CPT CODE 99243 - Office visit consultation level 3

CPT CODE and description

99243 - Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

Medicare no longer accept this code. use other appropriate CPT codes.

average fee amount - $120 - $130

99243 Office consultation for a new or established patient, which requires these three key components:

• A detailed history

• A detailed examination

• Medical decision making of low complexity

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

CPT Typical Time

99243 45

A consultation occurs when a treating physician seeks an opinion from another physician regarding a patient’s diagnosis or treatment and meets the CPT® requirements for a consultation. An independent medical exam (IME) occurs

when a physician is requested to evaluate a patient by any party or party’s representative and is billed in accordance with section 18-6(G).

 Outpatient Consultation RVUs:

 CPT® 99243 non-facility = 4.71; facility = 3.96


Consultation - diagnostic service provided by a dentist or physician other than requesting dentist or physician

 Office consultation - 99241, 99242, 99243, 99244, 99245 Inpatient consultation - 99251, 99252, 99253, 99254, 99255

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.




Billing and Coding Guidelines


The Centers for Medicare and Medicaid Services’ (CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultation codes 99241-99245 or 99251-99255.

In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established).

Per CMS, a physician who sees a patient in the hospital should bill an "initial hospital care" code (99221-99223) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC) to differentiate between the admitting physician and other physicians providing care. All physicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.

Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initial nursing facility care” code (99304-99306) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial nursing f facility care service, allowing the MAC to identify the physician as the admitting physician of record who is overseeing the patient’s care. All physicians should use the subsequent nursing facility care codes (99307-99310) for their follow-up care.

CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010 National Physician Fee Schedule. The status indicator of “I” is defined as:
“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.

For Commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.

For example UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these plans will follow CMS regulations and implement the change, effective January 1, 2010. The change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new coding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.

For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS and implement the change, effective January 1, 2010.

For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed by each state to pursue other strategies.

Insurance will consider services when resubmitted with the recommended new or established evaluation and management code (99201-99205; 99281-99285; 99221-99223, 99304-99306) as per CMS guidelines for physicians who see patients in the office or an outpatient/inpatient setting.

This policy shall apply to participating and non-participating professional providers.

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Denial process

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

CPT CODE 99243 has to be rebilled as 99203, 99213 or 99283 for Medicre and Medicare HMOs.


BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212
99242 to 99212
99243 to 99213

CONSULTATIONS

Note: Much of the confusion in reporting consultative services begins with terms used to describe the service requested. The terms “consultation” and “referral” may be mistakenly interchanged. These terms are not synonymous. Careful documentation of the services requested and provided will alleviate much of this confusion.

When a physician refers a patient to another physician it should not automatically be considered a consultation. A consultation would be appropriate if the service provided meets the criteria described below. Services provided that do not meet the criteria below should not be billed using consultation codes.

Louisiana Medicaid reimburses for a consultation, in either a hospital or office setting when:


• The service is performed by a physician other than the attending/primary care physician.

• The consultation is performed at the request of the attending/primary care physician, i.e., the ‘requesting physician’. This physician’s request for the consultation, as well as the need for the consultation, must be documented in the patient’s medical record.

• Consultations should not be requested unless they are medically necessary, unduplicative, reasonable, and needed for adequate diagnosis and/or treatment. The patient’s medical records must be available for review, and the documentation therein must substantiate the need for the consultation. Consultations for patients with simple diagnoses or who require non-complex care are not covered.

• The physician consultant may initiate diagnostic services.

• The consulting physician renders an opinion and/or gives advice to the requesting physician regarding the evaluation and/or management of a patient. The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician.

• Both physicians’ records should be reflective of the request for, and the results of the consultation.

• Confirmatory consultations are not covered.

• All claims are subject to post-payment review.



Billing for Consultations

The following criteria should be used to determine if a consultation code may be billed:

• See “Note” and consultation criteria on the previous page to determine if the service is a “referral” or a “consultation” prior to billing for consultations.

• If the consulting physician is to perform any indicated surgery, a consultation MAY NOT be billed. The appropriate level evaluation and management code may be billed if it does not conflict with global surgery policy. The GSP takes priority over consultation policy for recipients regardless of their age.

• If, by the end of the service, the consulting physician determines and documents in the patient’s record that the patient does not warrant further treatment by the consultant, the consultation code should be billed. If the patient returns at a later date for treatment, subsequent visits should be billed using the appropriate level evaluation and management service codes.

• If, by the end of the consultation, the consulting physician knows or suspects that the patient will have to return for treatment, the appropriate level evaluation and management code should be billed rather than the consultation code. The patient’s record should document the fact that the consulting physician expects to treat the patient again.

Recipients Age 21 or Older

One consultation may be billed in conjunction with diagnostic procedures, if it meets the definition of a consultation as previously described. Follow-up consultations for recipients who are age 21 or older are not covered by Louisiana Medicaid.

Recipients Under Age 21 Outpatient Consultations

• Outpatient consultation policy does not apply to state-funded foster children (aid category 15).

• Three office consultations per recipient per specialty per 180 days are allowed. (The consultant should be a specialist who is asked by the requesting physician to advise him on the management of a particular aspect of the recipient’s care on three different occasions within a six month period.) If a fourth consultation is needed, reimbursement will be made only after the documentation has been reviewed and medical necessity of the additional consultations is approved by Medical Review.



• A consultation by a provider of the same specialty as that of the requesting physician will be allowed when circumstances are of an emergent nature as supported by diagnosis;

and the requesting physician needs immediate consultation regarding the patient’s condition. In this circumstance, no higher consultation code than 99244 should be billed.

These claims will be sent to Medical Review and a review of the documentation will be made before reimbursement is authorized.

• The consulting physician may always bill for the initial consultation, if it meets the definition of a consultation as previously described. However, if the consultant subsequently assumes responsibility for some or all of the patient’s care after the initial consultation, he/she must bill evaluation and management codes for established patients.

If a provider bills an evaluation and management code for the initial visit, the provider cannot then bill a consultation code for subsequent visits.

• Claims for consultations should indicate the name of the requesting provider, which should be different from that of the consulting physician.

• The consulting physician should not have served as the primary care or concurrent care provider within the 180 days prior to performing the consultation.



Inpatient Consultations

• Inpatient consultation policy does not apply to state-funded foster children.

• One initial and two follow-up consultations are allowed per recipient per specialty per 45 days. If a third follow-up consultation is needed, reimbursement will be made only after the documentation has been reviewed and medical necessity of the additional consultation is approved by Medical Review.

• A consultation by a provider of the same specialty as that of the requesting physician will be allowed when circumstances are of an emergent nature as supported by diagnosis; and the requesting physician needs immediate consultation regarding the patient’s condition. In this circumstance, no higher consultation code than 99252 should be billed.

These claims will be sent to Medical Review and a review of the documentation will be made before reimbursement is authorized.


• Only one same-specialty consultation will be allowed every 365 days.

• The consulting physician may always bill for his initial consultation, if it meets the definition of a consultation as previously described. However, if the consultant subsequently assumes responsibility for some or all of the patient’s care after the initial consultation, he/she must bill subsequent hospital care codes for established patients for his daily visit services. If a provider bills a hospital visit code for his initial visit, the provider cannot then bill a consultation code for subsequent visits.

• Claims for consultations should indicate the name of the requesting physician, which should be different from that of the consulting physician. The consulting physician should not have served as the primary care or concurrent care provider within 730 days prior to performing the consultation.




Consultations CPT CODES: 99241-99243, 99244-99255

The CMS concurs with American Medical Association “Current Procedural Terminology (CPT)” guidelines related to physician reporting of inpatient and outpatient consultation services 99241-99243, 99244-99255:

99241 Office consultation for a new or established patient, which requires these three key components:

• a problem focused history;
• a problem focused examination; and
• straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99242 Office consultation for a new or established patient, which requires these three key components:

• an expanded problem focused history;
• an expanded problem focused examination; and
• straightforward medical decision making  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

The CMS will pay a consultation fee when the service is provided by a physician at the request of the patient’s attending physician when:
• All of the criteria for the use of a consultation code are met;

• The consultation is followed by treatment;

• The consultation is requested by members of the same group practice;

• The documentation for consultations has been met (written request from an appropriate source and a written report furnished the requesting physician);

• Pre-operative consultation for a new or established patient performed by any physician at the request of the surgeon; and

• A surgeon requests that another physician participate in post-operative care (provided that the physician did not perform a pre-operative consultation).Italicized and/or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association. All rights reserved. Applicable FARS/DFARS apply

Exceptions Allowing Extension of Time Limit

Medicare regulations at 42 C.F.R. §424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:

(1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (See 70.7.1).

(2) Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).

(3) Retroactive Medicare entitlement involving State Medicaid Agencies, where a State Medicaid Agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The State Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the the timely filing limit has expired

Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups it payment from a provider or supplier 6 months or more after the date the service was furnished

The conditions for meeting each exception, and a description of how filing extensions will be calculated, are described in sections 70.7.1 – 70.7.4.


Where the initial request for an exception to the timely filing limit is made by a provider or supplier, the Medicare contractor has responsibility for determining whether a late claim may be honored based on all pertinent documentation submitted by the provider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database. As explained in sections 70.7.1 – 70.7.4, the contractor will determine if the requirements for a particular exception are met. However, in certain circumstances, the contractor may contact the appropriate CMS regional office (RO) to ascertain whether it wants to participate in the review and decision-making of the specific exception request. In limited circumstances, the RO may conclude that the exception request should go to CMS Central Office for a final determination.

What we can do further if we receive timely filing denial

Filing Claim Where General Time Limit Has Expired


As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing.

Where it comes to the attention of a provider or supplier that health services that are or may be covered were furnished to a beneficiary but that the general time limit (defined in §70.1 above) on filing a claim for such services has expired, the provider or supplier should take the following action.

• Where the provider or supplier accepts responsibility for late filing, it should file a no-payment claim. (See Chapter 3 for no-payment bill processing instructions.) Where the provider or supplier believes the beneficiary is responsible for late filing, it should contact the contractor and also file a no-payment claim and include a statement in the remarks field on the claim explaining the circumstances which led to the late filing and giving the reasons for believing that the beneficiary (or other person acting for him/her) is responsible for the late filing. If a paper claim is submitted, such a statement may be attached and, if practicable, may include the statement of the beneficiary as to the beneficiary’s view on these circumstances.

• Where the beneficiary does not agree with the determination that the claim was not filed timely or the determination that he/she is responsible for the late filing, the usual appeal rights are available to the beneficiary. Where the provider or supplier is protesting the denial of payment or the assignment of responsibility, no formal channels of appeal are available. However, the contractor may, at the request of the provider or supplier, informally review its initial determination.

Handling Incomplete or Invalid Submissions - Medicare claim tips

The following provides additional information detailing submissions that are considered incomplete or invalid.

The matrix in Chapter 25 specifies whether a data element is required, not required, or conditional. (See definitions in §70.2 above.) The status of these data elements will affect whether or not an incomplete or invalid submission (hardcopy or electronic) will be returned to provider (RTP). FIs should not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction. (See §80.3.1 for Definitions.)

The FIs should take the following actions upon receipt of incomplete or invalid submissions:
• If a required data element is not accurately entered in the appropriate field, RTP the submission to the provider of service.

• If a not required data element is accurately or inaccurately entered in the appropriate field, but the required data elements are entered accurately and appropriately, process the submission.

• If a conditional data element (a data element which is required when certain conditions exist) is not accurately entered in the appropriate field, RTP the submission to the provider of service.


• If a submission is RTP for incomplete or invalid information, at a minimum, notify the provider of service of the following information:
o Beneficiary’s Name;
o Health Insurance Claim (HIC) Number;
o Statement Covers Period (From-Through);
o Patient Control Number (only if submitted);
o Medical Record Number (only if submitted); and
o Explanation of Errors.

NOTE: Some of the information listed above may in fact be the information missing from the submission. If this occurs, the FI includes what is available.

• If a submission is RTP for incomplete or invalid information, the FI shall not report the submission on the MSN to the beneficiary. The notice must only be given to the provider or supplier.

The matrix in Chapter 25 specifies data elements that are required, not required, and conditional. These standard data elements are minimal requirements. A crosswalk is provided to relate CMS-1450 (UB-04) form locators used on paper submissions with loops and data elements on the ANSI X12N 837 I used for electronic submissions.
The matrix does not specify loop and data element content and size. Refer to the implementation guide for the current HIPAA standard version of the 837I for these specifications. If a claim fails edits for any one of these content or size requirements, the FI will RTP the submission to the provider of service.

NOTE: The data element requirements in the matrix may be superceded by subsequent CMS instructions. The CMS is continuously revising instructions to accommodate new data element requirements. The matrix will be updated as frequently as annually to reflect revisions to other sections of the manual.

The FIs must provide a copy of the matrix listing the data element requirements, and attach a brief explanation to providers and suppliers. FIs must educate providers regarding the distinction between submissions which are not considered claims, but which are returned to provider (RTP) and submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected and re-submitted.

Medicare incarceration recoupment and appeal option

RECOUPMENTS 

Q1: Do suppliers and providers need to take any steps to be repaid for incorrect recoupments resulting from this issue? 

A1: Supplier claims will be reprocessed and refunds issued by the end of the first week of December 2013. The majority of non-supplier provider claim refunds will be made by the middle of December. Last updated 11-27-13

Q2: Will Medicare repay the recoupments with interest? 

A: The Medicare statute only permits CMS to pay interest under limited circumstances, and this situation does not trigger the payment of interest to providers and suppliers. Last updated 11-27-13

Q3: What happens to corrections of recoupments that occur after a new MAC has taken over a jurisdiction? 

A3: All claims and accounts receivables have been transferred to the incoming MAC.
Last updated 11-20-13

Q4: If a provider or supplier paid interest on one of the collected overpayments, will the repayment of that claim include the amount of interest the provider or supplier paid? 

A4: Yes, the provider or supplier will receive a refund for the amount paid including any interest paid.


I continue to receive demand letters and the MAC continues to recoup money for an incarcerated beneficiary related overpayment. What should I do?

A5: While CMS previously zeroed out most of the incarcerated beneficiary overpayments, due to changes in our records over the years, we are still working to identify, zero out, and process refunds for some of the erroneous overpayments. If you are aware of an incarcerated beneficiary overpayment that is still being collected, you should bring it to the attention of your MAC as soon as possible.

APPEALS

Q1: Can I appeal the denied claim? Who is liable for the denied claim? 

A1: Yes, providers, suppliers, and beneficiaries can appeal the denied claims. Liability for the denied claims will be determined for each claim on a case by case basis.
Last updated 11-20-13

RECOUPMENTS

Q1: Do suppliers and providers need to take any steps to be repaid for incorrect recoupments resulting from this issue?

A1: Supplier claims will be reprocessed and refunds issued by the end of the first week of December 2013. The majority of non-supplier provider claim refunds will be made by the middle of December. Last updated 11-27-13

Q2: Will Medicare repay the recoupments with interest?

A: The Medicare statute only permits CMS to pay interest under limited circumstances, and this situation does not trigger the payment of interest to providers and suppliers. Last updated 11-27-13

Q3: What happens to corrections of recoupments that occur after a new MAC has taken over a jurisdiction?

A3: All claims and accounts receivables have been transferred to the incoming MAC.
Last updated 11-20-13

Q4: If a provider or supplier paid interest on one of the collected overpayments, will the repayment of that claim include the amount of interest the provider or supplier paid?

A4: Yes, the provider or supplier will receive a refund for the amount paid including any interest paid.


I continue to receive demand letters and the MAC continues to recoup money for an incarcerated beneficiary related overpayment. What should I do?

A5: While CMS previously zeroed out most of the incarcerated beneficiary overpayments, due to changes in our records over the years, we are still working to identify, zero out, and process refunds for some of the erroneous overpayments. If you are aware of an incarcerated beneficiary overpayment that is still being collected, you should bring it to the attention of your MAC as soon as possible.

APPEALS

Q1: Can I appeal the denied claim? Who is liable for the denied claim?

A1: Yes, providers, suppliers, and beneficiaries can appeal the denied claims. Liability for the denied claims will be determined for each claim on a case by case basis.
Last updated 11-20-13

Q2: Once CMS reprocesses the inappropriate claim denials/cancellations, will there be a way for providers to appeal denied claims that were deemed appropriate even if the time limits for filing appeals expired?

A2: The Medicare Administrative Contractors have been instructed to accept appeal requests for claim denials or overpayments related to incarcerated beneficiaries without regard to the time limits for filing appeals.
A2: The Medicare Administrative Contractors have been instructed to accept appeal requests for claim denials or overpayments related to incarcerated beneficiaries without regard to the time limits for filing appeals.

Medicare incarcerated denial - all question and time frame solution

BACKGROUND

Medicare will generally not pay for medical items and services furnished to a beneficiary who was incarcerated or in custody under a penal statute or rule at the time items and services were furnished. For additional information about this policy, please refer to the Medicare Learning Network’s recent “Medicare Coverage of Items and Services Furnished to Beneficiaries in Custody Under a Penal Authority” Fact Sheet (ICD 908084).

Recently, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated or in custody on the date of service. For these recoveries, CMS identified previously paid claims that contained a date of service that partially or fully overlaps a period when a beneficiary was apparently incarcerated based on information from the Social Security Administration (SSA). As a result, a number of overpayments were identified. In some cases demand letters were released with appeals instructions, and, in many cases, automatic collections of overpayments were made. However, CMS has since learned that the information
was, in some cases, incomplete for purposes of collection.

CMS understands that this issue has been challenging for providers and beneficiaries, and we are actively addressing it. We have restored the original data on the Medicare Enrollment Data Base. Any new claims that are denied on or after October 28, 2013, because the beneficiary was incarcerated on the date of service, are based upon that information. We are also identifying all of the claims that were incorrectly demanded or collected, making changes to claims processing systems, and refunding amounts collected. This process will identify the claims that were denied in error and reprocessing will be completed by the Medicare Administrative Contractors.


RESOLUTION TIMEFRAME AND PROCESS 

Q1: How is CMS resolving the claims denial issues associated with the June, July, and August 2013 incarcerated beneficiaries’ data? 

A1: The resolution of this situation requires a series of complex actions, including the restoration of the original data on the Medicare Enrollment Data Base (EDB), the identification of claims that were incorrectly denied or cancelled, the determination of amounts that will need to be refunded, and making changes to our claims processing systems to update Medicare history and notify the other users of our data, such as secondary insurers. The EDB data has been updated and CMS has reduced related non-supplier open accounts receivable to zero in the majority of instances. Most suppliers will receive refunds by the first week in December.

Refunds for non-supplier providers will begin to be issued during the first week in December and the majority should be issued by the middle of December. Note that accounts receivable related to claims that have been appealed are not impacted by this action; appealed claims will be handled separately and, where appropriate, refunds will be generated at a later date.

Q2: As part of the reprocessing work to correct the erroneous claim denials, is Medicare reviewing the claims that were denied on a daily basis between CWF updates during June, July, and August 2013? 

A2: Yes. Now that the up-to-date incarcerated beneficiary data from the Social Security Administration has been loaded into its systems, CMS has instructed its Medicare Administrative Contractors (MACs) to reprocess any claims that may have been denied on or after May 1, 2013 through October 28, 2013, to ensure that the denial was correct. If the original denial was in error, the MAC will adjust the claim to pay. All of the reprocessing should be completed no later than the end of December 2013.

Q3: Were providers notified of which accounts receivable were closed? 

A3: No.


Q4: Were all of the accounts receivable associated with the erroneous claim denials/cancellations closed? 


No. Most of the accounts receivable for erroneous provider claims denials/cancellations were closed. However any accounts receivables in an appeal, bankruptcy, fraud or CMS hold status were not closed. Finally, a group of accounts receivable for affected professional provider claims that haven’t been closed will be closed by the Medicare Administrative Contractor. The timeframe for this activity is not yet finalized.
Last updated 11-27-13

Q5: If an accounts receivable was not closed, does that mean that the overpayment is valid and will be pursued using normal procedures? 

A5: If an accounts receivable was not closed and does not fall into one of these groups, appeal, bankruptcy, fraud or CMS hold status, the providers and suppliers should assume that the overpayment is valid and it will be recouped using normal procedures.



Q6: Will the overpayment letters/demand letters that went out for the claims that were subsequently reprocessed be rescinded? 
A6: No. This action is not necessary because the Accounts Receivable was closed if the demand was not paid, or refunded if the demand was paid.

CO 253 - Medicare EOB sequestration payment reduction code

New Claim Adjustment Reason Code (CARC) to Identify a Reduction in Payment Due to Sequestration 

This article is based on CR 8378 which informs Medicare contractors about a new Claim Adjustment Reason Code (CARC) reported when payments are reduced due to Sequestration. Make sure that your billing staffs are aware of these changes.

As required by law, President Obama issued a sequestration order on March 1, 2013, canceling budgetary resources across the Federal Government. As a result, Medicare Fee-For-Service claims, with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. The Centers for Medicare & Medicaid services (CMS) previously assigned CARC 223 (Adjustment code for mandated Federal, State or Local law/regulation that is not already covered by another code and is mandated before a new code can be created) to explain the adjustment in payment.

Effective June 3, 2013, a new CARC was created and will replace CARC 223 on all applicable claims.

The new CARC is as follows:

•  253 - Sequestration - Reduction in Federal Spending

Also, Medicare contractors will not take any action on claims processed prior to implementation of CR8378.


The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

For example:

The Net Medicare Payment for the claim line is $104.46 and the Medicare Payment Reduction was $2.13.

* Add $104.46 to $2.13, which is $106.59

* $104.46 represents Medicare’s Payment for the service or item and $2.13 represents the Medicare Payment Reduction related to the service or item

* Enter the Sum, which is $106.59, as ‘Medicare Paid (incl. Medicare Reduction(s)) Amount’


How will Medicare physician payments be affected?

• All Medicare physician claims with a date of service on or after April 1 will be subject to a 2 percent payment cut.

• Costs for physician-administered drugs included on the physician claim will also be subject to the 2 percent cut.

• The cut will be applied to the payment itself, not the underlying “allowed charge” in the Medicare fee schedule. As a result, beneficiary copayments and deductibles will not change. In other words, the 2 percent cut is imposed only on the 80 percent of the allowed charge that a participating physician would receive directly from
Medicare. The 20 percent copayment amount (and any deductible) that the physician collects from the patient will be based on the full allowed charge amount.

• With respect to unassigned claims for services provided by nonparticipating physicians, the 2 percent cut will be applied to the Medicare payment made to the beneficiary (but not to the limiting charge amount).

How long will the sequestration last?

• The Budget Control Act requires that $1.2 trillion in federal spending cuts be achieved over the course of nine years. So, unless Congress takes action to change the law, federal spending will be subject to sequestration until 2022.

• Because the American Taxpayer Relief Act that was signed into law in January delayed the 2013 sequester for two months (with a budget offset), the Defense and discretionary program cuts are less severe now than they will be in coming years.

• As an entitlement program, the Medicare payment cut is treated a little differently than the cuts being imposed on programs subject to the appropriations process. The Medicare cut will never be higher than 2 percent.

• Importantly, the Medicare cuts each year are not cumulative. So, the 2 percent cut this year will not be followed by another 2 percent cut next year, and so forth, producing a cumulative double-digit cut at the end of the sequestration period. In other words, this year’s 2 percent cut will simply remain in place every year through 2022 (unless Congress takes action to stop it).

What are the prospects of Congressional action to stop the sequester?

• With all the fiscal deadlines facing Congress this year, the sequester will remain a subject for debate. However, we are mid-way through the fiscal year and, barring a major backlash, it is expected that the sequester cuts will remain in effect through at least Sept 30, 2013.

• The future of sequestration beyond 2013 is likely to depend on whether or not Congress and the White House are able to reach a new budget agreement to address deficit and spending concerns.

Medicare rejection or Audit for incorrect POS

Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for Place of Service Billed by Physician Office and either Ambulatory Surgical Center or Inpatient Hospital 

The Medicare physician fee schedule includes two payment amounts depending on whether a service is performed in a facility setting, such as an outpatient hospital department or ambulatory surgical center, or in a non-facility setting, such as a physician’s office. The payments to physicians are higher when the services are performed in non-facility settings. The higher payments are designed to compensate physicians for the additional costs incurred to provide the service at an office location as opposed to a facility location.

The Office of Inspector General identified incorrect place of service billing by physicians as a payment error in an audit report (see A-01-11-00508).  This report stated, “Physicians are required to identify the place of service on the health insurance claim forms that they submit to Medicare contractors. The correct place-of-service code ensures that Medicare does not reimburse a physician incorrectly for the overhead portion of the payment if the service was performed in a facility setting.”  This report also states that several Medicare contractors overpaid physicians who did not correctly identify the place of service on their claims.

To ensure proper payment, CWF will create an IUR for all claims where the dates of service, the beneficiary information, and procedure, are all the same and billed with a physician place of service code 11 - office, and a facility code for inpatient hospital – 21, and ambulatory surgical center (ASC) – 24, that is posted due to an update from CMS.   An IUR is a message from CWF to a MAC, carrier or fiscal intermediary, as applicable, to review claims for accuracy.

The issue listed below has been identified by the recovery auditors as significant improper payments and requires the development of an edit to correct these improper payments.  The edit for this issue will include claims that have physician place of service code and either ambulatory surgical center (ASC) code or inpatient hospital code.  This edit will act as a tool to protect the Medicare Trust Fund by preventing improper billing practices.

Background:   

1)  An audit in October 2004 by the Office of the Inspector General (OIG) identified place of service billing by physicians as a payment error.  This report stated, “Medicare overpaid physicians due to incorrect place of service coding. Seventy-nine of 100 sampled physician services, selected from a population of services identified as having a high potential for error, were performed in a facility but were billed by the physicians using the “office” place of service code. As a result of the incorrect coding, Medicare paid the physicians a higher amount for these services.”  Because these claims cannot be denied prior to payment, CMS is implementing an IUR for all claim types to recover these payments.

CWF will create an Informational Unsolicited Response (IUR) for all claims where the dates of service, the beneficiary information, and procedure, are all the same and billed with a physician place of service code 11 - office, and a facility code for inpatient hospital – 21, and ambulatory surgical center (ASC) – 24, that is posted due to an update from CMS.

Medicare rejection - Accident date is required and rendering provider required

An accident date is required for Federal program when an accident related diagnosis is present.

What this means: Some claims to this payer may reject for 'An accident date is required for Federal program when an accident related diagnosis is present.'

Provider action: Check the codes on the claims, are they considered accident codes? If so you will need to submit an accident indicator and and accident date on your claim.

Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.


An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain

What this means: Claims to this payer may reject for 'An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain a [OTER].'  

Provider action: Verify that you are not sending the same insured and patient name on the claims, if so correct and resubmit.

Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any


 RENDERING PHYSICIAN IS REQUIRED 

What this means: There are two possible reasons for this

rejection:
1. If the provider sends the claim with only the individual NPI in the billing loop and they are credentialed with a group NPI, then the claims will be rejected by the payer.

2. If the provider sends the claim with only the individual NPI in the billing loop and the entity type qualifier is 2 (non-person), then the claims will be rejected by the payer.

Resubmit with Group NPI (Box 33) information.

Medicare Enrollment denials when overpayment exists with example

What you need to know
This article, based on CR 8039, informs you that Medicare contractors may deny a Form CMS-855 enrollment application if the current owner of the enrolling provider or supplier or the enrolling physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time an application for new enrollment or change of ownership (CHOW) is filed.

Background
Under 42 Code of Federal Regulations (CFR) Section 424.530(a)(6), an enrollment application may be denied if the current owner (as that term is defined in 42 CFR Section 424.502) of the applying provider or supplier, or the applying physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time the application was filed.(Under 42 CFR 424.502, the term “owner” means any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of the provider or supplier as defined in Sections 1124 and 1124A(A) of the Social Security Act) of the applying provider or supplier) Overpayments are Medicare payments that a provider or beneficiary has received in excess of amounts due and payable under the statute and regulations. Once a determination of an overpayment has been made, the amount is a debt owed by the debtor to the United States Government.

Upon receipt of a CMS-855A, CMS-855B, or CMS-855S application, the Medicare contractor will determine – whether any of the owners listed in Section 5 or 6 of the application has an existing or delinquent Medicare overpayment.

Upon receipt of a CMS-855I application, the Medicare contractor will determine whether the physician or non-physician practitioner has an existing or delinquent Medicare overpayment. (For purposes of this requirement, the term “non-physician practitioner” includes physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals.)

If an owner, physician, or non-physician practitioner has such an overpayment, the contractor shall deny the application, using 42 CFR 424.530(a)(6) as the basis.

Consider the following examples:

Example #1: Hospital X has a $200,000 overpayment. It terminates its Medicare enrollment. Three months later, it reopens as Hospital Y and submits a new CMS-855A application for enrollment as such. A denial is not warranted because §424.530 (a)(6) only applies to physicians, practitioners, and owners.

Example #2: Dr. John Smith’s practice (“Smith Medicine”) is set up as a sole proprietorship. He incurs a $50,000 overpayment. He terminates his Medicare enrollment. Six months later, he tries to enroll as a sole proprietorship; his practice is named “JS Medicine.” A denial is warranted because §424.530 (a)(6) applies to physicians and the $50,000 overpayment was attached to him as the sole proprietor.

Example #3: Dr. John Smith’s practice (“Smith Medicine”) is set up as a sole proprietorship. He incurs a $50,000 overpayment. He terminates his Medicare enrollment. Six months later, he tries to enroll as an LLC of which he is only a 30 percent owner; the practice is named “JS Medicine, LLC.” A denial is not warranted because the provision applies to “all” owners collectively and, again, the $50,000 overpayment was attached to him.

Medicare overpayment denial - what should provider do ?

Medicare E/M claims for new patients

As previously announced with MM8165, Medicare implemented a common working file system edit to identify claims where more than one new patient visit was billed for the same patient within three years.  Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period.


In addition to this new edit, the common working file has established an additional edit which identifies claims where an established patient visit was billed in advance of a new patient visit within a three year period.  This edit fails when the rendering provider on the claim with the established patient visit is the same as the rendering provider on the claim with the initial patient visit.  As a result of these new edits, you may begin to see services deny on the original claim submission or you may receive an overpayment request.


If you receive this denial on a new patient visit (not an overpayment request) and you determine that the procedure code should have been filed as an established visit, you can simply call the interactive voice response (IVR) system and request a reopening.

Additional IVR reopening information can be found by clicking here. If you do not want to use the IVR for this, you have the option of submitting a new claim or writing in for a reopening.

Note:  Submitting a new claim for the revised established E/M visit will not result in a duplicate denial since the original visit code was not paid.CMS has mandated that contractors request overpayments on any claims that were previously paid when either:

An established patient visit was billed prior to an initial visit within a three year period by the same rendering provider; orMore than one new patient visit was billed within a  three-year period by the same provider or different providers in the same group with the same specialty.

These new system edits were turned on October 1. A large number of paid claims have been identified as overpayments due to the above guidelines. As a result, First Coast Service Options Inc. (First Coast) has initiated recoupment of improper payments related to these claims. The impacted providers will be receiving an overpayment letter soon. To assist providers with questions that they may have relative to these new guidelines, we are providing the following Q&As:


Q: Can I appeal my overpayment?
A: You certainly have the right to appeal any overpayment. However, the overpayment finding will likely be affirmed since Medicare guidelines do not allow more than one new patient visit within three years. Medicare also does not allow payment for a new patient visit billed after an established patient visit by the same rendering provider.


Q: Can I submit a request to change my new patient visit (that generated the overpayment) to an established patient visit?
A: Yes, you can submit a reopening request in writing to change your new patient visit to an established patient visit code if this is the service you actually performed.  In your reopening request, you must tell us the specific established visit code you want us to change on your claim.  You want to be mindful that there will still likely be an overpayment since established patient visits typically allow less than new patient visits. You also want to note that if you choose to bill another new patient visit code within a three-year period, another overpayment will occur.


Q: I initially billed a claim with an established patient visit in error before I billed my claim for the initial visit.  As a result I received an overpayment letter.  Can I make corrections to both claims?

A: Yes, you can correct both claims. On your first claim which continued the established patient visit, you can simply call the IVR and request a reopening. You are only allowed to request a reopening if the claim was processed within the previous 12 month period. If it has been longer than 12 months, a reopening should not be submitted.

To correct your second claim, you would need to submit a written request and indicate the correct procedure that should have originally been billed on your claim. It is likely that a small overpayment will still be due since established patient visit codes allow less than new patient visit codes.

Basic of Handling of Invalid claim submission

 Handling Incomplete or Invalid Submissions 

 The following provides additional information detailing submissions that are considered incomplete or invalid.
The matrix in Chapter 25 specifies whether a data element is required, not required, or conditional. The status of these data elements will affect whether or not an incomplete or invalid submission (hardcopy or electronic) will be returned to provider (RTP). FIs should not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction.
The FIs should take the following actions upon receipt of incomplete or invalid submissions:

• If a required data element is not accurately entered in the appropriate field, RTP the submission to the provider of service.

• If a not required data element is accurately or inaccurately entered in the appropriate field, but the required data elements are entered accurately and appropriately, process the submission.

• If a conditional data element (a data element which is required when certain conditions exist) is not accurately entered in the appropriate field, RTP the submission to the provider of service.

• If a submission is RTP for incomplete or invalid information, at a minimum, notify the provider of service of the following information:
o Beneficiary’s Name; o Health Insurance Claim (HIC) Number; o Statement Covers Period (From-Through); o Patient Control Number (only if submitted); o Medical Record Number (only if submitted); and o Explanation of Errors.

NOTE: Some of the information listed above may in fact be the information missing from the submission. If this occurs, the FI includes what is available.

• If a submission is RTP for incomplete or invalid information, the FI shall not report the submission on the MSN to the beneficiary. The notice must only be given to the provider or supplier.

What is Incomplete or Invalid Submissions

Services not submitted in accordance with CMS instructions include:

• Incomplete Submissions - Any submissions missing required information (e.g., no provider name).

• Invalid submissions - Any submissions that contains complete and required information; however, the information is illogical or incorrect (e.g., incorrect HIC#, invalid procedure codes) or does not conform to required claim formats
 
The following definitions may be applied to determine whether submissions are incomplete or invalid:
• Required - Any data element that is needed in order to process the submission (e.g., Provider Name).
• Not Required - Any data element that is optional or is not needed in order to process the submission (e.g., Patient’s Marital Status).
• Conditional - Any data element that must be completed if other conditions exist (e.g. if there is insurance primary to Medicare, then the primary insurer’s group name and number must be entered on a claim). If these conditions exist, the data element becomes required.

Submissions that are found to be incomplete or invalid are returned to the provider (RTP). The incomplete or invalid information is detected by the FI’s claims processing system. The electronic submission is returned to the provider of service electronically, with notation explaining the error(s).  Assistance for making corrections is available in the on-line processing system (Direct Data Entry) or through the FI. In the limited cases where paper submission are applicable, paper submissions found to be incomplete or invalid prior to or during entry into the contractor’s claims processing system are returned to the provider of service by mail, with an attached form explaining the error(s).


The electronic records of claims that are RTP are held in a temporary storage location in the FI’s claims processing system. The records are held in this location for a period of time that may vary among FIs, typically 60 days or less. During this period, the provider may access the electronic record and correct it, enabling the submission to be processed by the FI. If the incomplete or invalid information is not corrected within the temporary storage period, the electronic record is purged by the FI. There is no subsequent audit trail or other record of the submission being received by Medicare. These submissions are never reflected on a RA. No permanent record is kept of the submissions because they are not considered claims under Medicare regulation.

How to File a Void Request on a Paper Claim

Requirements for Filing a Void Request

A void request will be processed as a replacement to the original, incorrectly paid claim. When a claim is voided, the total payment for the original claim is deducted. There is no time limit on submitting a void. The provider can submit a paper void request on the remittance voucher, a legible photocopy of the
original claim, or an entirely new claim.

Voiding Claims on the Remittance Voucher

A claim can be voided by photocopying the remittance voucher and in black ink circling the claim to be voided. Write “void” on the side of the remittance voucher and briefly explain why the void is requested. Sign and date the remittance voucher in the margin. Only one claim can be voided per copy of the remittance voucher. Additional claims on the same remittance voucher must be voided by submitting additional photocopies of the remittance voucher. Each copy of the remittance voucher can only have one claim circled on it.

Voiding Claims on a Paper Claim Form


When requesting a void, the provider must:
·  Resubmit a photocopy of the original claim or a new claim form;
·  Enter the items listed on following page;
·  Initial and date the form if it is a photocopy, or sign and date it if it is a new
form; and

·  Mail the void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080

How to Resubmit a Denied Claim

Instructions
Check the remittance voucher before submitting a second request for payment.  Claims may be resubmitted for one of the following reasons only:

·  The claim has not appeared on a remittance voucher as paid, denied, or suspended for thirty days after it was submitted; or
·  The claim was denied due to incorrect or missing information or lack of a required attachment.

Do not resubmit a claim denied because of Medicaid program limitations or policy regulations. Computer edits ensure that it will be denied again.


No Response Received

If the claim does not appear on a remittance voucher within 30 days of the day it was mailed, the provider should take the following steps:

·  Check recently received remittance voucher dates. Look for gaps. A remittance voucher may have been mailed but lost in transit. If the provider believes this is the case, call ACS Provider Inquiry.

·  If there is not a gap in the dates of remittance vouchers received, please call the Medicaid fiscal agent, Provider Inquiry. An associate will research the claim.

·  If the fiscal agent advises that the claim was never received, please resubmit another claim immediately. See the Resubmission Checklist on the following page in this chapter.

Correcting a Denied Claim

If the claim has been denied for incorrect or missing information, correct the errors before resubmitting the claim.

Resubmission Checklist
Use the following checklist to ensure that resubmittals are completed correctly before submitting.

*  Did you wait thirty days after the original submittal before resubmitting a missing claim?

* If using a photocopy of a claim, did you make sure it was legible and properly aligned?

* If you chose to fill out a new claim, did you type or print the form in black ink? Are all multi-part copies legible?

*  If you have corrected or changed the original claim form, have strikeovers been corrected on each copy? (Do not use whiteout.)

* Have you clipped all required attachments and documentation to the claim form?

*  Is the claim clean of all highlighting and whiteout?

*  Do you have the correct P.O. Box Number and corresponding nine-digit zip code for mailing the resubmitted claim?

Medicare screening test denials

REMINDERS FOR PATIENT SCREENING 

Quarterly data analysis identifies three top denials/rejections that could be significantly reduced or eliminated by providers who have an effective patient screening process in place. 

The three patient screening-related billing errors identified are: 

  MA plan denials.

  MSP denials.

  Beneficiary eligibility denials.

The following are suggestions to increase your existing patient screening office procedures: 

 Verify the patient’s name and Medicare number to his Medicare card. The name used on all documents should match the Medicare card exactly. 

  The patient’s name and Medicare number should match the claim that is submitted to Medicare. 

  Patient eligibility can be obtained from the Medicare card. However, if the patient joins an MA plan or terminates Part B coverage, the patient may still continue to carry the Medicare card. Do not use the Medicare card as a guarantee of Medicare eligibility. 

  Periodically verify the patient’s insurance information to determine if any changes

have occurred. If changes have occurred, the patient's records should be updated accordingly. Collection and maintenance of up-to-date patient and insurance information is critical for offices in today’s insurance environment. 

  Verify a picture ID of the patient to ensure the Medicare beneficiary/recipient is not a victim of identity theft and the Medicare identification is not being used without knowledge or consent.

 Failure to perform adequate patient screening and maintain up-to-date files can be viewed as a violation of the provider agreement with Medicare. Patients must be prompted to share other possible coverage that may be primary to Medicare. 

 Use the IVR or the online inquiry system to verify the patient’s Medicare eligibility, determine if Medicare is primary or secondary and identify those patients who have joined an MA plan that would replace “traditional” Medicare. 

 A few minutes of patient screening during each patient’s visit can save providers time and money later!

Something to think about: Fold the CMS-1500 claim form in half just below Item 12 and Item 13. The top half of the claim form is based on information that is obtained during patient screening. The bottom half of the claim lists what the physician provided for the patient and identifies the office information. 

Performance of the patient screening tasks should be considered a job with great responsibility. The physician services will not be processed correctly if there is no patient screening process in place to ensure the claim is submitted correctly – the first time.

NCCI Bundling Denials Code : M80, CO-B15

Creatinine (Blood): NCCI Bundling Denials Code : M80, CO-B15


Denial Reason, Reason/Remark Code(s)

• M-80: Not covered when performed during the same session/date as a previously processed service for the patient

• CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

• CPT code: 82565

National Correct Coding Initiative

The National Correct Coding Initiative (NCCI) packages or 'bundles' reimbursement for some services under Medicare. NCCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).



Resources

• Check NCCI edits prior to claim submission; edits are updated quarterly. NCCI edits are available at www.cms.gov/NationalCorrectCodInitEd/.

• Use the Palmetto GBA NCCI tool to determine if the service you are submitting is bundled with another service

• CPT code 82565 is bundled with CPT code 80047. CPT code 82565 is also bundled with the following CPT codes: 80048, 80053, 80069 and 82575.

o For these combinations of services, CPT code 82565 is designated with indicator '1' in the CCI edit list. If this is a separate, distinct service, submit CPT modifier 59 to denote it as a separate service.

Examples of separate, distinct services include tests that are performed different patient encounters. Supporting documentation is required in the medical records.

• For additional, specific information on modifiers that may be used to denote exceptions to CCI (including CPT modifier 59), refer to the Palmetto GBA Modifier Lookup tool:

o Jurisdiction 1: Select 'Articles' on the left side of the Palmetto GBA Web page

o Ohio, South Carolina and West Virginia: Select 'Browse by Topic' on the left side of the Palmetto GBA Web page


 Common Reasons for Message

    Combination of codes billed on same date of service by same provider may not be appropriately paired together due to National Correct Coding Initiative (NCCI) Edits
        Payment for service billed is bundled into payment for another service performed that day
        It is unusual for services billed to be performed together
    Modifier used to unbundle is on incorrect code or incorrect modifier was used

Next Step

    Verify code set is appropriate to be billed together
    Submit Appeal request to add modifier, if appropriate
        See Appeals webpage for instructions on how to submit a Reopening or Redetermination

Claim Submission Tips

    Review NCCI Coding Edits External Link prior to submitting claim to determine if codes are appropriately paired

        View How to Use Medicare NCCI Tools External Link

    When appropriate, modifier to identify separately identifiable service should be appended to Column 2 code
        Modifier Indicator "0" – there are no circumstances in which both procedures of a code pair should be paid; modifier is not allowed for NCCI purposes
        Modifier Indicator "1" – modifiers associated with NCCI are allowed with this code pair when appropriate
        Modifier Indicator "9" – NCCI edit does not apply to this code pair; edit for code pair was deleted retroactively

    Providers may not bill patient for NCCI edit denials
        Denial is based on incorrect coding
        Providers should not complete an ABN for NCCI edits

Chest X-ray or EKG: Duplicate Denials

Denial Reason, Reason/Remark Code(s)

M-80, CO-18 - Duplicate Service(s): Same service submitted for the same patient, same date of service by same doctor will be denied as a duplicate

CPT codes: 93010, 71010, 71020

Resolution/Resources

First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA eServices tool or by calling the Palmetto GBA Interactive Voice Response (IVR) unit.

Online Claim Status Verification through eServices

All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.

Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.


Billing services and clearinghouses should contact their provider clients to gain access to the system

Specific instructions for accessing claim status information through eServices are available in the eServices User Manual external link  (PDF, 5.73 MB)



Instructions

Submit multiple 'identical' services on the same claim. Use the quantity field to reflect the number of services. If the services cannot be submitted on a single claim, use CPT modifier 76 and specify the exact times of each service.

On electronic claims use the documentation record to specify the exact times that each diagnostic service (e.g., chest x-ray, EKG, etc.) was done

On electronic claims use the documentation record to explain why more than one diagnostic service was done on the same date by the same provider

Attachments (e.g., signed radiology reports, signed EKG reports, etc.) for paper claims must identify the patient’s name, Health Insurance Claim number, date of service and other pertinent information (e.g., times):

Attachments must be a full page (8 ½ x 11)

On appeal signed medical records (e.g., radiology reports, EKG reports, etc.) may be sent as evidence to show why more than one diagnostic service was billed on the same date by same or similar providers from the same group


Access specific instructions for documenting and submitting CPT modifier 76 through the Palmetto GBA Modifier Lookup. Select 'Browse by Topic' on the left side of the Palmetto GBA Web page.

NCCI Bundling Denials

Denial Reason, Reason/Remark Code(s)

M-80: Not covered when performed during the same session/date as a previously processed service for the patient


CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered.

The qualifying other service/procedure has not been received/adjudicated.

Correct Coding Initiative: The National Correct Coding Initiative (NCCI) packages/bundles reimbursement for some services under Medicare. NCCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resolution/Resources

Check NCCI edits prior to claim submission; edits are updated quarterly on CMS' website

Use the Palmetto GBA NCCI tool external link  to determine if the service you are submitting is bundled with another service
For specific information on modifiers that may be used to denote exceptions to NCCI (including CPT modifiers 24, 25, 59, 76 and 91), refer to the Palmetto GBA Modifier Lookup tool from the Self Service section on the Palmetto GBA Web page


Is the NCCI indicator '0'?

These code pairs will not be reimbursed if submitted for the same date of service. Exceptions to NCCI edits cannot be made for code combinations with an indicator of '0'

Is the code indicator '1'?

Submit the appropriate modifier to show the service should be separate. Documentation is required in the patient's medical record. Exceptions to NCCI edits can be made for code combinations with an indicator of '1'.


Examples of separate, distinct services include situations in which a bundled service was performed during a different patient encounter

Code/Modifier Combination Invalid and Modifier Invalid/Missing - B18,CO4, MA130

Remark Code/ Message Number:

• B18: Payment adjusted because this procedure code and modifier were invalid on the date of service

• 4: The procedure code is inconsistent with the modifier used or a required modifier is missing

• MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Resolution

• Review the CPT/HCPCS code narratives to determine if a modifier is needed

• Verify that the submitted modifier is appropriate to be submitted with the procedure code

• Access complete instructions for correctly submitting all CPT and HCPCS modifiers on the 'Palmetto GBA Modifier Lookup' Web page:

o Jurisdiction 1: Select 'Articles' on the left side of the Palmetto GBA Web page

o Ohio, South Carolina and West Virginia: Select 'Browse by Topic' on the left side of the Palmetto GBA Web page.

CO 18 - Duplicate Service(s): Same service submitted for the same patient

Clinical Laboratory Procedures: Duplicate Denials - CO18


Denial Reason, Reason/Remark Code(s)

• CO-18 - Duplicate Service(s): Same service submitted for the same patient

• CPT codes: 36415, 80048, 80053, 80061, 83036, 84443, 85610

Resolution/Resources

First: Verify the status of your claim before resubmitting. Use the Palmetto GBA Online Provider Services (OPS) tool or call the Palmetto GBA Interactive Voice Response unit (IVR).

• All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.

• Access the introductory article to learn more: click on the 'Introducing Online Provider Services' graphic on the top of any of our main state Web pages

• One important consideration: only one Provider Administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The Provider Administrator can then grant permission to additional users related to that PTAN/NPI.

• Billing services and clearinghouses should contact their provider clients to gain access to the system



0302  Duplicate of History File Record, Same Provider, Same Dates of Service

Provider has already received payment for this date of service. Review your prior remittance to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline

*Note- make sure the prior remittance’s provider number matches the number of the remit with the denied claim


0301  Duplicate Payment Request-Same Provider, Same Dates of Service

Provider has already received payment for this date of service. Review your prior remittances to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline

*Note- make sure the prior remittance’s provider number matches the number of the remittance with the denied claim

CPT modifier 91 may be submitted to identify an identical laboratory test for the same patient on the same date.

• This modifier may not be submitted when tests are rerun to confirm initial results due to testing problems with specimens or equipment, or for any other reason when a normal, one-time, reportable result is all that is required

• This modifier may not be used when other codes describe a series of test results (e.g., glucose tolerance tests)

• For clinical laboratory tests ordered by an ESRD facility: these tests must be submitted with CPT modifier 91 if any single service (same CPT code) is ordered for the same patient, and the specimen is collected more than once in a single day, and the service is medically necessary

o CPT modifier 91 must be submitted with services that meet these criteria, regardless of whether the test is also submitted with HCPCS modifiers CD, CE or EF

o Any line item on a claim that meets these criteria and is submitted with CPT modifier 91 will be included into the calculation of the 50/50 rule

o After calculation of the 50/50 rule, services used to determine the payment amount may not exceed 22.

Medicare Denial Code CO-B7, N570

CLIA: Laboratory Tests - Denial Code CO-B7


Denial Reason, Reason/Remark Code(s):

• CO-B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service

• CPT codes include: 82947 and 85610

Resolution

• HCPCS modifier QW must be submitted with certain clinical laboratory tests that are waived from the Clinical Laboratory Improvement Amendments of 1988 (CLIA) list. The Food and Drug Administration (FDA) determines which laboratory tests are waived.

• Note: Not all CLIA-waived tests require HCPCS modifier QW

• Determine if the CPT code is a waived test by accessing the CMS CLIA Web page

• Palmetto GBA will publish information on tests newly classified as 'waived' on our Web site. Please note, the list of CLIA-waived procedures is updated as often as quarterly.

• The CLIA certificate number is also required on claims for CLIA waived tests. Submit this information in Loop 2300 or 2400, REF/X4, 02 for electronic claims. For paper claims, submit the CLIA certification number in Item 23 of the CMS-1500 claim form.

• Access complete instructions for correctly submitting HCPCS modifier QW in the Palmetto GBA Modifier Lookup tool:

o Jurisdiction 1: Select 'Articles' on the left side of the Palmetto GBA Web page

o Ohio, South Carolina and West Virginia: Select 'Browse by Topic' on the left side of the Palmetto GBA Web page.


Denial reason code CO/PR B7 FAQ

Q: We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?

Provider was not certified/eligible to be paid for this procedure/service on this date of service.

A: This denial is received when the claim’s date of service is prior to the provider’s Medicare effective date or after his/her termination date, or when a procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or a laboratory service is missing a required modifier.

Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.

• If the date of service is not correct, follow procedures for correcting claim errors.

• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.

• View enrollment information through the internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date. Click here external link for more details.

Note: The provider’s Medicare effective date can be retroactive up to 30 days from receipt of application, or a future date, up to 60 days from receipt of application.

Submit claims for laboratory services within the scope of the provider’s CLIA certification.

• Verify service/procedure code is listed as approved under the scope of the provider’s certification.

• Refer to the complete list of downloads of Categorization of Tests external link on the Centers for Medicare & Medicaid Services (CMS) website.

• Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests). For assistance, you may review the CLIA - CPT codes requiring modifier QW tutorial.

• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.

Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.


 CO-B7  This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

N570 Missing/incomplete/invalid credentialing data.


Common Reasons for Message

    Lab code billed is not within CLIA certification type
    CLIA waived test was missing modifier QW
    Modifier QW was billed but not required

Next Step

    Verify correct CLIA certification number was submitted on claim
    Submit Appeal request to correct CLIA certification number or add/remove QW modifier
        See the Appeals webpage for instructions on how to submit a Reopening or Redetermination




Denial reason code CO/PR B7 FAQ

Q: We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?

Provider was not certified/eligible to be paid for this procedure/service on this date of service.

A: This denial is received when the claim’s date of service is prior to the provider’s Medicare effective date or after his/her termination date, the procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is missing a required modifier.
Submit claims for services rendered on/after the provider’s effective date and prior to the provider’s termination date.
Review the Medicare Remittance Advice (RA), and verify the date of service.
• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
• View enrollment information through the internet-based Provider Enrollment, Chain and Ownership System (PECOS), and confirm provider’s Medicare effective date. Click here external link for more details.

Note: The provider’s Medicare effective date can be retroactive up to 30 days from receipt of application, or a future date, up to 60 days from receipt of application.
• If you require additional assistance, you may contact Provider Enrollment.
If billing for laboratory services, submit claims within the scope of the provider’s CLIA certification.
• Verify service/procedure code is listed as approved under the scope of the provider’s certification.
• Refer to the complete list of downloads of Categorization of Tests external link on the Centers for Medicare & Medicaid Services (CMS) website.
• Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests). For assistance, you may review the CLIA - CPT codes requiring modifier QW tutorial.
• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.
Make the necessary correction(s), and resubmit the claim. Submit the corrected line(s) only. Resubmitting the entire claim may result in a duplicate claim denial.
Or, if applicable, you may request a reopening via the:spot