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December 2007 Medicare Bulletin - North Carolina Insert

Posted December 4, 2007
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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.

  1. Ordering/ Referring Provider Information
    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;

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.

  1. 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.

  1. 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.

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.

  1. 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.

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/partb/pubs/news/2005/0605/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.

  1. 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/medicare_dynamic/Education/index.asp by completing the “Medicare Part B Procedure Coding” Online Course.

  1. 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).

  1. 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/.

  1. Incomplete/invalid plan information for other insurance Item 11

This item must be completed, it is a required field. By completing this item,

The physician/supplier acknowledges having made a good faith effort to determinewhether 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. Items 4, 6, and 7 must also be completed.

NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare
is indicated in item 11.

If a lab has collected previously and retained MSP information for a beneficiary, the lab may use that information for billing purposes of the non-face-to-face lab service. If the lab has no MSP information for the beneficiary, the lab will enter the word “None” in Block 11 of Form CMS-1500, when submitting a claim for payment of a reference lab service.

Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to other insurance include:

NOTE: The Administrative Simplification Compliance Act (ASCA) requires mandatory electronic submission of claims unless a provider qualifies for one of the exceptions. The most common exception is that a small provider (fewer than 10 employees) may, if they choose, submit paper claims. ASCA provisions for mandatory submission of electronic claims applies to Medicare Secondary Payer claims unless there are multiple payers primary to Medicare (for example, both Workers’ Compensation and Employer Group Health insurance should be filed before filing a claim with Medicare for any additional payment.) For additional information on submitting MSP claim information electronically see the CIGNA Government Service Online Education Course “Billing MSP Claims Electronically” at: http://www.cignagovernmentservices.com/medicare_dynamic/Education/index.asp.

NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a copy of the primary payer’s explanation of benefits (EOB) notice must be forwarded
along with the claim form. (See Pub. 100-05, Medicare Secondary Payer Manual, chapter 3.)

  1. 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.

  1. 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.

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=1

Claim 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 Sseptember 30, 2008 December 31, 2008
October 1, 2008 and September 30, 2009 December 31, 2008

For 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).

 

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Denials for Multiple Inpatient Hospital Evaluation and Management Services

CIGNA Government Services customer service has recently been experiencing increasing calls concerning denials for Inpatient Hospital E&M services, performed on the same date of service as a Consultation by providers who are in the same group, but have different specialties using the same diagnosis code.

The following information is a reminder of the guidelines to apply when billing multiple Inpatient Hospital E&M services, including Consultations on the same date of service.

Example 1 Inpatient Hospital Visit and Consultation Same group

Example 2 Two or more Inpatient Hospital Visits Same Group

As stated in CMS Publication 100-4, chapter 12, section 30.6.9.c, CGS recognizes that there are limited occasions “where concurrent care may be billed by physicians of the same specialty.”

We are making efforts to provide a work around for these occasions. Those claims will be considered for (not guaranteed) for payment if all the following apply.

Example 3 Two or more Inpatient Hospital Visits Same Group – Same Specialty

References: CMS Publication 100-04, chapter 12, sections 30.6.5, 30.6.9.c.

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