How to Bill Medicare as a Provider

Learning how to bill Medicare as a provider involves several steps to ensure that your claims are processed accurately and promptly. Here is a comprehensive guide to help you navigate the process of medicare billing for providers.

How to Bill Medicare as a Provider

Let’s get started with learning how to accept medicare payments!

1. Enroll as a Medicare Provider

  • Provider Enrollment, Chain, and Ownership System (PECOS): Enroll in Medicare using PECOS, an online system for enrolling in Medicare. You will need to provide detailed information about your practice and submit necessary documentation.
  • National Provider Identifier (NPI): Obtain an NPI, a unique identification number for covered health care providers. Learn how to obtain an NPI number:

How to Bill Medicare as a Provider – Step #1

  1. Initial Contact:
    • Visit the PECOS Medicare Enrollment website:
    • Register for a PECOS account if you don’t already have one.
  2. Application Submission:
    • Complete the online Medicare enrollment application via PECOS.
    • Ensure all required documents are uploaded.
  3. Follow-Up:
    • Regularly check the status of your application on PECOS.
    • Respond promptly to any requests for additional information.
  4. Contract Review:
    • Once approved, review the participation agreement.
    • Ensure you understand Medicare’s billing and compliance requirements.
  5. Signing the Contract:
    • Sign the participation agreement and submit it through PECOS.

2. Understand Medicare Billing Codes

Access our free AI Medical Coding GPT & ICD 10 Codes Research Tool:

  • ICD-10 Codes: Used for diagnosis coding.
  • CPT Codes: Used for procedure coding.
  • HCPCS Codes: Used for billing Medicare for supplies, equipment, and services.

ICD-10-CM diagnosis codes provide the reason for seeking health care.

ICD-10-PCS procedure codes tell what inpatient treatment and services the patient received.

CPT (HCPCS Level I) codes describe outpatient services and procedures and providers generally use HCPCS (Level II) codes for equipment, drugs, and supplies for services and treatment. List of CPT/HCPCS Codes:

3. Set Up a Billing System

  • Electronic Health Records (EHR): Use an EHR system that integrates with billing software to streamline the billing process. The EHR Practice Better integrates with the clearinghouse Claim MD enabling the simplest insurance claim submission.
  • Billing Software: Ensure your billing software is capable of submitting electronic claims to Medicare.

4. Verify Patient Eligibility

  • Medicare Eligibility Tool: Verify each patient’s Medicare eligibility and benefits before providing services. This ensures that services are covered and prevents claim denials.

5. Submit Claims to Medicare

  • Electronic Claims: Submit claims electronically via the Medicare Administrative Contractor (MAC) for your region. Electronic submission is faster and reduces errors.
  • CMS-1500 Form: Use this standardized form for submitting claims for professional services.

6. Monitor Claims & Payments

  • Track Claim Status: Use your billing software or the Medicare online portal to monitor the status of submitted claims.
  • Remittance Advice (RA): Review the RA, which provides details about the payment, adjustments, and denials.

7. Handle Denied Claims

  • Identify the Reason: Review the RA or Explanation of Benefits (EOB) to understand why a claim was denied.
  • Correct and Resubmit: Make necessary corrections and resubmit the claim. If additional documentation is required, provide it promptly.
  • Appeals Process: If the denial is not resolved through resubmission, follow the Medicare appeals process.

8. Maintain Compliance

  • Regulatory Compliance: Ensure your billing practices comply with federal regulations, including HIPAA and Medicare guidelines.
  • Audits: Conduct regular internal audits to ensure accuracy and compliance with Medicare billing requirements.

Medicare Enrollment and Billing Guide

Types of Medicare Enrollment Applications

  1. CMS 855I: Enrollment Application for Physicians & Non-Physicians
    • Purpose: Used by individual physicians and non-physician practitioners to initiate the enrollment process in the Medicare program.
    • Application Details: Includes sections for personal information, practice location, reassignment of benefits, and billing agency information.
  2. CMS 855R: Enrollment Application for Medicare Reassignment
    • Purpose: Allows individual practitioners to reassign their Medicare benefits to a group practice or other entity.
    • Application Details: Includes sections for the individual practitioner’s information and the organization to which they are reassigning benefits.
  3. CMS 855B: Enrollment Application for Clinics & Groups
    • Purpose: Used by clinics, group practices, and other organizational providers to enroll in the Medicare program.
    • Application Details: Includes sections for organizational information, ownership, and managing/control information.

Who to Contact with Medicare Enrollment Questions

  • Medicare Administrative Contractors (MACs):
    • MACs are private health care insurers that process Medicare claims for both Part A and Part B services. They handle provider enrollment, claims processing, and reimbursement.
    • Contact your regional MAC for specific enrollment questions. A list of MACs and their contact information can be found on the CMS website: CMS MAC List
  • Provider Enrollment, Chain, and Ownership System (PECOS):
    • PECOS is the online system for Medicare enrollment. You can contact the PECOS help desk for assistance with online applications and technical support.
    • PECOS Help Desk: 1-866-484-8049

Obtaining Referrals for Medicare

  • Medicare Coverage Requirements:
    • Some Medicare services require referrals from a primary care physician (PCP) to see a specialist or obtain certain tests.
    • Verify if the service requires a referral by consulting the Medicare coverage guidelines or your MAC.
  • Referral Process:
    • Obtain the referral from the patient’s PCP.
    • Ensure the referral includes necessary information such as patient details, referring physician’s information, and the reason for the referral.
    • Document the referral in the patient’s medical record.

How to Properly Fill Out an Advance Beneficiary Notice of Noncoverage (ABN)

  • Purpose of an ABN:
    • An ABN is a written notice given to Medicare beneficiaries to inform them that Medicare may not cover a particular service or item. It allows patients to decide whether to receive the service and accept financial responsibility if Medicare denies the claim.
  • Steps to Fill Out an ABN:
    1. Header Information:
      • Include the patient’s name, ID number, and date.
    2. Description of Service:
      • Clearly describe the service/item that may not be covered.
    3. Reason Medicare May Not Pay:
      • Provide a specific reason why Medicare might not cover the service (e.g., “Medicare does not cover this service for your condition”).
    4. Estimated Cost:
      • Provide an estimated cost of the service/item.
    5. Options Box:
      • The patient must choose one of the following options:
        • Option 1: Receive the service and allow the provider to bill Medicare.
        • Option 2: Receive the service and pay out-of-pocket without billing Medicare.
        • Option 3: Do not receive the service.
    6. Signature:
      • The patient must sign and date the ABN.

CPT Codes for Billing Medicare

  • Common CPT Codes:
    • Office visits: 99201-99215
    • Preventive services: 99381-99397
    • Immunizations: 90460-90474
    • Diagnostic services: 70010-79999
    • Therapy services: 97001-97799
  • Consult the Medicare Fee Schedule:
    • Use the Medicare Physician Fee Schedule (MPFS) to determine allowable CPT codes and reimbursement rates.

Access our free AI Medical Coding GPT & ICD 10 Codes Research Tool:

Telehealth and Medicare

  • Current Telehealth Codes:
    • Office/outpatient visits: 99201-99215 (with modifier 95 or GT)
    • Preventive services: 99381-99397 (with modifier 95 or GT)
    • Behavioral health: 90791, 90792, 90832-90838 (with modifier 95 or GT)
    • Use the appropriate Place of Service (POS) code: typically 02 (Telehealth).
  • Telehealth Coverage:
    • Medicare covers a range of telehealth services under specific conditions. Stay updated on CMS guidelines for any changes in telehealth coverage.

Documentation and Medicare

  • Requirements:
    • Document all services accurately, including the patient’s history, examination, diagnosis, and treatment plan.
    • Ensure all entries are legible, dated, and signed by the provider.
    • Maintain detailed records for each patient encounter to support billing claims.

Billing Medicare – Options for Billing Medicare

  • Direct Billing:
    • Submit claims directly to Medicare through the MAC.
    • Use the CMS-1500 form for professional services and the UB-04 form for institutional services.
  • Electronic Billing:
    • Submit claims electronically using Medicare-approved billing software or through the PECOS system.
    • Electronic submission often results in faster processing and reimbursement.

Who Qualifies for Medicare

  • Eligibility Criteria:
    • Age: Individuals 65 or older.
    • Disability: Individuals under 65 with certain disabilities.
    • End-Stage Renal Disease (ESRD): Individuals with permanent kidney failure requiring dialysis or transplant.

Services You Can Bill Medicare For

  • Billable Services:
    • Office visits, preventive care, diagnostic tests, therapies, surgical procedures, mental health services, durable medical equipment (DME), and telehealth services.

Billing Factors of Medicare

  • Allowed Amounts:
    • Medicare reimburses based on the allowable amount for each service, which may differ from your usual charges.
  • Deductibles and Coinsurance:
    • Beneficiaries are responsible for meeting deductibles and coinsurance amounts.
  • Medicare Supplement Plans:
    • Also known as Medigap, these plans can help cover some of the costs not covered by Medicare, such as deductibles and coinsurance.

Key Terms and Concepts

  1. Deductibles: The amount a patient must pay out-of-pocket before Medicare begins to pay.
  2. Co-pays: A fixed amount a patient pays for a service at the time of visit.
  3. Co-insurance: A percentage of the service cost that the patient pays after meeting the deductible.
  4. Referrals: Required for certain services and specialists under Medicare Advantage plans.
  5. ABN: An Advance Beneficiary Notice used to inform patients of potential non-coverage by Medicare.

Securing Referrals

  1. Identify the Need:
    • Determine if a referral is needed based on the patient’s condition and the service required.
  2. Verify Insurance Requirements:
    • Check if the patient’s Medicare plan requires a referral for the service.
  3. Referral Process:
    • Contact the patient’s PCP to obtain a referral.
    • Ensure the referral includes necessary details and document it in the patient’s medical record.
  4. Follow-Up:
    • Confirm the specialist received the referral.
    • Verify that the patient attends the appointment with the specialist.

This guide provides an overview of Medicare enrollment applications, obtaining referrals, filling out an ABN, billing CPT codes, telehealth billing, documentation requirements, billing options, eligibility criteria, billable services, and various billing factors. By understanding these key areas, you can efficiently manage your Medicare billing and ensure compliance with Medicare guidelines.

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How to Bill Medicare as a Provider

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All content contains personal experiences and is not intended to provide medical advice. For personalized medical guidance, please consult with a qualified healthcare professional. The author and associated entities assume no liability for actions taken based on the content herein.