Medicare contractor · Jurisdictions J and M
Palmetto GBA Dermatology Billing (Jurisdictions J and M)
Palmetto GBA is the Medicare Administrative Contractor for Jurisdiction J (Alabama, Georgia and Tennessee) and Jurisdiction M (North Carolina, South Carolina, Virginia and West Virginia). It administers Part B dermatology claims across the southeast and writes the coverage policy that decides when destruction, excision and Mohs services are payable in those states.
Palmetto GBA is one of the contractors covered in our Medicare dermatology billing guide, which explains how local coverage determinations, advance beneficiary notices and global periods reach the claim before any contractor-specific rule applies.
What Palmetto reviews most in dermatology
- Actinic keratosis destruction volume, where lesion counts drive frequency scrutiny in high-UV coastal markets.
- Benign lesion removal, where the covered symptom must appear in the narrative and not only in the diagnosis code.
- Mohs staging on repeat skin-cancer patients, where the stage sequence has to reconcile with the operative note block by block.
What Palmetto GBA decides for your dermatology claims
Palmetto GBA does not write Medicare's benefit categories, but it writes the local coverage determinations, the billing and coding articles and the medical review edits that decide whether an individual dermatology claim is paid. Coverage language for benign lesion removal, actinic keratosis destruction, Mohs micrographic surgery and photodynamic therapy is contractor-level policy, and the version that matters is the one active on the date of service.
The billing and coding article attached to each policy usually carries the diagnosis code list and the documentation wording a reviewer applies. Practices that read only the policy and never the article are the ones surprised by a denial that cites a code they thought was covered.
How we work these claims
- Policy set is loaded per location so a group crossing a jurisdiction line bills each site under the contractor that actually governs it.
- Pre-bill scrub checks lesion counts, destruction units, excision measurements and Mohs stage sequences against the note before release.
- Liability modifiers are paired with a signed advance beneficiary notice obtained before the service, never reconstructed afterwards.
- Denials are grouped by policy citation rather than by CPT, so the corrective action lands on the documentation template that caused them.
- Redetermination deadlines are tracked per claim, with reconsideration and ALJ escalation where the contractor's reading of its own policy is wrong.
Appeals inside the Medicare levels
Medicare appeals run in fixed levels: redetermination by the contractor, reconsideration by a qualified independent contractor, then an administrative law judge hearing. Each level has its own filing window, and a claim that misses one cannot re-enter at the next.
Most dermatology redeterminations succeed or fail on one thing — whether the operative or progress note states the clinical fact the policy asks for. We attach the note excerpt and the policy language side by side rather than sending a form letter.
States in Jurisdictions J and M
- Alabama
- Georgia
- Tennessee
- North Carolina
- South Carolina
- Virginia
- West Virginia
Markets Palmetto GBA governs
These are the metro billing guides inside this jurisdiction. Each one sets out the local payer mix that sits on top of Palmetto GBA policy.
Frequently asked questions
Do we have to follow Palmetto GBA policy if our practice is somewhere else?
Jurisdiction follows the location where the service was rendered, not where the practice is headquartered. A group with sites in more than one jurisdiction is subject to both rulebooks.
Our claim was paid last year and the same claim denied this year. What changed?
Local coverage determinations and their billing and coding articles are revised on the contractor's own schedule. Check the policy version effective on the date of service before appealing.
Is a Palmetto GBA denial appealable?
Yes, through the standard Medicare appeal levels, provided the redetermination is filed within the window. Denials caused by documentation that never stated the covered indication are better fixed at the template than at appeal.
Other Medicare contractors
Working with Palmetto GBA
We bill dermatology only, inside your practice management system, with the Palmetto GBA policy set loaded per location. If your Medicare denials keep citing the same policy, send us a remittance sample and we will tell you which documentation line is producing them.