CLIA# REFLECTION ON RR MCR CLAIMS THROUGH EMDS SOFTWARE

DESCRIPTION OF THE ISSUE

RRMCR claims with CPT 81002 were denied for CLIA# update.  The number which was updated in the software was not reflected in the Claim form.

CONCEPT

EMDS software does not print CLIA# under the claim form.

SOLUTION

We suggested Client’s office to print CLIA# under Authorization slot of Charge posting Screen.  The same was implemented and the claims were refiled to the carrier.  Upon follow up found claims to be received by the carrier.  Awaiting for carrier’s response for further go.

NDC# REQUEST FOR INJECTION CODES BY MEDICAID

DESCRIPTION OF THE ISSUE

Medicaid denied all injection codes for need of NDC# update.

CPT code - j1100, J3420

CONCEPT

All injection drug codes should be billed along with NDC# updates for the claims to be reimbursed.

REASON

Compiled list of injection codes that were denied for NDC# update towards Dr’s office, for which we received NDC# information from the provider.  Later we refiled all denied claims with NDC#.  Awaiting for carrier’s response on the same.  

REQUEST OF NDC# FOR INJECTION CODES UNDER TRICARE

CPT CODE - J1100

DESCRIPTION OF THE ISSUE

Tricare denied all injection codes for need of NDC update.

CONCEPT

All injection drug codes should be billed along with NDC updates for the claims to be reimbursed.

SOLUTION

Compiled list of injection codes that were denied for NDC# update towards Dr’s office, for which we received NDC# information from the provider.  Later we refiled all denied claims with NDC#.  Henceforth all the injection codes were filed along with NDC# updates.

INCORRECT FILING OF CLAIMS TOWARDS ACCESS HEALTH

DESCRIPTION OF THE ISSUE

All the claims filed under Access Health were unpaid since it has to be filed along with authorization towards Medipass.

CONCEPT

Per standard instruction from the carrier, we are suppose to bill all the Access Health Claims towards Medipass with authorization# of the concerned Provider’s NPI.

SOLUTION

Per call verification with Access health for claim status informed that all the claims should be filed to Medipass along with Authorization.  Hence we refiled all the claims along with authorization# towards Medipass.  

INCOMPLETE INFORMATION IN THE SUPERBILL

DESCRIPTION OF THE ISSUE

Most of the charge sheet does not contain complete information of patient name, DOS, CPT, ICDs etc., Every week we would compile a big list of charges with superbill clarification.  In return we kept these charges for hold until the Client clarified us on the same.

CONCEPT

Superbill datas should be accurate and complete.  This would enable us to file claims in timely manner with accuracy.

REASON

We keep insisting our Client to forward us completed list of charges with appropriate updates.

MISSING UPDATE ON AUTHORIZATION INFORMATION

DESCRIPTION OF THE ISSUE

Humana HMO plans requested referral authorization for office and surgery services.  But most of the charges were not flagged properly with referral authorization.  Hence many claims were denied for request of authorization.

Non-participating carriers denied claims for authorization.

CONCEPT

Dr. Sondhi is a Gastroenterology specialist, for which Humana HMO plans with PCP other than our provider should contain referral authorization.

Our should be participating with the carriers for whom the claims were submitted.  If not then we require authorization to have the claims paid.

SOLUTION

During verification process, we started mentioning plans which require authorization.  Based on this information front office executives started retrieving authorization details. We initiated enrollment process for the provider, for the carriers which were non-par.

IDENITIFICATION OF APPROPRIATE PATIENTS FOR THE RESPECTIVE CHARGES

DESCRIPTION OF THE ISSUE

Patient names mentioned in the superbill were not clear.  Search of the patient during charge entry pulled out several patient names.  Hence it was very difficult to find out the exact patient. Many claims were incorrectly billed for incorrect patients which resulted in wrong payments.

CONCEPT

Superbill images should contain exact patient details info.  Either patient account# or DOB or SSN should be mentioned for appropriate charge entry process.

SOLUTION

We intimated Dr’s office to mention DOB information in the superbill to avoid further incorrect billing process.  Previously paid incorrect payments were refunded voluntarily with the consent of the provider. 

CPT code J0696 - description, NDC, administration, units, fees

DESCRIPTION OF THE ISSUE

CPT J0696 Rocephin injection was defined incorrectly as 500mg per unit instead of 250mg per unit. 

CONCEPT

When we gave 1 gram = 1000mg, we were billing 2 units, but it should have been 4 units.

SOLUTION

In IMS 500mg was redefined as 250mg per unit through CPT Macros set up. How to create CPT Macros? Goto - Setup and select - Bill – CPT Macros and start setting up Macros.

Billing and Coding Guidelines

Patient receives 1gram of Rocephin IM in the physician/s office.

• NDC for the product used: 00004-1963-02
• Descriptor: Rocephin 500 mg vial in powder form, reconstituted prior to injection.

Report:

• J0696 (ceftriaxone sodium, per 250 mg)
o 4 HCPCS units
• 00004196302 (NDC number)
o UN2 (NDC units as 2, also called 2 each)

J0696 Injection, ceftriaxone sodium, per 250 mg (Rocephin) Maximum 16 units per date of service

J0696 Rocephin Shot Injection IV/IM (Ceftriaxone) Billing Coding

J0696 HCPCS, 90788 CPT, 99201-99215 E/M codes for Rocephin shot (Ceftriaxone) injection (IV/IM) can increase revenue, when used in the right combination.

Yes, you read it right, Rocephin Shot (Ceftriaxone IV Injection) coding can increase medical reimbursement revenue. Yes, it is ethically and legally possible by billing for the procedure, the supply, and the E/M service correctly.

Rocephin (ceftriaxone sodium) is a cephalosporin antibiotic administered as Intramuscular (IM) or Intravenous(IV) injection. It works by fighting bacteria in your body. Rocephin is used to treat many kinds of bacterial infections, including severe or life-threatening forms such as meningitis.

Using CPT Code 90788 for the Rocephin Injection IV will get you $16.80. Use of NDC Code J0696 for Rocephin Short (Ceftriaxone Sodium) will reimburse you $13.35.

For 1 gram of ceftriaxone sodium, bill 4 units J0696 as the increments of 250 mg as 1 unit. It means if a doctor office uses Rocephin (ceftriaxone) 1 gram the code J0696 will be used as 4 units, which is equal to 1000 mg. However, make sure that you are using the correct NDC per vial.


Learn how to document Rocephin Shot (Ceftriaxone Sodium IV Injection) properly:

J0696 Rocephin Shot IV Injection (Ceftriaxone) Coding
For maximum Rocephin shot reimbursement, please follow these steps:
J0696 Rocephin Injection, Ceftriaxone Sodium, Per 250 mg
HCPCS code J0696 should be charged per unit. When Rocephin shot is administered at the medical practice, the medical biller should report CPT 90788 (Intramuscular injection of antibiotic [specify]). Physicians use Rocephin, a type of antibiotic, which you may know by the generic name of ceftriaxone sodium, to treat serious bacterial infections

Even if an insurer doesn’t pay much for 90788, this is the correct code to use. You may mistakenly use 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) as a catchall injection code. But 90782 isn’t for an antibiotic injection. Code 90782 instead describes a therapeutic, prophylactic or diagnostic injection. Translation: Use 90782 for a preventive shot, such as Synagis for respiratory syncytial virus (RSV), or a restorative treatment, like Decadron for croup.The difference between 90782 and 90788 is the injection material. 

Watch out: The only time that you should report 90788 for a Rocephin injection is if your payer instructs you to do so.

90788 CPT Code use for injection

Remember that 90782 includes the administration only -- you still need to bill for the supply. You should report the Rocephin with J0696 (Injection, ceftriaxone sodium, per 250 mg) per 250 mg.

Make sure you charge for the dose that you administer. For each 250 mg of Rocephin, you should bill one unit of J0696. List the unit(s) in the units field of the claim form next to the supply code. If you use a partial unit, such as 600 mg, round up to the next unit.

If appeals fail, consider writing a prescription for Rocephin. If you have a nearby pharmacy, the parent can pick up the antibiotic and return to your office for the injection. But sending the parent out to pick up the Rocephin for a very sick child may not be convenient, timely or appropriate.

99201-99215 E/M Code for office visit

For the evaluation, history and medical decision-making that lead you to administer the injection, you should report an office visit (99201-99215, Office or other outpatient visits for the evaluation and management of a new or established patient …). After examining and assessing the child, the physician decides that an antibiotic injection is the best treatment.

Often, the visit may qualify for a high-level E/M, such as 99214 or 99215. Before Rocephin injections were available, these patients would usually require intravenous antibiotics in the hospital. Now, the pediatrician can give a shot in the office. But the level of risk associated with these cases is still high.



NDC Units: These units are based on the numeric quantity administered to the patient and the unit of measurement. The unit of measurement (UOM) codes follow:

UOM Code  Descriptor

F2 International Unit
GR Gram
ML Milliliter
UN Unit (each)


The actual metric decimal quantity administered and the units of measurement are required for billing. If reporting a fraction (part of a unit), use a decimal point. (I.e. If three 0.5 ml vials are dispensed, report 1.5 ml.).

Examples of how units of measure qualifiers relate to NDC dose/volume:

NDC Dose Volume Unit Qualifier

1,000ML ML
50,000IU F2
1Unit UN
50mg GR
100mg/4ml ML




Facilities                Payment Limit for Drugs when Infused through DME 


J0696 Ceftriaxone sodium injection $13.35 $14.92

J0696 Ceftriaxone sodium injection $14.92

For the UB04 claim form, a CPT or HCPC procedure code must be reported when using pharmacy revenue codes 0250, 0251, 0252, 0254, 0631, 0632, 0633, 0634, 0635, or 0636. When the CPT or HCPC procedure code associated with these revenue codes is on the list below, the NDC code must also be on the claim. Alternatively, a provider may enter all NDC codes for all administered drug items rather than just for the codes below. 



J0696 Injection, ceftriaxone sodium, per 250 mg.



Some NDC Claims to Be Reprocessed for Procedure Codes J0696 and J0886

Information posted March 9, 2012

TMHP has identified an issue that impacts claims that were submitted with procedure codes J0696, or J0886 in combination with specific National Drug Code (NDC) numbers (values). These claims may have been denied in error by Texas Medicaid. Affected claims that were submitted within the last 24 months will be reprocessed and providers may receive additional payment, which will be reflected on Remittance and Status (R&S) Reports.

Claims submitted with the following procedure codes and National Drug Code (NDC) combination will be reprocessed:

Procedure Code         Corresponding NDC

J0696 25021010610  55390031110


J0886 55513028310

NCORRECT BILLING OF ALLERGY SHOTS AND ANTIGENS TOGETHER

ESCRIPTION OF THE ISSUE

Initially we received superbill either marked with Allergy shots (95115 / 95117) or Antigens (95165) along with units marked together for all the insurances. Based on the superbill we started billing both the Allergy shots and Antigens together for the same DOS for patients which is incorrect.

CONCEPT

We are not suppose to bill procedures with combination of Allergy shots and Antigens.  Because Allergy shots could be repeated more than once in a month for the same patient, whereas Antigens would be done only once in a month.

SOLUTION

Incorrectly paid procedures by the carriers were refunded through voluntary refund initiation letters. For which most of the carriers have taken offset in future payments and few insurances forwarded us the refund request letter for further go. And we have filed claims again with corrected CPTs.

CLAIMS OF NON-PARTICIPATING CARRIERS OF DR

DESCRIPTION OF THE ISSUE

Claims of non-participating carriers of Dr.  were processed as out-of-network deductibles and the responsibilities were forwarded to patients.  This frustrated most of the patients and returned us calls for explanation.

CONCEPT

Providers’ participation issue should not worry patients as they are enrolled properly with the plans and pay their

premiums correctly.  In such case it is provider’s responsibility to be enrolled with the carriers.

REASON

Until Dr. ’s enrollments with the concerned carriers were approved, we started filing the claims of non-participating carriers under the name of another Dr

NON-PAYMENT OF ULTRASOUND CHARGES UNDER MEDICARE

ESCRIPTION OF THE ISSUE

All the ultrasound charges were denied by Medicare stating “These are non-covered services because this is not deemed a “medical necessity' by the payer”.

CONCEPT

Medicare Part B pays depends on the setting in which the testing is provided. If the ultrasound testing is performed in a doctor's office, freestanding clinic, or independent testing facility, Medicare Part B pays 80 percent of the Medicare-approved amount. If the testing is conducted in a hospital outpatient department, Medicare Part B pays the full Medicare-approved amount, except for a set co-payment that the patient is responsible for...

Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:

1. The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper

2. The care must be performed or delivered by a healthcare provider who participates in Medicare.

REASON

We tried refiling these claims with higher specificity ICDs.  For which only very few claims were paid by Medicare.  And the rest were denied again as “These are non-covered services because this is not deemed a `medical necessity' by the payer”. We also tried appealing these claims towards MCR but was not successful.  Hence we raised request to the Client for approval of adjustments.  There is no response from the Client yet. 

Does hospital need to maintain the records of patient?

Are hospitals required to keep paper copies of attachments related to physicians’ inpatient services, e.g. Second Surgical Opinion Form, Sterilization Consent form, etc.?

Yes. The hospital must maintain a paper copy of these forms in the patient’s permanent file.
Is the inpatient hospital per diem rate based on the date of admission or the date of service when there is a rate change?

The per diem rate is based on the date of admission.

A hospital receives certification for a patient admission and admits the patient. Later in the admission day, the patient has to be transferred to another facility which also needs certification. How is this processed and how would the services be billed?

The MO HealthNet Hospital Provider Manual, Section 13.30.B - DAY OF DISCHARGE, DEATH, OR TRANSFER states: “MO HealthNet reimburses a facility for the day of admission. MO HealthNet does not cover the day of discharge, death or transfer unless it also is the day of admission and then it is reimbursable. The costs for the day of discharge, death or transfer cannot be billed to the recipient.”

In the example above, both facilities must obtain certification from Health Care Excel (HCE). Whichever facility submits a properly completed claim to MO HealthNet first should receive reimbursement. The facility that submits a claim to MO HealthNet second will have its claim denied as a duplicate unless a completed Certificate of Medical Necessity (CMN) is submitted with the claim to justify the care on the same date of service. It is advisable, however, for both facilities to submit a completed Certificate of Medical Necessity with their claims to avoid a duplicate service denial. The Certificate of Medical Necessity can be submitted electronically through the MO HealthNet Internet billing Web site, emomed.com, as an attachment to the electronic claim by clicking on the "Add Header Medical Necessity" link at the bottom of the claim page.

does precertification required for Medicare advantage plan?

Is a precertification required for a participant enrolled in a Medicare Advantage/Part C Plan?

Inpatient hospital claims for deductible and coinsurance for MO HealthNet patients with Medicare Part C benefits are exempt from admission certification. However, if Medicare Part C benefits have been exhausted and a claim is submitted for MO HealthNet only days, admission certification requirements must be met. Pre-admission certification is required also for denied Medicare Part C inpatient hospital claims including exhausted benefits. Before requesting a pre-certification, the provider must exhaust all appeals through the Medicare Advantage/Part C plan appeals process and have a final denial that can be submitted to Health Care Excel (HCE) with the pre-certification request.

For non-QMB MO HealthNet participants enrolled in a Medicare Advantage/Part C Plan, admissions require certification. Additional information regarding inpatient hospital certification reviews is covered in Section 13.31 of the MO HealthNet hospital provider manual available at www.dss.mo.gov/mhd/providers/index.htm.

SUBMISSION OF ALL THE REPORTED ICDs FOR CAPITATED PATIENTS

DESCRIPTION OF THE ISSUE

Per coding dept’s advice we initially billed only 4 ICDs(with higher specificity), though the progress notes contained more than 4 ICDs.

CONCEPT

IPA complained that claims were not filed with appropriate ICDs.  And they requested us to submit all the claims with complete ICDs for further go.

SOLUTION

We started billing all the left over ICDs through a separate claim with the concerned E/M codes of value $0.01.  After submission of these claims we adjusted the same since they were under capitation.

CAPITATED CLAIMS BILLED INCORRECTLY UNDER NON CAPITATED PAYOR ID

DESCRIPTION OF THE ISSUE

We billed all the Humana patients towards non capitated payor# 61102. For which we started receiving both capitation payments as well as fee-for-service payments incorrectly.

CONCEPT

Capitated patients should be billed only through capitated payor# which is 61101.

SOLUTION

We segregated both capitated and non capitated patients by identifying the plans through card copies as well as through online verifications.  Capitated claims were transmitted to the payor#61101 and non-capitated claims were transmitted to the payor#61102.  Refunds for fee-for-service payments were initiated voluntarily from our end with the provider’s

consent.

CPT J3301, J3420 - FILING OF J CODES WITH NDC#

DESCRIPTION OF THE ISSUE

Medicaid requests NDC# for CPTs J3420 and J3301.  Initially we have incorrectly filed claims without NDC# and they were denied for requests of NDC# update.

CONCEPT

All J codes should be filed with NDC# updates for Medicaid.

SOLUTION

We requested NDC# update from the Client by compiling the list of denied claims.  For which we received NDC# as 005-170-03125 only for CPT J3420.  Claims that were denied for the given procedure were refiled with appropriate NDC# and got paid.  NDC# request for CPT J3301 is still in pending on the table of Dr’s office.


Triamcinolone Acetonide Kenalog  10mg INJ J3301  

Vitamin B12 o Cyanocobalamin  1000mcg IM/SC J3420 


BILLING Guide for CPT J3301

NOTE: When giving injectable medications in the office, make sure your doctor is letting the billing department know how many Milligrams not how many CCs they are giving.


EXAMPLES

J3301 Kenalog is billed out per 10 mg If you gave 40 mg, it would be billed as J3301 x 4 units
J1885 Toradol is billed out per 15 mg If you have 30 mg, it would be billed as J1885 x 2 units
J0696 Rocephin is billed out per 250 m  If you have 1 g, it would be billed as J0696 x 4 units


The CPT code J3301, Kenalog injection is a good example of an NOC code that must be used. Read the user manual for instructions for submitting NDC numbers. You need to change your insurance layout and enter the NDC number using the format specified in the user manual.

To report the Kenalog, use the HCPCS code J3301. This J code is for triamcinolone acetonide per 10mg. The instructions for this code state to use for Kenalog- 10, Kenalog-40, Triam-A. This code may be billed in multiple units. Thus, if 20mg were used, report J3301 with 2 in the units box (box 24G on the CMS -1500 form).



Guidelines related to Maximum Units

Procedure codes have been assigned a maximum number of units that may be billed per day for a member,  regardless of the provider. When a provider bills a number of units that exceeds the daily assigned allowable unit(s) for that procedure, the excess units will be denied. Some procedure codes have been assigned a maximum number of units that may be billed within a 12 month period for a member. Those services would not be done more than once within a year, or twice a year for bilateral procedures. If a provider bills a number of units that exceed the annual assigned allowable unit(s) for that procedure for a member, the excess units will be denied. 

Anatomical modifiers E1-E4 (Eyes), FA-F9 (Fingers), and TA-T9 (Toes) have a maximum allowable of one unit per anatomical site for a given date of service. Any service billed with an anatomical modifier for more than one unit of service will be adjusted accordingly. Certain obstetrical diagnostic services may have assigned maximum units per day limits based upon presence or absence of diagnosis codes indicative of multiple gestation. Units billed in excess of the maximum per day  limits will be denied.

Team surgery and co-surgery maximums are handled separately and are edited based on the same provider, not at the member level. When the same provider bills a number of units of team surgery or co-surgery that  exceed the daily assigned allowable unit(s) for that procedure for the same member, the excess units will be
denied.

Each claim line is adjudicated separately against the maximal units of the code on that line. Blood glucose test or reagent strips (A4253) is limited to 20 units (boxes) per quarter for patients with insulin dependent diabetes, and 6 units (boxes) per quarter for patients with non-insulin dependent diabetes. Per unit reimbursement for allergy immunotherapy is based on the number of dosages prepared and intended for administration. Allergy immunotherapy is limited to 180 units for the first year of therapy during escalation, and 120 units for yearly maintenance therapy thereafter.

Multi-lead collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan (CPT 77338) is reported once per IMRT plan and is limited to 3 units per 60 day treatment course.


In the unusual clinical circumstance when the number of units billed on the claim exceeds the assigned maximum number for that procedure, clinical documentation of the number of units actually performed could be submitted for reconsideration. 


Injections

The following procedure codes are a benefit only when they are performed by an APRN, physician, or dentist in the office setting, or by a hospital in the outpatient setting:

Procedure Codes

J0290 J0295 J0330 J0530 J0540 J0550 J0560 J0570 J0580 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1020 J1030 J1040 J1094 J1100 J1170 J1200 J1364 J1580 J1700 J1710 J1720 J1850 J1885 J1890 J1940 J2010 J2400 J2460 J2510 J2540 J2560 J2650 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3430 J3480 J3490 J3520 J0280

Procedure codes J1631, J1790, and S0021 are a benefit for hospitals when they are performed in the outpatient setting and are no longer a benefit when they are performed by a physician or dentist in the inpatient or outpatient hospital setting. 

Provider Type and Place of Service Changes

The following procedure codes are a benefit for podiatrists when they are provided in the office setting:


Procedure Codes


J0120 J0290 J0295 J0530 J0540 J0550 J0560 J0570 J0580 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1200 J1364 J1459 J1580 J1885 J1890 J2010 J2400 J2460 J2510 J2540 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3490

Documentation requirement

Another example of insufficient or missing documentation was documented on another MAC’s website. This case involved the billing of HCPCS J1030- Methylprednisolone 40mg 8 units of service and J3301- Triamcinolone 10mg 8 units of service (in addition to CPT 99213, 20610 and 20551-RT/LT). The name/dose of medication administered was missing in the medical record documentation. The records submitted included an unsigned office visit note that is missing the name/dose of medication to be injected and which joints were injected with Methylprednisolone and which joints were injected with Triamcinolone acetonide. Documentation submitted for this case did not meet requirements per Medicare guidelines.

It is important to accurately document the patient’s medical record with all services performed/ordered. Documentation for injections must include the following:

• Name of drug injected

• Location of injection

• Dosage of injection given

• Route of administration

• Signed and dated physician order to include the drug name, dosage, route of administration and duration of treatment

A CERT reviewer also found insufficient documentation to support a continued arthrocentesis procedure (CPT 20610 X3) and Methylprednisolone 80 mg injection (J1040 X3). The medical record was missing a plan of treatment to support continued need for injections as billed. This case also lacked medical necessity for ongoing extended treatment for a chronic condition that has not shown improvement in a reasonable time and treatment has become supportive rather than corrective in nature and is then considered maintenance treatment. Per claim history, arthrocentesis procedure (X3) and Methylprednisolone 80 mg injection (X3) billed every three months since 2009 and additional submitted documentation indicates ongoing injections prior to 2009.

Pain management physicians need to understand in treating chronic pain that maintenance services are not considered medically reasonable or necessary under Medicare. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the treatment is then considered maintenance therapy. Upon medical review, maintenance treatment will be denied.

Date of admission - inpatient claim submission

FREQUENTLY ASKED QUESTIONS

INPATIENT HOSPITAL

What date is considered the date of admission for an inpatient hospital stay?
MO HealthNet follows Medicare policy on the date of admission. Medicare policy is: "A patient of a hospital is considered an inpatient upon issuance of written doctor orders to that effect".

How does a provider submit an inpatient claim that requires a two-page claim for all the services?
If at all possible, the provider should list all the services on a single claim form. If this is not possible, the provider may bill the services on two claim forms. In field 80 on the first page of the claim, put “page 1 of 2”. In field 80 of the second page, put “page 2 of 2”. Staple the claims together prior to submission.

Does a provider have to submit a claim to Medicare for a patient who has exhausted his/her Medicare inpatient benefits and get a denial from Medicare before filing a claim to MO HealthNet?

Yes. MO HealthNet requires that a claim be filed to Medicare first before filing a claim to MO HealthNet. Once the denial has been received, a paper claim can be filed to MO HealthNet and a copy of the Medicare denial or exhausted benefit letter attached to it. The claim can be filed also using the X12 837 institutional claims transaction or the direct data entry inpatient or outpatient claim through the MO HealthNet Internet billing Web site, emomed.com. The range of dates on the claim to be filed to MO HealthNet must fall within the range of dates on the claim filed to Medicare. The denial code description should be visible on the Medicare denial or entered in the appropriate field(s) on the electronic claim form.

 A hospital wants a pre-certification for a pregnant woman for a medical condition unrelated to the pregnancy, e.g. mental health services. Should a pregnancy diagnosis code be reported?
HCE does not review most pre-certifications if the admitting or primary diagnosis code is related to pregnancy. Therefore, a diagnosis code relating to pregnancy should not be used as the admitting/primary diagnosis code. If the hospital stay is not related to pregnancy, it must be clear that the pregnancy is incidental to the admitting/primary diagnosis.

DIRCECT FILING OF MCR HMO-HOSPICE CLAIMS TO MEDICARE

DESCRIPTION OF THE ISSUE

Medicare HMO Hospice Claims were billed incorrectly to the HMO plans directly.  We are suppose to bill the claims to Medicare.  Hence the claims were denied as “Bill Medicare Directly”

CONCEPT

Per 2010 Hospice Regulatory “The hospice, not the HMO, is responsible for managing the patient's hospice plan of care across all levels and sites of care. The Medicare-certified hospice bills Medicare, not the HMO, for the Medicare patient's hospice care”

SOLUTION

On receiving denials we analyzed 2010 Hospice Regulatory Act and started refiling denied claims towards Medicare directly. 

Hospice Claim Filing

• Must file claims electronically or bill on a UB-04 claim form.
• Must use appropriate revenue codes for services rendered. When billing revenue codes, use:
• 0651 – Routine Home Hospice (Intermittent)
• 0652 – Continuous Home Hospice
• 0655 – Inpatient Respite Care
• 0656 – Inpatient Hospice Services
• Must preauthorize before services are rendered.
• Must itemize all services and bill standard retail rates.
• Inpatient services and home services cannot be billed together on the same claim.
• Must use NPI in field 56.
• Type of bill must be 811 if non-hospital based, or 821 if hospital based (form locator 4).
• Form locators 12 (Source of Admission) and 17 (Patient Status) are required fields. If either field is blank, the claim will be returned for this information (refer to your UB-04 manual for the correct codes).
• Form locator 63 must be completed with a referral number and a precertification number from the HMO.
• All non-routine items must be supplied by the appropriate provider specialty. For example: A special hospital bed or customized
wheelchair must be supplied and billed by a Durable Medical Equipment (DME) provider.

Not covered by Medicare, can we submit to secondary insurance?

BILLING OF SERVICES NOT COVERED BY MEDICARE

Not all services covered under the Medicaid Program are covered by Medicare. (Examples are: prescription drugs, eyeglasses, most dental services, hearing aids, adult day health care, personal care or most eye exams performed by an optometrist.) In addition, some benefits that are provided under Medicare coverage may be subject to certain limitations. The provider will receive a Medicare Remittance Advice that indicates if a service has been denied by Medicare. The provider may submit a claim to Medicaid, using the proper claim form for consideration of reimbursement.

To bill Medicaid for a service that has been denied by Medicare, the provider may file a paper claim and attach a copy of the Medicare Remittance Advice that indicates the Medicare denial for the service billed to Medicaid. Highlight the Medicare denial of the service on the Medicare Remittance Advice by circling or using an asterisk.

File the paper claim using the instructions found in Section 15. If Medicare denies any service on the claim, the denied services only should be listed on the Medicaid claim.

MISSED TO UPDATE NEWLY REPLACED MODIFIER ON CLAIMS

DESCRIPTION OF THE ISSUE

During 2010 modifier AY (Item or service furnished to an ESRD patient that is not for the treatment of ESRD) was billed along with CPT 82947.  This modifier was replaced by CB (Service ordered by a Renal Dialysis Facility (RDF) physician as part of the ESRD beneficiary’s dialysis benefit, is not part of the composite rate and is separately reimbursable) effective from Jan 2011.  Claims were filed incorrectly with old updates for the year 2011.

CONCEPT

Coding updates should be verified for most frequently used procedures for any practice so that we have our claims filed with new and appropriate updates for the concerned year.

SOLUTION

On receiving ‘incorrect modifier used’ denials we analyzed procedure updates and modifier updates and started refiling the denied claims with correct modifiers.

FILING OF CLAIMS WITH INCORRECT PROVIDER TIN#

DESCRIPTION OF THE ISSUE

Most of the claims under Optimum healthcare were in outstanding for correct TIN# information.  Upon verification we found Dr. to be capitated under IPA which included both Optimum and Freedom healthcare plans as PCP with another TIN#.  Hence the claims were unpaid for submission of correct TIN#

CONCEPT

Dr.  being a specialist had dual TIN#, one for PCP and the other for Specialty.  IPA have enrollment record of Dr.  as a Specialist.  So upon filing of claims with PCP TIN# got denied for request of correct TIN#.

SOLUTION

On identification of this issue, we started resubmitting the unpaid claims with appropriate TIN# on records of IPA for Dr..  This in return reflected with the Capitated payments for the provider.

How to fill Medicare part b sticker

INSTRUCTIONS FOR COMPLETING THE PART B STICKER

Complete the Medicare Part B/Medicaid-Title XIX sticker as follows and attach it to the RA/EOMB so it does not cover the recipient’s identifying information or claim payment information.

FIELD NUMBER & NAME
INSTRUCTIONS FOR COMPLETION
1.
Provider Name
Enter the provider’s name as shown on the provider label.
2.
Provider Medicaid Number
Enter the provider’s nine-digit Medicaid number.
3.
Recipient Name
Enter the recipient’s name exactly as shown on the ID card.
4.
Recipient Medicaid Number
Enter the recipient’s eight-digit identification number as shown on the ID card.
5.
Other Insurance Payment
Enter the amount paid by any other insurance. Do not show the Medicare payment here.
6.
Name Other Insurance Company
If an insurance amount is shown on line 5, enter name of insurance company.
7.
Patient Account Number
For the provider’s own information, a number may be entered here.
8.
Beneficiary HIC Number
Enter the patient’s HIC Number as shown on the Medicare card.
9. & 10.
Service Date: From and Through
Enter the date of service. If multiple dates of service are shown on the Medicare RA/EOMB for a single claim, enter the first chronological date of service in “From” field and the last chronological date of service in “Through” field.
11.
Billed
Enter the total billed dollar amount for the claim. Use the amount shown on the Medicare RA/EOMB.
12.
Allowed
Enter the total Medicare allowed amount for the claim. Use the dollar amount shown on the RA/EOMB.
13.
Paid
Enter the total dollar amount paid for the claim by Medicare.
14.
Paid Date
Enter the date shown at the top of the RA/EOMB.
*15.
Deductible
If any deductible was applied on this claim, enter the amount due in this field.
*16.
Coinsurance
Enter the total amount of coinsurance due on this claim.
17.
Blood Deductible
If there is blood deductible due, enter that dollar amount.

OVERPAYMENT BY CAPITATED PLAN

DESCRIPTION OF THE ISSUE

Dr. was capitated with insurance for office visits.  In such case we received both Capitated as well as Fee-for-service payments for office visits for an amount of $18K.

CONCEPT

Being capitated plan for office services under PUP, we are not supposed to receive fee-for-service payments for the same.

SOLUTION

On identification of this issue, PUP insisted on off-set for the overpaid value in the future payments.  But we raised a request towards Dr’s office to issue refund in bulk in order to avoid off-set in future payments.  Both PUP and Dr’s office agreed for the same.