ACM Questions and Answers - July 17, 2025

Written Questions

Q: CPT code 93318 and 93355 are transesophageal echocardiogram services performed intraoperatively, real time, for monitoring cardiac function and guidance for structural heart procedures. Because these are not diagnostic imaging services, do they require a separate written report to support the technical charge, or can the performance of monitoring and guidance be documented in the procedure note by proceduralist?
A: CPT codes 93318 and 93355 describe intraoperative transesophageal echocardiography (TEE) services used for real-time cardiac monitoring and procedural guidance. While these services are not diagnostic imaging in the traditional sense, documentation expectations differ based on code descriptions and published guidance:

  • CPT 93318 described as TEE for monitoring purposes, including continuous assessment of cardiac function and immediate therapeutic decision-making. The CPT descriptor does not reference a separate written report. AAPC commentary notes that when performed intraoperatively (e.g., by anesthesiologist), this service may be considered part of the broader procedural documentation
  • CPT93355 includes TEE for guidance during structural heart interventions. The CPT descriptor explicitly includes image acquisition, interpretation, and a report. The RUC vignette and AAPC guidance both reference the preparation of a complete report and communication of findings to the procedural team.
    • 93318 may be documented within the procedural or anesthesia note
    • 93355 is expected to include a separate written report

Q: From the February 1, 2025, Cardiac and Pulmonary Rehabilitation webinar, treatment plans must be signed, established, and reviewed by the physician every 30 days. When does the initial treatment plan that contains the exercise prescription need to be signed? It has been my understanding that this is an order for exercise and must be signed prior to or on the first day of a Cardiac Rehab session. To bill, each session must include some sort of aerobic exercise combined with strengthening or stretching. I am hearing different expectations on the timing of signature with the prescription. Please advise.
A: It is a CMS requirement that a physician review, sign and date the initial treatment plan (ITP) (which includes the exercise prescription) prior to or on (i.e., no later than) the first billable cardiac rehabilitation session and at least every 30 calendar days thereafter, including discharge.

Q: We are an FQHC offering optometry services. Some cataract surgery patients are referred to an ophthalmologist but later request post-op care at our FQHC with their optometrist.

If the ophthalmologist sends a letter naming the optometrist and stating post-op care begins one day after surgery, is that enough documentation? Or is a formal transfer form with signatures from the patient, ophthalmologist, and optometrist required?

Since CPT 66984-55 is not a PPS-eligible service, how should we bill? Should we use E/M codes with G0559 if applicable and submit a PPS code, or bill Part B fee-for-service?
A: FQHCs are not subject to Medicare’s global surgery billing rules but must follow documentation requirements during the global period. Since cataract surgery is a major procedure with a 90-day global period. The surgeon is typically responsible for post-op care unless a formal, documented co-management agreement is in place. If an optometrist at an FQHC takes over post-op care, a written transfer agreement must be signed by the surgeon (ophthalmologist), optometrist, and patient. The optometrist bills CPT code 66984 with Modifier 55 (to indicate post-op care only) on a CMS-1500 form with place of service (POS) 50, including the transfer date, post-op care dates, and number of days in Item 19. Reminder: Routine co-management is not allowed, and each case must be clinically justified and clearly documented. Post-op care cannot be billed under Prospective Payment System (PPS) using modifier 55 or HCPCS G0559. These must be billed under the Medicare Physician Fee Schedule (MPFS). For reporting only post-op care, FQHCs may use CPT code 99024 (no payment) on the UB-04, when required. If a patient had surgery elsewhere and is in the global period, make sure to determine if the service is part of the global package. If included, FHQC cannot bill separately, but may include for reporting purposes only using CPT 99024. For details, refer to MLN907166 for "Post-Operative Claims-Based Reporting Requirements – CPT Code 99024." Additionally, if the FQHC provides services to a patient who had surgery elsewhere and is still within the global surgical period, the FQHC must ascertain if those are included in the global billing. The CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1B outlines which services are not included in the global package and may be billed separately. Otherwise, if the service is not included, the FQHC may bill for the visit using the appropriate FQHC PPS code (e.g., G0466-G0470).

Q: I have a question regarding a scenario we've encountered. When a patient has signed an Advance Beneficiary Notice (ABN) and received the service, and then gets billed, they will contact the doctor's office. The doctor's office then reaches out to us requesting an update to the billing with a new diagnosis. In this situation, are we still permitted to appeal the claim after all services have been provided?
A: Yes, a provider can still appeal a claim even after the services have been provided. In some cases, it may be more appropriate to request a reopening rather than a formal appeal- especially when correcting minor errors or omissions, such as a diagnosis code. Appeal rights remain intact if the request is submitted within the required timeframes.

Signing an ABN does not automatically grant appeal rights. Appeal rights are triggered only if a claim is submitted to Medicare and denied, fully or partially.

Q: If a patient was previously an MSP43 due to disability and then ages into Medicare, do they automatically change to MSP12?
A: Disability will end the month before the month in which a beneficiary attains full retirement age as defined in CFR 404.409 - CFR 404.321 When a period of disability begins and ends.

  • When a provider submits the claim, if the beneficiary, or family member, is still working, providers will append Value Code 12 for working aged instead of Value Code 43 for disability.

Q: As a CAH that does Method II billing, can we bill both G0439 both professional and technical charge on a UB04? We started billing both components and our claims are being rejected by Medicare.
A: Typically, when a preventive service is posted to a beneficiary’s utilization history, separate entries are posted for a "professional" service (the professional claim for the delivery of the service itself) and a "technical" service (the institutional claims for a facility fee). However, in the case of Annual Wellness Visits (AWV) services, since there is no separate payment for a facility fee, the AWV claim will be posted as the "professional" service only, regardless of whether it is paid on professional or institutional claim. As a CAH Method II, you will need to only bill the professional charge for G0439 with revenue code 096X, 097X or 098X.

Q: Are CAHs required to bill Information Only Bills to Medicare for Inpatients with MAOs? Is there some other reason we should be billing these other than EHR incentive payments? I called the provider contact center; I was told that CAHs were required to bill Information Only Bills, and I was directed to 100-04, Chapter 3, Section 300.2. This section is about EHR incentive payments. It was my understanding CAHs could only get this incentive for a certain number of years.
A: This practice is known as "shadow-billing," and is for more than just the calculation of EHR incentive payments. CMS mandates that all hospitals, including CAHs, submit claims to both the Medicare Advantage plan and Medicare. The submission to Medicare is on an 11X bill type and is marked with Condition Code 04. This bill allows the inpatient days to be captured and included in the disproportionate share and low-income patient calculations. The information also is used for computation of the hospital’s Indirect Medical Education payment. For additional information, see the Noridian Medicare website > Browse by Topic > Claims > Medicare Advantage Inpatient Claim "Shadow Billing."

Q: If a beneficiary is not entitled to Part A and is admitted as inpatient to a CAH is the patient responsible for the whole inpatient stay since they have no Part A coverage? Or are providers required to follow 0121 billing process per Internet Only Manuals 100-02, Chapter 6, Section 10 and 100-04, Chapter 4, Section 240?
A: Medicare pays for hospital (including CAH) inpatient Part B services in the circumstances specified in the CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 10. Whether or not the hospital has submitted a claim to Part A for payment, the hospital is required to submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services. In the situation you describe, the hospital will need to follow billing process for inpatient ancillary services detailed on Noridian’s website: Browse by Topic > Claims > Quick Reference Billing Guide > Inpatient Ancillary Services.

Q: I am seeking clarification on the billing process when a patient has two imaging visits on the same day. For example, if a patient has an outpatient chest X-ray and then later the same day, has a chest CT done in the ER, are the charges required to be on the same claim form, or can they be billed on two separate claim forms?
A: Since these services are being performed by the same hospital system and are not identical services, they would appear on a single outpatient Part A bill with the appropriate revenue and other codes to distinguish the separate services.

Q: I have a question regarding billing for patient infusion services and paracentesis. If a patient receives infusion services (revenue code 260) and a paracentesis on the same day, should these be billed separately or on the same claim form that they share the same diagnosis?
A: Generally speaking, yes. If the services are provided on the same date or as part of the same encounter, these would support single-claim billing of outpatient services. Noridian advises the provider to consult the NCCI Policy Manual to ensure compliance with the specific requirements for billing infusion services and paracentesis on the same day. NCCI PTP edits allows paracentesis CPT 49082 (diagnostic/therapeutic) and infusion services on same day with a modifier (e.g., Modifier 59 or X subsets: XE, XP, XS, XU)) to indicate that the services were separate and distinct procedures, and documentation clearly support the medical necessity for both services.

Q: I have a question regarding a patient being seen as an outpatient in a PPS facility. The patient has two different diagnoses and is receiving both occupational and physical therapy on the same day. Could you clarify if I can bill these services on separate claims, or if they are required to be billed on a single claim form?
A: The therapy services you describe are considered repetitive services by CMS. To that end, your answer is contained in the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, Section 50.2.2 Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services. Repetitive Part B services furnished to a single individual by providers that bill institutional claims shall be billed monthly (or at conclusion of treatment). The instructions in this subsection also apply to hospice services billed under Part A, though they do not apply to home health services. Consolidating repetitive services into a single monthly claim reduces CMS processing costs for relatively small claims and in instances where bills are held for monthly review.

Q: I am seeking clarification on claim responsibility in specific scenario. If a patient is admitted to the PPS hospital at 6:58 a.m., elects Hospice at 4:35 p.m. on the same day, and then expires the same day, who is responsible for inpatient admission on the 6:58 a.m. claim?
A: The hospital would be responsible for billing the services from admission up until the hospice election time. Between that time and time of death, the hospital could only bill for the "treatment of non-terminal conditions" indicated with the usage of Condition Code 07.

Q: The Noridian Supplemental Medical Review Contractor (SMRC) had a project for Select Carotid Artery Screening (CPT 93880) (project number 01-096). We were unable to locate any clinical indication guidelines or documentation requirements (i.e., national coverage determination or local coverage determination) to justify the medical necessity of the procedure. Are there any clinical indication guidelines or documentation requirements for jurisdiction JE?
A: Within the 01-096 project, JE was excluded from this review due to no local coverage guidance.

Q: According to the National Coverage Determination (NCD) 20.7 for Percutaneous Transluminal Angioplasty (effective date 10/11/2023, implementation date 05/13/2024), under Section 4 - Concurrent with Carotid Stent Placement, it states: "First-line evaluation of carotid artery stenosis must use duplex ultrasound." Does this imply a duplex ultrasound must be completed first, before a computed tomography imaging (CT) or magnetic resonance imaging (MRI) can be performed? Or can a CT or MRI be completed without a duplex ultrasound?
A: Duplex is the definitive diagnostic tool for carotid stenosis and the diagnosis of obstructive and functional symptomatic plaque, neither of which is defined by MR of CTA. The latter two of are considered more diagnostic of intracerebral carotid and its branches disease. So, yes for diagnostic criteria indicating treatment indicated as well as other testing considered, duplex of the extra cranial arteries is the definitive diagnostic test and first line investigative tool.

Q: If the follow-up copy of the Important Message from Medicare (IM) has not been delivered to the Medicare beneficiary patient within the delivery time frame (due to the miscalculation of the beneficiary's lifetime reserve days), what happens to the patient's claim? Are we still able to submit a claim to Medicare?
A: The timing of the follow-up copy of the IM must be provided to the beneficiary within two calendar days of discharge, up to as late as four hours prior to discharge. If the patient is not given the IM within the required timeframe, this may impact the hospital's liability in a QIO review. A miscalculation of LRDs may impact the patient's appeal rights, but not the hospital's submission of the claim itself. If the LRDs were inappropriately applied, then the beneficiary should be notified if the revised application could potentially impact their election or revocation of LRDs. The patient's window of opportunity for revocation of LRDs in a situation without this error is normally within 90 days of discharge. However, if the error is discovered late, the hospital may still have to offer the revocation, and any claim filed to Medicare would have to take these factors into account.

Q: According to Transmittal 13255 (Change Request 14081) - Internet-Only Manual (IOM) Update: Addition of Section 70.2 to Publication 100-04, Chapter 17 –Billing Zero Charges for Drug Line Items Provided at No Cost, dated June 6, 2025, it states: "Under such circumstances, to avoid drug administration code denials, a drug code must be present on the same or prior claim and $0.00 should be entered for the billed amount of the drug." Previously, when a drug is provided at no cost to the patient, it was billed to the payer with a "token charge," such as $0.01. With the new transmittal, do we have to bill the drug line item with a $0.00 charge? Or can we continue to bill the drug line item with a $0.01 charge?
A: Up until the implementation of CR 14081, the "token charge" of $0.01 was being used as a workaround by the claims systems because they weren't set up to process the billing of zero-dollar charges for these drugs. Under the update, the system now accepts the zero-dollar charge. Keeping in line with this policy instruction, providers should no longer be using the $0.01 amount in this billing scenario.

Q: There are minimal instructions on issuing the HINN 1. If hospitals do not have utilization management staff after 9 p.m. or sometimes on the weekends and we're able to issue the HINN 1 as soon as they return and we only bill the patient for services after the completion of the HINN 1 is this compliant? Or should we issue a HINN 12 and bill the patient only after the HINN 12 is completed?
A: The answers to both questions are NO. The timing of HINN 1 issuance affects the first day of liability. If issued before admission, the beneficiary is liable (if admitted) for customary charges during the stay. If issued by 3 p.m. on the admission day, the beneficiary is liable for services only after receiving the notice. If issued after 3 p.m., liability begins the following day. In all cases, liability excludes services eligible for Part B payment. The HINN 12 is misapplied in this example, as it pertains to potential Noncovered Continued Stay and is used with Hospital Discharge Appeal Notices.

Q: We've noticed that the TPE process has changed. Historically, we received a notification letter via USPS and fax requesting we contact the auditor with our contact information should questions arise during the audit and to arrange education, if necessary, post audit. Now we are not receiving this letter at all. We are receiving ADRs for a TPE audit via esMD. This week an auditor emailed our Chief Compliance Officer requesting additional documentation for a specific audit. If the point of TPE audits is to probe and educate, why has Noridian removed contact with the auditor from the team who manages the audits and arranges education? Is there a reason why the notification letter has been done away with?
A: Medical Review Part A sends notification letters via USPS when a file is initiated and does not utilize fax. Before starting a review, staff verify facility addresses and phone numbers using the billing system and/or facility contact forms if applicable. If contact information cannot be confirmed by phone, letters are mailed to the address listed in the billing system. Providers should contact the Provider Contact Center to update address or ADR delivery preferences, as Medical Review cannot make these changes. If someone outside the audit team within your facility receives a letter, they should forward it to the correct contact. Notification letters include clinician contact information and request a call to confirm the audit point of contact. Facilities with multiple audit contacts should communicate this to the clinician. Providers are encouraged to use the Noridian Medicare Portal to access letters at any time.
Note: This process applies only to Part A; other lines of business may differ.

Verbal Questions

Q: According to Local Coverage Article A53024, Billing and Coding: JW and JZ Modifier Billing Guidelines, in revision 7, it states that effective January 10, 2023, the units billed should correspond with smallest dose vial available for purchase from the manufacturers that could provide the appropriate does for the patient while minimizing any waste. However, in the most recent version, which is Revision eight, effective March 21, 2024, the statement is removed. The required use of the smallest available vial sizes also are not indicated in the Medicare Claims Processing Manual, Chapter 17, Sections 40 through 40.1. Does this mean that CMS no longer requires the smallest vial size commercially available to be used?
A: Although language was removed from the Billing and Coding article, Noridian would point to similar expectations by CMS as stated in the Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40. "The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer drugs and biologicals to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner."
In addition, items/services provided to Medicare beneficiaries would need to be considered reasonable and necessary as per SSA 1862(a)(1)(A) which is further clarified in Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2; with the definition of "Reasonable and Necessary" to include an item/service that "meets, but does not exceed, the beneficiary's medical need."

Q: We are an inpatient rehab facility attached to a hospital in Southern California. We’ve been looking at the documentation of our physician history and physical (H&Ps). When the H&P is completed on rehab, it must be signed and dated within 24 hours of admission. If the physician finds out more information and adds that to the H&P after 24 hours, does that change the time stamp, thus putting it out of compliance?
A: If a provider documented the H&P within 24 hours of the IRF admission and then corrected/amended the document we would still review this document.  Medical Review reviews documents in their entirety, taking into consideration all aspects including when a note was initiated (if identifiable), when signed, and any amendments/corrections that were completed if applicable.  If a document was amended or corrected Noridian reviews the document per the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5. The H&P is still required under the Conditions of Participation at 42 CFR § 482.24(c)(4)(i)(A).

Q: Regarding code 94762 (overnight oximetry) in a Critical Access Hospital (CAH), it appears we can charge the technical component, but we are receiving denials on the professional component. Are we able to bill an evaluation and management (E/M) code instead? The billing provider has reassigned billing rights to the CAH and is using revenue code 0983.
A: After further review, the service code 94762 has a PC/TC indicator of three (technical component only, professional component is not applicable). This is common for certain diagnostic tests or procedures where the physician’s interpretation is not separately billable or not required. To capture physician work time, you could bill an appropriate E/M code in addition to 94762. The choice of the E/M code will depend on the specific circumstances of the encounter. Be sure to document the medical necessity and the distinct services provided when billing multiple codes for a single encounter. The GY modifier is only used to indicate that the service is statutorily excluded.

Last Updated Aug 26 , 2025