New Medicare Cards Now Required

You must now use Medicare Beneficiary Identifiers (MBIs) to get paid.  If you do not use MBIs on claims (with a few exceptions), regardless of the date of service, you will get:

  • Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)
  • Paper claims notices: Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

See the MLN Matters Article to learn how to get and use MBIs.

2019 MIPS Data Submission Begins

CMS is now accepting data submissions from Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2019 performance period of the Quality Payment Program (QPP). Data can be submitted and updated through March 31.  Sign in to the QPP website to get started.  Check the QPP Resource Library to learn more or call 1-866-288-8292, M-F, 8 AM-8 PM or email

Check Your Final MIPS Status

Use the Quality Payment Program (QPP) Participation Status Tool to view your final 2019 eligibility status for the Merit-based Incentive Payment System (MIPS). Your initial 2019 status was based on Part B claims and PECOS data from October 1, 2017 to September 30, 2018.  CMS has now updated provider eligibility status based on a second review of data from October 1, 2018 to September 30, 2019.  Your status may have changed, so use the tool to confirm.  [If you already checked your status in December, please recheck since CMS identified and corrected some errors late in the month.]

If, after the first review earlier this year, you were determined to be:

  • Eligible for MIPS: Your eligibility status might change, and you may no longer be eligible. Use the tool to be sure.
  • Not eligible for MIPS at a particular practice: Your eligibility status, based on your association with that particular practice, will not change.

If you joined a new practice (meaning you billed under, or assigned your billing rights to, a new or different TIN) between October 1, 2018, and September 30, 2019, CMS evaluated your MIPS eligibility based on your association with that new practice (identified by TIN) during its second review.  If you joined a new practice after September 30, 2019, you are not eligible for MIPS as an individual based on your association with that new practice (identified by TIN). However, you may be eligible to receive a MIPS payment adjustment based on your group’s participation, if the new practice you joined chooses to participate in MIPS as a group.

For more information, visit the MIPS Participation page or contact the Quality Payment Program at or 1-866-288-8292 (TTY: 1-877-715-6222). To receive assistance more quickly, consider calling during non-peak hours—before 10 AM and after 2 PM ET.

Exemption from MIPS Reporting

Three low-volume threshold criteria determine Merit-based Incentive Payment System (MIPS) eligibility for 2019. Clinicians and groups are excluded from MIPS if they:

  1. Billed $90,000 or less in Medicare Part B allowed charges for covered professional services during either of the two determination periods (October 1, 2017 – September 30, 2018 or October 1, 2018 – September 30, 2019); OR
  2. Provided care to 200 or fewer Part B-enrolled patients during either of the two determination periods; OR
  3. New for 2019 – Provided 200 or fewer covered professional services under the Physician Fee Schedule during either of the two determination periods.

To be eligible for MIPS, a clinician or group must exceed all three criteria listed above.  Please review your final 2019 status.  [See column at left.]

Assistance with Medicare Appeals, Denials and Grievances

The State Health Insurance Assistance Program (SHIP) meets the most universal needs of Medicare beneficiaries, such as understanding their health insurance benefits, bills, and rights. Trained staff and volunteer counselors in all 23 counties and Baltimore City provide in-person and telephone assistance.  Topics covered include:

  • Medicare Part A: Hospital Insurance
  • Medicare Part B: Medical Insurance
  • Medicare Part C: Advantage Plans
  • Medicare Part D: Prescription Drug Plans
  • Financial Assistance for Low-Income Beneficiaries
  • Billing Issues, Appeals, Denials, and Grievances
  • Medicare Fraud and Abuse

Click here to contact the closest SHIP office.

Qualified Registries for MIPS Data Submission

Under the Medicare Quality Payment Program option, MIPS, there are several data submission methods, one of which is Qualified Registries. A qualified registry is a CMS-approved entity that collects clinical data from MIPS eligible clinicians (both individual and groups) and submits it to CMS on their behalf for purposes of MIPS.  CMS has designated the qualified registries that can report data (measures and/or activities) for the Quality, Advancing Care Information, and Improvement Activities performance categories, on behalf of individual MIPS eligible clinicians and groups.  The APA’s PsychPRO registry is approved by CMS.

Medicare Quality Payment Program

Resources on the Quality Payment Program (QPP) website help eligible clinicians prepare to participate:

Download the APA’s fact sheet about the MIPS Quality Performance Category for help deciphering your MIPS composite score and its impact on Medicare Part B payments.   It also includes a Mental/Behavioral Health specialty measure set as well as a list of measures pertinent to psychiatrists.  Visit the APA website for more Medicare payment reform resources, including a MACRA toolkit.

CMS educational videos are available on YouTube at

Quality Payment Program: Pick Your Pace Online CME

A new, online, self-paced course on participating in the Quality Payment Program (QPP) and Picking a Pace that meets the needs of your practice is now available through the MLN Learning Management System. Find out about::

  • QPP basics;
  • Steps to actively participate to avoid a payment penalty and possibly earn a positive payment adjustment; and
  • Factors in choosing how to participate through either the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM).

This course is part of an evolving QPP curriculum that offers knowledge, insight and CME credit. CMS designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation. Credit for this course expires May 30, 2020.

MACRA Assistance from the APA

The Medicare Access & CHIP Reauthorization Act (MACRA) completely transforms Medicare payment and quality reporting, though the Merit-Based Incentive Payment System (MIPS) and new incentives for “advanced” alternative payment models (APMs).  To help members understand the new regulations, APA has relaunched its Payment Reform webpage and prepared free educational materials and a webinar series. Download the MACRA 101 Primer For Psychiatrists. The recorded presentation “Quality Reporting 101: A How-to Guide for Psychiatrists” is available through the APA Learning Center.

The APA Practice Management Helpline at 1-800-343-4671 is available for coding, reimbursement and practice management questions.

E&M Interactive Score Sheet

Novitas posted the E/M Interactive Score Sheet to assist with coding Evaluation and Management services.

Medicare Revalidation Reminder

The Affordable Care Act requires all currently and actively enrolled providers to revalidate their enrollment information every three or five years.  CMS sets every provider’s revalidation due-date at the end of a month, and posts the upcoming six months online. A due date of “TBD” means that CMS has not set the date yet.  Go to the revalidation dates page to search for your due date by name or browse the entire list to find the information needed. For more information, see the revalidation webpage and the FAQs.

If a provider fails to submit the revalidation application by the due date, the provider enrollment record will be deactivated. Deactivated providers must submit a full and complete application to reestablish their provider enrollment record and Medicare billing privileges. An interruption in billing will occur during the period of deactivation, resulting in a gap in coverage.  Retroactive billing privileges back to the period of deactivation will not be granted.  Services provided to Medicare beneficiaries during the period between deactivation and reactivation are the provider’s liability.

Please review the CMS revalidation document for more information.  Any questions or concerns should be directed to Andrea King, Novitas Provider Outreach and Education, at: or 717-526-6392.

Medicare Provider Data Published

CMS is making publicly available a subset of PECOS data to allow providers, suppliers, state Medicaid programs, private payers, etc. to leverage Medicare provider enrollment data. Click here for more information.  The Public Provider Enrollment files are published at and will be updated on a quarterly basis. Opt-out providers will not be included. Elements include:

  • Enrollment ID and PECOS Unique IDs
  • Provider Enrollment Type and State
  • Provider’s First and Last Name/ Legal Business Name
  • Gender
  • NPI
  • Provider or Supplier Specialty
  • Limited address information (City, State, ZIP code)

CMS Provider Screening

CMS has four tactics to reinforce provider screening activities:

  • Increase site visits to Medicare-enrolled providers
  • Enhance address verification software in PECOS to better detect vacant or invalid addresses
  • Deactivate providers who have not billed Medicare in the last 13 months
  • Identify potentially invalid addresses on a monthly basis using the U.S. Postal Service database

Providers should promptly inform CMS of any changes. For more information, see the fact sheet.

Psychiatry and Psychotherapy Documentation

Proper payment and sufficient documentation go hand in hand. CMS has created a video series to help providers improve in areas identified with a high degree of noncompliance.  The CMS Provider Minute: Psychiatry and Psychotherapy video includes pointers to properly submit documentation for these services.  In about three minutes, the video explains:

  • Use of add-on codes when billing for same day evaluation and management and psychotherapy services
  • Three factors needed for sufficient documentation

Small Practices and Health Professional Shortage Areas & Medically Underserved Populations

CMS launched a new section of the Medicare Quality Payment Program (QPP) dedicated to clinicians working in small or rural practices as well as those treating patients in underserved areas. This page is a single point of reference for the QPP, especially, for those participating under the Merit-based Incentive Payment System (MIPS) track. Quickly locate contact information for organizations that assist practices through the Small, Underserved, and Rural Support initiative using an interactive map. Review the flexibilities to help reduce the participation and reporting burden on small practices for 2017.  More features and information will be added, so submit your feedback to CMS.

MACRA provides direct technical assistance for small practices to participate in the QPP through an organization called IPRO, which serves Maryland, DC and Virginia.

Health Professional Shortage Areas (HPSAs) are designated as having shortages of primary care, dental care, or mental health providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible) or facilities (e.g., federally qualified health centers, or state or federal prisons).  Providers who serve these areas are eligible for bonus payments under Medicare.  A search tool is available to check an address for bonus eligibility.  Use another online tool to find HPSAs by state, country and discipline.

Do You Prescribe Part D Drugs?

Medical practitioners must have a status with Medicare for their Medicare patients’ prescriptions or tests or referrals to covered.  Being opted out is a valid status with Medicare, and Medicare will continue to cover all ordering and referring that is done by an opted out physician.  Physicians who do not wish to either opt out or enroll in Medicare now have the option of enrolling just to be able to have their orders and referrals covered by Medicare.  This new option is referred to as the OPR option (ordering, prescribing and referring).

To minimize the impact on beneficiaries, CMS will use a phased approach to enforcement that will begin in the second calendar quarter of 2017 and end with full implementation and enforcement of the Part D prescriber requirement on January 1, 2019.  Please click here for more details.  CMS encourages all providers who prescribe Part D drugs, but are not yet enrolled or validly opted out of Medicare, to enroll in the Medicare Program. Click here for enrollment information.  If you are unsure of your status, check the CMS list of providers who are enrolled in Medicare in an approved or opt out status.

Send questions directly to CMS at or visit Novitas’ JL Enrollment Center for CMS Forms, tutorials, and additional help.

Changes to the Medicare Opt-Out Law

Prior to enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician opt-out affidavits were only effective for 2 years. As a result of changes made by MACRA, valid opt-out affidavits signed on or after June 16, 2015 will automatically renew every 2 years. If physicians who file affidavits effective on or after June 16, 2015 do not want their opt-out to automatically renew, they may cancel the renewal by notifying all Medicare Administrative Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period. Valid opt-out affidavits signed before June 16, 2015 will expire 2 years after the effective date of the opt out. If physicians who filed affidavits effective before June 16, 2015 want to extend their opt out, they must submit a renewal affidavit within 30 days after the current opt-out period expires to all MACs with which they would have filed claims absent the opt-out.  Check this CMS publication for more details.

Medicare Private Contracting Change

Physicians who opt-out of Medicare should be aware that CMS has changed its definition of emergency care services to encompass urgent care services, which are furnished within 12 hours to avoid the likely onset of an emergency medical condition.   It has also specified that the enrollment appeals process should be used to appeal Medicare opt-out determinations, such as whether a physician or practitioner has failed to properly opt-out, failed to maintain opt-out, failed to timely renew opt-out, failed to privately contract, or failed to properly terminate opt-out. These changes are effective July 13, 2015. For details, click here.

Opting Out of Medicare

Since 1998, physicians have been permitted to opt out of Medicare and enter into private contracts with Medicare patients that allow them to set their own fees. A physician who opts out of Medicare agrees not to see any Medicare patients for two years (barring emergencies or urgent services), except for those with whom s/he has entered into private contracts. The opt-out applies for every Medicare patient a physician sees in clinics or elsewhere, not just those seen in private practice. If there is any possibility of having to see Medicare patients as part of a new contract or employment, a physician should not consider opting out of Medicare.  The rules for opting out are very specific. Please continue reading at the APA website.

To search for providers who have opted out of the Medicare program, see the CMS Opt-Out Affidavit listing, which is updated on a quarterly basis.  If you opted out of Medicare and cannot locate your information, please call 1-877-235-8073.

Medicare Resources

A new Behavioral Health Integration Services fact sheet explains psychiatric collaborative care services and how to bill for this model of care.

A new Care Management page is available with fact sheets, FAQs, etc.  Those who provide patients with chronic care management, non-face-to-face services such as reviewing test results or coordinating with other providers, may not be aware of the separate payments under the Medicare Physician Fee Schedule and may not be receiving the full separate payments that are now available. The Chronic Care Management Services Changes for 2017 fact sheet has information about 2017 coding changes, included services and reduced requirements for initiating care. The existing Chronic Care Management Services fact sheet has been revised, and addresses separately payable services for patients with multiple chronic conditions, codes and billing requirements, etc.

Novitas Behavioral Health Page – up-to-date topics, resources, training and coverage information.

Medicare Physician Fee Schedule Fact Sheet — Revised

Health Professional Shortage Area Physician Bonus Program

Medicare Enrollment Guidelines for Ordering/Referring Providers Fact Sheet—Covers three basic requirements for ordering and referring, and who may order and refer for Medicare Part A Home Health Agency, Part B, etc.

Medicare Fraud & Abuse: Prevention, Detection, and Reporting Fact Sheet

Mental Health Services Booklet — Revised—Explains covered and non-covered mental health services, eligible professionals, supplier charts, assignment, outpatient and inpatient psychiatric hospital services, same day billing guidelines, and National Correct Coding Initiative.

Definition of Treatment-Resistant Depression in the Medicare Population

Substance Abuse Services – Describes the levels of services and authorized suppliers that are covered under Medicare, as well as Part D drugs for opioid dependence.

Guidance on dually eligible individuals enrolled in the Qualified Medicare Beneficiary (QMB) Program was updated February 1, 2016. QMB is a Medicaid program for Medicare beneficiaries that exempts them from liability for Medicare cost-sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary.

Transitional Care Management Services can be billed by one clinician for services during the 30 days after discharge from an inpatient setting that include three TCM components: an interactive contact, certain non-face-to-face services, and a face-to-face visit.

HIPAA Privacy and Security Basics for Providers – Information on covered entities, business associates, and resources.

HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules – HIPAA basics, such as privacy, security, breach notification rules, covered entities, business associates, and disposal of private health information.

Medical Privacy of Protected Health Information addresses how the privacy rule applies to customary health care practices, tips for securing health information on a mobile device, and HIPAA resources.

Telehealth Services describes services that can be furnished to Medicare beneficiaries via a telecommunications system, including information about originating sites, distant site practitioners, telehealth services, billing and payment for services and facility fees, etc.  Several psychiatric services became eligible for telehealth coverage in 2015.

PECOS Fact Sheet includes Medicare enrollment application submission options, how to complete an enrollment application using PECOS, and PECOS user ID and password helpful hints.

Safeguard Your Identity and Privacy Using PECOS Fact Sheet

Medicare Appeals Process fact sheet explains the five levels of claim appeals in Original Medicare (Parts A and B).

Medicare Secondary Payer fact sheet explains situations when Medicare may pay first or second, coordination of benefits, et.

Medicare Enrollment for Physicians covers determining whether you want to be a participating provider and enrolling in the Medicare Program.