December 2006 Medicare Bulletin - North Carolina Insert
Posted December 5, 2006
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Table of Contents
- Chiropractic Specialty Workshop – NEW!
- North Carolina Health Professionals Shortage Areas (HPSAs)
- North Carolina Mental Health Professional Shortage Areas (HPSAs)
- Retired Local Coverage Determinations - Effective October 1, 2006
- Troubleshooting Claim Submission Errors - North Carolina
TopRetired Local Coverage Determinations - Effective October 1, 2006
Urolume Endoprosthesis (L6685)
Breath Test for Helicobacter Pylori (L5723)
Serum Magnesium (L6579)
Folic Acid, Serum (L6028)
Chiropractic Specialty Workshop – NEW!
CIGNA Government Services will be conducting a “Chiropractic Specialty” workshop in Greensboro on Wednesday, December 6, 2006, at the Greensboro Airport Marriott.
Topics to be covered include:
- Chiropractic coverage and billing guidelines
- Principles of medical record documentation
- Proper use of the Advance Beneficiary Notice (ABN)
- National Provider Identifer (NPI)
- Medicare tools and resources
Space is limited, so register now!
http://www.cignagovernmentservices.com/wrkshp/nc/wrkshp_sem_NC.html#
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 8 (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 Medi care coverage (Hospital Part A, Medical Part B) 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 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 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) must report at least one ICD-9-CM diagnosis code. Diagnoses should always be coded 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. o Numeric codes (001.0 to 999.9) are broken down into 17 classifications of diseases and injuries. o 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 fordates 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 effec tive 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?kc_ident=kc0001&loc=1.
- Missing/ Incomplete/ Invalid Information on where the Services were Furnished (MA114)
Effective April 1, 2004, Item 32 of the CMS-1500 form, or the electronic equivalent, must be completed by entering the name and physical address, including ZIP code, of the location where the services were rendered for all services other than those rendered in the patient’s home, place of service 12.
If a service was rendered in the patient’s home, this field may be left blank.
Post Office boxes are not considered acceptable for this field. The physical street address of the location where the services were rendered must be entered.
- 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 may be reported per service line on the CMS-1500 claim form. If the service or procedure requires more than two modifiers then modifier “99” should be appended to the procedure code and all additional modifiers reported 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 entitled “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). Additional information may be requested if it is needed. In addition, if a surgical procedure is submitted, the operative report should clearly indicate what the unlisted code is 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 the unlisted code.
Procedure code changes are effective January1 of each year. Codes are deleted, added, or modified annually. 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) 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 at: http://www.cms.hhs.gov/HCPCSReleaseCodeSets/.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 additional Web-based training related to CPT and HCPCS coding on the CIGNA Government Services Web site at:
http://www.cignagovernmentservices.com/webtraining/Logon.asp.
- Missing/ Incomplete/ Invalid Place of Service (M77)
Item 24b of the CMS-1500 form, or its electronic equivalent, must be completed as follows. Enter the appropriate place of service code(s) from the list provided in the CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 26, Section 10.5 (http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf).
Identify the location, using a place of service code, for each item used or service performed. This is a required field.
The place of service code and the procedure code used on the claim should be consistent. For example, the code descriptor for CPT code 99213 instructs that this code represents an “office or outpatient visit for the evaluation and management of an established patient…” Therefore, the appropriate office or outpa tient place of service code should be used to ensure agreement with the CPT code reported.
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.
