November 2005 Medicare Bulletin - North Carolina Insert
Posted November 4, 2005
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Table of Contents
- North Carolina Health Professionals Shortage Areas (HPSAs)
- North Carolina Mental Health Professional Shortage Areas (HPSAs)
- Troubleshooting Claim Submission Errors – North Carolina
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Troubleshooting Claim Submission Errors – North Carolina
“Getting it right the first time” is a cost- and time-saving efficiency for your office and the Medicare Program. We have compiled a listing of recent top ten claim submission errors. Please review the following recommendations for eliminating these errors to ensure that you receive appropriate reimbursement at the time of initial claim submission. The following claim submission errors will have a Group/Reason Code CO-16 with the exception of item number 9 (CLIA) which has Group/Reason Code CO-96. The Group/Reason Code will be accompanied by either a Remarks Code or MOA Code identifying the missing/invalid information needed to process the claim.
For complete CMS-1500 claim form instructions, refer to the CMS Manual System, Pub 100-4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 26, Section 10, (http://www.cms.hhs.gov/manuals/104_claims/clm104c26.pdf).
Web-based training for completion of the CMS-1500 claim form is available on the Internet at:
http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1
1. Missing/incomplete/invalid group practice information (MOA Code MA112)
Enter the provider of service/supplier’s billing name, address, ZIP code, and telephone number in Item 33 of the CMS-1500 claim form (or equivalent electronic field). This is a required field.
For a provider who is not a member of a group practice (e.g., private practice), enter the PIN at the bottom of item 33 (or the electronic equivalent). The PIN should be entered on the left side, next to the PIN# field.
If a group practice is billing, then the group PIN is to be placed in item 33 (or the electronic equivalent). Enter the group PIN at the bottom of item 33 on the right side, next to the GRP# field. In addition, enter the PIN for the performing provider of service/supplier who is a member of that group practice in item 24K. When several different providers of service or suppliers within a group are billing on the same Form CMS-1500, or electronic equivalent, show the individual PIN of each performing provider in the corresponding line item. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in item 24K.
2. Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification (Remarks Code N286)
The name and Unique Physician Identification Number (UPIN) are required on all claims for Medicare covered services and items that are the result of a physician’s order or referral. This includes all claims that contain diagnostic tests, clinical laboratory services, consultations, and other referrals. The name and UPIN identify the referring/ordering physician for the consultation, diagnostic test, or other referred/ordered service.
Enter the referring/ordering physician’s name and UPIN in Items 17 and 17a of the CMS-1500 claim form (or the equivalent electronic field).
Additional Resources:
For additional information regarding UPINs, including appropriate surrogate UPINs when an individual UPIN is not available, refer to the CMS Manual System, Pub 100-4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 26, Section 10, (http://www.cms.hhs.gov/manuals/104_claims/clm104c26.pdf).
A UPIN directory is also available on CIGNA Government Service’s Web site at: http://www.cignagovernmentservices.com/links.html
3. Missing/incomplete/invalid information on where the services were furnished (MOA Code MA114)
Enter the name, address, and ZIP code of the service location for all services other than those furnished in place of service home (12) in Item 32 of the CMS-1500 (or equivalent electronic field). Only one name, address and zip code may be entered in Item 32. If additional entries are needed, separate claim forms must be submitted. Electronic claims in a HIPAA-compliant format allow reporting of multiple service locations. Providers of service (namely physicians) identify the supplier’s name, address, ZIP code and PIN when billing for purchased diagnostic tests. When more than one supplier is used, a separate Form CMS-1500 should be used to bill for each supplier.
Complete Item 32 (or electronic equivalent) for all laboratory work performed outside a physician’s office. If an independent laboratory is billing, enter the place where the test was performed, and the PIN.
4. Missing/incomplete/invalid HCPCS modifier (Remarks Code M78)
Modifiers are two-character codes that are appended to procedure codes to further describe the procedure or service in Item 24d of the CMS-1500 claim form (or the equivalent electronic field). Modifiers may be alpha-alpha (JJ), numeric-numeric (25), or alpha-numeric (T2). Some modifiers describe additional work or circumstances that could impact reimbursement. Other modifiers simply provide additional information and do not impact reimbursement. CPT (Level 1) modifiers are published in the CPT manual. HCPCS Level II (CMS-assigned) are published in the HCPCS book or are available online at http://www.cms.hhs.gov/providers/pufdownload/anhcpcdl.asp.
Only two modifiers can be reported per service line in the claim submission. If the service or procedure requires more than two modifiers then modifier “99” should be appended to the procedure code and all modifiers indicated in Item 19 of the CMS-1500 claim form (or the equivalent electronic field) as follows: 1=(mod), where the number 1 represents the line item and “mod” represents all modifiers applicable to the referenced line item.
Note: With the implementation of the CMS Multi-Carrier System (MCS), electronic claims may include up to four modifiers per service line, if necessary.
5. Missing/incomplete/invalid procedure code(s) (Remarks Code M51)
Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code in Item 24d of the CMS-1500 claim form (or equivalent electronic field) without a narrative description. When applicable, show HCPCS code modifiers with the HCPCS code.
In the event that a physician performs a procedure that does not have a designated CPT code, the physician should then bill the procedure using an “unlisted procedure code” or a NOC code, and include a narrative description in Item19 of the CMS-1500 claim form (or the equivalent electronic field) if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim. In addition, if a surgical procedure is submitted, the operative report should clearly indicate what the unlisted code is for by describing in detail the procedure being performed. If the unlisted code being used is for a non-surgical procedure and no other instructions have been published pertaining to that procedure then the provider should submit supporting documentation with an explanation of what the unlisted code is for.
Procedure code changes are effective January 1 of each year. Codes are deleted, added, or modified. It is important to update your billing system to reflect these changes.
Effective January 1, 2005, Medicare providers no longer have a 90-day grace period to use discontinued HCPCS codes for services rendered in the first 90 days of the year. The Health Insurance Portability and Accountability Act (HIPAA) require that medical codes sets must be date of service compliant. Use of such codes to bill services provided after the date on which the codes are discontinued will cause your claims to be returned as unprocessable and not paid. In essence, HCPCS codes must be valid at the time the service is rendered.
HCPCS codes (Level I CPT-4 and Level II alpha-numeric) are updated on an annual basis. The elimination of the grace period applies to the annual HCPCS update and to any mid-year coding changes. Providers can purchase the American Medical Association’s CPT-4 coding book that is published each October that contains new, revised, and discontinued CPT-4 codes for the upcoming year. In addition, CMS posts on its Web site the annual alpha-numeric HCPCS file for the upcoming year at the end of each October.
To determine the status of codes under Medicare rules, access the 2005 Medicare Physician Fee Schedule Database (MPFSDB) on the Internet at: http://www.cms.gov/providers/pufdownload/rvudown.asp.
Providers are encouraged to access the CMS Web site to see the new, revised, and discontinued alpha-numeric codes for the upcoming year. The CMS Web site to view the annual HCPCS update is http://www.cms.hhs.gov/providers/pufdownload/anhcpcdl.asp.
6. Missing/incomplete/invalid place of service (Remarks Code M77)
Two-digit place of service (POS) codes are required in Item 24b of the CMS-1500 claim form (or the equivalent electronic field) for each line of your claim submission. We encourage providers to verify that they are reporting the POS code that applies to the setting in which the service was provided and that the submitted procedure code is compatible with that POS.
For example, Office or Other Outpatient Consultation (procedure codes 99241-99245) should be billed with POS codes 11(Office), 22 (Outpatient Hospital), 23 (Emergency Room), etc., while an Inpatient Consultation (99251-99255) should be billed with POS 21 (Inpatient Hospital), 31 (Skilled Nursing Facility), etc.
Evaluation and Management and Psychiatric Therapeutic codes are also edited for compatibility with the POS code submitted.
Additional Resources:
For a complete listing of place of service codes and definitions, refer to the CMS Manual System, Pub 100-4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 26, Section 10, (http://www.cms.hhs.gov/manuals/104_claims/clm104c26.pdf).
7. Missing/incomplete/invalid diagnosis or condition (Remarks Code M76)
Enter the patient’s diagnosis/condition in Item 21 of the CMS-1500 claim form (or the equivalent electronic field). With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and non-physician specialties (i.e., PA, NP, CNS, CRNA) use an ICD-9-CM code number and code to the highest level of specificity. Enter up to four codes in priority order (primary, secondary condition).
The full ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) system consists of three volumes. For Medicare purposes, providers should only use the first two volumes.
- Numeric codes (001.0 to 999.9) are broken down into 17 classifications of diseases and injuries.
- V codes (V01.0 to V82.9) describe circumstances of a patient visit for reasons other than disease or injury.
The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets must be date of service compliant. Since ICD-9-CM is a medical code set, effective for dates of service on and after October 1, 2004, CMS no longer provides a 90-day grace period for providers to use in billing discontinued ICD-9-CM diagnosis codes on Medicare claims.
The updated ICD-9-CM codes are published in the Federal Register in April/May of each year as part of the Proposed Changes to the Hospital Inpatient Prospective Payment Systems in Table 6 and effective each October 1. After the ICD-9-CM codes are published in the Federal Register, CMS places the new, revised, and discontinued codes on the following Web site: http://www.cms.hhs.gov/medlearn/icd9code.asp.
Physicians, practitioners, and suppliers must use the current and valid diagnosis code that is in effect for the date of service being billed.
For additional ICD-9 Coding resources and Web Based Training (WBT), access http://www.cms.hhs.gov/medlearn/icd9code.asp.
8. Missing/Incomplete/Invalid CLIA Certification Number (MA120)
Enter the 10-digit CLIA certification number for laboratory services billed by an entity performing CLIA covered procedures in Item 23 of the CMS-1500 claim form (or the equivalent electronic field).
For additional information, refer to the CMS Manual System, Pub 100-4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 16, Section 70, (http://www.cms.hhs.gov/manuals/104_claims/clm104c16.pdf).
9. Missing/incomplete/invalid days or units of service (Remarks Code M53)
Enter the number of days or units in Item 24G of the CMS-1500 claim form (or the equivalent electronic field).
10. Missing/incomplete/invalid date the patient was last seen or the provider identifier of the attending physician (MOA Code MA104)
Claims for Routine Foot Care
Claims for routine foot care must include the date the patient was last seen by a medical doctor (M.D.) or doctor of osteopathy (D.O.) and the unique physician identification number (UPIN) of the M.D or D.O. for treatment of the “severe peripheral complication.” The date last seen must be within the last six months. The date last seen and UPIN should be reported in Item 19 of the CMS-1500 claim form (or the equivalent electronic field). All claims for routine foot care requiring a date last seen must contain a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date. If you are unsure of the exact day of the month and year being reported, you may use the first day of the month. If you are billing for non-covered routine foot care, for denial purposes only, enter “No date last seen.”
Additional Resources:
For additional information regarding foot care coverage, refer to the CMS Manual System, Pub 100-2, Medicare Benefit Policy (basic coverage rules), Chapter 15, Section 290, (http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf).
Claims for Physical and Occupational Therapy
For physical and occupational therapists, entering this information certifies that the required physician certification (or recertification) is being kept on file. The name and UPIN of the attending physician should be reported in Items 17 and 17a of the CMS-1500 claim form (or the equivalent electronic field). In addition, the date the attending physician last saw the patient must be reported in Item 19 of the CMS-1500 claim form (or the equivalent electronic field).
For additional coverage information, refer to the CMS Manual System, Pub 100-2, Medicare Benefit Policy (basic coverage rules), Chapter 15, Section 220, (http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf).
For information concerning physicians certification and recertification for outpatient physical therapy, refer to the CMS Manual System, Pub 100-1, Medicare General Information, Eligibility, and Entitlement, Chapter 4, Section 50, (http://www.cms.hhs.gov/manuals/101_general/ge101c04.pdf).
North Carolina Mental Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 Classified as a Mental Health HPSA, Effective February 2, 2005
2 Classified as a Mental Health HPSA, Effective June 30, 2005
North Carolina Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 No longer classified as a HPSA, effective August 1, 2002.
2 Classifed as a HPSA, effective June 1, 2004.
3 No longer classified as a HPSA, effective December 1, 2004.
