Top Ten Billing Errors: J1 Part B Palmetto GBAAugust 26, 2009Provider 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 HMOReason/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 SeparatelyReason/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

Promote correct coding

Control improper coding

Ensure most comprehensive codes are billed

NCCI Edits

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 SurgeryReason/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

Intra-operative services

Complications following surgery

Post-surgery pain management

Anesthesia by surgeon

Supplies

Miscellaneous services

Post-operative visits

Excluded Services

Initial Evaluation & Management (E/M) service

Other physicians’ care

Unrelated visits/surgeries

Complications with return to operating room

Return to operating room

Unrelated Critical care

Staged/distinct procedures

Diagnostic tests/procedures

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

Resolution

#4: Service not medically necessaryReason/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 R- 131 Form

Modifier GA indicates signed

ABN on file

#5: Medicare is Secondary Payer

Reason/Remark Code

PR-22: Payment adjusted because this care maybe covered by another payer per

Coordination of benefits

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

Medicare Secondary Payer

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 chiropractorReason/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 certifiedReason/Remark Code

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

Resolution

To enroll or make changes to your existing Medicare information, submit a CMS-855 application by following one of these two steps:

1. Use the Internet-Based Provider Enrollment, Chain and Ownership System (PECOS) to submit the application online

2. 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 ServicesReason/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 ServicesReason/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 CalendarServices 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 Claims must be filed by: 10-01-2006 thru 09-30-2007 12-31-200810-01-2007 thru 09-30-2008 12-31-200910-01-2008 thru 09-30-2009 12-31-2010

Resources

www.palmettogba.com/j1b

Self-Service Tools and Top Links

Modifier Lookup

CMS MA Plan Lookup

MSP Lookup Tool

Denial Finder

www.cms.hhs.gov

MPFSDB

NCCI Edits

LCDs/NCDs

www.wpc-edi.com/codes

Reason/Remark codes

Questions???

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.

Thank you!!!

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