Part B – Browse by Topic
ABN
Behavioral Health Initiatives
The Consolidated Appropriations Act (CAA), 2023 (Sections 4123, 4128 and 4129) outlines 3 behavioral health services Medicare will pay for that may improve outcomes for your Medicare patients. Learn more about beneficiary eligibility and billing requirements:
- Behavioral Health Integration (BHI) Services
- Psychotherapy for Crisis
- Opioid Use Disorder (OUD) Screening & Treatment
Resources
CGS-MolDx
Cognitive Assessment & Care Plan Services
CRD/ESRD
Find helpful resources regarding CRD- and ESRD-related services on the CMS website:
- Determining the 30 Month Coordination Period: CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 2, section 20.1
- Documentation Fact Sheet: Outpatient Physician Dialysis
- ESRD Monthly Capitation: Claim Submission, Documentation, and Payment
- Evaluation & Management (E/M) services on the same date as dialysis services: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 40.2.A.8
- Items and services included in ESRD Consolidated Billing(see document under Downloads)
- Kidney disease patient education information: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 310
- Kidney transplant information: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 11, section 140
- National Coverage Determination: Laboratory Tests – CRD Patients
- Payment for immunosuppressive management: CMS Medicare Claims Processing Manual, chapter 12, section 30.6.3
- Requirements for Erythropoiesis Stimulating Agents, including required modifiers: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17, sections 80.8-80.12
Dental
Diagnostic Tests
Access these CMS resources for additional information regarding diagnostic tests:
- Physician supervision requirements for diagnostic tests:
- Levels of supervision are defined by CMS, in the Medicare Physician Fee Schedule Database (MPFSDB). For definitions of the levels, refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 23, in the Addendum-MPFSDB Record Layouts (see field 31A)
- Access the CMS Physician Fee Schedule look-up tool to identify the supervision indicator for specific CPT and HCPCS codes
- Levels of supervision are defined by CMS, in the Medicare Physician Fee Schedule Database (MPFSDB). For definitions of the levels, refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 23, in the Addendum-MPFSDB Record Layouts
- Multiple interpretations of the same X-ray or EKG, and multiple X-rays or EKGs furnished on the same date of service: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 13, section 100.1
- Coverage of portable X-ray services: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 80.4
- Multiple procedure payment reduction (MPPR) for imaging services provided by physicians in the same group practice.
DMEPOS
Evaluation & Management (E/M)
Refer to these helpful resources for CMS-level information regarding E/M services:
- CMS Evaluation and Management Services Guide
- Correct coding guidance: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6
- Transitional care management: CMS Medicare Learning Network Fact Sheet
- "Incident To" Services: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 60
- Billing Instructions for Concurrent Care – E&M Service: Similar Services from Multiple Physicians & NPPs Within the Same Group – 04.24.2025
- Chronic Care Management (CPT Code 99490)
- Critical Care Fact Sheet
- Critical Care: Reminders
- Documentation Checklist for CPT code 99285 – Emergency Department
- Documentation Fact Sheet: CPT Code 99215
- Documentation Fact Sheet: CPT Code 99222
- Documentation Fact Sheet: CPT Code 99223
- Documentation Fact Sheet: CPT Code 99232
- Documentation Fact Sheet: CPT Code 99233
- Documentation Fact Sheet: Evaluation & Management 99205
- Documentation Fact Sheet: Evaluation & Management 99213
- Documentation Fact Sheet: Evaluation & Management 99214
- Non-Physicians Acting as Scribes for Physicians
- Nurse Practitioner (NP) Claims Submitted for Inpatient Hospital Admissions
- Probe Medical Reviews
- Reporting Federally Mandated Visits
- Submitting Evaluation & Management (E/M) Services Separately from the Global Surgery Package
- Targeted Probe and Educate (TPE) Process
- Top Provider Questions – Evaluation and Management
General
Access the articles listed below for more information about topics and programs that are of general interest to Medicare providers. You may also find the following additional resources helpful:
- Acronyms
- CMS Medicare home page
- Code pairs associated with National Correct Coding Initiative (CCI) edits
- Fee schedules: Medicare Physician Fee Schedule Database, drug & biological fee schedule, clinical laboratory fee schedule
Home Health & Hospice
Find helpful resources regarding Medicare's home health and hospice benefits, including required documentation from certifying physicians:
- Payment for physician services associated with certification and ongoing management of patients receiving home health or hospice care under Medicare:
- Care Plan Oversight services: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 15, section 180
- Care Plan Oversight services: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 15, section 180
- Home Health:
- Certifying Patients for the Medicare Home Health Benefit
- Clarification and definition of what it means to be "confined to the home": Medicare Benefit Policy Manual, Chapter 7, Section 30.1
- The Medicare Home Health Benefit
- What Physicians Need to Know: Home Health Patient-Driven Groupings Model (PDGM)
- Physician NPP Guide to Home Health
- Provider Compliance Tips for Home Health Services (Part A Non DRG)
- Certifying Patients for the Medicare Home Health Benefit
- Hospice:
- Medicare hospice benefit: CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 9
- Medicare hospice benefit: CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 9
- Care Plan Oversight Services for Patients Receiving Care through Home Health Agencies or Hospices
- Home Health Certification
- Home Health Face-to-Face (FTF) Encounter
- Home Health Face-to-Face Documentation
- Home Health Face-To-Face Encounter Calendar
- Home Health Review Choice Demonstration (RCD) Program
- Homebound
- Hospice Certification / Recertification Requirements
- Hospice Election Requirements
- Professional Services during a Patient Hospice Election
- Provider Resources
Incentive Programs
Medicare providers (including physicians and, in some cases, nonphysician practitioners) may be eligible for and participate in a variety of incentive programs. Find out more about these programs:
Quality Payment Program (QPP)
With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS did away with the Sustainable Growth Rate (SGR) law. Now, with the QPP, CMS can reward high-value, high-quality Medicare clinicians with payment increases – while at the same time reducing payments to those clinicians who aren't meeting performance standards.
Clinicians have two tracks to choose from in the Quality Payment Program based on their practice size, specialty, location, or patient population:
Health Professional Shortage Area (HPSA)
Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the Health Resources and Services Administration (HRSA) as primary medical care HPSAs. In addition, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. If a ZIP code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.
- Find out if the service location qualifies for one of these incentives. Access the list of ZIP codes in HPSAs for which automatic incentive payments can be made from the CMS Physician Bonuses web page. (Select the file you want under Downloads; there are separate files for primary care and mental health HPSAs for each calendar year). If the ZIP code where the service was furnished IS on this list, the applicable HPSA bonus payment will be calculated automatically.
- If the ZIP code where the service was furnished is in a HPSA but is not on the list of ZIP codes for which automatic payments can be made, verify that the ZIP code is in a HPSA:
- If you determine that the ZIP code where the service was rendered IS in a HPSA based on one of these sources, submit HCPCS modifier AQ with:
- Physicians' professional services rendered in a designated HPSA, when the ZIP code where the services were furnished is in a HPSA but is not on the list of ZIP codes for which automatic HPSA payments can be made.
- Services furnished by psychiatrists in designated Mental Health HPSAs, when the ZIP code where the services were furnished is in a HPSA but is not on the list of ZIP codes for which automatic HPSA payments can be made.
Injections & Drugs
Find helpful resources regarding payment, claim submission requirements, and coverage under Medicare Part B for injections and drugs:
CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17
- Payment for drugs and biologicals: sections 10-30
- Discarded drugs: section 40
- Self-administered drugs: section 80.5, and refer to the CMS Medicare Coverage Database for the list of drugs CGS has deemed to be "usually self-administered"
- Requirements for Erythropoiesis Stimulating Agents, including required modifiers: sections 80.8-80.12
- Billing Update for Zoledronic Acid – J3489
- CMS Drug & Biological Fee Schedules
- Correct Coding for Hydration Administration
- Immunosuppressive Drugs: Submit Claims to the Correct Contractor
- Overpayments for Trastuzumab (Herceptin)
- Process to Determine Which Drugs Are Not Usually Self-administered by the Patient
- Invoice Claim Filing Instructions
- Reimbursement for Drugs & Biologicals: How Are Payments Calculated?
- Reminder: Hemophilia Drugs
- Vaccine Pricing
- Self-Administered Drug Exclusion List and Biologicals Excluded from Coverage – Medical Policy Article (A52527)
- Solesta Treatment for Fecal Incontinence
- Billing and Coding: Tetanus Immunization (A52438)
- CMS Discarded Drugs
- Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy HCPCS Codes
- Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy Frequently Asked Questions
Laboratory & Pathology
The following resources provide CMS-level information regarding laboratory and pathology services, including the CLIA program:
- CMS Clinical Labs Center Web page
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 16
- Mandatory Assignment: section 30.1
- Referred tests: section 40.1
- Date of service for clinical laboratory and pathology specimens: section 40.8
- Specimen collection fee and travel allowance: section 60
- Clinical Laboratory Improvement Act (CLIA) requirements:
- National Coverage Determinations for laboratory tests: CMS Lab NCD Web page (access the associated list of ICD-9 codes as well as NCD language under Downloads)
Other Lab & Pathology Services
Medicare Crossover
The Coordination of Benefits Agreement is a Center for Medicare & Medicaid Services (CMS) national contract, which standardizes the way that eligibility and Medicare claims payment information, within a claim's crossover context, is exchanged. COBAs permit other insurers and benefit programs (also known as trading partners) to send eligibility information to CMS and receive Medicare claims data for processing supplemental insurance benefits from CMS' national crossover contractor, the Benefits Coordination & Recovery Center (BCRC).
Click here for more information, including the COBA Trading Partners Customer Service Contacts.
Top Questions – Medicare Crossover
- Do Medicare contractors cross over claims to supplemental payers/insurers?
-
No, CMS implemented the Coordination of Benefits Agreement (COBA), which states that the Benefits Coordination and Recovery Center will process all claims crossovers. Government Health Incorporated (GHI) is the contractor selected by CMS.
- How are claims crossed over?
-
An eligibility file is sent from the Trading Partner (supplemental insurance company) to the BCRC. The file contains data to identify the Medicare ID number and claims criteria, specified by the Trading Partner, for crossovers. Each Trading Partner is issued a COBA ID. The COBA ID and eligibility file data, along with information specific to that trading partner, are stored in Medicare's Common Working File (CWF). When claims are processed, CWF compares each COB trading partner's claims selection criteria against the Medicare claims. If the claim matches the Trading Partner's claims criteria and the Medicare ID number in their eligibility file, the claim information is automatically forwarded to the Trading Partner, via an electronic file
- Whom do I contact if my remittance advice shows that a claim crossed over and the supplemental insurance company has not received it?
-
Because Medicare no longer crosses over claims, you will need to contact the Trading Partner so they may investigate the situation to confirm if it is an internal issue or an issue with the BCRC.
- Who do I contact if Medicare records indicate that claims have crossed over, but the trading partner says they did not, or if I am experiencing problems with claims being forwarded to other payers?
-
This situation could suggest that some type of error occurred during the crossover process from the Medicare contractor to the BCRC or from the BCRC to the trading partner. In order to determine if such an error occurred or if a problem exists, the trading partner must contact the BCRC. The BCRC will correct any possible issues on their end, or report to the contractor any issues that require action on the part of the contractor. The Contractor can verify whether Medicare claims processing records indicate crossover; however, when our records indicate that claims did not crossover, we cannot provide any specifics on the trading partner's criteria.
- If supplemental insurer information is not on the claim, will it still crossover?
-
Yes. The Common Working File (CWF) includes the eligibility file that contains specific information pertaining to the trading partner contracted with the BCRC. As Medicare claims are processed, CWF applies each COB Trading Partner's claims selection criteria against the Medicare claim. The COBA ID of the trading partner and their eligibility file data are stored in CWF. The eligibility file is sent from the Trading Partner to the BCRC. The file contains data to identify the claims for cross over.
Medicare Diabetes Prevention Program (MDPP)
CMS Resources
- Medicare Diabetes Prevention Program (MDPP) Expanded Model | CMS
- MDPP Expanded Model Fact Sheet
- MDPP Expanded ModelMLN booklet
- MDPP Frequently Asked Questions
- MDPP: Preparing to Enroll as an MDPP Supplier
- MDPP Quick Reference Guide to Payment and Billing
- MDPP Sessions Journey Map
- MDPP Supplier Requirements Checklist
Mental Health Services
Access helpful resources regarding coverage, claim submission requirements, and payment information related to mental health services:
- CMS Medicare Benefit Policy Manual (Pub.100-02), Chapter 15
- Clinical Social Worker services: section 170
- Outpatient Mental Health Treatment Limitation: section 80
- Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
- LCD – Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians (L34539)
- Psychotherapy Documentation Fact Sheet (CPT Codes 90832, 90838, 90846, and 90785)
MSP
The determination as to whether Medicare pays as primary or secondary is based on various laws. For more information about Medicare Secondary Payer (MSP) provisions and billing requirements, refer to the following CMS resources:
- MSP provisions (including information about situations in which Medicare pays as secondary): CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 2
- MSP billing/claim submission requirements: CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 3
- MSP Fact Sheet
- Coordination of benefits: CMS Benefits Coordination & Recovery Center (BCRC) Web page
- CMS Medicare Secondary Payer Web page
- Top Provider Questions – Coordination of Benefits
- Top Provider Questions – MSP
- Medicare Secondary Payer Information and Filing Claims: Getting It Right the First Time
- MSP Job Aid
- myCGS: Submitting a Part B Medicare Secondary Payer (MSP) eClaim
- Reminder: Submitting Electronic Medicare Secondary Payer (MSP) Claims
- Top Five Claim Denials… MSP
Opioid Treatment Program Services
Section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act established a Medicare Part B benefit for opioid use disorder (OUD) treatment services, including medications for medication-assisted treatment (MAT), furnished by opioid treatment programs (OTPs).
REMINDER: OTPs should not bill more than once in a 7-day period, except in limited situations, such as a beneficiary starting treatment at the OTP in the middle of the OTP's standard weekly billing cycle. Please reference the resources below for additional information.
CMS Resources
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 17
- CMS Medicare Claims Processing Manual (Pub. 100-04) chapter 39
- COVID-19: CMS Allowing Audio-Only Calls for OTP Therapy, Counseling, and Periodic Assessments
- Opioid Treatment Programs (OTP) CMS Web Page
- Opioid Treatment Program Billing & Payment
- Opioid Treatment Programs (OTPs) Medicare Enrollment Fact Sheet
Physical & Occupational Therapy
Find information regarding claim submission and documentation requirements for physical and occupational therapy, including therapy caps and functional reporting, through these CMS resources:
- CMS Therapy Services Web page
- CMS Annual Therapy Update
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15
- Coverage of outpatient rehabilitation services: section 220
- Practice of physical therapy, occupational therapy, and speech-language pathology: section 230
- CMS Therapy Caps and Advance Beneficiary Notice of Non-Coverage (ABN) FAQs
- Counting Units for Therapy Codes (Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2)
- Task Force Scenario: Documenting Therapy and Rehabilitation Services
- Physical Therapy Documentation Fact Sheet
- Physical Therapists Billing for EMC/NCV Studies
- "Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo v. Sebelius" MLN Matters Article – Released
Preventive Services
Medicare pays for many preventive services that can help prevent illness from occurring or determine if a person is at risk for certain conditions so he or she can take steps to prevent them.
Use the resources below to find more information about the preventive services that Medicare covers and offer them to your patients.
CMS Resources
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 18
- Medicare Preventive Services CMS MLN Educational Tool
- Preventive Services CMS Web page
CGS Resources
Sleep Studies
Teaching Facilities
Access guidance for teaching physicians through these CMS resources:
- CMS Medicare Learning Network Fact Sheet, "Guidelines for Teaching Physicians, Interns, and Residents"
- Documentation and claim submission guidelines for teaching physicians: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 100
- Teaching Physician Services: Supervision, Documentation, and HCPCS Modifier GC
Updated: 06.08.2026
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