Medicare Compliance & Reimbursement

Before you submit your Medicare claims, one Medicare Administrative Contractor (MAC) reminds that some CPT® and HCPCS codes also require an additional invoice — or you may find yourself in the denial zone.

Here’s the scoop: Specific codes are priced via invoice, and “failure to submit an invoice, submitting unclear invoices or submitting incomplete invoices could result in claim rejections,” cautions Part B MAC Palmetto GBA in a Jan. 23 news alert.

Caveat: “Contractor pricing is determined upon the receipt of a covered claim,” Palmetto says. What that means is that it can be a challenge to figure out which codes actually require an invoice. Despite the MACs best efforts to identify the CPT® and HCPCS codes in question, industry pricing and regulations change. “The [code] lists are not all-inclusive,” suggests the Part B MAC.

The MACs use the Medicare Claims Processing Manual, IOM Publication 100-04, Chapter 17, Drugs and Biologicals, Section 20.1.3, in their pricing and payment methodology. This is especially the case when the Centers for Medicare & Medicaid Services (CMS) doesn’t offer an Average Sales Price (ASP) for a code and an invoice is required, according to Palmetto.

Tip: Check with the MAC in your jurisdiction to ensure you’ve got the most updated pricing file and if you need to submit additional documentation with your claims and invoices.