Coding & Billing News
Common Billing Errors to Avoid when Billing Medicare Carriers
This article was revised on May 7, 2007, to add this statement that Medicare FFS has announced a contingency plan regarding the May 23, 2007 implementation of the NPI. For some period after May 23, 2007, Medicare FFS will allow continued use of legacy numbers on transactions; accept transactions with only NPIs; and accept transactions with both legacy numbers and NPIs. For details of this contingency plan, see the MLN Matters article, MM5595 on the CMS website.
COMMON BILLING ERRORS
The following list includes common billing errors that you should avoid when submitting your claims to Medicare carriers:
- The patient cannot be identified as a Medicare patient. Always use the Health Insurance Claim Number (HICN) and name as it appears on the patient's Medicare card.
- Item 32 (and the electronic claim equivalent) requires you to indicate the place where the service was rendered to the patient including the name and address (including a valid ZIP code) for all services unless rendered in the patient's home. Please be advised that any missing, incomplete, or invalid information recorded in this required field will result in the claim being returned or rejected in the system as unprocessable. Any claims received with the word "SAME" in Item 32 indicating that the information is the same as supplied in Item 33 are not acceptable. (NOTE: References to an item number, such as item 32, refer to paper claim forms. However, note that the whenever an item number is used in this article, the related concept and information required also applies to equivalent fields on electronic claims.)
- The referring / ordering physician's name and UPIN were not present on the claim. Please keep in mind this information is required in Item 17 and 17a on all diagnostic services, including consultations. In addition, be aware of the new requirements for use of National Provider Identifiers (NPIs). To learn more about NPIs and how to obtain your NPI, see the MLN Matters article
- SE0679 (PDF) at on the CMS web site. Also, see the MLN Matters articles SE0555 (PDF), SE0659 (PDF), and MM4203 (PDF) for important information regarding CMS' schedule for implementing the NPI.
- Evaluation and management (E&M) procedure codes and the place of service do not match. An incorrect place of service is being submitted with the E&M procedure code. (Example: Procedure code 99283, which is an emergency room visit, is submitted with place of service 11, which is office).
- Please keep in mind, when billing services for more than one provider within your group, that you must put the individual provider number in Item 24k, as Item 33 can only accept one individual provider number. Also, please make sure the provider number on the claim is accurate and that it belongs to the group. (Also, remember that as of May 23, 2007, NPIs are to be used.)
- Diagnosis codes being used are either invalid or truncated. Diagnosis codes are considered invalid usually because an extra digit is being added to make it 5 digits. Please remember not all diagnosis codes are 5 digits. Please check your ICD-9-CM coding book for the correct diagnosis code.
- Procedure code/modifier was invalid on the date of service. Remember that, as of January 1, 2005, CMS no longer provides a 90-day grace period for billing discontinued CPT/HCPCS codes. (Note: Please read the Medicare provider bulletins, especially at the end of each year, as Medicare list all the additions, deletions, and code changes for the following year.)
- Claims are being submitted with deleted procedure codes. This information can also be found in the CPT Book. It is important to be using a current book.
- When Medicare is secondary, Item 11, 11a, 11b, and 11c must be completed.
Billing Tips
The following topics will assist you with correct billing and help you complete and submit error free claims:
A. Provider Numbers
Individual vs. Group PIN - Use the individual rendering provider identification number (PIN) on each detail line. Make sure the group number, when applicable, corresponds to the appropriate individual PIN. When a physician has more than one PIN (private practice, hospital, etc.), use the appropriate PIN for the services rendered. A rendering provider number, if not a solo number, must always belong to the group number that is billing. Electronic submitter ID numbers (not UPINs) should be entered in place of the PIN (group or individual). When billing any service to Medicare, if you have doubts as to which provider number to use, please verify with your carrier. (Remember to use NPIs on claims as of May 23, 2007.)
"Zero-Filling" - Do not substitute zeros or a submitter identification number where a Medicare PIN, UPIN, or NPI is required.
B. Health Insurance Claim (HIC) Numbers
HIC Accuracy - Your carrier receives numerous claims that are submitted with invalid or incorrect HIC numbers. These claims require manual intervention and can sometimes result in beneficiaries receiving incorrect EOMB information. Please be certain the HIC number you are keying is entered correctly, and is also the HIC that belongs to the patient (based on what is on his/her Medicare card) for which you are billing.
HIC Format - A correct HIC number consists of 9 numbers immediately followed by an alpha suffix. Take special care when entering the HIC number for members of the same family who are Medicare beneficiaries. A husband and wife may have a HIC number that share the same Social Security numerics. However, every individual has their own alpha suffix at the end of the HIC number. In order to ensure proper claim payment, it is essential that the correct alpha suffix is appended to each HIC.
No hyphens or dashes should be used.
"Railroad Retirees" - Railroad Retirement Board (RRB) HIC numbers generally have two alpha characters as a prefix to the number. These claims should be billed to the RRB carrier, at this address:
Palmetto Government Benefit Administrators
Railroad Medicare Services
PO Box 10066
Augusta, GA 30999-0001
C. Name Accuracy
Titles should not be used as part of the name (e.g., Dr., Mr., Rev., M.D., etc.). Be sure to use the name as it appears on the patient's Medicare card.
Non-Medicare Claims - Do not send claims for non-Medicare beneficiaries to your Medicare carrier.
D. Complete Address
U.S. Postal Addressing Standars - It is very important to meet the U.S. Postal addressing standards. Patient and provider information must be correct. This is necessary so that checks and Medicare Summary Notices (MSNs) or remittance notices arrive at the correct destination. It is also to ensure the quickest service to your office.
Medicare Fee-For-Service Providers: Register Now for the Individuals Authorized Access to CMS Computer Services - Provider Community (IACS-PC)
In the near future, the Centers for Medicare & Medicaid Services (CMS) will be announcing new online enterprise applications that will allow Medicare fee-for-service providers to access, update, and submit information over the Internet. Details of these provider applications will be announced as they become available. Even though these new internet applications are not yet available, CMS recommends that providers take the time now to set up their online account so they can access these applications as soon as they are available. The first step is for the provider or appropriate staff to register for access through a new CMS security system known as the Individuals Authorized Access to CMS Computer Services - Provider Community (IACS-PC).
A recent MLN Matters article, the first in a new series on IACS-PC, addresses key questions and answers about the registration process and can be found at on the CMS website.
Potential Issues Related to Clearinghouse and Billing Service Practices
As part of efforts to fully implement the NPI, Medicare FIs, carriers, and A/B MACs have begun calling providers who are not sending their NPI on claims or are sending incorrect NPI information. It has come to CMS' attention that:
Some Clearinghouses may be stripping the National Provider Identifier (NPI) off the claim prior to its submission to Medicare for claims processing. Clearinghouses may be adding the NPI back onto the Remittance Advice, so that providers are unaware that NPIs are being removed prior to being sent forward.
Some billing services (or "key" shops) are not putting the NPI on the claim, contrary to provider instructions.
Some clearinghouses are not forwarding, to providers, carrier NPI informational claim error messages designed to help the provider understand the problems Medicare is encountering in attempts to crosswalk the NPI to legacy identifiers.
Medicare Contractors are turning on edits to begin validating the NPI/legacy pair against the Medicare NPI Crosswalk. If the pair on the claim is not found on the crosswalk, the claim will reject. Stripping the NPI submitted by a provider from the claim adversely affects Medicare provider incentive cash flow, payers that receive crossover claims, and the efforts of Medicare to fully implement NPI.
If you are a Clearinghouse or billing service that is stripping or not sending the NPI, Medicare would like to better understand the reasons behind this practice as well as the expected timeframe during which this will continue to occur. Therefore, we ask those willing to discuss this problem with CMS staff to please contact Aryeh Langer at Aryeh.langer@cms.hhs.gov or Nicole Cooney at Nicole.cooney@cms.hhs.gov before October 10, 2007.
"Finding HIPPA in the new CMS website"
CODING TIP
Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.
Read information on the proper way of using modifier -59 from CMS.
National Provider Identifier for Fee-for-Service Medicare
The Centers for Medicare and Medicaid Services announces the following plans for transitioning to the National Provider Identifier (NPI) in the Fee-for Service Medicare Program:
Between May 23, 2005 and January 2, 2006, our claims processing systems will accept an existing legacy Medicare number and reject as unprocessable any claim that includes only an NPI .
Beginning January 3, 2006, and through October 1, 2006, our systems will accept an existing legacy Medicare number or an NPI as long as it is accompanied by an existing legacy Medicare number.
Beginning October 2, 2006, and through May 22, 2007, our systems will accept an existing legacy Medicare number and/or an NPI. This will allow for 6-7 months of provider testing before only an NPI will be accepted by the Medicare Program on May 23, 2007.
Beginning May 23, 2007, our systems will only accept an NPI .
For additional information, to complete an NPI application, and to access educational tools, visit https://nppes.cms.hhs.gov on the web.
Security Regulations Must Be In Place !
If you have not complied with HIPAA security regulations, then you are currently out of compliance with federal law!
First it was electronic transactions, and then it was privacy regulations. Now it is security regulations. If your practice was considered a "covered entity," which required you to comply with privacy regulations, you must now comply with security regulations. The difference between privacy and security regulations is that security is an internal matter only. Patients need not know anything about security regulations.
The emphasis is on how to secure the integrity, confidentiality and access for all electronic protected health information on your computer system. In order to become compliant, you must review, and update if necessary, your administrative procedures and physical/technical safeguards. The good news is that you may be compliant with most security requirements, including password protection, personal login names, virus protection, and backup procedures.
Some security regulations are mandatory and some are general and easy to implement. For instance, you may implement an alternative safeguard rather than following a specific security regulation if the alternative accomplishes the required result.
Here is a partial list of requirements:
Your first step is to appoint a security officer who can be your practice manager or managing physician. Be sure that your security officer understands HIPAA and your computer system.
Purchase a security regulation manual. The cost is approximately $250. It contains all forms and templates you will need. The template can be adjusted to fit your practice. The security officer can then conduct a risk analysis of your computer system and procedures to discover weaknesses. For instance, if you transmit claims over telephone lines, those are secure. If you transmit claims over the Internet, you need to check with your software provider who will make sure that your Internet transmissions are encrypted.
Develop a back up plan for all computer data. This includes disaster, fire, flood, vandalism, and any natural disaster that may shut down your practice. Suggestion: Back up your data daily and take the disk home. It does no good to back up your data and leave the disk in the office.
Develop logins and passwords to control access. Do not leave your login or password where someone can find it.
Install virus protection.
Make sure that protected health information is erased from discarded hardware.
Write a security plan, complete with dates, actions, personnel and signatures.
Train the staff.
Keep all security documents for six years.
Document everything. "If it is not written down, it did not happen" is a good rule to follow.