September 2006 Medicare Bulletin - North Carolina Insert
Posted September 1, 2006
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Table of Contents
- Computer Corneal Topography - LCD Revision
- North Carolina Health Professionals Shortage Areas (HPSAs)
- North Carolina Mental Health Professional Shortage Areas (HPSAs)
- Troubleshooting Claim Submission Errors - North Carolina
TopTroubleshooting 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 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/downloads/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
- Incorrect Entitlement Number (MA27)
- Incomplete/Invalid Patient's Name (31)
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. - 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. - Incorrect/Invalid UPIN and/or Name (M68)
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). 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, con- tractor interface with CWF, and MSN), Chapter 26, Section 10, (http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf). A UPIN directory is also available on CIGNA Government Services's Web site at:
http://www.cignagovernmentservices.com/links.html - Incomplete/Invalid Diagnosis Code (M76)
Enter the patient's diagnosis/condition in Item 21 of the CMS-1500 claim form (or the equiva lent 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 Account ability 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 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 a current and valid diagnosis code on all claims
submitted to Medicare. 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/ICD9ProviderDiagnosticCodes/.
For ICD-9 Coding Web Based Training (WBT), you may access the following on the Internet at: http://cms.meridianksi.com/kc/main/kc_frame.asp?kcident=kc0001&loc=1.
- Did Not Indicate Whether Medicare is
Primary or Secondary Payer (MA83)
Item 11 of the CMS-1500 claim form (or the equivalent electronic field) must be completed. By completing this item, the physician/supplier acknowl edges having made a good faith effort to determine whether Medicare is the primary or secondary payer.
If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to Items 11a - 11c of the CMS-1500 claim form (or the equivalent electronic field).
If Medicare is primary, enter the word "NONE" in Item 11 of the CMS-1500 claim form. Please note the requirements are different for electronic claims. Electronic claims do not require the word
"NONE." The Primary Payer information is indicated in the SBR segment of Loop 2000B with
a "P" code in SBR01. This information can be found on page 110 of the 837 Professional Imple mentation Guide. The name of the payer will go in the Payer Name segment in Loop 2010BB as refer enced on page 130. Specifications may be down loaded free of charge on the Internet at:
http://www.wpc-edi.com/hipaa/HIPAA_40.asp.
For additional information on Medicare Secondary Payer, refer to the CMS Manual System, Pub 100- 4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 1, Section 100, (http://www.cms.hhs.gov/manuals/ downloads/clm104c01.pdf). MSP Web-based train- ing is available by accessing the following on the Internet at: http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1 - 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-as signed) 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. - 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/downloads/clm104c16.pdf).
You may also view or download our specialty manual en titled "Laboratory/Pathology" on the Internet at: http://www.cignagovernmentservices.com/partb/specman/clickwrap.html. - 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) requires 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.
Additionally, on occasion, CMS determines that certain CPT/HCPCS codes are invalid for Medicare purposes. An important example of this is:
HCPCS code G0001, Routine venipuncture for collection of specimen(s), remains invalid for Medicare purposes.For 2006, the clinical laboratory fee schedule will continue to include CPT code 36415, Collection of venous blood by venipuncture. Providers should continue to bill code 36415 for Medicare payment of venous blood collection by veni puncture.
To determine the status of codes under Medicare rules, access the 2006 Medicare Physician Fee Schedule Database (MPFSDB) on the Internet at: http://www.cms.hhs.gov/apps/pfslookup/step1.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/HCPCSReleaseCodeSets/.
- Did Not Complete or Enter Accurately the Date the 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 (D.O.) medical doctor (M.D.) or doctor of osteopaty (D.O.) and the unique physician identification number (UPIN) of the M.D or D.O. for treat-ment 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/ CYY) 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 cover age, 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/Downloads/bp102c15.pdf ).
You may also view and/or download our specialty manual entitled "Podiatry" on the Internet at:
http://www.cignagovernmentservices.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/Downloads/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/downloads/ge101c04.pdf).
You may also view and/or download our specialty manual entitled "Physical Therapy/Occupational Therapy" on the Internet at: http://www.cignagovernmentservices.com/partb/specman/clickwrap.html.
Computer Corneal Topography - LCD Revision
The LCD for Computer Corneal Topography has been revised for and North Carolina (L5790). To view the policy for your particular state, please visit the CIGNA Government Services or CMS Web site.
North Carolina Mental Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
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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.
