Written Questions

Q1: CPT 77387 had an update on January 1, 2026, where the facility component is now bundled but we are still able to bill the professional component. Currently our radiation oncology claims are stopping in DDE due to CPT 77387 revenue code 973 with reason code 32391 "no PC/TC indicator is present for the valid HCPCS code." The Provider Contact Center told us a resolution is pending in the system. Is there any update or timeline for resolution?
A1: Noridian applied system updates on August 7, 2026, to allow the professional component of 77387 to process with modifier -26.

Q2: Is there a webinar concerning overlapping dates of service and how to bill them? We have questions and are unclear and would like to become experts. Can you include this in the Ask the Contractor meeting or provide a resource to assist us in the meantime?
A2: Noridian will be hosting a webinar on November 19, 2026, on the topic of overlapping claims.

There is also a page on Noridian's website dedicated to the topic of Overlapping Claim Resolutions Tips.

Resource: Noridian Medicare Website > Browse by Topic > Claims > Claims Submission Billing, Errors, and Solutions > Overlapping Claim Resolution Tips

Q3: Our facility has about 150 claims pending with Return to Provider (RTP) reason code 32000 when Z23 (Encounter for immunization) is the diagnosis. Are you able to provide an update or guidance on how to handle these claims?
A3: This issue was not related to provider error. We can confirm a fix was installed, and that all affected claims that were RTP'ing for this issue have been reprocessed. If you identify any claims that were not reprocessed, please bring them to the attention of the Provider Contact Center.

Q4a: Federally Qualified Health Center (FQHC) - Will modifiers 93 or 95 be required for both the qualifying code and the payable code?
A4a: Report the payable code (for example, a standard E/M or behavioral health code) and append the modifier that reflects how the service was delivered.

Modifier 93: Use when the visit was conducted in real time using audio-only (telephone) communication.

Modifier 95: Use when the visit was conducted in real time using audio and video technology.

Q4b: Federally Qualified Health Center (FQHC) - Will reimbursement under the Physician Fee Schedule change for the distant site telehealth services for FQHCs?
A4b: No, reimbursement methodology is remaining the same; however, the billing is changing October 1, 2026.

Q4c: Federally Qualified Health Center (FQHC) - Are distant telehealth services eligible for Medicare Advantage wrap-around (MAWRAP) supplemental payments?
A4c: No, distant-site telehealth services provided by FQHCs are generally not eligible for Medicare Advantage wrap-around (MAWRAP) supplemental payments. Because these telehealth encounters are paid under separate statutory payment rates rather than the standard FQHC Prospective Payment System (PPS) encounter rate, standard MA reconciliation and wrap-around rules do not apply.

Q5: With the retirement of LCA A54070, cardiac rehab medical necessity is based on seven conditions (MI within 12 months, CABG, stable angina, heart valve repair or replacement, PTCA/stenting, transplant, and stable CHF). For the heart valve repair or replacement condition, we are seeing an increase in valve sparing procedures such as valve-sparing aortic root replacement with reconstruction of ascending aorta or AAA stent graft. Are the AAA conditions and procedures non-covered for cardiac rehab?
A5: AAA is not a covered condition. We are bound by the language of Title 42 CFR § 410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage.

Aortic aneurysm diagnoses and procedures, including ascending aortic aneurysm repair, thoracic aortic grafting, and AAA/EVAR stent graft procedures, are considered aortic aneurysm repairs rather than heart valve repair or replacement procedures. As such, they are not among Medicare's nationally covered indications for cardiac rehabilitation on their own.

Q6a: End Stage Renal Disease (ESRD), diagnosis code N18.6, is a major complication or comorbidity (MCC) that could significantly affect DRG assignment, reimbursement, quality measures and regulatory reporting. Medicare, American Hospital Association (AHA), Kidney Disease: Improving Global Outcomes (KDIGO) and state specific regulatory framework vary in their definitions of ESRD. When the attending provider's documentation conflicts with the nephrologist's documentation (ESRD vs dialysis-dependent Acute Kidney Injury (AKI)), is it compliant and appropriate to issue a provider query when ESRD has been documented but clinical findings, specialist documentation and regulatory definitions appear inconsistent with ESRD?
A6a: Yes. When ESRD documentation conflicts with the clinical record, specialist documentation, or applicable Medicare requirements, it is appropriate for the facility to use a compliant provider query process to clarify the patient's renal status. The diagnosis reported on the claim should be supported by the complete medical record and consistent with Medicare billing and documentation requirements.

Q6b: If a query is issued and the attending physician confirms ESRD, but the nephrologist's documentation, clinical criteria in the medical record, and treatment course support dialysis-dependent acute kidney injury (AKI) rather than permanent, irreversible kidney failure, what is Noridian's expectation for the facility?
A6b: Noridian expects the diagnosis reported on a claim to be supported by the medical record as a whole. If the attending physician confirms ESRD following a query, but the nephrology documentation, clinical evidence, and documented course continue to support AKI rather than permanent kidney failure, the facility should follow its established documentation integrity and compliance processes to resolve the discrepancy. The final diagnosis reported should be consistent with the complete medical record and supported by sufficient clinical documentation.

Q6c: Specifically, should the facility report diagnosis N18.6 ESRD based solely on the attending physician's query response?
A6c: The assignment of N18.6 (End Stage Renal Disease) should be supported by the complete medical record. While the attending physician's documentation is an important component of code assignment, the diagnosis should be consistent with the overall clinical picture and supported by documentation demonstrating ESRD. Facilities should ensure the record substantiates the diagnosis reported.

Q6d: Should the facility pursue additional clarification because the attending physician's response appears inconsistent with the nephrology documentation, the clinical record, and the Medicare regulatory definition of ESRD?
A6d: Yes. When documentation contains conflicting information regarding a patient's renal status, additional clarification may be necessary to ensure the reported diagnosis accurately reflects the patient's condition. If the clinical record supports AKI rather than ESRD, the diagnosis code reported should align with the documented clinical findings and applicable coding requirements.

Q6e: Does Noridian expect facilities to perform further clinical validation review when unresolved conflicts remain between the attending physician's documentation, specialist documentation, and the underlying clinical facts?
A6e: Facilities are responsible for ensuring that diagnoses reported on claims are supported by the medical record. When discrepancies exist between provider documentation, specialist assessments, and clinical evidence, the facility should follow its established documentation integrity and clinical validation processes to resolve inconsistencies. The submitted diagnosis should be supported by the available medical documentation and clinical circumstances reflected in the record.

Q6f: How should a facility proceed when the attending physician's confirmed diagnosis appears consistent with one clinical classification framework (e.g., KDIGO kidney failure terminology) but not with the Medicare ESRD definition set forth in 42 CFR § 406.13?
A6f: For Medicare billing purposes, facilities should ensure that diagnosis reporting is consistent with applicable Medicare statutes, regulations, and coverage requirements. When terminology used in a clinical classification system differs from Medicare's regulatory definition of ESRD, providers should document the patient's condition with sufficient specificity to support accurate code assignment and compliance with Medicare billing requirements. The medical record should clearly support the diagnosis reported on the claim.

Q7: Does a Federally Qualified Health Center (FQHC) need to enroll a separate Type 2 National Provider Identifier (NPI) for each practice location? I know it is required for each practice location to have its own Provider Enrollment, Chain, and Ownership System (PECOS) application, and FQHCs require a Type 2 NPI, but can multiple practice locations share the same NPI? Where do I find this information?
A7: Yes. Under the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.2.1.4 multiple practice locations operating under the same legal entity and Tax Identification Number (TIN) may share a single Type 2 organizational NPI. However, industry best practice is for each FQHC site to obtain its own NPI. Separate NPIs help create a cleaner billing process, improve claim tracking, and reduce administrative confusion.

It is important to note that each distinct physical service location must enroll separately with Medicare using Form CMS-855A and may also need separate enrollment with state Medicaid programs. These enrollments allow the site to receive its own CMS Certification Number (CCN) and any site-specific reimbursement rates, even when a single Type 2 organizational NPI is used across multiple locations.

Q8: We have noticed that Zoladex - HCPCS J9202 was updated from a status K drug to a status E1 indicator as of April 1, 2026, making the drug now non-allowed/non-covered service for Medicare. Is this change correct as this impacts the treatment of many Medicare beneficiaries receiving this therapy?
A8: Noridian reviewed the Outpatient Prospective Payment System (OPPS) Addendum B file from CMS. It does indicate a change from status indicator K to E1 for J9202 effective April 1, 2026. The ** asterisk notes in the file indicate that this is due to the manufacturer not having a current Medicaid National Drug Rebate Agreement (NDRA) for the drug. If the manufacturer satisfies this statutory requirement, then Medicare is likely to resume the previous status once this issue is resolved. CMS sends the file to MACs to load into the system which is done by the support team. Unless CMS were to advise MACs on an update to that, claims will continue to process as status E1. For questions on the OPPS, please contact this mailbox: outpatientpps@cms.hhs.gov. (Reference: CMS Medicare Learning Network (MLN) Matters (MM) 14380, Hospital Outpatient Prospective Payment System: April 2026 Update)

Q9: When we bill G0260-injection procedure for sacroiliac (SI) joint, we are getting a denial for missing imaging guidance codes 77002 or 77012 which is considered inclusive of the procedure. These were being paid without the 77002 or 77012 and now they are being denied. What changed?
A9: A system update was made in error which required G0260 to be billed with 77002 or 77012. We have identified the issue and requested a system update. G0260 does NOT require 77002 or 77012 to be billed with it. Once the system updates are complete, we will be identifying all affected claims and internally reprocessing them. No action needed from providers.

Q10: If a lab test is ordered by a properly licensed provider, does the order remain valid if the provider is no longer licensed, practicing, or alive when the patient later presents for specimen collection? Must the laboratory verify the ordering provider's current status when the patient presents for collection?
A10: The validity of the order is determined when the order is placed, not when the specimen is collected. If the provider was an authorized treating provider at the time the test was ordered and the order remains properly documented and otherwise valid, CMS does not require the laboratory to verify that the ordering provider still holds an active license on the date of the specimen collection.

Q11: 30-Day Readmissions

• Scenario 1: A patient is discharged from an inpatient admission at a PPS hospital to a skilled nursing facility (SNF) and later returns for a separate inpatient admission at the same PPS hospital. How should the subsequent inpatient stay be billed to comply with Medicare billing requirements and prevent an inappropriate duplicate DRG payment?
• Scenario 2: A patient is admitted as an inpatient to a PPS hospital, discharged, and then experiences multiple unplanned subsequent inpatient readmissions to the same PPS hospital within 30 days of the prior discharge dates. How should facilities bill these encounters to ensure compliance and avoid inappropriate DRG payments, denials, or recoupments?

A11: Same-day Related Stays: If a patient is readmitted to the same Inpatient Prospective Payment System (IPPS) hospital on the same calendar day for symptoms related to or for evaluation and management of the prior medical condition, Medicare instructions require combining the original and subsequent stays onto a single claim. Separate individual DRG billing for both will trigger an inappropriate payment recoupment or denial.

For a same-day, unrelated inpatient admission (where a patient is discharged but unexpectedly returns to the same acute care IPPS hospital on the same calendar day for an entirely distinct medical reason), hospitals must submit two separate inpatient claims. The hospital must place Condition Code B4 ("Admission Related to Condition Outside of Prior Stay") on the second inpatient claim.

Subsequent days (1 to 30 Days): For readmissions occurring on later calendar days within the 30-day window, Medicare allows separate billing for each distinct inpatient admission provided each represents a medically necessary, separate acute care episode.

CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Sections 40.1 and 40.2.5

Verbal Questions

Q12a: CMS CY 2026 OPPS Addendum B lists CPT 98940-98942 (chiropractic manipulation) with Payment Status Indicator Q1: STV-Packaged Codes. It also lists APC 5811, a relative weight, and a published OPPS payment rate. For a hospital-based outpatient department, may the hospital report the applicable CPT code on an UB-04 institutional claim for OPPS, in addition to the chiropractor reporting the professional service on a CMS-1500?
A12a. Yes. The hospital may report the applicable CPT code on an UB-04 institutional claim for OPPS, in addition to the chiropractor reporting the professional service on a CMS-1500. However, Payment Status Indicator Q1 means the CPT code is sometimes paid separately and sometimes packaged into another payment, depending on what was billed on the same date of service. For CPT 98940-98942:

• If the service is billed on the same date as a service with status indicator S, T, or V, the payment for 98940-98942 is packaged into the payment for the other service.
• If the service is billed without any S, T, or V services on the same date of service, Medicare makes a separate APC payment based on the APC assignment shown in Addendum B.

Resource: Noridian Medicare Website > Browse by Provider Type > Outpatient Prospective Payment System (OPPS) > OPPS Payment Status Indicators

Q12b. If the hospital may not bill 98940-98942 under OPPS when performed by a chiropractor in a provider-based outpatient department, what is the purpose of CMS assigning these codes Status Indicator Q1, APC 5811, a relative weight, and an OPPS payment rate in CY 2026 Addendum B? In what circumstances would the OPPS payment assignment for 98940-98942 apply?
A12b. The OPPS payment assignment for 98940-98942 applies when there are not other services billed on the same date of service that would have a Payment Status Indicator of S, T, or V.

Q13. Can Noridian clarify how overlapping claim edits should be handled for Intensive Outpatient Program (IOP) services under CMS Change Request 13222 (Transmittal 12423)? Specifically, when IOP claims are billed monthly using sequencing TOBs and a patient receives other outpatient services during the same month, but on different dates, should Noridian bypass the overlapping edits in DDE or should providers report Occurrence Span Code (OSC) 74 with the dates of the other outpatient service (e.g., Observation)? An example is an IOP claim stopping in DDE for overlap with an Observation claim, despite no services occurring on the same day.
A13. Condition code 92 needs to be appended on the IOP claim. OSC 74 is not used in this situation.

CMS Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 261.

Q14. I need to understand Demand Bills better. What is the correct coding? Is it Condition Code 20, submit charges and days as covered? Do I use Occurrence Code 21? Where can I find a resource on this?
A14. To submit a Skilled Nursing Facility (SNF) demand bill on behalf of the beneficiary, the SNF must:

• Append condition code 20 to the claim
• Submit all charges associated with condition code 20 as non-covered
• Submit all charges on a 210 type of bill