Top Ten Billing Errors: J1 Part B Palmetto GBA August 26, 2009 Provider Outreach and Education

Objectives 





To increase provider awareness and understanding of the most common claim denials To provide appropriate information on how to avoid or resolve these common denials To reduce and/or eliminate inquiries to the Provider Contact Center (PCC) regarding these denials

Glossary 

Reason Codes:   



Provide information about claims decisions Explain why a claim was paid differently than it was billed CO, PR

Remark Codes:   

Numerical codes that further explain the denial Indicate if/why appeal rights apply B, M, MOA, and N

Glossary 

CO: Contractual Obligation   



Patient cannot be billed Provider filing error Provider must correct and file a new claim

PR: Patient Responsibility 

Patient can be billed

Top Ten Billing Errors 

What should you do when you get a denial?  



Do you file a new claim? Request an appeal?

Top denials will be discussed, including:   

Denial codes and descriptions Reason denial occurred How to resolve and avoid future denials

Top Ten Billing Errors

#1: Beneficiary enrolled in HMO Reason/Remark Code OA-109: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

Resolution 

Check beneficiary eligibility and benefits status using the Interactive Voice Response (IVR) at 866-931-3903 



From the Main Menu, press “3”, then “3” for Medicare Advantage plan number

If IVR indicates the beneficiary has a Medicare Advantage plan, use the CMS MA Plan Lookup 

Can be accessed from the Palmetto GBA J1B Web site under Self Service Tools and Top Links

#2: Services Not Paid Separately Reason/Remark Code 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 M80: Not covered when performed during the same session/date as a previously processed service for the patient

NCCI Edits 

Promote correct coding



Control improper coding



Ensure most comprehensive codes are billed

Two CCI Tables 



Column I/Column II  Column 2 is integral part of column 1  Should not be reported together Mutually Exclusive  Could not be performed in same encounter  Pick only one  Column 1 = lowest RVU usually

Medicine Evaluation and Management Services (90000-99999)

Resolution 

Check NCCI before billing  www.cms.hhs.gov/NationalCorrectCodInitEd



Is a modifier necessary to denote exception? (24, 25, 59, 76, and 91)  Refer to the Modifier Look-up tool 



www.PalmettoGBA.com/j1b

Supporting documentation maintained in the patient’s medical record

#3: Global Surgery Reason/Remark Codes CO-97: The benefit for this service is included in the payment/allowance for another service/ procedure that has already been adjudicated M144: Pre- or post-operative care payment is included in the allowance for the surgery/procedure CO-B15: This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated

Global Surgery The Medicare approved amount for surgical and some therapeutic or diagnostic procedures includes payment for services related to the surgery and are not separately payable if performed within the global period

Global Periods  Minor Procedures  Total global period is either one or eleven days  Count the day of the surgery and the appropriate number of days (either 0 or 10) immediately following the day of surgery

 Major Procedures  Total global period is ninety-two days  Count one day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery

Included Components 

Pre-operative visits



Anesthesia by surgeon



Intra-operative services



Supplies



Complications following surgery



Miscellaneous services



Post-surgery pain management



Post-operative visits

Excluded Services 

Initial Evaluation & Management (E/M) service



Return to operating room



Other physicians’ care



Unrelated Critical care



Unrelated visits/surgeries



Staged/distinct procedures



Complications with return to operating room



Diagnostic tests/procedures

Resolution 

Determine the global period of the surgery 



www.cms.hhs.gov/PFSlookup

Is a modifier necessary to denote exception? (24, 25, 57, 58, 78, and 79)  Refer to the Modifier Look-up tool 



www.PalmettoGBA.com/j1b

Documentation in the patient’s medical record

#4: Service not medically necessary Reason/Remark Code CO-50: These are non-covered services because this is not deemed a “medical necessity” by the payer N115: This decision was based on a local medical review policy (LMRP) or Local Coverage Determination (LCD). An LMRP/LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LMRP/LCD.

Coverage Guidelines  

Local Coverage Determination (LCD) National Coverage Determination (NCD)

Advance Beneficiary Notice/ Notice of Exclusions from Medicare Benefits

Revised ABN CMS R131 Form

Modifier GA indicates signed ABN on file

#5: Medicare is Secondary Payer Reason/Remark Code PR-22: Payment adjusted because this care may be covered by another payer per Coordination of benefits

Medicare Secondary Payer        

Working Aged End Stage Renal Disease (ESRD): 30-month initial coordination period in which other insurer is primary No-Fault Situations: Medicare is secondary if illness/injury results from a no fault liability Workers Compensation (WC) situations Black Lung benefits Veterans Administration (VA): either Medicare or VA may pay, not both Disability Liability Situations: Medicare is secondary if illness/injury results from a liability situation

Resolution 

Ask patient about eligibility at time of visit  MSP Look-up Tool  www.PalmettoGBA.com/j1b



Check beneficiary eligibility and benefits status using the Interactive Voice Response (IVR) at 866-931-3903 



From the Main Menu, press “3”, then “4” for Medicare Secondary Payer Information

Verify all required information is submitted with your paper claim or electronic submission. For complete MSP claim form instructions on our Web site:  www.PalmettoGBA.com/j1b/guide

#6: Service not paid to a chiropractor Reason/Remark Code PR-170: Payment is denied when performed/billed by this type of provider

Resolution 

The only service Medicare will reimburse, when performed by a chiropractor, is manual manipulation of the spine



CPT codes 98940, 98941, and 98942



Physical therapy and x-rays performed by chiropractors are never covered by Medicare

#7: Provider not certified Reason/Remark Code PR-B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service

Resolution 

1. 2.

To enroll or make changes to your existing Medicare information, submit a CMS-855 application by following one of these two steps: Use the Internet-Based Provider Enrollment, Chain and Ownership System (PECOS) to submit the application online Download, complete and mail in the application form for your situation below. If you are:   

A provider group, use form CMS 855B to bill Medicare Carriers An individual provider, use form CMS 855I to enroll as Individual Health Care Practitioners An individual provider joining a group or if you are a member of a group and want to reassign your benefits to the group, use form CMS 855R to reassign benefits

#8: Routine Exams/Related Services Reason/Remark Codes PR-49: These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam CO-49: Contractual obligation, these are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam

#9: Non-Covered Services Reason/Remark Codes PR-204: This service/equipment/drug is not covered under the patient's current benefit plan N122: Add-on code cannot be billed by itself

Resolution 



 

Routine physical exams are never covered by Medicare except under the Welcome to Medicare Physical guidelines Non-covered services are never covered, including eye refraction, hearing aids and hot/cold packs used in physical therapy Not required to submit claims for services that are excluded To submit non-covered services to Medicare (per beneficiary request) for denial purposes, submit with HCPCS modifier GY

#10: Timely Filing Reason/Remark Codes CO-29: The time limit for filing has expired N211: You may not appeal this decision

Timely Filing 





Medicare claims must be filed within one year from the date of service in order to be considered for the full allowed amount Claims that are filed after one year from the date of service are subject to a 10 percent reduction in the allowed amount In most situations, claims must be filed in the same calendar year or the following calendar year in order to be considered for any reimbursement

Timely Filing Calendar Services that are performed in October, November or December this year may be filed during that calendar year, the following calendar year or the year after that in order to be considered for reimbursement

Service Dates 10-01-2006 thru 09-30-2007

Claims must be filed by: 12-31-2008

10-01-2007 thru 09-30-2008 10-01-2008 thru 09-30-2009

12-31-2009 12-31-2010

Resources 

www.palmettogba.com/j1b 

Self-Service Tools and Top Links    



www.cms.hhs.gov   



Modifier Lookup CMS MA Plan Lookup MSP Lookup Tool Denial Finder

MPFSDB NCCI Edits LCDs/NCDs

www.wpc-edi.com/codes 

Reason/Remark codes

Questions???

Thank you!!!

The information provided in this presentation was current as of 09/04/09. Any changes or new information superceding the information in this presentation are provided in articles with publication dates after 09/04/09 posted on our Web site at www.PalmettoGBA.com/J1B.

Survey Questions Please take a moment at the end of today’s call to answer a few survey questions. The operator will assist you.