June 2007 Medicare Bulletin - North Carolina Insert
Posted June 6, 2007
Download a PDF copy
of this issue 
Table of Contents
- Troubleshooting Claim Submission Errors - North Carolina
- North Carolina Health Professionals Shortage Areas (HPSAs)
- North Carolina Mental Health Professional Shortage Areas (HPSAs)
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 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 Medicare 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, 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).
- 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, all physician and non-physician specialties (i.e., PA, NP, CNS, CRNA) must report at least one ICD-9-CM diagnosis code per claim. 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.
- 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.
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)
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 four 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” at the following Web address: 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 equiv alent 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 isfor 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 January 1 of each year. Codes are deleted, added, or modified annually. It is important to update your billing system to reflect these changes.
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 2007, 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 venipuncture.
To determine the status of codes under Medicare rules, access the 2007 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 per formed.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 outpatient 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
3Classified as a Mental Health HPSA, Effective December 15, 2006
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.
4No longer classified as a HPSA, effective September 8, 2006
