General Medicare data requirements

Claims for Kaiser Permanente Medicare Advantage plans, are subject to all Medicare billing and National Correct Coding Initiative requirements.

Billing and coding reminders

Ambulatory surgical centers should bill with modifier SG if billing the facility charges on a CMS-1500 claim form.

Physical, occupational, and speech therapy

Physical, occupational, and speech therapy services must use their appropriate modifiers when billing:

• Physical therapy: Modifier GP
• Occupational therapy: Modifier G0
• Speech therapy pathology: Modifier GN

Spinal manipulation

Medicare allows for acute care spinal manipulations only. This service must be billed with modifier AT to indicate acute care.

Emergency room and observation care

Revenue codes 450 and 762: When emergency room or observation care extends past midnight to the following day, the service must be billed with only one date of service — the date when care was initiated. The service line date must agree with the from/to date in field 6 (statement cover period).

Additional UB-04 field requirements

• Field 6: All dates on a claim must fall within the from/to dates listed in this field. This requirement includes preoperative services.
• Fields 18-28: Use the appropriate condition codes. Condition code 07 indicates that the patient has elected hospice care but the provider is not treating the terminal condition and is, therefore, requesting regular Medicare payment.
• Field 56: Record the entity NPI.
• Field 57: Include the appropriate taxonomy code.
• Fields 66-67: Present On Admission (POA) indicators must be submitted with primary and secondary diagnoses for acute care hospitals or other facilities subject to CMS regulations for reporting POA information. See POA indicators for inpatient Claims: Provider Q&A (PDF) for additional information.