April 15, 2008
Troubleshooting Claim Submission Errors — North Carolina
Top 10 Claim Submission Errors for January, February, and March
“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 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. 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.
2. 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;
- 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.
Note: UPINs will be allowed to identify ordering/referring physicians
until May 23, 2008 .
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 .
Note: NPIs will be required to identify referring/ordering physicians effective May 23, 2008 .
When a claim involves multiple referring and/or ordering physicians, a separate Form CMS- 1500 must be used for each ordering/referring physician.
3. Missing/Incomplete/Invalid Billing Provider Primary Identifier NPI Claims should include group Provider Transaction Access Number (PTAN) and individual PTAN and/or Individual NPI and Group NPI. Providers are strongly encouraged to begin billing claims including their NPI.
If the provider is a group or part of a group, they need an NPI for the Group.
Item 33 Form CMS-1500 (08/05) - Enter billing name, address, zip code, and telephone number of the group.
Item 33a Form CMS-1500 (08/05) – Enter the NPI of Billing Provider or Group
Item 33b Form CMS-1500 (08/05) – Enter Qualifier “1C” followed by one space and the PTAN of the Billing Provider or Group
Note: Effective March 1, 2008 , all claims must contain an NPI as the primary identifier.
Note: Effective May 23, 2008 , no PTAN information will be accepted. Use of the PTAN will result in claim rejection.
Provider must register their PTAN in NPPES. If the provider has multiple PTANS they must list all PTANS in NPPES.
More information and education on the NPI may be found at the CMS NPI page, http://www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Also, providers can apply for an NPI online at https://nppes.cms.hhs.gov.
4. Incomplete/Invalid Group Practice Information Enter the provider of service/supplier’s billing name, address, ZIP code, and telephone number in item 33. This is a required field.
Item 33a Form CMS-1500 (08-05) - The National Provider Identifier (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.
5. 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/.
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=1
6. 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.
7. 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.
8. 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 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. 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 there is no insurance primary to Medicare, enter the word " NONE" and proceed to item 12.
- If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word "NONE" and proceed to item 11b.
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.
- Where there has been no face-to-face encounter with the beneficiary, the claim will then follow the normal claims process.
- When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.
Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to other insurance include:
- Group Health Plan Coverage
- Working Aged;
- Disability (Large Group Health Plan); and
- End Stage Renal Disease;
- No Fault and/or Other Liability; and
- Work-Related Illness/Injury:
- Workers' Compensation;
- Black Lung; and
- Veterans Benefits.
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.)
9. 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).
10. 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. If you purchased the technical component of a laboratory service, you must enter the NPI of the service facility as soon as it is available using the electronic claim format or the CMS-1500 (08-05) in item 32a.
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. This is not the same number as your group or organizational NPI. Information may be reported in this field until further notice by CMS.
Note: At this time, the situation above is the only instance where the Service Facility NPI and Service Facility PTAN (Items 32a & 32b) are required for Medicare Part B services.
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 September 30, 2008 |
December 31, 2009 |
October 1, 2008 and September 30, 2009 |
December 31, 2010 |
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).
