Fee-for-service Medicare runs appeals on five levels and five separate clocks, all of them sitting in 42 CFR part 405, subpart I. Here is who decides each level, what the practice files and on which form, how long each side has, and what changes as the case moves up.
The notice is a one-page form with one decision inside it. Used on the right service and coded with the right modifier, it moves a denied charge to the patient. Missed, it moves the charge to you.
A facility visit a physician and a nonphysician practitioner each contributed to is billed by one of them, and the rule that decides which one changed on January 1, 2024. The current test is time or medical decision making, the modifier is FS, and the record has to say who did what.
Four conditions decide whether a visit your nurse practitioner furnished can go out under the physician's number at 100 percent of the fee schedule. Miss one and the same visit reverts to the practitioner's own rate, which is the difference the OIG keeps auditing.
Every bundling denial asks one question: can this pair ever be split? The indicator on the edit answers it, and the modifier you append only matters when the answer is yes.
The hard therapy cap was repealed in 2018, but the annual threshold that replaced it still decides whether a claim pays. Here is what the KX modifier, the plan of care, and the assistant modifiers actually require in 2026.
