September 2007 Medicare Bulletin - North Carolina Insert
Posted September 4, 2007
Download a PDF copy
of this issue 
Table of Contents
- Mark Your Calendar For The Upcoming Ask The Contractor (ACT) Teleconference
- New CIGNA Government Services Web Site Launch!
- North Carolina Health Professional Shortage Areas (HPSAs)
- North Carolina Mental Health Professional Shortage Areas (HPSAs)
- Skin Procedures for Hyperkeatosis - Retired LCD
- Troubleshooting Claims Submission Errors - North Carolina
TopMark Your Calendar For The Upcoming Ask The Contractor (ACT) Teleconference.
Attention North Carolina Providers!
This is your opportunity to interact directly with the Subject Matter Experts at CIGNA Government Services to ask your questions regarding Medicare issues that impact you and your practice. This quarterly call is scheduled for Thursday, September 20, 2007, from 3-4 pm ET. There is no registration required to participate. Simply dial in on the day of the teleconference using the following toll-free number: 1.866.793.1308.
For additional details about this teleconference, including minutes from previous ACT teleconferences, please visit our Web site at: http://www.cignagovernmentservices.com/partb/education/ACT/NC_ACT.html.
Skin Procedures for Hyperkeratosis – Retired LCD
The Local Coverage Determination for “Skin Procedures for Hyperkeratosis” for North Carolina (L6599) and Idaho (L17924) will be retired effective 8-1-07.
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. As such, 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 your initial claim submission. Should you encounter the following claim rejections or denials, the Group/Reason Code on your Remittance Advice 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, please refer to the CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, 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.
The instructions provided below reference the newly revised CMS-1500 (08-05) paper claim form, which became mandatory for use for all paper claims submitted as of July 1, 2007. However, providers may also apply these instructions to electronic billing by using the electronic equivalents to the paper claim items listed below.
- Incomplete/Invalid Group Practice Information
Item 33 - Enter the provider of service/supplier’s billing name, address, ZIP code, and telephone number. This is a required field.
Item 33a Form CMS-1500 (08-05) - The NPI may be reported on the Form CMS- 1500 (08-05) as early as January 1, 2007. Complete Item 33a and/or 33b until further notice from CMS.
Item 33b Form CMS-1500 (08-05) - Enter the ID qualifier 1C followed by one blank space and then the Provider Identification Number (PIN) of the billing provider or group.
- For a provider who is not a member of a group practice (e.g., private practice), enter the NPI/PIN of the individual physician/practitioner.
- If a group practice is billing, then the group NPI/PIN is reported.
- In addition, enter the information for the performing provider of service who is a member of the group practice reported in Item(s) 24I and 24J as follows:
Item 24I Form CMS-1500 (08-05) – Enter the ID qualifier 1C in the shaded portion. Complete Item 24I along with the PIN in Item 24J and/ or the NPI in Item 24J until further notice from CMS.
Item 24J Form CMS-1500 (08-05) – Enter the rendering provider’s PIN in the shaded portion. 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 not supervising, enter the PIN of the supervisor in the shaded portion.
Beginning January 1, 2007, you may enter the rendering provider’s NPI number in the lower portion. 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 NPI of the supervisor in the lower portion.
- Incomplete/Invalid Entitlement Number or
Patient Name
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. Do not place hyphens or blanks in the HICN field.
If the Medicare card shows that the beneficiary name has a suffix (e.g., Jr., Sr., II, III, etc.), report the name exactly as shown on the card. 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. - Ordering/ Referring Provider Information SUB MISSION ERRORS – MA
All claims for Medicare covered services and items that are the result of a physician’s order or referral must include the ordering/referring physician’s name (Item 17). See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s UPIN and/or NPI.
Referring physician - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15 (http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf) for non-physician practitioner rules.
Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service.
The following services/situations require the submission of the referring/ordering provider information:
- Medicare covered services and items that are the result of a physician’s order or referral;
- Parenteral and enteral nutrition;
- Immunosuppressive drug claims;
- Hepatitis B claims;
- Diagnostic laboratory services;
- Diagnostic radiology services;
- Portable x-ray services;
- Consultative services;
- Durable medical equipment;
- When the ordering physician is also the
performing physician (as often is the case with in-
office clinical laboratory tests); - When a service is incident to the service of a
physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-
physician service must appear in Item 17;
Item 17 - Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
All physicians who order or refer Medicare beneficiaries or services must report either a National Provider Identifier (NPI) or Unique Physician Identification Number (UPIN) or both until further notice from CMS.
NOTE: Item 17a and/or 17b is required when a service was ordered or referred by a physician. Complete 17a and/or 17b until further notice from CMS.Item 17a – Enter the CMS-assigned Unique Physician Identification Number (UPIN) of the referring/ ordering physician listed in Item 17.
Item 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in Item 17 as soon as it is available. The NPI may be reported on the Form CMS- 1500 (08-05) as early as January 1, 2007.When a claim involves multiple referring and/or ordering physicians, a separate Form CMS- 1500 must be used for each ordering/referring physician.
- Missing/Incomplete/Invalid HCPCS Modifier
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) modifiers are published in the HCPCS manual.
The electronic claim format and the new CMS-1500 (08-05) claim form accommodate up to four (4) modifiers per service line in the claim submission.
For the correct use of modifiers, see the CIGNA Government Services NetCourse entitled “Modifiers” at: http://www.cignagovernmentservices.com/wrkshp/netcourses.html.
CIGNA Government Services would like to remind all providers that it is imperative when submitting claims containing pricing modifiers, that the pricing modifier should be suffixed as the first modifier listed with each applicable procedure code. This will help to ensure appropriate pricing and payment of the claim. Please access the following link for additional information: http://www.cignagovernmentservices.com/articles/june05/cope2621.html
Use the Physician Fee Schedule (PFS) Relative Value file available at http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=3 to help determine what procedure codes may appropriately have modifiers for bilateral surgery; multiple surgery; assistant at surgery; technical and professional components; co-surgery, etc. Open the zip file “RVU07A4” and view or download the Excel file PPRRVU07 and the Word file RVUPUF07.
- Missing/ Incomplete/ Invalid Place of Service
Two-digit place of service (POS) codes are required in Item 24b of the CMS-1500 claim form (or the electronic equivalent) 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 edited for compatibility with the POS code submitted.
For a complete listing of place of service codes and definitions, refer to the CMS Online Manual, Pub.100-04, Medicare Claims Processing, Chapter 26, Section 10 (http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf).
- Missing/Incomplete/Invalid CLIA Certification
Number
Report the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures in Item 23 of the CMS-1500 (08-05) or equivalent electronic field.
Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 establishing quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results regardless of where the test was performed. The final CLIA regulations were published in the Federal Register on February 28, 1992. The requirements are based on the complexity of the test and not the type of laboratory where the testing is performed. On January 24, 2003, the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare &Medicaid Services (CMS) published final CLIA Quality Systems laboratory regulations that became effective April, 24, 2003.
CLIA requires all facilities that perform even one test, including waived tests, on “materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings” to meet certain Federal requirements. If a facility performs tests for these purposes, it is considered a laboratory under CLIA and must apply and obtain a certificate from the CLIA program that corresponds to the complexity of tests performed.
A list of waived tests can be found at:
http://www.cms.hhs.gov/CLIA/10_Categorization_of_Tests.asp#TopOfPage.A list of state survey agencies can be found at:
http://www.cms.hhs.gov/CLIA/downloads/CLIA.SA.pdf.Find more information about CLIA at: http://www.cms.hhs.gov/CLIA/.
- Duplicate claim/ service
It is never appropriate to automatically resubmit claims to Medicare without first obtaining the status of the original claim. Therefore, for those who have automatic claims refiling capabilities within their software, the capability should be eliminated, or limited to wait at least 45 days from the date the first claim was filed. Several alternatives to automatically refiling claims include:
- Carefully reviewing your Medicare Remittance Advice;
- Contacting the Interactive Voice Response (IVR) for the status of specific claims after waiting for the
payment floor:
- 29 days for paper claims, or
- 14 days for electronic claims
- Incomplete/Invalid Procedure Code
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 Item 19 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.
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/01_Overview.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 Information on where the Services were Furnished
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.
Providers of service (namely physicians) shall identify the supplier’s name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate Form CMS-1500 shall be used to bill for each supplier.
If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number.
If an independent laboratory is billing, enter the place where the test was performed.
Report the NPI of the service facility as soon as it is available using the electronic claim format or the CMS-1500 (08-05). The NPI may be reported on the Form CMS-1500 (08-05) as early as January 1, 2007.
Item 32b Form CMS-1500 (08-05) - Enter the ID qualifier 1C followed by one blank space and then the PIN of the service facility. Information may be reported in this field until further notice by CMS.
- Incomplete/Invalid Diagnosis Code
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 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 Accountability Act (HIPAA) requires that medical code sets must be date of service compliant. This means that physicians, practitioners, and suppliers must use the current and valid diagnosis code that is in effect for the date of service being billed.
Updated ICD-9-CM codes are effective October 1 of each year. CMS posts new, revised, and discontinued codes at on the following Web site:
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/01_overview.asp This Web page also includes a link to “ICD-9-CM Official Guidelines”.For additional ICD-9 Coding resources and Web Based Training (WBT), access
http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1Claim Timely Filing Limits
As a reminder, providers who furnish covered services to Medicare beneficiaries are required to file claims on behalf of their patients.They have until the end of the calendar year following the year in which the service was furnished to file a claim, unless the service was furnished in the last three months of the year. Then the service is considered to have been furnished in the subsequent year. Fifteen months is the absolute maximum that providers have to file a claim timely, and within the Mandatory Claim Submission requirements.
In addition to claim filing deadlines, claims where assignment is taken are also subject to a ten percent reduction in payment if the claim is not filed within 12 months of the date of service. If an assigned claim is filed beyond the 12 month allowed period, the provider is not allowed to charge the beneficiary for the ten-percent reduction.
Carriers will process submitted claims within the
following time limits:For Services Received Between: Claims Must Be Submitted By:
October 1, 2006 and September 30, 2007
December 31, 2008
October 1, 2007 and September 30, 2008
December 31, 2009
October 1, 2008 and September 30, 2009
December 31, 2010For additional information on time limitations, refer to the CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 1, Section 70, (http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf).
New CIGNA Government Services Web Site Launch!
Have you always wanted to “click less” to get information you want?
We have worked hard to help you find things more easily by redesigning the site to meet your immediate needs. The new site will be much easier to navigate and will rovide quicker options for you to locate specific information. Enhancements include:
- Enhanced search functionality, allowing you to search and retrieve information specific to a particular contract!
- Steamlines, easy-to-use Fee Schedule page.
- All published articles will appear on one central News Items page. We will continue to maintain archivedpages for articles.
We have also expanded our Online Education Center tools, to improve your online edication, experience and to enhance your use or our, provider Self Service products.
“Click less” and get more! Visit our new Web site today!
http://www.cignagovernmentservices.com
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.
4 No longer classified as a HPSA, effective September 8, 2006
5 Classified as a HPSA, effective May 11, 2007
6 No longer classified as a HPSA, effective May 11, 2007
