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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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• Exact Dates and Charges Needed– Denial for those procedures that may not be
quantity billed
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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Common Unprocessable Errors
• 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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Avoid Duplicate Denials
• 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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Avoid Duplicate Denials
• 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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Questions?
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