Written Questions

Q1: For ambulance billing, what are the requirements for providers being listed on the claim? We have come across a few claims that now require the provider for certain codes. Is this correct? If so, which codes require the provider's information?
A1: For Medicare ambulance claims, a rendering/servicing practitioner National Provider Identifier (NPI) is generally not required. Ambulance services are billed under the ambulance supplier or hospital, not under an individual practitioner. Claims that "require a provider" are typically the result of claim-form placement rules, billing provider versus rendering provider distinctions, or non-ambulance services being billed on the same claim, not because specific ambulance HCPCS codes require a practitioner NPI. On its Part B ambulance pages, Noridian explicitly states in CMS-1500 claim item 24J (Rendering Provider) – "Not required for ambulance suppliers."

Q2: Is the work Relative Value Unit (RVU) included in the UB-04 revenue code 42X, 43X, or 44X reimbursement for hospital outpatient rehab (place of service 22) services performed by hospital-employed physical therapist (PT), occupational therapist (OT), or speech language therapist (SLP) providers? If not, can a hospital outpatient department bill for the facility charge using revenue code 42X, 43X, or 44X as well as billing on a CMS-1500 claim form for professional RVU work for PT, OT, and SLP providers professional services?
A2: No. Facility billing does not include work RVUs. RVUs are calculated only for services reimbursed under Medicare Physician Fee Schedule (MPFS). Hospital-employed therapists cannot bill separately for professional services. Hospital-based therapy services are paid under Outpatient Prospective Payment System (OPPS), which uses ambulatory payment classifications (APCs) based on the UB revenue codes (42X, 43X, 44X). The professional component is already accounted for within the hospital payment structure.

Q3: Can we include time spent in the care of the patient from providers operating within the scope of their practice and within their license who are not billable Medicare providers (i.e., Doctor of naturopathy, massage therapist)?
A3: Chronic Care Management (CCM) services may include time spent by the billing provider and by clinical staff who are employed by or under contract with the billing provider. When a clinician working under the billing provider performs services to manage the patient's chronic conditions, and those services are included in the established CCM care plan, that time may be counted toward the monthly CCM time.

Q4: On the 2026 HCPCS quarterly update file, code Q4106 (dermagraft) is clearly marked as discontinued. We can't default to Q4100 (skin substitute) as this not otherwise classified (NOC) code is also discontinued. However, on Addendum B, there is a proposed price and shows change to status indicate S1 along with the other skin substitutes. Also, it is still listed as covered on Local Coverage Determination (LCD)/Billing article A59628 starting January 1, 2026. Is there a proposed HCPCS change or crosswalk for Q4106? How is this submitted on a claim if Q4106 is discontinued?
A4: Use and billing of these questions are not well-defined by CMS, other than all presently cleared products by 510(k), PMA (Premarket Approval) and 361 pathways are now called "non-BLA" (non- Biologics License Application) products and consistent with their HCPCS granted code descriptor, they are dressings billed "incident to" at a set rate/sq cm by CMS.

However, they cannot be billed as skin substitutes in association with the skin sub application codes because they are not considered skin substitute allografts. At present, there are no Food and Drug Administration (FDA)-cleared BLA products eligible for billing as a biologic skin substitute.

Per the 2026 Physician Final Rule, they will be billed as "incident to"; but since they are not considered skin substitutes eligible for billing with the skin substitute CPT codes, they technically are nothing more than dressings. Dressings separately billable are DME products.

Q5: We are requesting direction from Noridian regarding a conflict between LCD billing requirements and American Hospital Association/CMS Coding guidelines for the Inspire Implant (Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (OSA)). The LCD requires a secondary body mass index (BMI) Z-code, but ICD-10 has no diagnosis that clinically supports assigning a BMI Z-code (Z68.1-Z68.24) for patients with normal BMI (18.5-25). AHA Coding Clinic guidance, Official Guidelines Section I.B.14, states that a related diagnosis (e.g., overweight or obesity) must be documented by the provider in order to assign a BMI Z-code. We understand the LCD's intent is to confirm BMI <35; however, for patients with a normal BMI, assigning a BMI Z-code would be clinically inappropriate, leaving these cases subject to final denial. Given these conflicting requirements, how should providers report BMI for patients with a normal BMI so claims are not denied?
A5: The LCD and Billing and Coding articles are being updated to address these concerns. A release date is not yet known, so Noridian advises providers to watch the website for notifications of those updates being implemented. On a related note, in its February 26, 2026, edition of the MLN Connects newsletter, CMS stated that it would be adding six new HCPCS codes to the April 2026 Integrated Outpatient Code Editor (IOCE) for hypoglossal nerve neurostimulators for the treatment of obstructive sleep apnea. The codes will be effective January 1, 2026.

Q6: For Method II billing concerning the outpatient facility claim and the inpatient facility claim, when we have a specialist do a history and physical (H&P) to determine inpatient eligibility, does that professional charge need to fall in Item 21 on a CMS-1500 claim form or does it fall as part of Method II and belong on the outpatient facility claim if it falls before the admission date and time?
A6: If a Critical Access Hospital (CAH) provider is Method II, the H&P to determine inpatient eligibility is billed on the outpatient UB-04 when it falls before the admission date. Professional services billed after admission are billed on the CMS-1500.

Q7: We are a CAH. When a beneficiary has Medicare on the day of inpatient admission and changes to a Medicare Advantage plan during their inpatient stay, is the claim for the entire stay billed to Medicare or split between Medicare and the Medicare Advantage plan? When a beneficiary has a Medicare Advantage plan on the day of inpatient admission and changes to a Medicare during their inpatient stay, is the claim for the entire stay billed to the Medicare Advantage or split between the Medicare Advantage plan and Medicare?
A7: If a facility is exempt from the prospective payment system, such as a CAH, children's hospital, cancer hospital, or a Maryland waiver hospital, then the facility splits their claim and bills each payer accordingly.

Q8: According to article titled Billing and Coding Guidelines for CV-016; Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring), it states "When submitting claims for the recording only (CPT code 93225) or for the analysis with report only (CPT code 93226) use the date the service (DOS) performed as the DOS." Is the intent of this to ensure that the DOS is accurate when billing both services on the same claim or is it expected that each charge is on a separate claim because they are on different days?
A8: We are unable to address the article referenced as "CV 016," as we do not know its origin or ownership. However, Noridian would like to highlight the CMS guidance outlined in MLN SE17023. According to coding convention, when the technical (TC) and professional (PC) components of a service are performed by different providers, each provider is expected to submit a separate Medicare claim for the component they furnished. Conversely, when a single provider performs both the PC and TC components, that provider should bill the global code instead once all services included in the code descriptor have been completed.

Q9: According to the Noridian Part B Electrocardiographic Monitoring Services Billing page, it states, "Electrocardiographic monitoring codes must be billed in sets." Can Noridian clarify if "set" is related to the previous question (Question 8) and should be billed together?
A9: When Noridian refers to services being "billed in sets," this pertains to the set of codes describing different components of the same service. If the PC and TC components must be billed separately and the global code is not appropriate, the expectation is that the TC and PC components correspond to the same CPT code. It would not be appropriate to bill the TC component of one CPT code together with the PC component of a different CPT code on the same Medicare claim. In this case, since the PC/TC components are described by different CPT codes altogether, one would still expect the same concept to apply. An example of this type of scenario is posted on the table on our Noridian Medicare webpage. The set of codes that make up the different components of the same service are listed in rows.

Q10: Regarding echocardiogram orders versus documentation and what to bill, for professional billing, is the expectation to bill the same CPT code for the technical and professional components based on what was ordered (medical necessity) and performed or is the professional coding based on what was interpreted by the reading provider? Example: A limited echo is ordered (93308) and performed. However, the physician reports on all components required for a full study (93306), even though he says "poorly visualized" for most of them. Should the provider report 93308 or 93306?
A10: Coding rules dictate that if the PC/TC components of a service were billed separately to Medicare, it would be the same CPT code with the 26 and TC modifiers added respectively. The same concept applies if CPT code 93306 was ordered and the technical component of that service was performed by the echo tech. Then the expectation is the professional component of CPT 93306 would be performed and subsequently billed. If the provider performs more than what the code descriptor includes, this does not mean a different CPT code for the PC component would be billed.

Q11: Does the Medicare Advantage (MA) rate for supplemental payments need to be revised yearly?
A11: Yes, eligible Federally Qualified Health Centers (FQHCs) report actual MA revenue and visits on their cost reports. At the end of each cost reporting period the MAC uses actual MA revenue and visit data along with the FQHCs final all-inclusive payment rate to determine the FQHC;s final actual supplemental per visit payment. Once this amount (per visit basis) is determined it will serve as the interim rate for the next full rate year. Actual aggregated supplemental payments will then be reconciled with aggregated interim supplemental payments, and any underpayment or overpayment thereon will then be accounted for in determining final Medicare FQHC program liability at cost settlement.

Q12: Will there be a dedicated portal for the Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD), that is beginning May 1, 2026, or will the Noridian Medicare Portal (NMP) be modified to allow RCD documentation submission and unique tracking number (UTN) tracking? Will there be any RCD webinars prior to the implementation?
A12: Yes. This question and answer is relevant for California IRFs and Units (IRUs) who are participating in the RCD. Functionality within the NMP to accommodate the choice selection period will go live on March 16, with the remaining functionality to go live on May 1. Noridian has already begun a weekly webinar series on IRF RCD that will run in March and April. Content on the JEA section of the Noridian website has just been published for IRF RCD, as well as updates to the NMP user manual. Please check out these new resources if your work overlaps IRF services in the state of California.

Q13: As a CAH Method II facility, please clarify how Certified Registered Nurse Anesthetist (CRNA) professional charges are to be billed. Our facility does not qualify for the pass-through exception due to the number of surgeries we do. We have not had an active CRNA cert on file with Medicare since July 1, 2020. Do we continue to bill our CRNA professional charges on the UB004 claim? If so, which revenue code should we be using? Should the QZ modifier be used? Or since we do not qualify for the pass-through exception, do we bill the CRNA professional charges on a 1500 claim form even though we are Method II?
A13: As a Method II CAH without the CRNA pass through exemption, you must continue billing CRNA professional services on the UB 04 (TOB 85X) using revenue code 0964. Because you do not qualify for the pass-through exemption, CRNA services are paid under the Method II professional rate calculation, and QZ should be used when the CRNA is non-medically directed. See the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.3.3.2 for more information.

Q14. Please provide clarification when billing CPT 63047 (posterior spinal decompression procedure) to Medicare for both the technical and professional charge. Does Medicare require a laterality modifier even though this CPT code is a unilateral code? Does Medicare allow a surgery assist by a Nurse Practitioner for this CPT code?
A14: CPT code 63047 code description encompasses both unilateral and bilateral procedures. It is considered a "non-paired" structure code and describes physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Laterality modifiers would not apply since this code reimburses as a unilateral or bilateral service.

Q15: Which modifiers should be used when a surgery assist is done by a Nurse Practitioner (NP)?
A15: Surgery assist performed for Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist would append modifier AS.

Q16: LCD L35170 states that providers must use each drug according to FDA-approved indications unless there are valid, documented reasons for using an unapproved/off-label form. It also instructs providers to consult each neurotoxin's package insert for FDA-approved indications, and to reference FDA manufacturer recommendations or the AHFS for appropriate dosing. According to the FDA prescribing information for Botox, the recommended total dose for chronic migraine is 155 units, with allowable range of 155-195 units. Given the additional discretionary 40 units above the recommended 155-unit dose, are there any restrictions on where these units may be injected within the head/neck muscle groups? May providers follow pain protocol and inject based on the patient's reported areas of pain?
A16: The location of injection in the head/neck muscles are limited to those listed in LCD. Other muscles injected would not be presumed to be reasonable and necessary and may deny. Such cases may be reviewed on appeal with supporting documentation to determine if they are reasonable and necessary.

Q17: Do we use Q-codes for non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid, or injected skin substitutes)?
A17: Skin substitute Q‑codes must not be used for non‑graft wound dressings such as gels, powders, ointments, foams, liquids, or injected products, because these items are not considered skin substitute grafts and are treated solely as supplies, which are not separately payable in physician offices and are packaged under facility billing. Under the 2026 CMS Final Rule, all non‑BLA skin substitute products are now classified as "incident to" supplies rather than biologics, and CMS confirms that no currently marketed products meet FDA 351‑BLA graft criteria, making the skin substitute application codes inapplicable and unbillable at this time. CMS has issued no new instructions for billing these "incident to" supplies, and none of these products may be billed with skin substitute codes under current policy.

Q18: Seeking clarification on documentation of formal shared decision making (SDM). Does the non-implanting physician who performs SDM need to complete a separate document such as an evaluation and management (E/M) note or referral note on the discussion they had with the patient about anticoagulation, or can the implanting physician verify in their evaluation note that SDM occurred, by who, and that criteria has been met to proceed? Ultimately it is the implanting provider that is attesting the patient's "must have" indications have been met. The National Coverage Determination (NCD) states that SDM must be an independent non-interventional physician. However, other NCDs such as 20.4 for implantable cardioverter defibrillators, allow qualified nonphysician practitioners to complete SDM. For LAAO (Left Atrial Appendage Occlusion), can SDM be completed by an independent, non-interventional, qualified nonphysician practitioner? Can SDM be completed through a video visit?
A18: The NCD requires documentation establishing the appropriateness of the procedure, based on a full history and physical examination performed by a physician (as explicitly stated in the NCD) with full scope of practice and nationally recognized training and credentialing; Non physician practitioners (NPPs) do not meet this requirement. An independent, non‑interventional physician must use an evidence‑based decision tool to document alternatives and contraindications, with all findings, labs, procedural data, dates, and times included in the medical record. This documentation must be complete, available to Medicare upon request, and cannot rely solely on references in the implanting physician's notes. Telemedicine is not permitted for this evaluation. The record must also document the qualifying facility's capabilities and compliance with the NCD, and all coverage criteria must be fully supported in the medical record by appropriately qualified physicians across all contributing specialties.

Verbal Questions

Q19: Regarding FQHC distant telehealth services and code G2025, the newest update indicates the extension of flexibilities through December 31, 2027, but claims are hitting RTP for edit 36477. When can we expect these claims to be released? We called Customer Service, but they indicated it could be up to 45 days to respond.
A19: Jan is reaching out to Tanya – Ultimate Health Services, Los Angelas CA

Q20: For Q8 on holter monitoring, the answer suggested billing technical and professional together. For that service, there are two charges: A hook and when the patient returns the monitor, there is a scan charge. These two charges are a set. Does Noridian expect both charges to be on the same claim or because they are on different dates of service, do they need to be on different claims?
A20: Based on MLN SE17023, CMS guidance addresses how to determine the correct date of service for each component of a Holter monitoring claim. It does not require that the services be submitted on a single claim or split across two claims.

Whether one or two claims are used can depend on whether different entities are responsible for the individual components. If separate organizations each perform and bill for only one part of the service, submitting separate claims may be necessary. Ultimately, the billing approach depends on how your clinic has structured its Holter monitoring process, including equipment ownership, setup responsibilities, and assigned roles.

Q21: Regarding question 13 on CRNA charges, is the QZ modifier required on the professional line of the claim? In the past, we did append the QZ but the claims were RTPing.
A21: Providers need to be approved to bill Method II. If a CAH would like to bill their CRNAs Method II, they will need to submit a request to do so no later than 30 days prior to their next fiscal year begin date. This request must include a request letter on hospital letterhead signed by an authorized official, a list of all CRNAs that will be billing Method II including their NPIs, and copies of the 855I or Approved Medicare Enrollment Record (from PECOS) for each CRNA. and The QZ modifier should be used when the CRNA is non-medically directed. See the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.3.3.2 for more information.

Q22: Is the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Lookup for all jurisdictions?
A22: Yes. It is for both JE and JF.