Getting Paid

Navigating the Medicare Web Site

A guide to unearthing answers at the Centers for Medicare & Medicaid Services Web site.

Kent J. Moore

Covered in FPM Quiz

As a family physician, you probably have a lot of questions about Medicare, the answers to which may affect whether you get paid for your services. The Centers for Medicare & Medicaid Services (CMS) Web site has an amazing number of answers - if you know where to look.

Getting started

The best place to start is the site's main page at http://www.cms.hhs.gov. Along the left side of the page, you will find links to each of CMS's major program areas - such as Medicare, Medicaid, the Health Insurance Portability and Accountability Act (HIPAA) and Clinical Laboratory Improvement Amendments (CLIA) - as well as key topics such as "Coverage" and "Quality Initiatives." Along the top of the home page, you will find, among other things, a link to a Frequently Asked Questions (FAQ) database and a search feature powered by Google. You'll also see pull-down menus for various CMS audiences. Under the "Professionals" tab is a link for "Physicians," which is our next stop on the tour.

Information for physicians

The CMS Web site has an amazing number of answers - if you know where to look.

At http://www.cms.hhs.gov/physicians/ is Medicare information specifically for physicians. For example, if you want to find the Medicare allowance for a given code (or series of codes) in your area, you can do that by clicking on the link labeled "Medicare Physician Fee Schedule Look-up." This online tool also allows you to access other payment policy indicators associated with codes in the Medicare physician fee schedule.

You can download the entire Medicare fee schedule through the link to "CMS Files for Download for Medicare Payment Systems." You can even access the most current National Correct Coding Initiative edits (http://www.cms.hhs.gov/physicians/cciedits/) to determine whether two codes you are considering billing together will both be paid. Of course, getting claims paid by Medicare also depends on proper coding. You can find HCPCS codes on the CMS Web site at http://www.cms.hhs.gov/medicare/hcpcs/default.asp as well as ICD-9 codes at http://www.cms.hhs.gov/medlearn/icd9code.asp. You can even find Medicare place of service codes http://www.cms.hhs.gov/states/poshome.asp. About the only code set you can't access for free on the CMS site is CPT, which is owned and maintained by the American Medical Association (see http://www.ama-assn.org/go/cpt).

Forms and coverage

What would Medicare be without forms? Thankfully, you can find almost all of them on the CMS Web site. For example, if you are not yet enrolled as a physician in Medicare and want to do so, you can find the necessary enrollment forms at http://www.cms.hhs.gov/providers/enrollment/forms/. Likewise, if you need to provide a patient with an Advance Beneficiary Notice (ABN), you can find one (in English or Spanish) at http://www.cms.hhs.gov/medicare/bni/. For almost any other CMS form you might be seeking, check out http://www.cms.hhs.gov/forms/.

Speaking of ABNs, knowing when you need one often depends on knowing whether Medicare covers the service in question and under what conditions. Fortunately, CMS has provided an online, searchable database of both national and local (i.e., carrier-specific) coverage policy. You can use the database at http://www.cms.hhs.gov/mcd/search.asp. For other information on Medicare coverage, visit the Medicare coverage home page at http://www.cms.hhs.gov/coverage/default.asp.

Other questions, other places

If you have a question about Medicare as a secondary payer, try the Medicare Secondary Payer Manual at http://www.cms.hhs.gov/manuals/105_msp/msp105index.asp. For related questions about Medicare coordination of benefits, try http://www.cms.hhs.gov/medicare/cob/default.asp.

If you have a physician office laboratory, you may have questions about CLIA. A good place to start looking for answers to those questions is at http://www.cms.hhs.gov/clia/. Here you can learn how to apply for a CLIA certificate. You can also find out what tests are CLIA waived.

For HIPAA questions, visit http://www.cms.hhs.gov/hipaa/. But note most of the CMS information related to HIPAA is at http://www.cms.hhs.gov/hipaa/hipaa2/default.asp, including general information, regulations and standards, and educational materials.

It's not what you know; it's who you know

Finally, if you still can't find the answer you're looking for, the CMS Web site does provide contact information for a variety of resources, including Medicare carriers (http://www.cms.hhs.gov/medlearn/tollnums.asp) and CMS regional offices (http://www.cms.hhs.gov/about/regions/professionals.asp). Please don't hesitate to use this information. That's what it's there for.

CMS QUICK LINKS

Negotiating the CMS Web site can be a daunting and intricate task. Here is a quick guide to parts of the site most often visited by physicians. Coding questions National Correct Coding Initiative edits http://www.cms.hhs.gov/physicians/cciedits/ HCPCS codes http://www.cms.hhs.gov/medicare/hcpcs/default.asp ICD-9 codes http://www.cms.hhs.gov/medlearn/icd9code.asp Medicare place of service codes http://www.cms.hhs.gov/states/poshome.asp CPT codes http://www.ama-assn.org/go/cpt Forms Physician Medicare enrollment http://www.cms.hhs.gov/providers/enrollment/forms/ Advance Beneficiary Notice (ABN) http://www.cms.hhs.gov/medicare/bni/ Other CMS forms http://www.cms.hhs.gov/forms/ Searchable databases National and local coverage policies http://www.cms.hhs.gov/mcd/search.asp Medicare coverage http://www.cms.hhs.gov/coverage/default.asp Medicare questions Medicare Secondary Payer Manual http://www.cms.hhs.gov/manuals/105_msp/msp105index.asp Physician Medicare information http://www.cms.hhs.gov/physicians/ Medicare coordination of benefits http://www.cms.hhs.gov/medicare/cob/default.asp Medicare carriers http://www.cms.hhs.gov/medlearn/tollnums.asp CMS regional offices http://www.cms.hhs.gov/about/regions/professionals.asp Other CLIA certification and testing http://www.cms.hhs.gov/clia/ HIPAA http://www.cms.hhs.gov/hipaa/ CMS-related HIPAA information http://www.cms.hhs.gov/hipaa/hipaa2/default.asp

Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to Family Practice Management. Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

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