December 2005 Medicare Bulletin - Idaho Insert
Posted December 5, 2005
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of this issue 
Table of Contents
- Idaho Health Professional Shortage Areas (HPSAs)
- Idaho Mental Health Professional Shortage Areas
- Idaho - Troubleshooting Claim Submission Errors
Troubleshooting Claim Submission Errors - Idaho
“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 for Fourth Quarter FY2005. 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. 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 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 is available on the Internet at: http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1
1. Missing/Incomplete/Invalid Medicare Number and/or Name (MA27)
Providers are encouraged to keep a copy of each patient’s Medicare card and other insurance cards on file. The Medicare card shows the beneficiary’s Medicare coverage (Hospital, Medical) and the effective dates. Be sure to report the patient’s name and Medicare Health Insurance Claim Number (HICN) exactly as they appear on the Medicare card. No special characters (such as hyphens) should be used in an electronic claim submission even when the patient’s name includes a hyphen.
Do not place hyphens or blanks in the HICN field.
Claims Filed with a Beneficiary Last Name & Suffix CIGNA Government Services, in conjunction with CMS and other Medicare Carriers, has identified a problem with how MCS handles a beneficiary last name submitted with a suffix (e.g., Jr., Sr., II, III, etc.). The last name validation process was changed and has resulted in the potential that claims could be rejected with a rejection code of MA27.
CMS and the MCS System Maintainer are working to develop a permanent solution. In the short term, CIGNA has implemented a process to assist in processing claims that are submitted correctly. To ensure claim submissions do not bypass this process, CIGNA Government Services is requesting providers ensure the Beneficiary Name is filed exactly as shown on the red, white and blue Medicare card. This would mean appropriately including (or excluding) a suffix. Additionally, if claims are filed electronically, providers should ensure the EMC file loop 2010BB, NM107 (the suffix field) is populated and that the suffix is not added to the beneficiary’s last name. If the suffix is not included in the appropriate locations, claims will be rejected.
2. Missing/Incomplete/Invalid HCPCS Modifier (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), or numeric-numeric (33). 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) is published in the HCPCS book.
Only two modifiers can be reported per service line in claim the 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.
3. Missing/Incomplete/Invalid Information on Where Services Were Furnished (MA114)
Block 32 of the CMS-1500 form should contain the actual street address of the facility where a service is performed. If Block 32 is populated with incomplete or incorrect information, such as “PO Box” or “Route” information the claim will reject as unprocessable.
4. Missing/Incomplete/Invalid Group Practice Information (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). In addition, enter the Provider Identification Number (PIN) for the performing provider of service/supplier who is not a member of a group practice.
5. Referring Name and UPIN Required. Resubmit as a New Claim. (M68)
Providers are required to enter their seven (7) digit Provider Identification Number (PIN) in block 33 of the CMS-1500 form. This number was originally issued from the CIGNA Medicare Provider Enrollment department. If there are questions regarding the seven digit PIN contact Provider Enrollment’s Customer Service department at 1.866.520.4007.
6. Missing/Incomplete/Invalid Place of Service (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.
7. Missing/Incomplete/Invalid Procedure 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 will 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 2004 Medicare Physician Fee Schedule Database (MPFSDB) on the Internet at: http://www.cms.gov/providers/pufdownload/rvudown.asp.
Providers are encouraged to access 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.
8.Missing/Incomplete/Invalid Date Patient Was Last Seen and/or the UPIN of the Attending
Physician (MA104)
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.”
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).
You may also view and/or download our specialty manual entitled “Podiatry” on the Internet at:
http://www.cignamedicare.com/partb/specman/clickwrap.html.
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).
You may also view and/or download our specialty manual entitled “Physical Therapy/Occupational Therapy” on the Internet at: http://www.cignamedicare.com/partb/specman/clickwrap.html.
9.Missing/Incomplete/Invalid Diagnosis or Condition (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) require 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 will no longer provide 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.
Claims containing a discontinued ICD-9-CM diagnosis code will be returned as unprocessable. Physicians, practitioners, and suppliers must use the current and valid diagnosis code that is in effect beginning October 1, 2004. 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.
For additional ICD-9 Coding resources and Web - Based Training (WBT), you may access the following on the Internet at: http://www.cms.hhs.gov/medlearn/icd9code.asp.
10. Claim Contains Incomplete/Invalid Information (MA130)
This Remark Code, MA130, informs providers that there is missing information on the claim which is needed for adjudication. Providers are encouraged to review the additional remark codes listed on the definition portion of the Explanation of Benefits (EOB) for further details. The EOB also contains a remark code at the “line level” which provides more detail as to why that particular line denied.
Top
Mental Health Professional Shortage Areas
Designated Geographic Areas
Effective July 1, 2004
Idaho
| County | Area Name/Parts | Rural/Urban |
| Ada | Mental Hlth Region IV Ada |
Rural |
| Adams | Catchment Area # 3 Adams |
Rural |
| Bannock | Mental Hlth Region VI Bannock |
Rural |
| Bear Lake | Mental Hlth Region VI Bear Lake |
Rural |
| Benewah | Mental Hlth Region I Benewah |
Urban |
| Bingham | Mental Hlth Region VI Bingham |
Rural |
| Blaine | Mental Hlth Region V Blaine |
Rural |
| Boise | Mental Hlth Region IV Boise |
Rural |
| Bonner | Mental Hlth Region I Bonner |
Urban |
| Bonneville | Mental Hlth Region VII Bonneville |
Rural |
| Boundary | Mental Hlth Region I Boundary |
Urban |
| Butte | Mental Hlth Region VII Butte |
Rural |
| Camas | Mental Hlth Region V Camas |
Rural |
| Canyon | Catchment Area # 3 Canyon |
Rural |
| Caribou | Mental Hlth Region VI Caribou |
Rural |
| Cassia | Mental Hlth Region V Cassia |
Rural |
| Clark | Mental Hlth Region VII Clark |
Rural |
| Clearwater | Mental Hlth Region II Clearwater |
Rural |
| Custer | Mental Hlth Region VII Custer |
Rural |
| Elmore | Mental Hlth Region IV Elmore |
Rural |
| Franklin | Mental Hlth Region VI Franklin |
Rural |
| Fremont | Mental Hlth Region VII Fremont |
Rural |
| Gem | Catchment Area # 3 Gem |
Rural |
| Gooding | Mental Hlth Region V Gooding |
Rural |
| Idaho | Mental Hlth Region II Idaho |
Rural |
| Jefferson | Mental Hlth Region VII Jefferson |
Rural |
| Jerome | Mental Hlth Region V Jerome |
Rural |
| Kootenai | Mental Hlth Region I Kootenai |
Urban |
| Latah | Mental Hlth Region II Latah |
Rural |
| Lemhi | Mental Hlth Region VII Lemhi |
Rural |
| Lewis | Mental Hlth Region II Lewis |
Rural |
| Lincoln | Mental Hlth Region V Lincoln |
Rural |
| Madison | Mental Hlth Region VII Madison |
Rural |
| Minidoka | Mental Hlth Region V Minidoka |
Rural |
| Nez Perce | Mental Hlth Region II Nez Perce |
Rural |
| Oneida | Mental Hlth REgion VI Oneida |
Rural |
| Owyhee | Catchment Area #3 Owyhee |
Rural |
| Payette | Catchment Area # 3 Payette |
Rural |
| Power | Mental Hlth Region VI Power |
Rural |
| Shoshone | Mental Hlth Region I Shoshone |
Urban |
| Teton | Mental Hlth Region VII Teton |
Rural |
| Twin Falls | Mental Hlth Region V Twin Falls |
Rural |
| Valley | Mental Hlth Region IV Valley |
Rural |
| Washington | Catchment Area # 3 Washington |
Rural |
Idaho Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1Classified as HPSA, effective 3/1/02
2 No longer classified as HPSA, effective 3/1/02
3 No longer classified as HPSA, effective 9/1/03
4 Classified as HPSA, effective 9/1/03
5 Classified as HPSA, effective 5/1/04
6No longer classified as a HPSA, effective April 12, 2005
7
Classified as a HPSA, effective November 30, 2004
8No longer classified as a HPSA, effective January 7, 2005
9 Classified as a HPSA, effective September 8, 2005
