Claim Submission Erros

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Transcript Claim Submission Erros

TrailBlazer Health Enterprises Education Makes the Difference

Claim Submission Errors

Kelly Langford Provider Outreach and Education (866) 237-4482

Important

The information contained in this presentation was current as of March 2012 and can be found in the

CMS-1500 Claim Form and Unprocessable/Rejected Claims

manual. All manuals can be downloaded from:

http://www.trailblazerhealth.com/Publications/Manuals/

Slide 2

Agenda

• Discuss 5010 updates and reminders.

• Highlight the top claim submission errors for November 2011 through January 2012.

• Discuss common Medicare Remittance Advice (MRA) codes seen on claim rejections. • Provide resolutions for each claim rejection. • Convey the importance of filing Medicare claims correctly the first time, every time, which results in better cash flow for providers.

• Provide instructional resources.

Slide 3

TrailBlazer Health Enterprises Education Makes the Difference

Updates and Reminders

2013 Electronic Prescribing Payment Adjustment

Slide 5

Additional Resources

• CMS Electronic Prescribing (eRx) Overview. https://www.cms.gov/ERxIncentive/01_Overview.as

p • Quick Reference Guide for Understanding the 2012 eRx Payment Adjustment. https://www.cms.gov/ERxIncentive/Downloads/QR Guide_Understanding_2012eRxPayAdj_F01-09 2012_508.pdf

Slide 6

ASC X12 Version 5010

On March 15, 2012, CMS announced that it will not initiate enforcement action until July 1, 2012, with respect to ASC X12 Version 5010. This means that non-compliant covered entities will not incur monetary fines until July 1, 2012.

TrailBlazer will not reject compliant ASC X12 4010 claims prior to July 1, 2012. The exact date non-compliant 5010 claims will reject will be published at a later date.

CMS encourages providers to continue testing and take the next step to move into production for 5010 billing.

Slide 7

ASC X12 Version 5010 (Cont.)

5010 HIPAA Implementation Guides: • Institutional (Part A) Electronic Claim (837I).

• Professional (Part B) Electronic Claim (837P).

• Electronic Remittance Advice (835).

• Claim Status and Response (276/277).

• Eligibility Inquiry and Response (270/271).

Side-by-side comparisons (4010A1  5010): http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

Slide 8

ASC X12 Version 5010 (Cont.)

The HIPAA-compliant version of PC-ACE Pro32 is available on the Software & Manuals Web page. http://www.trailblazerhealth.com/Electronic Data Interchange/Software Manuals Consult your software vendor, clearinghouse or billing service to ensure they have tested and your software version is compliant prior to contacting the Electronic Data Interchange (EDI) Technology Support Center.

You do not have to test if your vendor has tested and is compliant.

If you have any questions, please call the EDI Technology Support Center at (866) 749-4302. Slide 9

ASC X12 Version 5010 (Cont.)

Providers can stay abreast of important ASC X12 Version 5010 information by visiting the TrailBlazer EDI Web page. Valuable online educational materials are only a mouse click away. http://www.trailblazerhealth.com/Electronic Data Interchange/5010.aspx

The following resources are helpful: • ASC X12 837 5010 Move-to-Production Procedures.

• HIPAA 5010 835 Production ERAs.

• Notices relating to 5010 implementation and transition.

• Online resource links (e.g., CMS 5010 Web page, Companion Guide, FAQs, 5010 job aids).

Slide 10

ASC X12 Version 5010 – 835 for Part B

TrailBlazer is currently accepting requests to transition your ERA receiver IDs to the HIPAA 5010 production remittance. If you have already transitioned to 5010 for the 837 claims submission, you still need to send a request to transition your 835 files as well because these are two separate processes. Also, if you are only running your ERA files through Medicare Remit Easy Print (MREP), we still need your request to transition your ERA receiver IDs to the HIPAA 5010 version.

If you are ready to transition to the HIPAA 5010 version, please

fax

signed

letter on facility/company letterhead informing us that you are ready to convert to the HIPAA 5010 version for the 835 claims submission. Please ensure you include the ERA receiver IDs that you want transitioned. Fax: (469) 372-1045 If you have any additional questions/concerns, please call any of the following numbers for further assistance: (866) 528-1605 (866) 528-1606 Slide 11

TrailBlazer Health Enterprises Education Makes the Difference

Claim Submission Errors

Unprocessable/Rejected Claims

An unprocessable claim is any claim with incomplete or missing required information, or any claim that contains complete and necessary information but the information provided is invalid.

Slide 13

Unprocessable/Rejected Claims (Cont.)

In each rejection situation, the MRA will reflect a CO-16 message. This message reads as follows:

CO 16:

Claim/service lacks information which is needed for adjudication.

In addition to the CO-16 message, providers need to review the MRA for additional messages that will explain why the claim rejected. In some instances, there may be more than one message that is needed to explain the reason for the claim rejection. The CO-16 message should cue providers that the next step is claim research and timely claim resubmission.

Slide 14

Unprocessable/Rejected Claims (Cont.)

Rejected/unprocessable claims will also reflect an additional message (MA130) on the MRA:

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 complete/correct information.

This message directs providers to the appeal rights for the individual claim along with a message to submit the claim with corrected information.

Slide 15

PERF PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC-AMT PROV PD NAME DOE, JOHN HIC XXXXXXXXXA ACNT 22284-1 ICN 1505214XXXXXX ASG Y MOA MA130 MA15 XXXXX 1125 112508 24 1 18699 SGT5 655.00 0.00 0.00 0.00 CO-16 655.00 0.00 REM: M20 PT RESP 0.00 CLAIM TOTALS 655.00 0.00 0.00 0.00 655.00 0.00 0.0 NET _________________________________________________________________________________________________ Remark Code CO-16 Message MOA Codes

Top Rejections

November 2011 – January 2012

Patient eligibility.

Referring or ordering physician (Item 17).

Procedure code incomplete/missing/invalid.

Billing provider information.

Clinical Laboratory Improvement Amendments (CLIA). Slide 17

Top Rejections (Cont.)

November 2011 – January 2012

Medicare Secondary Payer (MSP).

Claim not covered by this payer/contractor.

Patient signature.

Days/units.

10.

Where services furnished (Item 32).

Slide 18

Patient Eligibility Rejection messages: 140

Patient/insured health identification number and name do not match.

MA61

Missing/incomplete/invalid Social Security number or health insurance claim number.

Slide 19

Patient Eligibility Requirements

• The patient’s name and Medicare number should be obtained during patient registration and screening and reverified periodically to maintain current and accurate patient information.

• It is critical for the patient’s information to be shown/entered on the claim correctly (paper or electronically). Slide 20

* Required field

Patient Eligibility

Slide 21

* Required field

Patient Eligibility (Cont.)

Slide 22

Patient Eligibility Rejection Solutions

• Patient screening is vital in capturing the necessary information for correct claim submission.

• Verify the patient’s name and Medicare number to his Medicare card. • Make a copy of the patient’s Medicare card for office reference.

• Periodically re-verify the patient’s eligibility.

• The

Patient Registration and Screening Guide

provides ways to implement a process or improve existing processes. It is located on the TrailBlazer Web site under Publications/Manuals.

• The Interactive Voice Response (IVR) provides patient eligibility and benefit information.

• Incorporate the use of the Patient Screening/Eligibility Checklist located on the TrailBlazer Web site under Publications/Forms.

Slide 23

Instructional Resources

•

Patient Registration and Screening Guide.

http://www.trailblazerhealth.com/Publications/Training Manual/PatientRegistrationScreening.pdf

• IVR Web page. http://www.trailblazerhealth.com/Customer Service/Interactive Voice Response • IVR Operating Guide. http://www.trailblazerhealth.com/Publications/Job Aid/IVR Operating Guide.pdf

• Part B Patient Screening/Eligibility Checklist. http://www.trailblazerhealth.com/Publications/PDF Form/PatientScreeningEligibilityChecklist.pdf

Slide 24

Referring or Ordering Physician

Rejection messages: N264 N265 N285 N286

Missing/incomplete/invalid ordering provider name.

Missing/incomplete/invalid ordering provider primary identifier.

Missing/incomplete/invalid referring provider name.

Missing/incomplete/invalid referring provider primary identifier.

Slide 25

Referring or Ordering Physician (Cont.)

Item 17:

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 must be used for each ordering/referring physician.

Referring physician:

A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering physician:

A physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services or durable medical equipment and services “incident to” that physician’s or non-physician practitioner’s service. See Internet-Only Manual (IOM) Pub. 100-02,

Medicare Benefit Policy Manual,

Chapter 15, for non-physician practitioner rules. Slide 26

Referring or Ordering Physician (Cont.)

The following services/situations require the submission of the referring/ordering provider information: • Medicare-covered services and items that are the result of a physician’s order or referral. • Parenteral and enteral nutrition. • Immunosuppressive drug claims. • Hepatitis B claims. • Diagnostic laboratory services.

Slide 27

Referring or Ordering Physician (Cont.)

• Diagnostic radiology services. • Portable X-ray services. • Durable medical equipment. • When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests). • When a service is “incident to” the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in Item 17 or the electronic equivalent. Slide 28

Referring or Ordering Physician (Cont.)

+ Conditional field Note:

Item 17a or the electronic equivalent should be left blank. Slide 29

Instructional Resources

• Use the “Electronic Claims Crosswalk to the CMS 1500 Claim Form” job aid to view all of the necessary loops and segments needed to file an electronic claim to Medicare. http://www.trailblazerhealth.com/Publications/Job Aid/Crosswalkto1500ClaimForm.pdf

•

CMS-1500 Claim Form

manual.

http://www.trailblazerhealth.com/Publications/Trai ning Manual/claim form instructions.pdf

Slide 30

Procedure Code Incomplete/ Missing/Invalid

Rejection messages: 4

The procedure code is inconsistent with the modifier used, or a required modifier is missing.

M51

Missing/incomplete/invalid procedure code(s).

M20

Missing/incomplete/invalid HCPCS.

N56

Procedure code billed is not correct/valid for the services billed or the date of service billed.

Slide 31

* Required field

Procedure Code Requirements

Slide 32

Procedure Code Solutions

• If the narrative description cannot be defined on the claim, an attachment to the claim will be accepted to provide additional information related to the unlisted or Not Otherwise Classified (NOC) code (Item 19 on the CMS-1500 claim form).

• Comment field for electronic claims.

Slide 33

Procedure Code Solutions (Cont.)

SE1138 – “Non-Specific Procedure Code Description Requirement for HIPAA Version 5010 Claims” The 5010 versions of the institutional and professional claim implementation guides mandate that when claims use non-specific procedure codes, a corresponding description of the service is now required.

Please ensure: • Billing and coding staff follow these requirements for submitting a HIPAA compliant claim when non-specific procedure codes are used. • These implementation guide requirements are followed when submitting a HIPAA-compliant claim for all non-specific procedure codes. A complete listing of the NOC code set is available on the CMS Web site.

Slide 34

Procedure Code Solutions (Cont.)

http://www.cms.gov/ElectronicBillingEDITrans/40_FFSEditing.asp

Slide 35

Procedure Code Solutions (Cont.)

• Item 24d of the CMS-1500 claim form or the electronic equivalent should reflect the specific procedure code.

• Maintain an up-to-date CPT and/or HCPCS manual to assist with correct procedure code selection.

• The

CMS-1500 Claim Form

manual will help with claim submission requirements.

• The “Part B Crosswalk to the CMS 1500 Claim Form” job aid will help with the necessary electronic loops/segments.

• Remember, the use of unlisted procedure codes or NOC codes should include a narrative description of the procedure in Item 19 of the claim form or the electronic equivalent.

Slide 36

Instructional Resources

• Maintain an up-to-date CPT and/or HCPCS manual to assist with correct procedure code selection.

• View the

CMS-1500 Claim Form

manual. http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

• Claims requiring additional documentation can be filed electronically and the additional information can be faxed or mailed to Medicare by using the Fax/Mail Documentation Instructions and Cover Sheet. http://www.trailblazerhealth.com/Publications/PDF Form/Fax MailEMCDocForms.pdf

Slide 37

Instructional Resources (Cont.)

• Use the “Part B Crosswalk to the CMS-1500 Claim Form” job aid to view all of the necessary loops and segments needed to file an electronic claim to Medicare. http://www.trailblazerhealth.com/Publications/Job Aid/Crosswalkto1500ClaimForm.pdf

• SE1138 – “Non-Specific Procedure Code Description Requirement for HIPAA Version 5010 Claims.” http://www.trailblazerhealth.com/Tools/Notices.aspx

?ID=14729 Slide 38

Billing Provider Information

MRA Rejection Messages N256

Missing/incomplete/invalid billing provider/supplier name.

N257

Missing/incomplete/invalid billing provider primary identifier.

N258

Missing/incomplete/invalid billing provider/supplier address.

N290

Missing/incomplete/invalid rendering provider primary identifier.

Slide 39

Billing Provider Information (Cont.)

The performing provider and/or the billing provider (solo provider or group practice, depending on the type of practice) is always required for claims processing.

Billing Provider Information

Slide 40

Billing Provider Information (Cont.)

Group practice billing example:

Slide 41

Billing Provider Information (Cont.)

* Required field

Slide 42

Billing Provider Information (Cont.)

Note: Item 33b is no longer used by Medicare.

* Required field

Slide 43

Instructional Resources

• Use the “Part B Crosswalk to the CMS-1500 Claim Form” job aid to view all of the necessary loops and segments needed to file an electronic claim to Medicare.

http://www.trailblazerhealth.com/Publications/Job Aid/Crosswalkto1500ClaimForm.pdf

• View the

CMS-1500 Claim Form

manual.

http://www.trailblazerhealth.com/Publications/Traini ng Manual/claim form instructions.pdf

Slide 44

CLIA – Item 23 Rejection messages:

MA120

Missing/incomplete/invalid CLIA number.

MA128

Missing/incomplete/invalid Food and Drug Administration (FDA) approval number.

MA50

Missing/incomplete/invalid Investigational Device Exemption (IDE) number for FDA approved clinical trial services.

Slide 45

CLIA – Item 23 (Cont.)

Item 23: Prior Authorization Number • Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval.

• Enter the IDE number when an investigational device is used in an FDA approved clinical trial. The Post-Market Approval number should also be placed here when applicable.

• For physicians performing Care Plan Oversight (CPO) services, enter the six digit Medicare provider number of the Home Health Agency (HHA) or hospice when procedure code G0181 (home health) or G0182 (hospice) is billed.

Note:

Until further notice, do not submit an HHA or hospice provider number when billing for CPO services. Submission of the home health or hospice provider number will result in the services being returned as unprocessable. Further information can be found in IOM Pub. 100-04, Change Request (CR) 4374, Transmittal 999.

Slide 46

+ Conditional field

CLIA – Item 23 (Cont.)

Slide 47

+ Conditional field

CLIA – Item 23 (Cont.)

Slide 48

Instructional Resources

• Use the “Electronic Claims Crosswalk to the CMS-1500 Claim Form” job aid to view all of the necessary loops and segments needed to file an electronic claim to Medicare. http://www.trailblazerhealth.com/Publications/Job Aid/Crosswalkto1500ClaimForm.pdf

•

CMS-1500 Claim Form

manual.

http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

•

Laboratory and Pathology

manual. http://www.trailblazerhealth.com/Publications/Training Manual/Lab-Path.pdf

Slide 49

Medicare Secondary Payer (MSP)

MSP claim rejections continue to be one of the top claim rejections for all states and all provider types. Patient screening is the only way to identify instances where Medicare could be the secondary payer.

Slide 50

MSP Rejection Messages

MA04

Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

N155

Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.

MA83

Did not indicate whether we are primary or secondary payer.

N541

Mismatch between the submitted insurance type code and the information stored in our system.

MA88

Missing/incomplete/invalid insured’s address and/or telephone number for the primary payer.

MA89

Missing/incomplete/invalid patient’s relationship to the insured for the primary payer. Slide 51

MSP Claim Information

• Medicare closely screens all MSP claims to ensure that information was accurate and consistent with the Common Working File (CWF). • MSP claims must be submitted with accurate primary insurance information to ensure the result is an accurate Medicare payment.

• Medicare verifies each claim with CWF, including the patient name, Medicare number, eligibility, MSP benefits and other key eligibility items.

• Patient screening is more important than ever to submit MSP claims correctly to Medicare.

Slide 52

MSP Claim Information (Cont.)

Claims filed for Medicare secondary payment must be submitted with accurate primary insurance information to ensure the result is an accurate Medicare payment. For example, use of an incorrect MSP type code could result in a claim rejection. The valid MSP type codes are: • 12 – Working Aged. • 13 – End Stage Renal Disease (ESRD). • 14 – Auto/Med/No-Fault Liability. • 15 – Workers’ Compensation. • 41 – Federal Black Lung. • 42 – Veterans Affairs. • 43 – Disability. • 47 – Other Liability.

Slide 53

MSP Claim Rejection Example

The CWF reflects Medicare is primary payer.

• The provider submitted the claim indicating “other liability” (MSP type 47), which indicates that there should be an open liability accident record, but the date of the accident was not included on the claim and none of the diagnosis codes submitted appear to be accident-related.

The claim rejected due to the conflicting MSP liability information submitted on the claim. The claim type “liability” was not consistent with any accident type of diagnosis and no date of accident was provided on the claim. The claim diagnosis codes were reflective of the surgery performed but not of any type of accident.

Slide 54

MSP Rejection Solutions

• • Patient screening is vital in capturing necessary information for correct claim submission.

The Patient Registration and Screening Guide

provides ways to implement a process or improve existing processes.

• The IVR provides patient eligibility and benefit information.

• The “Part B Crosswalk to the CMS 1500 Claim Form” job aid helps with the necessary electronic loops/segments for MSP requirements.

• The

CMS-1500 Claim Form

manual will help with claim submission requirements.

• The

Medicare Secondary Payer (MSP)

manual provides detailed MSP provision information and MSP payer type codes along with the required electronic loops/ segments and instructions for billing.

• Incorporate the use of the Patient Screening/Eligibility Checklist. • The Coordination of Benefits Contractor (COBC) can assist with MSP situations where there is a possible conflict. Providers can call (800) 999-1118.

Slide 55

Instructional Resources

•

Patient Registration and Screening Guide.

http://www.trailblazerhealth.com/Publications/Training Manual/PatientRegistrationScreening.pdf

• IVR Web page.

http://www.trailblazerhealth.com/Customer Service/Interactive Voice Response • Online Services computer inquiry system. http://www.trailblazerhealth.com/Electronic Data Interchange/Claim Status - Eligibility • “Part B Crosswalk to the CMS-1500 Claim Form” job aid.

http://www.trailblazerhealth.com/Publications/Job Aid/Crosswalkto1500ClaimForm.pdf

Slide 56

Instructional Resources (Cont.)

•

CMS-1500 Claim Form

manual. http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

•

Medicare Secondary Payer (MSP)

manual. http://www.trailblazerhealth.com/Publications/Training Manual/MSP.pdf

• COBC information. http://www.cms.gov/COBGeneralInformation/01_Overview.a

sp • Part B Patient Screening/Eligibility Checklist. http://www.trailblazerhealth.com/Publications/PDF Form/PatientScreeningEligibilityChecklist.pdf

Slide 57

Rejection messages:

Claim Not Covered by This Payer/Contractor

109

Claim not covered by this payer/contractor.

N104

This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at http://www.cms.gov/ .

N127

This is a misdirected claim/service for a United Mine Workers (UMWA) beneficiary. Please submit claims to them.

N105

This is a misdirected claim/service for a Railroad Retirement Board (RRB) beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call (866) 749-4301 for RRB Electronic Data Interchange (EDI) information for electronic claims processing.

Slide 58

UMWA Rejection Solutions

United Mine Workers of America (UMWA) is a multi-employer insurance plan that funds health and pension benefits for retired coal miners and their eligible dependents. All claims for Medicare Part B services provided to Medicare eligible beneficiaries must be submitted to the “funds” for payment. Services will automatically deny (regardless of diagnosis) when billed to Medicare for beneficiaries entitled to UMWA insurance.

Individuals with questions about the UMWA may call (800) 291-1425.

Slide 59

Railroad Retirement Medicare Rejection Solutions

Railroad Retirement

Railroad retirement beneficiaries have a prefix in front of the Health Insurance Claim (HIC) number instead of a suffix after it. The number itself has either six digits or the regular nine digits.

Example: A # # # # # # # # # Send claims for railroad retirees to: Palmetto GBA – Railroad Medicare P.O. Box 10066 Augusta, GA 30999-0001 Do not send these claims to TrailBlazer.

Slide 60

Instructional Resources

•

Patient Registration and Screening Guide

. http://www.trailblazerhealth.com/Publications/Training Manual/PatientRegistrationScreening.pdf

• IVR Web page.

http://www.trailblazerhealth.com/Customer Service/Interactive Voice Response/ • Claim Status and Eligibility Web page. http://www.trailblazerhealth.com/Electronic Data Interchange/Claim Status - Eligibility • Part B Patient Screening/Eligibility Checklist. http://www.trailblazerhealth.com/Publications/PDF Form/PatientScreeningEligibilityChecklist.pdf

Slide 61

Instructional Resources (Cont.)

•

Medicare Secondary Payer (MSP)

manual. http://www.trailblazerhealth.com/Publications/Training Manual/MSP.pdf

•

CMS-1500 Claim Form

manual. http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

Slide 62

MA75

Patient Signature

Missing/incomplete/invalid patient or authorized representative signature.

Slide 63

Patient Signature Requirements

The patient or authorized representative must sign and enter either a six-digit date, an eight-digit date or an alphanumeric date unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician or supplier file in accordance with Chapter 1, “General Billing Requirements,” of IOM Pub. 100-04. If the patient is physically or mentally unable to sign, a representative may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed with “by,” the representative’s name, address, relationship to the patient and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient’s representative revokes this arrangement.

Note:

This can be “Signature on File” for paper or electronic claims. A computer generated signature will be accepted for electronic claims only. The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim. Signature by Mark (X) – When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his name and address next to the mark. Slide 64

Instructional Resources

•

CMS-1500 Claim Form

manual.

http://www.trailblazerhealth.com/Publications/Trai ning Manual/claim form instructions.pdf

Slide 65

Days/Units

M53 Missing/incomplete/invalid days or units of service.

Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral “1” must be entered. Slide 66

* Required field

Days/Units Requirements

Slide 67

Days/Units Solutions

Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages or allergy testing procedures). When multiple services are provided, enter the actual number provided. For anesthesia, show the elapsed time (minutes) in Item 24g. Convert hours into minutes and enter the total minutes required for this procedure. For instructions on submitting units for oxygen claims, see IOM Pub 100-04, Chapter 20, Section 130.6 on the CMS Web site.

Beginning with dates of service on or after January 1, 2011, for ambulance mileage enter the number of loaded miles traveled rounded up to the nearest tenth of a mile up to 100 miles. For mileage totaling 100 miles and greater, enter the number of covered miles rounded up to the nearest whole number miles. If the total mileage is less than one whole mile, enter a zero before the decimal (e.g., 0.9). See IOM Pub. 100-04, Chapter 15, Section 20.2 for more information on loaded mileage and Section 30.1.2 for more information on reporting fractional mileage. Slide 68

Instructional Resources

• • • Use the “Electronic Claims Crosswalk to the CMS-1500 Claim Form” job aid to view all of the necessary loops and segments needed to file an electronic claim to Medicare. http://www.trailblazerhealth.com/Publications/Job Aid/Crosswalkto1500ClaimForm.pdf

CMS-1500 Claim Form

manual.

http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

Anesthesia

manual. http://www.trailblazerhealth.com/Publications/Training Manual/anesthesia.pdf

•

Ambulance

manual. http://www.trailblazerhealth.com/Publications/Training Manual/Ambulance.pdf

• CMS Internet-Only Manuals (IOMs).

http://www.cms.gov/Manuals/IOM/list.asp

Slide 69

Rejection messages:

Where Services Furnished (Item 32)

MA114

Missing/incomplete/invalid information on where the services were furnished.

N256

Missing/incomplete/invalid billing provider/supplier name.

N258

Missing/incomplete/invalid billing provider/supplier address.

N293

Missing/incomplete/invalid service facility primary identifier.

Slide 70

Item 32 Requirements Item 32:

Enter the name, address and ZIP code of the service location for all services other than those furnished in place of service home – 12.

Effective for claims processed on or after January 1, 2011, submission of the location where the service was rendered is required for

all

including home – 12.

place of service codes Slide 71

Item 32 Requirements (Cont.)

Slide 72

Verify ZIP Code Extension From USPS Web Site

Slide 73

Item 32 Requirements (Cont.)

Slide 74

Instructional Resources

•

CMS-1500 Claim Form

manual. http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

• MLN Matters ® Article MM6947.

http://www.cms.gov/MLNMattersArticles/downloads/MM694 7.pdf

Slide 75

Reminder – Place of Service

An improper payment exists when physicians bill services with an incorrect place of service based on the setting in which the services were rendered.

Place of service codes and descriptions can be found on the CMS Web site at: http://www.cms.gov/place-of-service codes/20_Place_of_Service_Code_Set.asp

Slide 76

Place of Service (Cont.)

As a result of incorrect billing of the place of service, numerous overpayments are identified through various means of claims review. It is important to report the claim based on where the patient was seen/treated. A published list of valid places of service can be found in the

1500 Claim Form

TrailBlazer Web site. instructions.pdf

CMS-

manual on the http://www.trailblazerhealth.com/Pub lications/Training Manual/claim form Excerpt from the places of service listing: 11 – Office 12 – Home 21 – Inpatient hospital 22 – Outpatient hospital 23 – Emergency room 24 – Ambulatory Surgery Center (ASC) 31 – Skilled Nursing Facility (SNF) 32 – Nursing facility 81 – Independent laboratory 99 – Other listed facility Slide 77

Place of Service Example Facility Versus Non-Facility

A patient was admitted to an inpatient hospital stay on June 21 and was discharged on July 19.

The physician billed CPT code 99291 © (critical care, first hour) for Date of Service (DOS) June 23, with a place of service code 11. CPT code 99291 has a site of service differential. CPT code 99291 has a non-facility allowed amount of $257.90 and a provider paid amount of $206.32. DOS June 23 is during the inpatient hospital stay, and data analysis confirms that the patient was not on a leave of absence from the hospital on that date. The correct place of service code for this service date is 21.

The allowed amount for CPT code 99291 for the facility rate is $213.37. The provider paid amount is $170.70. This results in an overpaid amount of $35.62.

Slide 78

Questions

Slide 79

TrailBlazer Health Enterprises Education Makes the Difference

Claim Submission Errors

Thank you for attending.