J8 Part B Targeted Probe and Educate Problem Error Rates
MACs conduct Targeted Probe and Educate (TPE) reviews to decrease provider burden, reduce appeals, and improve the medical review and education process. To avoid errors, providers should be aware of problem error rates and top reasons for denial.

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Prolonged Care Procedure Codes
There are several ways physicians and non-physician practitioners can show prolonged services provided to a patient. The choice of the prolonged code and documentation requirements depends on the originating (companion) procedure code. When submitting a prolonged care code, you must also submit the companion code. For more information, refer to the CMS Medicare NCCI Add-on Code Edits webpage.

Documentation must include the total of the face-to-face time (including the visit) spent on the patient along with any time spent in qualifying activities. The CPT Codebook’s E/M Services Guidelines (Guidelines for Selecting Level of Service based on Time) list the qualifying activities.  Providers may use these activities when using time to choose the level of service when performed and medically necessary. The CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners, section 30.6.15, reviews the use of prolonged services. This section provides a chart showing the face-to-face threshold times required.

Providers must use time to choose the level of service. Use of a prolonged care code is only valid when exceeding the time for the highest level of service.

Prolonged Care Resources

• CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysicians Practitioners, Section 30.6.15.1 and 30.6.15.2
• CMS Medicare NCCI Add-on Code Edits webpage
• Fact Sheet - Physician Fee Schedule Payment for Office/Outpatient Evaluation and Management Visits 
• CMS 2023 Medicare Physician Fee Schedule Final Rule 

WPS PARTS A & B

Multi-MAC Evidentiary CAC – MolDX: Molecular Testing for Detection of Upper GI Metaplasia, Dysplasia, Neoplasia
On Thursday, September 4, 2025, at 2:00 - 4:00 pm ET, Palmetto GBA along with CGS Administrators, Noridian Healthcare Solutions, and WPS will host a Multi-MAC Evidentiary Contractor Advisory Committee (CAC) meeting via Microsoft Teams webinar.

Discussions will focus on MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, Neoplasia

The Centers for Medicare & Medicaid Services (CMS) assigned Medicare Administrative Contractors (MACs) the task of developing Local Coverage Determinations (LCDs). The purpose of the CAC meeting is to provide a formal mechanism for healthcare professionals to be informed of the evidence used in developing an LCD and to also promote communication between the MACs and the healthcare community. The CAC panel will discuss the clinical literature related to molecular testing for detection of upper gastrointestinal metaplasia, dysplasia, and neoplasia and rate their confidence in a series of Key Questions. Discussions will occur between Subject Matter Expert (SME) panelists and Contractor Medical Directors (CMDs). The public may attend; however, questions from the public will not be answered.

Interested stakeholders are invited to listen via Microsoft Teams webinar; however, advance registration is required. Register Here 

Note: The registration deadline is September 3, 2025, 11:59 pm ET.

You can locate additional information, including the link to the webinar, on the WPS Contractor Advisory Committee (CAC) Meetings webpage.

Process Change for Customer Service
To better serve our providers and streamline call handling, the Provider Contact Center (PCC) will accept only one NPI and PTAN combination per phone call, effective August 4, 2025.

This change is being made to improve call efficiency, decrease call wait times, and ensure quicker resolution of your inquiries.

What This Means for You
Going forward, each call to the PCC must focus on a single NPI/PTAN combination. If you need assistance with multiple combinations, please place separate calls for each one. This allows our team to handle your phone calls more efficiently.

Be Prepared Before Your Call
To help make your call as smooth and efficient as possible, please have the following information ready:

• NPI/PTAN combination for the inquiry
• Last five digits of your Tax ID
• For claim-specific questions:
• Patient’s last name and first initial
• Date of service
• Relevant claim billing details

Being prepared upfront will reduce the likelihood of needing to call back.

Timely Filing of Claims
To be eligible for Medicare reimbursement, providers must file claims for services furnished on or after January 1, 2010, within one calendar year of the date of service.

Patient Responsibility on Claims Denied for Late Filing
The provider may collect 20% of what would have been the Medicare fee schedule allowed amount, when the claim denies for late filing. The patient is not responsible for the entire billed amount.

Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights
CMS requires Medicare contractors to deny claims submitted after the timely filing limit. In addition, the CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1 – General Billing Requirements Section 70.4 states, "When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal."

Denied Claim Not Filed Within the Time Limits due to Third Party Error
Providers often ask Medicare contractors to reopen claims denied for timely filing when another insurer recouping their previous payment caused the delay. CMS does not accept errors caused by incorrect third-party payment as justification for not submitting timely claims to Medicare. The CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 34 – Reopening and Revision of Claim Determinations and Decisions, Section 10.11, states the following:

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Chimeric Antigen Receptor (CAR) T-Cell Therapy Billing Instructions
The CMS National Coverage Determination (NCD) 110.24 – Chimeric Antigen Receptor (CAR) T-cell Therapy provides coverage and billing guidelines for autologous CAR T-cell Therapy.   

On June 26, 2025, the Food and Drug Administration (FDA) issued a communication announcing the elimination of Risk Evaluation and Mitigation Strategies (REMS) for CAR T-cell therapies and updated product labeling.

As a result of the FDA communication, the KX modifier is no longer required to be appended to Part B CAR T-cell therapy claims. Part A claims no longer require CAR T-cell therapy services to be submitted by or performed in an FDA REMS approved facility.

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Chronic Care Management
Chronic Care Management (CCM) is a critical primary care service contributing to better patient health and care. CCM is:

• Generally non-face-to-face 
• Provided by clinical staff 
  • Under the incident to guidelines 
  • General supervision of the billing practitioner
• General supervision is when staff furnish the procedure or service under the physician's overall direction and control
  • Medicare does not need the physician's presence during the performance of the procedure

You can find information in the CMS MLN Booklet - Chronic Care Management Services. 

CCM provides a structure to provide a more proactive, holistic approach to caring for the patient. By understanding the Medicare rules, you can begin receiving payment for services you likely already provide to your patients. You can involve clinical staff to provide care management services. This can reduce your burden.

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