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Simple Solutions to Avoid the Top WPS Medicare Claim

Submission Errors

Presented by Mary E. MuchowSr. Analyst, Provider Outreach & Education

MSMA Insurance ConferenceJune 2, 2009

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Agenda

1. Unprocessable Errors

2. Duplicate Denials

3. Modifier Errors

4. Resources

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Unprocessable Errors• Medicare will return as “unprocessable,” any

claim– Missing certain “required” or “conditional” information– With invalid, illogical, or incorrect information

• Explanation of the error in the form of a description or code is provided on the Remittance Advice– Reason code will be CO-16 – “Claim/service lacks

information needed for adjudication”

• Unprocessable claims must be corrected and resubmitted to Medicare– No appeal rights

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Common Unprocessable Errors

• Invalid/Missing Rendering Physician– Provider number

needed in Rendering Provider ID # field

– Item 24J of the CMS-1500 Claim form (08-05 version)

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• Missing Referring/Attending Physician– Name/National Provider Identifier (NPI) required in

Item 17, and 17B on the CMS-1500 form– Electronic Claims

• Referring Physician - Loop 2310A, 2420F (if different then on the claim level)

• Ordering Physician – Loop 2420E

– Examples of services that require this information:• Consultations• Diagnostic Laboratory Services• Diagnostic Radiology Services

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• Invalid Procedure/Modifier– Refer to Medicare Physician Fee Schedule Database

(MPFSDB), Computer Based Trainings, or Modifier Fact Sheets for appropriate use of modifier information

• Invalid/Missing Modifier – Some codes cannot be billed with certain modifiers

• Check Item 24D for combinations (payment modifier versus informational modifier)

– Refer to Medicare Physician Fee Schedule Database (MPFSDB), Computer Based Trainings, or Modifier Fact Sheets for appropriate use of modifier information

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• Invalid Procedure– Check Current

Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS)

– Make certain the information is applicable on the date of service

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• Missing Address of Facility– Facility address required in Item 32 or

electronic equivalent– Not required for Place of Service (POS) office

(11) on an electronic claim only

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• Missing Initial Date of Treatment– Common denial for

Chiropractic claims– Date should be placed

in Item 14 of the CMS-1500 claim form or in Loop 2300

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• Missing/Incomplete Invalid Billing Provider/Supplier Identifier– Check Item 33 and 33A on the CMS 1500

claim form – Check Loop 2010AA or 2010AB

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• Missing Clinical Laboratory Improvement Amendments (CLIA) Number– CLIA Certification Number required in Item 23

or Loop 2300 for most clinical laboratory procedures

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• Primary Explanation of Benefits (EOB) Missing/Incomplete– When Medicare is secondary, a primary EOB

must accompany the claim– For electronic claims the primary payment

information must be correctly entered in the ANSI 837 X12 4010A format

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• Medicare Secondary Payer (MSP) Information– If no other insurer is primary to Medicare, the

submitter must enter “none” in Item 11 on paper claim only

– Loop 2320, 2330A, 2000B are used on the electronic claim to report MSP situations

• Verify all fields are completed or that all fields are left blank

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• Exact Dates and Charges Needed– Denial for those procedures that may not be

quantity billed

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• Injection was denied because name and dosage was not furnished– The drug name and dosage must be listed in

Item 19 on the CMS 1500 claim form– The drug name and dosage needs to be listed

in 2300 NTE or 2400 NTE of the electronic claim

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• Two-digit Place of Service Code Required– Verify the Place of

Service code in Item 24B of the paper claim or Loop 2300 is current and contains both digits

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Common Unprocessable Errors• Diagnosis Code Errors

– Diagnosis Missing/Not linked• Verify the claim has a diagnosis code and the indicator is in

place

• Truncated Diagnosis Code– Diagnosis code must be carried out to its greatest

level of specificity

• Invalid/Incorrect Diagnosis Code– Diagnosis Code used in 24E or electronic equivalent

is not recognized by Medicare• Check date of service to ensure submission of correct

diagnosis code

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• Physician Assistant, Nurse Practitioner, or Certified Nurse Specialist Not Associated with the Billing Provider– Contact Provider Enrollment to verify that the

non-physician practitioner is linked to the billing provider

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• Patient/Authorized Representative Signature on File– Check that Item 12– Check Item 13 when needed– Check Loop 2300

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Duplicate Claim Denials

• Explanation of the error in the form of a description or code is provided on the Remittance Advice– Reason code will be CO-18 – “Duplicate

claim/service”

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How many duplicate claims did WPS Medicare Process?

• Between September, 2008 and February, 2009, WPS Medicare processed 1.3 million duplicate claims in Jurisdiction 5

• That is 21,856,486 claims– Represents 5.5% of total clams processed for

Jurisdiction 5

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What do duplicate claims cost?

• $ .96 to process one claim• 2.6 million claims per year @ $ .96 each =

$2.5 million per year• This is only 4 of 50 states• It is the goal of CMS that the duplicate

error rate be 1%

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Three Types of Duplicate Charges

Duplicate of charges now being processed…

Duplicate of charges we have previously processed

Duplicate of another service on this claim

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Avoid Duplicate Denials

• Verify claim receipts and processing– Receipt

• Review Pre-Pass Edit Reports• IVR• CMS Secure Net Access Portal (C-SNAP

– Processing• Review Remittance Advice• C-SNAP• Customer Service (last resort)

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• Do not routinely resubmit claims– Wait for Medicare Payment Floor

• HIPAA-compliant Electronic Claims: 13 calendar days from claim receipt date

• Non-HIPAA-compliance Electronic Claims: 26 calendar days from claim receipt date

• Paper Claims: 29 calendar days from claim receipt date

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• If you use a billing service, verify that the Billing Service is not routinely submitting duplicate claims

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Avoid Duplicate Line Denials

• Check if the service you are billing can be quantity billed

• Build edits into your software to catch multiple lines with the same procedure code

• Check for automatic duplicate submission dates

• Verify your remittance information is posted timely

Duplicates

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Avoid Modifier Errors• Providers should know:

– Modifiers are used, under certain circumstances, to more accurately represent the service or item performed and documented in the patient’s medical record

– There are two levels of modifiers• Level I – numeric two-digit numeric modifiers

updated annually by the American Medical Association

– CMS does not always use these as does the AMA

• Level II – two-digit alpha modifiers nationally recognized and created by CMS

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Utilize CMS Tools to Avoid Modifier Errors

• Medicare Physician Fee Schedule Database (MPFSDB), or CMS Physician Fee Schedule (PFS) Relative Value File– Includes payment indicators that provide

information about when you may or may not append a modifier in certain situations.

• National Correct Coding Initiative (NCCI) Edit Tables

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Utilize WPS Medicare Tools to Avoid Modifier Errors

• WPS Medicare Modifiers Homepage– Includes Numerous Modifier Fact Sheets

• WPS Medicare Computer Based Training– Includes NCCI, MPFSDB, various modifiers

and more

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Resources• CMS 1500 Claim Form Instructions

http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf

• Health Insurance Portability and Accountability Act (HIPAA) Electronic Claim Submission Requirements (crosswalk to CMS 1500 claim form)http://www.wpsmedicare.com/j5macpartb/business/cms1500_xwalk.pdf

• Medicare Physician Fee Schedule Database (MPFSDB)

http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage

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Resources• WPS Medicare Part B Computer Based Training

http://wpsmedicare.com/j5macpartb/education/b_cbt.shtml

• WPS Medicare Part B Modifier Fact Sheets http://wpsmedicare.com/j5macpartb/education/b_modifiers.shtml

• WPS Medicare Place of Service codes

http://www.wpsmedicare.com/j5macpartb/business/b_pos.pdf

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Resources

• How to File an Electronic Claim When Medicare is Secondary

http://wpsmedicare.com/j5macpartb/business/b_msp_claims.pdf

• WPS Medicare Provider Enrollment Homepage http://wpsmedicare.com/j5macpartb/business/b_enroll.shtml

• Washington Publishing Company Code Lists (Reason/Remark Codes)

http://www.wpc-edi.com/codes

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Resources• WPS Electronic Data Information (EDI) Pre-Pass

Edit Information http://www.wpsic.com/edi/pdf/hipaa_mcs837.pdf• National Correct Coding Initiative (NCCI) Edits

http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage

• WPS Medicare Systems Quantity Billing Lists (updated quarterly) http://wpsmedicare.com/j5macpartb/business/quantitybilled.shtml

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