Chapter 3 — Further Reading

Tier 1 — Verified canonical sources

The Medicare Coverage Database, CMS. Searchable by code, keyword, contractor, or state; contains every national coverage determination, every local coverage determination, and every billing and coding article. This is the single most operationally valuable free resource in this book. Learn to search it by CPT code, and learn to filter by your own contractor. Chapter 22 uses it constantly.

Medicare Claims Processing Manual, CMS Publication 100-04. How claims are processed, chapter by chapter, by claim type. Chapter 1 of the manual covers general billing requirements; Chapter 12 covers physician and non-physician practitioner services; Chapter 4 covers hospital outpatient. Free, searchable, and authoritative over any secondary description including this one.

Medicare Program Integrity Manual, CMS Publication 100-08. What medical review contractors do and the standards they apply. Chapter 3 of the manual, on verifying potential errors and taking corrective action, is the document an auditor is working from. Chapter 37 of this book returns to it.

Medicare Benefit Policy Manual, CMS Publication 100-02. What is and is not a Medicare benefit — the statutory exclusions, the conditions of coverage, and the definitions that decide whether a service is a benefit at all before any coverage determination applies.

Social Security Act § 1862(a)(1)(A) — the "reasonable and necessary" language that every coverage determination is an application of. Chapter 22 §22.2 examines it.

Social Security Act § 1848 — the physician fee schedule and the relative value methodology. Chapter 23.

Medicare Secondary Payer provisions, 42 U.S.C. § 1395y(b), and the Medicare Secondary Payer Manual, CMS Publication 100-05. The source of the 20- and 100-employee thresholds and the rest of the primacy rules.

Your own Medicare Administrative Contractor's website. Find out which MAC has your jurisdiction and bookmark its LCD index, its bulletins, and its education pages. There is no substitute and no national equivalent. This is a specific action item, not a reading suggestion.

Medicare.gov beneficiary materials, including the annual Medicare & You handbook. Written for a non-specialist audience and genuinely good — the best available resource when you need to explain something to a patient rather than to a colleague.

CMS guidance on billing Qualified Medicare Beneficiaries. CMS has issued repeated guidance on the prohibition against billing QMBs for Medicare cost sharing, because the prohibition is widely and inadvertently violated. If your practice sees dual eligibles, read it and build the control.

Your state Medicaid agency's provider manual and fee schedule. There is no national substitute for this either. §3.7 exists to tell you that.

Families First Coronavirus Response Act of 2020 (continuous enrollment condition) and the Consolidated Appropriations Act, 2023 (which decoupled it and set the March 31, 2023 date) — the statutory basis for Case Study 2.

FY 2014 IPPS final rule — the two-midnight benchmark, and the subsequent rulemaking and sub-regulatory guidance revising it. The Notice of Observation Treatment and Implication for Care Eligibility Act and Form CMS-10611 (the Medicare Outpatient Observation Notice). The subject of Case Study 1.

Tier 2 — Attributed, specifics unverified

Medicare Payment Advisory Commission (MedPAC) reports to Congress, published twice yearly. The best available independent analysis of how Medicare payment systems actually behave, including observation stays, Medicare Advantage payment and risk adjustment, and the adequacy of physician payment. Written for policymakers, readable by practitioners, and free.

Kaiser Family Foundation Medicaid and Medicare tracking. The standard source for enrollment figures, Medicare Advantage penetration, and — for Case Study 2 — state-by-state unwinding data. This is where to get the numbers this chapter deliberately did not print.

CMS published unwinding data. State-reported monthly disenrollment data from the Medicaid continuous enrollment unwinding, including procedural termination rates. Specific, public, current.

Medicare Advantage enrollment and risk-adjustment literature, including OIG reports on risk-adjustment practices. Chapter 36 returns to this at length; for Chapter 3 the relevant point is that Medicare Advantage payment is risk-adjusted and that the adjustment is driven by documented diagnoses.

Health services research on observation status, including the documented growth in observation stays and their consequences for skilled nursing facility eligibility. The mechanism described in Case Study 1 is well documented; the magnitudes vary by study and period.

Tier 3 — Illustrative and constructed

Figure 3.1 — the LCD and billing-and-coding-article structure. Modeled on the real structure of CMS coverage documents; the contractor, numbers, and content are constructed and shown schematically.

Every fee schedule amount in this chapter, including the \$200.00, \$260.00, and \$400.00 used in limiting-charge calculations and the \$96.52 / \$63.28 / \$5.44 / \$3.00 Medicare allowed amounts in the Encounter counterfactual. All constructed; see Chapter 23 §23.6 for the derivation of \$96.52.

The Medicare Summary Notice line in §3.9 — constructed to match the Encounter's figures.

The payer-mix arithmetic in Exercise 3.17 — constructed.

If you read only three things after this chapter

1. Find out which MAC covers your jurisdiction, and bookmark its LCD index. Five minutes. It will answer more of your questions over a career than anything else on this page.
2. Search the Medicare Coverage Database for a code you bill often. See what comes back — the NCD if there is one, the LCD, and the article with the diagnosis list. Do it once and the abstraction in §3.5 becomes a concrete document you know how to find.
3. The current-year Medicare & You handbook, skimmed. It is the version of this chapter your patients have read, and knowing what it told them is worth a great deal at a front desk.