................................................................................................... 12
How Can I Tell if a Patient Has Railroad Medicare? ............................................................... 14
eServices: COVID-19 Transition .............................................................................................. 16
Medicare FFS Response to the PHE on COVID-19 ................................................................. 17
2022 Annual Update for the Health Professional Shortage Area (HPSA) Bonus
Payments ............................................................................................................................... 34
Drugs and Biologicals
Influenza Vaccine Payment Allowances - Annual Update for 2021-2022 Season.................... 35
Electronic Data Interchange (EDI)
Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic
Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE)
360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark
Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council
for Affordable Quality Health Care (CAQH) CORE ............................................................ 37
Continued >>
palmettogba.com/rr
The Medicare Advisory contains coverage, billing and other information for Railroad Medicare. This
information is not intended to constitute legal advice. It is our official notice to those we serve concerning
their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information
is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain
this information and to follow the guidelines. The Railroad Medicare Advisory includes information provided
by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The
information is subject to change at any time. This bulletin should be shared with all health care practitioners
and managerial members of the provider staff. Bulletins are available at no-cost from our website at https://
www.PalmettoGBA.com/rr.
CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark
of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee
schedules, relative value units, conversion factors and/or related components are not assigned by the AMA,
and are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly
practice medicine or dispense medical services. The AMA assumes no liability for data contained or not con-
tained herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology
(CDT), Copyright © 2020 American Dental Association (ADA). All rights reserved.
Fee Schedules and Reimbursement
Quarterly Update to the Medicare Physician Fee Schedule..........................................................................................39
Annual Clotting Factor Furnishing Fee Update 2022 ...................................................................................................41
Medicine
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage
Determination (NCDs)--January 2022 .....................................................................................................................42
National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds ..........44
Ambulatory Surgical Center (ASC)
October 2021 Update of the Ambulatory Surgical Center (ASC) Payment System ....................................................46
Cardiology
Claims Processing Instructions for National Coverage Determination 20.33 - Transcatheter Edge-to-Edge Repair
[TEER] for Mitral Valve Regurgitation.....................................................................................................................50
Laboratory
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable
Charge Payment ........................................................................................................................................................52
MLN Connects
MLN Connects ..............................................................................................................................................................54
Do You Have a Question Regarding eServices? We Can Help!
Palmetto GBA has dedicated representatives available to provide technical assistance and answer
questions about our secure online portal — eServices. Our Provider Contact Center (PCC) representatives
can be reached at 888-355-9165 (Monday – Friday, 8:30 a.m. to 4:30 p.m. ET for all time zones with the
exception of PT, which receives services from 8 a.m. to 4 p.m.).
To connect with an eServices representative:
• Press 2 for EDI/eServices, then
• Press 1 for eServices inquiries
CMS Provider Minute Videos
The Medicare Learning Network has a series of CMS Provider Minute Videos
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-
Multimedia) on a variety of topics, such as psychiatry, preventive services, lumbar spinal fusion, and much
more. The videos offer tips and guidelines to help you properly submit claims and maintain sufficient supporting
documentation. Check the site often as CMS adds new videos periodically to further help you navigate the
Medicare program.
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
2 10/2021
Help Us to Help You: Have Your Provider and Patient
Information Ready When You Call Customer Service
Having the required provider and beneficiary authentication elements available when you call Customer Service
will save you time and help us handle your inquiry more efficiently.
You will be asked for the following information about the provider:
• The provider’s National Provider Identifier (NPI)
• The provider’s Railroad Medicare Provider Transaction Access Number (PTAN)
• The provider’s Tax Identification Number (TIN): last five digits
The Centers for Medicare & Medicaid Services (CMS) requires authentication of these provider elements
whenever a request would involve the disclosure of personally-identifiable information (PII) or protected health
information (PHI). If you are not able to provide the required elements, our Customer Service Advocates may
ask you to obtain the information and call back.
Don’t have your Railroad Medicare PTAN? Providers can use our PTAN Lookup and Request Tool to lookup
their Railroad Medicare PTAN. If you are employed by a clearinghouse or third-party biller, you must contact
the provider to obtain the Railroad Medicare PTAN. See our Using Railroad Medicare’s Online PTAN Lookup
and Request Tool article for details https://www.palmettogba.com/palmetto/rr.nsf/DID/AK7K447304.
You will be asked to provide the following information about the beneficiary:
• The beneficiary’s Medicare Beneficiary Identifier (MBI)
• The beneficiary’s last name
• The beneficiary’s first name or initial, and either
• The claim date(s) of service (for post-claim inquiries, such as reason for denial or rejection) or
• The beneficiary’s date or birth (for pre-claim inquiries, such as entitlement requests/issues)
The CMS requires authentication of these beneficiary elements prior to disclosing PII or PHI about a Medicare
beneficiary to an authenticated provider. All information must match. If you are not able to provide the required
elements, our Customer Service Advocates may ask you to obtain the information and call back.
Don’t have the patient’s MBI? There are three ways you and your office staff can get MBIs:
1. Ask your patient
2. Use the MBI Look-up tool on the Palmetto GBA eServices portal or your local Medicare Administrative
Contractor’s portal
• You can look up MBIs for your Medicare patients when they don’t or can’t give them. You must have
your patient’s first name, last name, date of birth and Social Security Number (SSN) to search. If a
patient doesn’t want to release their SSN to you, the patient will need to provide you with their MBI.
3. Check a remittance advice
• If you previously saw a patient and got a claim payment decision based on a claim submission with a
HICN before January 1, 2020, look at that remittance advice. We returned the MBI on every remittance
advice when a provider submitted a claim with a valid and active HICN from October 1, 2018 through
December 31, 2019.
Resource: MLN SE18006 — New Medicare Beneficiary Identifier (MBI) Get It, Use It at
https://tinyurl.com/SE18006
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
3 10/2021
Provider Customer Service Center Training
and Closure Dates
The Centers for Medicare & Medicaid Services (CMS) and the Railroad Retirement
Board (RRB) have approved the RRB Specialty Medicare Administrative Contractor
(RRB SMAC) to close up to eight hours per month for provider Customer Service
Advocates (CSAs) training and/or staff development. The goal is to help CSAs
improve the consistency and accuracy of their responses to provider questions;
enhance their awareness and understanding of Medicare policies and issues; and
facilitate CSAs’ retention of the facts of their training by increasing its frequency.
When our CSAs participate in training and developmental sessions on Thursdays
of each month, you may use our online provider portal called eServices. eServices
provides claim status, duplicate remittances, patient eligibility and much more. Register now at
https://www.PalmettoGBA.com/eServices. Please refer to the training schedule below for specific closure
dates and times.
Date Phones Closed
September 30, 2021 PCC closed for training / 2:30 to 4:30 PM ET
October 7, 2021 PCC closed for training / 2:30 to 4:30 PM ET
October 14, 2021 PCC closed for training / 2:30 to 4:30 PM ET
October 21, 2021 PCC closed for training / 2:30 to 4:30 PM ET
October 28, 2021 PCC closed for training / 2:30 to 4:30 PM ET
November 25, 2021 Office closed / Thanksgiving Day
November 26, 2021 Office closed / Day After Thanksgiving
December 23, 2021 Office closed / Christmas Eve
December 24, 2021 Office closed / Christmas Day
December 31, 2021 Office closed / New Year’s Day
Please note that we will attempt to provide advance notice of any changes to the above training schedule via
the website, IVR features and automatic email notices.
If you have not already done so, we encourage you to sign up for automatic email notices of updates to our
website. Subscribing to the email update is the fastest way to find out about Medicare changes that may affect
you. There is no charge for the service, and we will not share your email address with others. To register, go
to Email Updates at https://www.palmettogba.com/registration.nsf/Push+Mail+Archive+Home?OpenForm.
If you have questions, please call our Provider Contact Center at 888-355-9165 and select Option 5. Customer
Service Advocates are available between the hours of 8:30 a.m. to 4:30 p.m. for all time zones, with the exception
of PT, which receives service from 8 a.m. to 4 p.m. PT. Our eServices portal is available 24/7 with the exception
of claims, remittance, and financial data, which is available from 8 a.m. to 7 p.m. Monday through Friday. You
may access eServices at http://www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
4 10/2021
MACtoberfest®
October 19, 2021
Learn about the Railroad Medicare Program with a Spotlight on Medical Review
12:30 – 1:30 p.m. ET
Have questions about Railroad Medicare? Then this event is for you! During this informative session, we will
cover Railroad Medicare topics including:
• Who we are and what we do
• Requesting a Railroad Medicare Provider Transaction Access Number (PTAN)
• Enrolling to submit electronic claims
• Registering for our eServices portal
• Submitting Appeals and Reopenings requests
Our spotlight topic will be the Railroad Medicare Medical Review program. We will provide an overview of
the types of reviews Railroad Medicare conducts with emphasis on the available Medical Review resources. We
will also answer audience questions about the topics covered.
Register Today! https://event.on24.com/wcc/r/3372139/EDD90E069AC58EB736901DA5EBF81F24
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
5 10/2021
eDelivery Reminder: Are You Getting Your Greenmail?
Palmetto GBA would like to remind providers that you have the option to receive letters electronically
through eServices. Gaining access to these letters is a simple process! To start receiving your Medicare letters,
such as Medical Review Additional Documentation Request (ADR) letters and first level appeal Medicare
Redetermination Notices (MRNs) electronically, you must be signed up for our eServices online provider portal.
Once you have signed into eServices, select the Admin tab, next you can choose your eDelivery preferences.
Just click the drop down box to choose eDelivery of the letters you would like to receive via greenmail. You
can also select “User Email Notification” to start receiving emails when your letters are available in eServices
for you. Selecting this choice is so easy and allows you to receive your letters faster!
Once you have chosen the eDelivery option, all of the letters you selected will come to you electronically, even
if you sent in your request via fax or mail.
Railroad Medicare’s online
“PTAN Lookup and Request Tool”
Providers can now obtain their existing Railroad Medicare Provider Transaction Access Number (PTAN) or
request a new Railroad Medicare PTAN through our “PTAN Lookup and Request Tool” at
https://www.PalmettoGBA.com/RR/PTAN.
Please review the following resources before using the PTAN Tool:
• Using Railroad Medicare’s online “PTAN Lookup and Request Tool”
https://www.palmettogba.com/palmetto/rr.nsf/DID/AK7K447304
• Railroad Medicare PTAN Lookup and Request Tool FAQs
https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Railroad-Medicare~AXCNMG2662
Unsolicited Voluntary Refunds
The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the
rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil,
or administrative remedies arising from or relating to these or any other claims.
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
6 10/2021
Tell Us What You Think of Our Service
If your experience with Railroad Medicare was awesome or not, we’d like to hear from you! Telling us what
we do well lets us know what we should keep doing, and telling us how we can improve gives us room to grow.
Just visit our website and take our Palmetto GBA/Railroad Medicare Provider Experience survey at
https://www.surveymonkey.com/r/JPYHTDN. Here you can provide feedback on your most recent interaction
with Railroad Medicare that occurred via telephone, chat, email, mail or social media (Facebook, Twitter or
LinkedIn). We value your comments and opinions, and we look forward to a culture of continuous improvement
in the way we conduct business and serve our customers.
Our survey has eight easy questions and takes about three minutes to complete (if that). Those three minutes
can help us coach a Palmetto GBA team member to give a customer an awesome experience every time they
contact Railroad Medicare.
We thank you in advance for your participation!
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
7 10/2021eServices and Google Authenticator
To enhance the security of Medicare information, the Centers for Medicare & Medicaid Services (CMS) requires
the use of multi-factor authentication (MFA) each time you log in to eServices. We're excited to announce a
new option to protect your account - Google Authenticator.
You now have three options to receive an MFA code:
• Email
• Text
• Google Authenticator
Are you new to eServices? Or maybe you already have an eServices account...no worries! In just a few quick
steps, you can set up Google Authenticator. This two-step verification is available when initially registering
for eServices or if you already have an existing eServices account.
Initial Registration
Upon initial registration to eServices, you must complete the fields on the MFA Setup screen.
The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google
Authenticator option.
After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These
steps are based on your device - iPhone or Android:
• iPhone users must access iTunes
• Android users must access Google Play
A successful installation prompts this screen showing your device is now linked. Select Submit to save the
changes.
At your initial login to eServices, you are asked to choose your preferred method for receiving your MFA code.
Select the Use the app button to receive the MFA code via the Google Authenticator app.
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
8 10/2021After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will
renew every 30 seconds.
Enter the code in the available field and select the Submit button.
Existing Account
At your next login to eServices, you are asked to choose your preferred method for receiving your MFA code.
You must choose from the text or email options since you haven’t set up the Google Authenticator option yet.
After verification, go to the My Account tab to change your account settings.
From the My Account tab, scroll down until you see the MFA Setup options.
The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google
Authenticator option.
After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These
steps are based on your device - iPhone or Android:
• iPhone users must access iTunes
• Android users must access Google Play
A successful installation prompts this screen showing your device is now linked. Select Submit to save the
changes.
At your next login to eServices, you are again asked to choose your preferred method for receiving your MFA
code. But not you’ll notice you can also choose to receive your code with the Google Authenticator app.
Select the Use the app button to receive the MFA code via the Google Authenticator app.
After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will
renew every 30 seconds.
Enter the code in the available field and select the Submit button.
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
9 10/2021Get Your Railroad Medicare News Electronically
Register now to receive customized daily or weekly emails on the latest Medicare news and Palmetto GBA
features.
How to register to receive Palmetto GBA Railroad Medicare email updates:
Subscribing to our email updates is quick, easy and free! Go to https://tinyurl.com/RailroadMedicareEmailUpdates.
Enter your email address and select the topics you are interested in receiving updates about. Complete the
CAPTCHA equation and submit.
Note: After you click “Submit”, a confirmation email will be sent to your email address. Please use the link
provided in the email to confirm your registration.
eServices Eligibility
eServices, by Palmetto GBA, allows you to search for patient eligibility. The eServices eligibility functions
are based on CMS’ HIPAA Eligibility Transaction System (HETS). See options below:
• Medicare ID Number, Last Name, First Name, Birth Date
• Medicare ID Number, Last Name, Birth Date
• Medicare ID Number, Last Name, First Name
For more information about eServices and the many services it offers, see our eServices User Manual at
http://www.PalmettoGBA.com/eServicesuserguide.
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
10 10/2021Medicare Learning Network® (MLN)
Want to stay informed about the latest changes to the Medicare Program? Get
connected with the Medicare Learning Network® (MLN) – the home for education,
information, and resources for health care professionals.
The Medicare Learning Network® is a registered trademark of the Centers for
Medicare & Medicaid Services (CMS) and the brand name for official CMS education
and information for health care professionals. It provides educational products on
Medicare-related topics, such as provider enrollment, preventive services, claims
processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of
formats, including articles, educational tools, booklets, fact sheets, web-based training courses (many of which
offer continuing education credits) – all available to you free of charge!
You can find links to the following resources on the CMS MLN web page at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo
• Publications & Multimedia
• Events & Training
• News & Updates
• Association Continuing Education Credit
MLN Connects Electronic Mailing List
Subscribe to the MLN Connects weekly email newsletter for all national Fee-for-Service (FFS) program news,
including MLN Matters Article and MLN product updates.
To subscribe to the service:
1. Go to https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&topic_id=USCMS_7819.
Enter you email address and select Submit.
2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!
If you would like to contact the MLN, please email CMS at MLN@cms.hhs.gov.
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
11 10/2021ePass is Now Available in the Railroad Medicare Interactive
Voice Response (IVR) Unit
Provider authentication by Provider Transaction Access Number (PTAN), National Provider Identifier (NPI) and
Tax Identification Number (TIN) is required before the Palmetto GBA Interactive Voice Response (IVR) Unit
is authorized to release Railroad Medicare claim status information, financial information, patient eligibility
information, or to order a copy of a remittance advice.
An “ePass” is an eight-digit code you will be prompted to receive or enter each time you choose the IVR options
for claims, finance, eligibility or duplicate remittance advice. When you choose option 2 to receive an ePass,
you will be assigned an ePass code for the provider’s PTAN/NPI/TIN combination you enter. You can then
enter that ePass in the IVR for the remainder of the day in order to authenticate that provider. This eliminates
the need to repeatedly enter the same PTAN, NPI and TIN into the IVR.
The goal of the ePass is to ease provider burden by eliminating the need to repeatedly authenticate the same
provider each time you contact the IVR in a given day.
We hope this service will be effective and helpful to you.
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12 10/2021eServices Extends Administrator Unlock Feature
Beyond 30 Days
Palmetto GBA has implemented a “Disable User” functionality in eServices that will disable a user that has
been inactive for 30 days instead of terminating the User ID. Administrators are able to enable the user up to
120 days after 30 days of inactivity. If the user ID is not enabled within this time, the account will be terminated.
We will send notification to providers through a series of periodic emails (up to the 120-day limit) to remind
the user of their status and provide instructions to re-enable eServices IDs.
In short, provider administrators can simply unlock users as well as other administrators. This is a significant
change from past guidelines. Previously:
• Provider Administrators and users were required to login at least once every 30 days
• Accounts in which users did not login past 30 days were deactivated/terminated
• If the provider admin did not login, all user accounts associated with the provider admin were also
deactivated/terminated
• This created additional work for administrators as they were required to create new accounts for deactivated/
terminated users
The Provider Contact Center eServices Helpdesk is also able to assist if the provider administrator is unable to
complete this task. Provider Contact Center (PCC) representatives can be reached at 888-355-9165 (Monday
– Friday, 8:30 a.m. to 4:30 p.m. ET for all time zones with the exception of PT, which receives services from
8 a.m. to 4 p.m.). To connect with an eServices representative:
• Press 2 for EDI/eServices, then
• Press 1 for eServices inquiries
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
13 10/2021How Can I Tell if a Patient Has Railroad Medicare?
Railroad Medicare beneficiaries historically have had unique Medicare numbers, which made them easily
distinguishable from Social Security Medicare patients. With today’s Medicare Beneficiary Identifiers (MBIs),
the you can’t tell the difference by the MBI. Instead, the difference lies in the design of the Medicare card.
The Medicare card of a person with Railroad Medicare is unique. The Railroad Retirement Board (RRB) issues
Railroad Medicare cards with the RRB logo in the upper left corner, and ‘Railroad Retirement Board’ at the
bottom, as shown here. Railroad Medicare cards also have a QR code on the front lower right-hand corner of
the cards, while Medicare cards will have a QR code on the back of the card. Make sure to ask your patients for
their new cards and program your system to identify Railroad Medicare patients based on their cards, if possible.
If you verify your patient’s eligibility electronically, CMS will return a message on the eligibility transaction
response for a Fee-For-Service (FFS) Railroad Medicare MBI inquiry that will read “Railroad Retirement
Medicare Beneficiary” in 271 Loop 2110C, Segment MSG.
If you verify a patient’s eligibility using an MBI in the Palmetto GBA eServices online provider portal, the
portal will return the “Railroad Retirement Medicare Beneficiary” message in the Additional Information field
of the Eligibility sub-tab, as shown below.
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
14 10/2021For more information on the new Medicare cards and using the MBIs, see the following Medicare Learning
Network (MLN) resources:
• MBI website: https://www.cms.gov/Medicare/New-Medicare-Card/index
• MLN SE18006 - New Medicare Beneficiary Identifier (MBI) Get It, Use It: https://tinyurl.com/SE18006
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
15 10/2021eServices: COVID-19 Transition
In light of the COVID-19 pandemic, organizations are proactively transitioning employees across the health
care industry back into the office.
Palmetto GBA is providing a quick reference eServices guide to assist with common issues you may experi-
ence if you have not logged into your eServices account in the past 30-60 days.
If you are not currently registered to use eServices, we have also included some resources to get you started.
Railroad Medicare:
https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BRKJM375&url=yes
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
16 10/2021Medicare FFS Response to the PHE on COVID-19
MLN Matters Number: SE20011 Revised
Article Release Date: September 8, 2021
Related CR Transmittal Number: N/A
Related Change Request (CR) Number: N/A
Effective Date: N/A
Implementation Date: N/A
Note: We revised this Article to add more information about the SNF waivers. You’ll find substantive content
updates in dark red font on page 13. All other information remains the same.
Provider Types Affected
This MLN Matters® Special Edition Article is for physicians, providers and suppliers who bill Medicare Fee-
for-Service (FFS).
Provider Information Available
The Secretary of the HHS declared a public health emergency (PHE) in the entire United States on January
31, 2020. On March 13, 2020, HHS authorized waivers and modifications under Section 1135 of the Social
Security Act (the Act) (https://www.ssa.gov/OP_Home/ssact/title11/1135.htm), retroactive to March 1, 2020.
CMS is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent
gaps in access to care for patients affected by the emergency. You don’t need to apply for an individual waiver
if a blanket waiver is issued.
For more Information, refer to:
• Coronavirus Waivers and Flexibilities (https://www.cms.gov/about-cms/emergency-preparedness-response-
operations/current-emergencies/coronavirus-waivers) webpage
• Instructions (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-
an-1135-Waiver-Updated-11-16-2016.pdf) to ask for an individual waiver if no blanket waiver exists
Background
Section 1135 and Section 1812(f) Waivers
As a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal
waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:
1. The “DR” (disaster related) condition code for institutional billing, that is, claims you submit using the
ASC X12 837 institutional claims format or paper Form CMS-1450.
2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-institution-
al, that is, claims you submit using the ASC X12 837 professional claim format or paper Form CMS-
1500 or, for pharmacies, in the NCPDP format.
Clarification for Using the “CR” Modifier and “DR” Condition Code
When HHS declares a PHE and invokes Section 1135 authority, we have the authority to take proactive steps
through 1135 waivers as well as, where applicable, authority granted under Section 1812(f) of the Act, to
approve blanket waivers of certain Social Security Act requirements. These waivers help prevent gaps in access
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17 10/2021to care for patients affected by the emergency. In prior emergencies, we issued waivers for the Medicare Fee-
for-Service program. To allow us to assess the impact of prior emergencies, we needed modifier “CR” and
condition code “DR” for all services provided in a facility operating per CMS waivers that typically were in
place, for limited geographical locations and durations of time.
For the COVID-19 PHE, we added many blanket waivers, flexibilities, and modifications to existing deadlines
and timetables that apply to the whole country. See the full list
(https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf) of waivers and
flexibilities. Due to the large volume and scope of these new blanket waivers and flexibilities, we are clarifying
which need the usage of modifier “CR” or condition code “DR” when submitting claims to Medicare. The
chart below identifies those blanket waivers and flexibilities for which CMS requires the modifier or condition
code. Submission of the modifier or condition code isn’t needed for any waivers or flexibilities not included
in this chart.
Please note that we wouldn’t deny claims due to the presence of the “CR” modifier or “DR” condition code for
services or items related to a COVID-19 waiver that aren’t on this list, or for services or items that aren’t related
to a COVID-19 waiver. There may be potential claims implications, like claims denials, for claims that don’t
contain the modifier or condition code as identified in the below chart, but providers don’t need to resubmit or
adjust previously processed claims to conform to the requirements below, unless claims payment was affected.
Waiver/Flexibility Summary CR DR
Care for Excluded Allows acute care hospitals with excluded distinct part inpatient X
Inpatient Psychiatric psychiatric units to move inpatients from the excluded distinct part
Unit Patients in the psychiatric unit to an acute care bed and unit as a result of a disaster
Acute Care Unit of a or emergency.
Hospital
Housing Acute Care Allows acute care hospitals to house acute care inpatients in excluded X
Patients in the IRF or distinct part units, like excluded distinct part unit IRFs or IPFs, where
Inpatient Psychiatric the distinct part unit’s beds are appropriate for acute care inpatients.
Facility (IPF)
Excluded Distinct
Part Units
Care for Excluded Allows acute care hospitals with excluded distinct part inpatient X
Inpatient rehabilitation units to move inpatients from the excluded distinct
Rehabilitation Unit part rehabilitation unit to an acute care bed and unit as a result of
Patients in the Acute this PHE.
Care Unit of a
Hospital
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
18 10/2021Waiver/Flexibility Summary CR DR
Supporting Care for We decided to issue a blanket waiver to long-term care hospitals X
Patients in Long Term (LTCHs) where an LTCH admits or discharges patients to meet the
Care Acute Hospitals demands of the emergency from the 25-day average length of stay
(LTCHs) requirement at § 412.23(e)(2), which allows these hospitals to take
part in the LTCH PPS. Also, during the applicable waiver period,
we decided to issue a blanket waiver to hospitals not yet classified
as LTCHs, but seeking classification as an LTCH, to exclude patient
stays where the hospital admits or discharges patients to meet the
demands of the emergency from the 25-day average length of stay
requirement, which must be met in order for these hospitals to be
eligible to take part in the LTCH PPS.
Care for Patients in Allows extended neoplastic disease care hospitals to exclude X
Extended Neoplastic inpatient stays where the hospital admits or discharges patients to
Disease Care Hospital meet the demands of the emergency from the greater than 20-day
average length of stay requirement, which allows these facilities to
be excluded from the hospital inpatient prospective payment system
and paid an adjusted payment for Medicare inpatient operating and
capital-related costs under the reasonable cost-based payment rules.
Skilled Nursing Using the authority under Section 1812(f) of the Act, we are waiving X
Facilities (SNFs) the requirement for a 3-day prior hospitalization for coverage of a
SNF stay, which provides temporary emergency coverage of SNF
services without a qualifying hospital stay, for those people who
experience dislocations, or are otherwise affected by COVID-19.
Also, for certain patients who exhausted their SNF benefits, it
authorizes renewed SNF coverage without first having to start a
new benefit period (this waiver will apply only for those patients
who have been delayed or prevented by the emergency itself from
commencing or completing the process of ending their up-to-date
benefit period and renewing their SNF benefits that would have
occurred under normal circumstances).
Durable Medical When DMEPOS is lost, destroyed, irreparably damaged, or X
Equipment, otherwise unusable, allow the DME MACs to have the flexibility to
Prosthetics, Orthotics, waive replacements requirements so the face-to-face requirement,
and Supplies a new physician’s order, and new medical necessity documentation
(DMEPOS) aren’t needed. Suppliers must still include a narrative description on
the claim explaining the reason why they are replacing equipment
and we remind them to keep documentation indicating that the
DMEPOS was lost, destroyed, irreparably damaged, or otherwise
unusable or unavailable as a result of the emergency.
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
19 10/2021Waiver/Flexibility Summary CR DR
Modification of Modifies the 60-day limit to allow a physician or physical therapist X
60-Day Limit for to use the same substitute for the entire time he or she is unavailable
Substitute Billing to provide services during the COVID-19 emergency, plus an added
Arrangements period of no more than 60 continuous days after the PHE expires. On
(Locum Tenens) the 61st day after the PHE ends (or earlier), the regular physician or
physical therapist must use a different substitute or return to work
in his or her practice for at least 1 day to reset the 60-day clock.
Physicians and eligible physical therapists must continue to use the
Q5 or Q6 modifier (as applicable) and don’t need to begin including
the CR modifier until the 61st continuous day.
Critical Access Waives the requirements that Critical Access Hospitals limit the X
Hospitals number of inpatient beds to 25, and that the length of stay, on an
average annual basis, be limited to 96 hours.
Replacement We allow Medicare payment for replacement prescription fills (for X
Prescription Fills a quantity up to the amount originally dispensed) of covered Part B
drugs in circumstances where dispensed medication has been lost
or otherwise unusable by damage due to the disaster or emergency.
Hospitals Classified Waives certain eligibility requirements for hospitals classified as X
as Sole Community SCHs before the PHE, specifically the distance requirements and
Hospitals (SCHs) the “market share” and bed requirements (as applicable).
Hospitals Classified For hospitals classified as MDHs before the PHE, waives the X
as Medicare- eligibility requirements that the hospital has 100 or fewer beds
Dependent, Small during the cost reporting period and that at least 60 percent of
Rural Hospitals the hospital’s inpatient days or discharges were attributable to
(MDHs) individuals entitled to Medicare Part A benefits during the specified
hospital cost reporting periods.
IRF 60 Percent Rule Allows an IRF to exclude patients from its inpatient population for X
purposes of calculating the applicable thresholds associated with the
requirements to get payment as an IRF (commonly referred to as
the “60 percent rule”) if an IRF admits a patient solely to respond to
the emergency. Also, during the applicable waiver period, we would
also apply the exception to facilities not yet classified as IRFs, but
that are trying to obtain classification as an IRF.
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20 10/2021Waiver/Flexibility Summary CR DR
Waivers of certain Allows a hospital or Community Mental Health Center (CMHC) X X
hospital and to consider temporary expansion locations, including the patient’s
Community Mental home, to be a provider-based department of the hospital or extension
Health Center of the CMHC, which allows institutional billing for certain outpatient
(CMHC) Conditions services provided in temporary expansion locations. If the entire
of Participation and claim falls under the waiver, the provider would only use the DR
provider-based rules condition code. If some claim lines fall under this waiver and others
don’t, then the provider would only append the CR modifier to the
particular line(s) that falls under the waiver.
Billing Procedures To keep patients in their SNF/NF and decrease their risk of being X X
for ESRD services exposed to COVID-19, ESRD facilities may temporarily provide
when the patient is in renal dialysis services to ESRD patients in the SNF/NF instead of
a SNF/NF the offsite ESRD facility. The in-center dialysis center should bill
Medicare using Condition Code 71 (Full care unit. Billing for a
patient who got staff-assisted dialysis services in a hospital or renal
dialysis facility). The in-center dialysis center should also apply
condition code DR to claims if all the treatments billed on the claim
meet this condition or modifier CR on the line level to identify
individual treatments meeting this condition.
Billing Procedures To keep patients in their SNF/NF and decrease their risk of being X
for ESRD services exposed to COVID-19, ESRD facilities may temporarily provide
when the patient is in renal dialysis services to ESRD patients in the SNF/NF instead of
a SNF/NF the offsite ESRD facility. The in-center dialysis center should bill
Medicare using Condition Code 71 (Full care unit. Billing for a
patient who got staff-assisted dialysis services in a hospital or renal
dialysis facility). The in-center dialysis center should also apply
condition code DR to claims if all the treatments billed on the claim
meet this condition or modifier CR on the line level to identify
individual treatments meeting this condition.
Clinical Indications In the interim final rule with comment period (CMS-1744-IFC and X
for Certain CMS-5531-IFC) we state that clinical indications of certain national
Respiratory, Home and local coverage determinations wouldn’t be enforced during
Anticoagulation the COVID-19 PHE. We wouldn’t enforce clinical indications for
Management, respiratory, oxygen, infusion pump and continuous glucose monitor
Infusion Pump national coverage determinations and local coverage determinations
and Therapeutic
Continuous Glucose
Monitor national
and local coverage
determinations
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
21 10/2021Waiver/Flexibility Summary CR DR
Face-to-face and In- In the interim final rule with comment period (CMS-1744-IFC) we X
person Requirements state that to the extent a national or local coverage determination
for national and would otherwise need a face-to-face or in-person encounter for
local coverage evaluations, assessments, certifications or other implied face-to-face
determinations services, those requirements wouldn’t apply during the COVID-19
PHE.
Requirement for We paused the requirement to send a prior authorization request X
DMEPOS Prior for certain DMEPOS items and services. Suppliers were given the
Authorization choice to voluntarily continue to send prior authorization requests
or to skip prior authorization and have the claim reviewed through
post payment review at a later date. Claims that would normally
need prior authorization, but were submitted without going through
the process should be submitted with a CR modifier
Signature We waived the signature requirement for Part B drugs and certain X
requirements for Durable Medical Equipment (DME) that need a proof of delivery
proof of delivery and or a patient signature. You should use a CR modifier on the claim
and document in the medical record the right delivery date and that
a signature couldn’t be obtained because of COVID-19
Part B Prescription MACs may exercise flexibilities about the payment of Medicare Part X
Drug Refills B claims for drug quantities that exceed usual supply limits, and to
allow payment for larger quantities of drugs, if necessary. MACs
may require the CR modifier in these cases.
Services provided During the COVID-19 PHE, hospitals may send clinical staff services X
by the hospital in in the patient’s home as a provider-based outpatient department and
the patient’s home bill and be paid for these services as Hospital Outpatient Department
as a provider-based (HOPD) services when the patient is registered as a hospital
outpatient department outpatient. Hospitals should bill as if they provided the services
when the patient in the hospital, including appending the PO modifier for excepted
is registered as a items and services and the PN modifier for non-excepted services.
hospital outpatient. The DR condition code should also be appended to these claims.
Ground Ambulance CMS waived the requirements that an ambulance service include the X
Services: Treatment transport of an individual to the extent necessary to allow payment
in Place for ground ambulance services furnished in response to a 911 call
(or the equivalent in areas without a 911 call system) in cases in
which an individual would have been transported to a destination
permitted under Medicare regulations but such transport did not
occur as a result of community-wide emergency medical service
(EMS) protocols due to the COVID-19 PHE.
Medicare FFS, FAQs available on the Waivers and Flexibilities webpage
(https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-
flexibilities.html) apply to items and services for Medicare patients in the current emergency. We display these
FAQs in these files:
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
22 10/2021• COVID-19 FAQs (https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf)
• FAQs that apply without any Section 1135 (https://www.cms.gov/About-CMS/Agency-Information/
Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf) or other formal waiver.
• FAQs apply only with a Section 1135 waiver or, when applicable, a Section 1812(f) (https://www.cms.
gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.
pdf) waiver.
Blanket Waivers Issued by CMS
View the complete list
(https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf) of COVID-19
blanket waivers.
Counseling and COVID-19 Testing
To prevent further spread of COVID-19, a key strategy includes quarantine and isolation while patients wait
for test results or after they get positive test results – regardless of showing symptoms.
Health care providers who counsel patients during their medical visits have an opportunity to decrease the
time between patient-testing and quarantine or isolation, especially when this counseling happens concurrent
with COVID-19 testing. Working in partnership with public health personnel, you could speed the counseling,
testing, and referrals for case tracing initiation to reduce potential exposures and added cases of COVID-19.
By having patients isolated 1-2 days earlier, you can reduce the spread of COVID-19 significantly. Modeling
shows early isolation can reduce transmission by up to 86 percent.
Through counseling, you can discuss with patients:
• The signs and symptoms of COVID-19
• The immediate need to separate from others by isolation or quarantine, particularly while awaiting test results
• The importance of informing close contacts of the person being tested (for example, family members) to
separate from the patient awaiting test results
• If the patient tests positive, the patient will be contacted by the public health department to learn the names
of the patient’s close contacts. The patient should be encouraged to speak with the health department
• The services that may be available to help the patient in successfully isolating or quarantining at home
This early intervention of counseling steps and isolation can reduce spread of COVID-19.
How to Bill for Counseling Services
Medicare covers these counseling services. Health care providers providing counseling services to people with
Original Medicare should use existing and applicable coding and payment policies to report services, including
evaluation and management
(https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-
mgmt-serv-guide-icn006764.pdf) visits.
When providing these services during 2020, when you spend more than 50 percent of the face-to-face time (for
non-inpatient services) or more than 50 percent of the floor time (for inpatient services) providing counseling
or coordination of care, you may use that time to select the level of visit reported.
Please review the following provider resources:
Continued >>
CPT codes, descriptors and other data only are copyright 2020 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
23 10/2021You can also read
