Wednesday, March 26, 2008

Dermabrasion ICD-9 codes approved by Aetna

Aetna health insurance will pay out on Dermabrasion procedure codes 15780, 15781, 15782, 15783 when the correct ICD-9 codes are used which are:

173.0-173.9 Basal cell carcinoma
702.0 Actinic Keratosis

ICD codes not covered for indications listed in the CPB
706.0 Acne Varioliformis
706.1 Other Acne
709.00 - 709.09 Dsychromia
709.2 Scar conditions and fibrosis of skin

When billing Aetna Health Insurance medical claims in the billing office make sure that you code your claims correctly based on Aetna's Insurance requirements.

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4 Diagnosis Codes to use when billing Procedure 10040 to Aetna

If your medical providers office is credentialed with Aetna health insurance and you bill Procedure Code 10040 for Acne Surgery to Aetna health insurance make sure to use the proper ICD-9 codes.

659.3 Rosacea (acute)
706.0 Acne Varioliformis
706.1 Other Acne
706.2 Sebaceous Cyst (due to acne)

Correctly billing claims to your Aetna medical health insurance is important for correct processing of claims. At this time these are the only 4 ICD-9 codes Aetna health insurance will pay when billed with this procedure code.



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Scanners in Medical Offices

Starting a Medical Biling Service from home takes a lot of strength from anyone. You can't leave your work at the office your home is the office. But what I have found is that working from home can be as comfortable as working in the office when you have the right products to complete your work.

One item that I have absolutely enjoyed is my Fugitsu ScanSnap S510 scanner. It has saved me so many times when I needed to email clients documents within minutes. I scribble on my paper, scan it or duplex it, PDF it and shoot it on it's way. The software is so smart it can tell if it needs to kick out "blank" pages. It really has been a benefit to my company and we have one at every computer in our home office (which is currently 2). We have them in each one of our doctors offices where they scan and upload the documents to the billing software (HIPPA compliant) and they love how quickly it completes the scans. You can scan legal paper, regular paper or even Insurance cards.

You don't need to be in the medical billing industry to appreciate this scanner. But if you are in the market for scanners check it out!

Confused by
Electronic Medical Claim billing then read these articles on Billing Health Insurance medical claims

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Monday, March 24, 2008

Submit claims from RelayHealth to Office Ally

All customers currently using RelayHealth for electronic claims have an additional option to forward on to Office Ally using CPID# 4264. When submitting claims electronically through RelayHealth they will identify all claims using the 4264 CPID# and forward on to Office Ally for processing.

To set this up you will log into your software, pull up your insurance carrier, enter the CPID# 4264 in the correct place and save your changes. When you submit this carrier to RelayHealth they will understand that CPID# 4264 needs to be forwarded on to Office Ally clearinghouse.

In order for Office Ally to correctly forward your claim on to the correct health insurance carrier they require the proper payor name be added to the the claim in Loop 2010BB NM103. If you do not have the carriers name entered correctly or they can not identify who the claim should be forwarded on to it will cause a denial.


video

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How to register for NPI or update your NPI data

All new medical doctors or providers are required to have a National Provider Identifier (NPI) number. You do not need to be credentialed with Medicare (meaning you do not need to accept assignment with Medicare) in order to register for the NPI number.

It takes approximately 20 minutes to apply for a NPI number and it can be completed online or by paper.

I have attached a short video under two minutes showing you the steps of how to apply for your NPI number online.

https://nppes.cms.hhs.gov/

video


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Clearinghouses are still Stripping information from Medicare Claims

Medicare has made an announcement to let customers know that they have identified that medical clearinghouses are still stripping information from Medicare claims which could be resulting in claim denials for customers.

Medicare would like to let customers know that if they have identified any clearinghouse that is stripping the NPI number from the claim to notify your Medicare Contractor immediately so CMS can work with your clearinghouse to resolve this issue.

To verify if this is happening follow these steps:

  1. identify that you are sending your NPI # in the correct fields and bill Medicare claims electronically.

  2. Call your medical billing software vendor to verify the NPI # is being forwarded on to your clearinghouse (they should be able to track how your eClaims are being submitted)

  3. Place a call with your clearinghouse and have them pull your claim file. Have them verify the NPI#'s are on the claim and they are receiving it

  4. Call Medicare a few days later and identify if Medicare received the NPI #

If not you can then tell them where the issue is lying - i.e. you verified that your medical billing software vendor forwarded the NPI # to your clearinghouse and that your clearinghouse verified receiving the NPI #. The issue would be at this point that your clearinghouse is not forwarding that information on to Medicare.

Medicare has also identified that some clearinghouse are stripping the SY qualifer and the Social security number (SSN) from claims that contain NPI. Clearinghouses are required to send this information as a result of business requirement 4320.17 (outlined in transmittal number 204, dated Feb 1 2006).

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NPPES and NPI Registry cross walk to Medicare rejections

NPPES stands for National Plan and Provider Enumeration System. NPI Registry is a online website to identify referring provider NPPES information including NPI number. All information found on the NPI registry website is provided in accordance with the NPPES Data Dissemination Notice.

As of March 1st 2008 all CMS 1500 claims received must hand an NPI or NPI/Legacy pair in the required primary provider fields. If these are not setup correctly the claims will be rejected by Medicare.

If your claim is rejected these are some simple rules to follow to identify how to fix those rejections:
1. Check your record in the National Plan and Provider Enumeration System (NPPES)
2. Verify the Legacy number you are submitting on claims is also reported through the NPPES system.
3. Verify that the legal business name is correct
4. Verify the correct ENTITY type was selected at the time of NPI Application.

  • Entity Type 1 is for individuals
  • Entity Type 2 is for Organizations

If you have verfiied everything above is correctly entered on your eClaims and paper claims and you are still getting claim rejections please call your Medicare Customer Service department with the following information:

  1. Legal Business Name of orginazation
  2. Contractor Tracking Number (if known)
  3. Approximate date when the CMS-855 enrollment application was submitted or last updated
  4. Provider/Supplier Tax ID # (EIN or SSN)
  5. NPI
  6. Medicare Legacy Identifier or PTAN
  7. Practice Location on Claim
  8. Your contact information

NPI registry site to verify your providers NPI information: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do

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Blue Shield of Illinois requires NPI in all provider loops

As of March 28th 2008 Blue Shield of Illinois is requiring the NPI number to be sent on eClaims in all provider loops. If the provider does not submit electronic claims with this NPI format you may get the following claim rejections:

Exclusion Examples
HU 0019C:INVALID BILLING PROVIDER ID QUAL - IN LOOP 2010AA, NM108 MUST BE EQUAL TO XX
HU 0020C:INVALID PAY-TO PROVIDER ID QUAL - IN LOOP 2010AB, NM108 MUST BE EQUAL TO XX
HU 0021C:INVALID CLAIM REF PROV ID QUAL - IN LOOP 2310A(PROF), NM108 MUST BE EQUAL TO XX
HU 0022C:INVALID CLAIM REND PRV ID QUAL - IN LOOP 2310B(PROF)/2310C(INST), NM108 MUST BE EQUAL TO XX
HU 0023C:INVALID CLAIM PUR SRV ID QUAL - IN LOOP 2310C(PROF), NM108 MUST BE EQUAL TO XX
HU 0024C:INVALID CLAIM SRV FAC ID QUAL - IN LOOP 2310D(PROF)/2310E(INST), NM108 MUST BE EQUAL TO XX
HU 0025C:INVALID CLAIM SUP PROV ID QUAL - IN LOOP 2310E(PROF), NM108 MUST BE EQUAL TO XX
HU 0026C:INVALID CLAIM ATTEND PHY ID QUAL - IN LOOP 2310A(INST), NM108 MUST BE EQUAL TO XX
HU 0027C:INVALID CLAIM OPERATE PHY ID QUAL - IN LOOP 2310B(INST), NM108 MUST BE EQUAL TO XX
HU 0028D:INVALID SRV LINE REND PRV ID QUAL - IN LOOP 2420A(PROF)/2420C(INST), NM108 MUST BE EQUAL TO XX
HU 0029D:INVALID SRV LINE PUR SRV ID QUAL - IN LOOP 2420B(PROF), NM108 MUST BE EQUAL TO XX
HU 0030D:INVALID SRV LINE SRV FAC ID QUAL - IN LOOP 2420C(PROF), NM108 MUST BE EQUAL TO XX
HU 0031D:INVALID SRV LINE SUP PROV ID QUAL - IN LOOP 2420D(PROF), NM108 MUST BE EQUAL TO XX
HU 0032D:INVALID ORDERING PROVIDER ID QUAL - IN LOOP 2420E(PROF), NM108 MUST BE EQUAL TO XX
HU 0033D:INVALID SRV LINE REF PROV ID QUAL - IN LOOP 2420F(PROF), NM108 MUST BE EQUAL TO XX

If you get these rejections call your medical billing software vendor immediatly to identify where to place your Blue Shield of Illinois Provider NPI number correctly. Rebill all claims from the time you started getting these Blue Shield of Illinois NPI rejections.

To read more about Medicare updates including Billing Health Insurance Information check out Medicare Medical Coding and Billing Courses

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Medicare Professional Claims must have NPI

Effective March 1st 2008, Medicare professional claim subsmission, must have an NPI or NPI Legacy pair in the required primary provider fields. Failure to include an NPI will cause the claim to reject.


To read more about Medicare updates including
Billing Health Insurance Information check out Medicare Medical Coding and Billing Courses

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Ohio Medicare remittance issues

On March 3rd 2008 Ohio Medicare (relay health CPID# 1447) released a new system upgrade. They later identified a bug in the system upgrade resulting in Ohio Medicare deleting provider numbers. This resulted in electronic remittance advice reports not generating.

Customers billing Ohio Medicare receiving ERA through McKesson/RelayHealth should post payments manually using the Explanation of Benefits or utilizing the IVR system to identify how claims were processed.

Ohio Medicare anticipates having the provider numbers loaded into their system by end of day on March 20th 2008. ERA reports will be available from RelayHealth on March 24th 2008.

If you need assistance to work the Medicare Ohio's IVR software please review this blog:

All 50 states
Medicare Health Insurance IVR Phone Number for Part A and Part B
Steps on
How to use Medicare’s IVR system

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Benefits of Using Relay Health for eClaims

I have been a client of Relay Health for over 3 years and I am exceptionally happy with their services and customer support. The phone calls are answered within 10-15 seconds of calling and the support tech can usually answer my question over the phone. If it can't be answered they log a case and the follow through is amazing. Some of the other benefits of using Relay Health is

1600+ electronic claim connections (Medicare, Medicaid, UHC, Cigna, Blue Cross/Blue Shied)
450+ electronic remittance connections
Payor specific edits performed at the clearinghouse
Collection Letters
eStatements
Complete your eClaim and ERA agreements (for carriers that require this like Medicare/Medicaid) online through McKesson's registration tools. These tools actually scrub your agreement to verify it was completed correctly.

RelayHealth is a great company to work with so if you are looking for a new clearinghouse check them out.


Questions on
Electronic Medical Billing and Claims then click here medical claims electronic billing
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Friday, March 21, 2008

Procedure Code 86580 billed with 90471 or 90472

As a medical biller I find that my job allows for some interesting insight into how different medical offices bill their services and I always seem to stumble upon "gold" nuggets.

In this Medical Billing Example I am comparing two Pediatricians Medical Office in where the providers bill for a 86580 TB Intradermal Test:
1 Medical providers office includes a charge for 90471 Immunization Administrative code
1 Medical providers office bills for just the 86580 (no admin code attached)

Many coders would tell you (rightfully so) that a Doctor should not bill a 90471 for administrating the 86580 code. But are you curious to know what I found out on the office that includes a 90471? The medical office that bills for 90471 with use of 86580 in all situations received full payment for the 90471 .

The medical office performed this code over 50x's a year. When you take the high's on the allowables for insurance carriers:
90471 around $20-25
90472 $8-13

& we will say we billed 25 patients with a 90471 and 25 patients with 90472 we are close to increasing the providers revenue by $1000.00 each year.

This providers office is not contracted with Medicare (pediatricians) or Medi-Cal (california location). I did identify that all carriers including Blue Cross, Blue Shield, SCCIPA, Aetna, Cigna, UHC and Great West paid on the code.


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Proper use of procedure code 99354 Prolonged Service

Here is a common Pediatricians office sample using Procedure Code 99354 Prolonged Physician Service with Direct Face to Face Patient Contact.

In this situation the patient was having breathing issues and came to the office for treatment. The provider documented that the patient was in the office for 40 minutes and had signs of wheezing and breathing issues. The provider remained in the room with the patient for 32 minutes during the office visit.

99214 - Office or outpatient E&M code 25 minutes face to face with patient and/or family
charge amount for 99214 $190.44
Allowed Amount by pts ins $126.28

99354 - Prolonged Office visit 30+ minutes face to face
charge amount for 99354 $200.00
Allowed Amount by pts ins $127.86

94640 - Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes
charge amount for 94640 $64.32
Allowed Amount by pts ins $0.00

J7603 - Albuterol
charge amount for J7603 $40.00
Allowed Amount by pts ins $.88

A7015 - Aerosol mask, used with the DME nebulizer
charge amount for A7015 $10.00
Allowed Amount by pts ins $1.41


A7016 - Dome and mouthpiece, used with small volumne ultrasonic nebulizer
charge amount for A7016 $15.00
Allowed Amount by pts ins $5.44

94664 - Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device
charge amount for 94664 $34.01
Allowed Amount by pts ins $0.00


94640 - Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (for more than one inhalation treatment use modifier 76)
charge amount for 94640 $45.00
Allowed Amount by pts ins $18.05

Total Charge: $598.77
Total Allowed: $279.92


A call would be placed with UHC for the two denied codes to fix and reprocess:
94640 - IJ-THE NUMBER OF UNITS BILLED FOR THIS SERVICE APPEARS TO BE INCORRECT. IT EXCEEDS THE TYPICAL FREQUENCY PER DAY FOR THIS PROCEDURE CODE. WE'VE ADJUSTED THE UNITS FOR THIS PROCEDURE CODE AND CHARGE.

94664 - KW-WE PROCESSED THESE CHARGES USING A PROCEDURE CODE THAT MORE ACCURATELY DESCRIBES THE SERVICES PROVIDED.


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CPT Category 1 Codes by Section

Grouping of codes assist with finding the procedure code needed quickly. This is a to the point tutorial on the grouping of the CPT Category 1 Codes:

99201-99499 Evaluation and Management
00100-01999, 99100-99140 Anesthesiology
10021-69990 Surgery
70010-79999 Radiology
80048-89356 Pathology and Laboratory
90281-99602 Medicine

Now that you have a grouping of the codes let's take this one step further. When you open your CPT manual for 2008 most CPT books have color coordinated Tabs based on the Grouping of the Procedure Codes. In my 2008 CPT manual the grouping is in this format:

99201-99499 Evaluation and Management -
Tab Color RED
00100-01999, 99100-99140 Anesthesiology - Tab Color Blue
10021-69990 Surgery - Tab Color Green
70010-79999 Radiology -
Tab Color RED
80048-89356 Pathology and Laboratory - Tab Color Blue
90281-99602 Medicine - Tab Color Green

Memorizing the Tab colors and the grouping will help you quickly pull up the correct code/descriptions when coding or reviewing procedure codes for medical billing. I would recommend printing this information out and keeping it near your CPT book for review.

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Listing of 2008 Discontinued HCPCS Codes

These are a handful of discontinued HCPCS Healthcare Common Procedure Coding System codes starting on Jauary 1st 2008 -


K0553 Combination oral/nasal mask, used with continuous positive airway pressure device, each

K0554 Oral cushion for combination oral/nasal mask, replacement only, each

K0555 Nasal pillows for combination oral/nasal mask, replacement only, pair


L1855 Knee orthosis, molded plastic, thigh and calf sections, with double upright knee joints, custom-fabricated

L1858 Knee orthosis, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom-fabricated

L1870 Knee orthosis, double upright, thigh and calf lacers with knee joints, custom-fabricated

L1880 Knee orthosis, double upright, non-molded thigh and calf cuffs/lacers with knee joints, custom-fabricated

Q4087 Injection, immune globulin, (Octogam), intravenous, non-lyophilized (e.g. liquid), 500 mg

Q4088 Injection, immune globulin, (Gammagard liquid), intravenous, non-lyophilized, (e.g. liquid), 500 mg

Q4091 Injection, immune globulin, (Flebogamma), intravenous, non-lyophilized, (e.g. liquid), 500 mg

Q4092 Injection, immune globulin, (Gamunex), intravenous, non-lyophilized (e.g. liquid), 500 mg

Q4093 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol)

Q4094 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol)


L3800 Wrist hand finger orthosis, short opponens, no attachments, custom-fabricated

L3805 Wrist hand finger orthosis, long opponens, no attachment, custom-fabricated

L3810 WHFO, addition to short and long opponens, thumb abduction (C) bar

L3815 WHFO, addition to short and long opponens, second M.P. abduction assist

L3820 WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop

L3825 WHFO, addition to short and long opponens, M.P. extension stop

L3938 Wrist hand finger orthosis, dorsal wrist, prefabricated, includes fitting and adjustment

L3940 Wrist hand finger orthosis, dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment

L3942 Hand finger orthosis, reverse knuckle bender, prefabricated, includes fitting and adjustment

L3944 Hand finger orthosis, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment

L3946 Hand finger orthosis, composite elastic, prefabricated, includes fitting and adjustment

L3948 Finger orthosis, finger knuckle bender, prefabricated, includes fitting and adjustment

L3950 Wrist hand finger orthosis, combination Oppenheimer with knuckle bender and two attachments, prefabricated, includes fitting and adjustment

L3952 Wrist hand finger orthosis, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment

L3954 Hand finger orthosis, spreading hand, prefabricated, includes fitting and adjustment

L3985 Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom-fabricated

L3986 Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist, custom fabricated

E2618 Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, includes any type mounting hardware

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Procedure Code J7613 denied change to J7603

Starting on January 1st 2008 you may have seen denials on the J7613 procedure code. If you modify that code to reflect as J7603 and rebill the claim you will get paid out.

As of January 1st 2008 the following codes have been deleted:
J7611 - Albuterol, noncompounded, concentrated form, 1 mg
Other names: AccuNeb, Proventil, Respirol, Ventolin

J7612 - Levalbuteral, noncompounded, concentrated form, o.5 mg
Other names: Xopenex HFA

J7613 - Albuterol, noncompounded, unit dose, 1 mg
Other names: AccuNeb, Proventil, Respirol, Ventolin

J7614 - Levalbuterol, noncompounded, unit does, 0.5 mg
Other name: Xopenex

The code to use in these deleted codes place as of Jan 1st 2008:
J7602 - Albuterol, inhalation solution, non-compounded, unit dose, 1 mg (Albuterol) or per0.5 mg (Levalbuterol)

J7603 - Albuterol, inhalation solution, non-compounded, unit dose, 1 mg (Albuterol) or per 0.5 (Levalbuterol)

Additional codes added for Nebulizers Added Jan 1st 2008

J7604 - Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram

J7605 - Arformoterol, inhalation solution, FDA approved final product, non-compounded, administered through DME, unit dose form, 15 micrograms

J7632 - Cromolyn sodium, inhalation solution, compounded product, administered through DME, unit dose form, per 10 milligrams

J7676 - Pentamidine isethionate, inhalation solution, compounded product, administered through DME, unit dose form, per 300 mg


To view over 250 articles on Medical Billing and Coding information please check out Medical Billing and Coding Articles


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Medicare Interactive Voice Response IVR phone numbers by State

If you ever need the phone number for Medicare Part A or Medicare Part B Interactive Voice Response (IVR) system you can locate your states number here:

Medicare A IVR Medicare B IVR Medicare IVR State
866-539-5598 866-539-5598
Medicare Part A and B IVR phone number for Alabama

866-277-7287 877-908-8431
Medicare Part A and B IVR phone number for Alaska

866-277-7287 877-908-8431
Medicare Part A and B IVR phone number for Arizona

877-207-4251 877-908-8434
Medicare Part A and B IVR phone number for Arkansas

866-277-7287 877-591-1587
Medicare Part A and B IVR phone number for N California

866-277-7287 866-502-9054
Medicare Part A and B IVR phone number for S California

866-839-2441 877-908-8431
Medicare Part A and B IVR phone number for Colorado

877-567-7205 866-419-9458
Medicare Part A and B IVR phone number for Connecticut

877-567-7205 877-391-2610
Medicare Part A and B IVR phone number for Delaware

866-488-0545 877-391-2610
Medicare Part A and B IVR phone number for District of Columbia

877-602-8816 877-847-4992
Medicare Part A and B IVR phone number for Florida

800-560-6170 877-567-7271
Medicare Part A and B IVR phone number for Georgia

866-380-4745 877-908-8431
Medicare Part A and B IVR phone number for Guam

866-277-7287 877-908-8431
Medicare Part A and B IVR phone number for Hawaii

866-277-7287 866-502-9051
Medicare Part A and B IVR phone number for Idaho

877-309-4290 877-908-9499
Medicare Part A and B IVR phone number for Illinois

866-419-9462 866-250-5665
Medicare Part A and B IVR phone number for Indiana

877-567-3092 866-502-9057
Medicare Part A and B IVR phone number for Iowa

866-839-2443 877-567-7270
Medicare Part A and B IVR phone number for Kansas

866-289-6501 866-250-5665
Medicare Part A and B IVR phone number for Kentucky

877-567-3097 877-567-7204
Medicare Part A and B IVR phone number for Louisiana

866-275-7396 877-567-3129
Medicare Part A and B IVR phone number for Maine

866-488-0545 866-539-5591
Medicare Part A and B IVR phone number for Maryland

866-275-7396 877-567-3130
Medicare Part A and B IVR phone number for Massachusetts

866-275-3033 877-567-7201
Medicare Part A and B IVR phone number for Michigan

866-275-3033 877-908-8470
Medicare Part A and B IVR phone number for Minnesota

877-567-3097 866-419-9454
Medicare Part A and B IVR phone number for Mississippi

877-567-3097 866-539-5599
Medicare Part A and B IVR phone number for Missouri

877-567-7202 877-567-7203
Medicare Part A and B IVR phone number for Montana

877-869-6503 866-839-2438
Medicare Part A and B IVR phone number for Nebraska

866-277-7287 877-908-8431
Medicare Part A and B IVR phone number for Nevada

866-275-7396 866-539-5595
Medicare Part A and B IVR phone number for New Hampshire

866-275-3033 877-567-9235
Medicare Part A and B IVR phone number for New Jersey

877-391-2610 877-567-9230
Medicare Part A and B IVR phone number for New Mexico

877-567-7205 877-567-7173
Medicare Part A and B IVR phone number for New York

800-560-6170 866-238-9651
Medicare Part A and B IVR phone number for North Carolina

866-380-4741 877-908-8431
Medicare Part A and B IVR phone number for North Dakota

877-908-8431
Medicare Part A and B IVR phone number for Northern Marianna Islands

866-289-6501 877-567-9232
Medicare Part A and B IVR phone number for Ohio

877-567-3094 877-567-9230
Medicare Part A and B IVR phone number for Oklahoma

866-277-7287 877-908-8431
Medicare Part A and B IVR phone number for Oregon

800-560-6170 866-488-0548
Medicare Part A and B IVR phone number for Pennsylvania

866-275-3033 877-715-1921
Medicare Part A and B IVR phone number for Puerto Rico

866-275-7396 877-846-2820
Medicare Part A and B IVR phone number for Rhode Island

877-272-5786 866-238-9654
Medicare Part A and B IVR phone number for South Carolina

877-567-3092 877-908-8431
Medicare Part A and B IVR phone number for South Dakota

877-296-6189 866-502-9056
Medicare Part A and B IVR phone number for Tennessee

888-763-9836 877-392-9865 877-567-9230
Medicare Part A and B IVR phone number for Texas

877-839-2441 866-539-5600
Medicare Part A and B IVR phone number for Utah

866-275-3033
Medicare Part A and B IVR phone number for US Virgin Islands

866-275-7396 866-539-5595
Medicare Part A and B IVR phone number for Vermont

877-908-8474 866-502-9049
Medicare Part A and B IVR phone number for Virginia

866-277-7287 877-908-8431
Medicare Part A and B IVR phone number for Washington

877-908-8474 877-567-9232
Medicare Part A and B IVR phone number for West Virginia

866-275-3033 877-567-7176
Medicare Part A and B IVR phone number for Wisconsin

877-567-3093 877-908-8431
Medicare Part A and B IVR phone number for Wyoming

For those needing Medicare Rail Road's phone # it is 877-288-7600

To learn how to use the IVR software please read the following blog: Medicares IVR Phone System and How to Use

If you come across my blog and you find a phone # that has been changed for your state please leave comments and I will update this so other users get correct information. - Thank you!

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Thursday, March 20, 2008

Durable Medical Equipment Regional Carriers Contact List

Have you ever spent time trying to identify a states contact information for Medicares Durable Medical Equipment? Here is the official Medicare Durable Medical Equipment Regional Carriers Contact information by State.

Medicare Durable Medical Equipment Regional Carriers Contact List
DMERC State website
DMERC Region C Alabama http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region D Alaska
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D Arizona
http://www.noridianmedicare.com/
Provider # 866-243-7272
DMERC Region C Arkansas
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region D N California
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D S California
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region C Colorado
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region A Connecticut
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region A Delaware
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region A District of Columbia
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region C Florida
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region C Georgia
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region D Guam
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D Hawaii
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D Idaho
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region B Illinois
http://www.adminastar.com
Provider # 877-299-7900
DMERC Region B Indiana
http://www.adminastar.com
Provider # 877-299-7900
DMERC Region D Iowa
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D Kansas
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region B Kentucky
http://www.adminastar.com
Provider # 877-299-7900
DMERC Region C Louisiana
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region A Maine
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region A Maryland
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region A Massachusetts
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region B Michigan
http://www.adminastar.com
Provider # 877-299-7900
DMERC Region B Minnesota
http://www.adminastar.com
Provider # 877-299-7900
DMERC Region C Mississippi
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region D Missouri
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D Montana
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D Nebraska
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region D Nevada
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region A New Hampshire
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region A New Jersey
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region C New Mexico
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region A New York
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region C North Carolina
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region D North Dakota
http://www.noridianmedicare.com/
Provider # 866-243-7272
DMERC Region D Northern Marianna Islands
http://www.noridianmedicare.com/
Provider # 866-243-7272
DMERC Region B Ohio
http://www.adminastar.com
Provider # 877-299-7900
DMERC Region C Oklahoma
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region D Oregon
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region A Pennsylvania
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region C Puerto Rico
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region A Rhode Island
www.medicarenhic.com
Provider #866-419-9458
DMERC Region C South Carolina
http://www.cignamedicare.com
Provider #866-270-4909
DMERC Region D South Dakota
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region C Tennessee
http://www.cignamedicare.com
Provider # 866-270-4909
DMERC Region C Texas
http://www.cignamedicare.com
Provider #866-270-4909
DMERC Region D Utah
http://www.noridianmedicare.com
Provider # 866-243-7272
DMERC Region C US Virgin Islands
http://www.cignamedicare.com
Provider #866-270-4909
DMERC Region A Vermont
www.medicarenhic.com
Provider # 866-419-9458
DMERC Region C West Virginia
http://www.cignamedicare.com
Provider #866-270-4909
DMERC Region D Washington
http://www.noridianmedicare.com/
Provider #866-243-7272
DMERC Region C West Virginia
http://www.cignamedicare.com
Provider #866-270-4909
DMERC Region B Wisconsin
http://www.adminastar.com
Provider #877-299-7900
DMERC Region D Wyoming
http://www.noridianmedicare.com
Provider #866-243-7272
**Any patients that need to call Medicare DMERC will use the Beneficiary phone number which is the same for all states at 800-633-4227.


To read more about Medicare updates including Billing Health Insurance Information check out Medicare Medical Coding and Billing Courses

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How to use Medicares Interactive Voice Response (IVR)

For the states of Illinois, Michigan, Minnesota and Wisconsin you can call Medicare Interactive Response (IVR) at these numbers:

To use the IVR, call:
Illinois (877) 908-9499
Michigan (877) 567-7201
Minnesota (877) 908-8470
Wisconsin (877) 567-7176

IVR hours:
Monday – Friday 6:00 am – 6:00 pm CT*
Saturday 7:00 am – 12:00 pm CT*

*Please note that the functions which require a Provider Transaction Access Number (PTAN) to be entered, such as eligibility and claim status, have limited hours due to system availability. The hours vary by state and option.

Information you need to use the Interactive Voice Response (IVR) system.
PTAN number
Patients name
Patients Medicare number (9 numbers followed by a letter)
Patients Date of Birth
Date of Service MMDDYY or MMDDCCYY
Telephone with handset or headset (do not use speakerphone or cell phone)
Knowledge of how use the touch tone keypad (this one takes a bit of skill to perform)

Enter the patients Medicare Number through IVR
Patients Medicare #: 123456789A
Entered in IVR using phone: 123456789*21
* indicates the next entry is a letter
2 after star tells Medicare its the 2nd (view pic where 2 is the second key)
1 indicates A is the first letter of the ABC sequence


Patients Medicare #: 123456789B
IVR using phone: 123456789*22


Patients Medicare #: 123456789C1
IVR using phone: 123456789*231


Exceptions:
Q = *11
R = *72
S = *73
Z = *12

Enter Patients Name through IVR
patients last name followed by the first initial
QZ = 1
ABC = 2
DEF = 3
GHI = 4
JKL = 5
MNO = 6
PRS = 7
TUV = 8
WXY = 9

Example:
Manqi Xiong 946646; X = 9, I = 4, O = 6, N = 6, G = 4, M = 6

Calling IVR for Claim Status walk through
Dial your states IVR phone #
Say or enter your PTAN
Say or enter the patients Medicare number
Say or enter the patients name as it appears on his or her Medicare Card
Say or enter the date of service in MMDDYY format

Press 4 for claim details
Once you have heard all information your next options are to say or key:
  • 1 Repeat that
  • 2 next claim
  • 3 previous claim
  • 5 duplicate remittance (for assigned claims only)
  • 6 change date
  • 7 change Medicare number
  • 8 change PTAN
  • Say Main Menu

I hope this information helps all billers that have to deal with Medicare. Truly this information can be extremely complicated (*21) which I am not sure why they can't keep it simple like United Health Cares IVR system but it's all about learning how to crack the code and this should at least get you started.

Interested in additional Online Medical Billing and Coding articles? Then click out Billing and Coding Online Courses

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How easy is it to be a Medical Biller?

Any medical billing service who reads this will probably want to tar and feather me but the truth is Medical billing is quite easy. It's about the desire and willingness to learn the proper foundation to a good medical billing and collections process.

If you want to break medical billing processes down to simple steps:
1. Doctor treats a patient
2. Doctor complets a form (encounter, Charge Slip, Routing Slip)
3. The form makes it's way to the billing department
4. The billing department is responsible for many aspects at this point but to keep things simple lets just say they convert the form into a claim and bill the insurance carrier.
5. The claim gets paid out
6. Payment is posted to the software
7. Patient is billed
8. Patient pays the bill

Wow! That was simple however; lets add a few medical billing "problems" to this -

Eligibilty - Does the patient being treated actually have insurance even though they present a ins card
Mailing Address - Did the patient give us a legit mailing address and contact information
Insurance Cards - Did the correct insurance information get uploaded to the patient demographics?
eClaims - Is the proper connection setup between the billing service and the insurance carrier for payment?
Check vs. EFT - Is the insurance carrier mailing a hard check or performing Electronic Fund Transfers (this affects the different way of posting the payment)?
EOB vs ERA - Will the insurance carrier be mailing paper explanation of benefits (EOB) or sending Electronic Remittance Advice
ERA Translating issues - All software carriers including insurance carriers have problems with electronic remittance advice. From dropping interest payments, translation of denials, and codes included with global code and yet look like the patient is resp for payment etc.
Denial EOB's - Identifying time to work and process?
Overpayments - Processing these in a timely matter and refunding
Refund Patients - Processing these in a timely matter
Patient Phone Calls - Keeping it nice and professional with patients
Statements - Sending in a timely matter and crossing fingers patients will pay
Collection Letters - Keeping it nice Hi I want you to keep coming to my office however; I show you have this outstanding balance - PAY IT NOW OR GO TO COLLECTIONS
Collections - After several phone calls, statements, collection letters and maybe even personal letters it comes to this.
End of Month - Yes, every last day of the month for most doctors office is the end of month. You get everything as clean as possible and take a snapshot of the progress you made for the month.
Reports - Front office, Doctors, Billers and Managers all need varying reports to identify what's going on.

It takes desire to want to do this kind of work.

When I first started in the medical billing industry 13 years ago most everything was done by paper . Now things are becoming much more techy. Things have become increasingly streamlined and time saving software can really help the billing offices. I would also recommend visiting
http://videotrainingpro.com/ to learn Microsoft Excel and Word as this will help you in the Medical Industry.

I have had several jobs in the medical industry over my 13 years and what I find is that after 6 months of training just about anyone with desire can work in the medical industry. If you would like to learn more about how to become a medical biller you can leave a message or question.

I have been contemplating putting a course together on basic 101 Medical Billing for a low price. The medical billing training would include:
* live web-based training by phone and internet
* downloadable videos
* Access to a Demo Key to play as you learn the techniques in our online class

If you feel this would be valuable please leave comments and visit my site often to review any updates on?

Additional
Medical Billing and Codingquestions are answered here: Online Medical Coding and Billing Courses


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Save time by not calling Medicare on denied claims

Time is money and calling insurance carriers some consider is a waste of time. I don't mind calling the insurance carriers but I normally do my own research on the claim prior to placing the call.

I find that reading Explanation of Benefits can be tricky for some people and I think in my next blog I will write about EOB's and how to read them but for now let's look at some tricks in reading Medicare's EOB's.

Medicare says that these questions are becoming their top tiered questions -
Call: CO-16 this code usually means the claim denied as unprocessable because information was missing or invalid
Resolution: Review the next Remittance Advice code under the CO-16 for the reason why the claim was denied.

Call: I'm working from a report
Resolution: Medicare would like clients to review the Remittance Advice tied to the Explanation of Benefits or Electronic Remittance Advice prior to calling on any claim (this means they would like you to review documentation supplied prior to calling them and wasting their time)

Call: I only know the claim did not pay and I was asked to call -
Resolution: Medicare recommends trying the IVR (interactive voice Response system) prior to talking with a Customer Support Rep or pulling out the EOB or ERA.

Call: I don't have the last page of the Remittance Advice
Resolution: You are getting the codes but you can't tell what they mean so you can either find the original Remittance Advice form or compare your codes to this list which was effective in December 2007:

Payment Reason Codes
CO1
Deductible Amount
CO10
The diagnosis is inconsistent with the patient's gender. Note: Changed as of 2/00
CO100
Payment made to patient/insured/responsible party.
CO101
Predetermination: anticipated payment upon completion of services or claim adjudication. Note: Changed as of 2/99
CO102
Major Medical Adjustment.
CO103
Provider promotional discount (e.g., Senior citizen discount). Note: Changed as of 6/01
CO104
Managed care withholding.
CO105
Tax withholding.
CO106
Patient payment option/election not in effect.
CO107
Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim. Note: Changed as of 6/03
CO108
Payment adjusted because rent/purchase guidelines were not met. Note: Changed as of 6/02
CO109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CO11
The diagnosis is inconsistent with the procedure.
CO110
Billing date predates service date.
CO111
Not covered unless the provider accepts assignment.
CO112
Payment adjusted as not furnished directly to the patient and/or not documented. Note: Changed as of 2/01
CO113
Payment denied because service/procedure was provided outside the United States or as a result of war. Note: Changed as of 2/01
CO114
Procedure/product not approved by the Food and Drug Administration.
CO115
Payment adjusted as procedure postponed or canceled. Note: Changed as of 2/01
CO116
Payment denied. The advance indemnification notice signed by the patient did not comply with requirements. Note: Changed as of 2/01
CO117
Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. Note: Changed as of 2/01
CO118
Charges reduced for ESRD network support.
CO119
Benefit maximum for this time period has been reached.
CO12
The diagnosis is inconsistent with the provider type.
CO120
Patient is covered by a managed care plan. Note: Inactive for 004030, since 6/99. Use code 24.
CO121
Indemnification adjustment.
CO122
Psychiatric reduction.
CO123
Payer refund due to overpayment. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
CO124
Payer refund amount - not our patient. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
CO125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Note: Changed as of 2/02
CO126
Deductible -- Major Medical Note: New as of 2/97
CO127
Coinsurance -- Major Medical Note: New as of 2/97
CO128
Newborn's services are covered in the mother's Allowance. Note: New as of 2/97
CO129
Payment denied - Prior processing information appears incorrect. Note: Changed as of 2/01
CO13
The date of death precedes the date of service.
CO130
Claim submission fee. Note: Changed as of 6/01
CO131
Claim specific negotiated discount. Note: New as of 2/97
CO132
Prearranged demonstration project adjustment. Note: New as of 2/97
CO133
The disposition of this claim/service is pending further review. Note: Changed as of 10/99
CO134
Technical fees removed from charges. Note: New as of 10/98
CO135
Claim denied. Interim bills cannot be processed. Note: New as of 10/98
CO136
Claim Adjusted. Plan procedures of a prior payer were not followed. Note: Changed as of 6/00
CO137
Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Note: New as of 2/99
CO138
Claim/service denied. Appeal procedures not followed or time limits not met. Note: New as of 6/99
CO139
Contracted funding agreement - Subscriber is employed by the provider of services. Note: New as of 6/99
CO14
The date of birth follows the date of service.
CO140
Patient/Insured health identification number and name do not match. Note: New as of 6/99
CO141
Claim adjustment because the claim spans eligible and ineligible periods of coverage. Note: Changed as of 6/00
CO142
Claim adjusted by the monthly Medicaid patient liability amount. Note: New as of 6/00
CO143
Portion of payment deferred. Note: New as of 2/01
CO144
Incentive adjustment, e.g. preferred product/service. Note: New as of 6/01
CO145
Premium payment withholding Note: New as of 6/02
CO146
Payment denied because the diagnosis was invalid for the date(s) of service reported. Note: New as of 6/02
CO147
Provider contracted/negotiated rate expired or not on file. Note: New as of 6/02
CO148
Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. Note: New as of 6/02
CO149
Lifetime benefit maximum has been reached for this service/benefit category. Note: New as of 10/02
CO15
Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Note: Changed as of 2/01
CO150
Payment adjusted because the payer deems the information submitted does not support this level of service. Note: New as of 10/02
CO151
Payment adjusted because the payer deems the information submitted does not support this many services. Note: New as of 10/02
CO152
Payment adjusted because the payer deems the information submitted does not support this length of service. Note: New as of 10/02
CO153
Payment adjusted because the payer deems the information submitted does not support this dosage. Note: New as of 10/02
CO154
Payment adjusted because the payer deems the information submitted does not support this day's supply. Note: New as of 10/02
CO155
This claim is denied because the patient refused the service/procedure. Note: New as of 6/03
CO16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate Note: Changed as of 2/02
CO165
Payment denied/reduced for absence of, or exceeded, referral .
CO167
This (these) diagnosis (es) is (are) not covered.
CO169
Payment adjusted because an alternate benefit has been provided.
CO17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. Note: Changed as of 2/02
CO170
Payment denied when performed/billed by this type of provider.
CO171
Payment denied when performed/billed by this type of provider in this type of facility.
CO172
Payment adjusted when performed/billed by a provider of this specialty.
CO177
Payment denied because patient has not met the required eligibility requirements.
CO178
Payment adjusted because the patient has not met the required spend down requirements.
CO18
Duplicate claim/service.
CO181
Payment adjusted because this procedure code was invalid on the date of service.
CO183
The referring provider is not eligible to refer the service billed.
CO185
The rendering provider is not eligible to perform the service billed.
CO19
Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
CO2
Coinsurance Amount
CO20
Claim denied because this injury/illness is covered by the liability carrier.
CO21
Claim denied because this injury/illness is the liability of the no-fault carrier.
CO22
Payment adjusted because this care may be covered by another payer per coordination of benefits. Note: Changed as of 2/01
CO23
Payment adjusted because charges have been paid by another payer. Note: Changed as of 2/01
CO24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. Note: Changed as of 6/00
CO25
Payment denied. Your Stop loss deductible has not been met.
CO26
Expenses incurred prior to coverage.
CO27
Expenses incurred after coverage terminated.
CO28
Coverage not in effect at the time the service was provided. Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.
CO29
The time limit for filing has expired.
CO3
Co-payment Amount
CO30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Note: Changed as of 2/01
CO31
Claim denied as patient cannot be identified as our insured.
CO32
Our records indicate that this dependent is not an eligible dependent as defined.
CO33
Claim denied. Insured has no dependent coverage.
CO34
Claim denied. Insured has no coverage for newborns.
CO35
Lifetime benefit maximum has been reached. Note: Changed as of 10/02
CO36
Balance does not exceed co-payment amount. Note: Inactive for 003040
CO37
Balance does not exceed deductible. Note: Inactive for 003040
CO38
Services not provided or authorized by designated (network/primary care) providers. Note: Changed as of 6/03
CO39
Services denied at the time authorization/pre-certification was requested.
CO4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
CO40
Charges do not meet qualifications for emergent/urgent care.
CO41
Discount agreed to in Preferred Provider contract. Note: Inactive for 003040
CO42
Charges exceed our fee schedule or maximum allowable amount.
CO43
Gramm-Rudman reduction.
CO44
Prompt-pay discount.
CO45
Charges exceed your contracted/ legislated fee arrangement.
CO46
This (these) service(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96.
CO47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Note: Changed as of 6/00
CO48
This (these) procedure(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96.
CO49
These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO5
The procedure code/bill type is inconsistent with the place of service.
CO50
These are non-covered services because this is not deemed a `medical necessity' by the payer.
CO51
These are non-covered services because this is a pre-existing condition
CO52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Note: Changed as of 10/98
CO53
Services by an immediate relative or a member of the same household are not covered.
CO54
Multiple physicians/assistants are not covered in this case .
CO55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CO56
Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer.
CO57
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
CO58
Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Changed as of 2/01
CO59
Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. Note: Changed as of 6/00
CO6
The procedure/revenue code is inconsistent with the patient's age. Note: Changed as of 6/02
CO60
Charges for outpatient services with this proximity to inpatient services are not covered.
CO61
Charges adjusted as penalty for failure to obtain second surgical opinion. Note: Changed as of 6/00
CO62
Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Note: Changed as of 2/01
CO63
Correction to a prior claim. Note: Inactive for 003040
CO64
Denial reversed per Medical Review. Note: Inactive for 003040
CO65
Procedure code was incorrect. This payment reflects the correct code. Note: Inactive for 003040
CO66
Blood Deductible.
CO67
Lifetime reserve days. (Handled in QTY, QTY01=LA) Note: Inactive for 003040
CO68
DRG weight. (Handled in CLP12) Note: Inactive for 003040
CO69
Day outlier amount.
CO7
The procedure/revenue code is inconsistent with the patient's gender. Note: Changed as of 6/02
CO70
Cost outlier - Adjustment to compensate for additonal costs. Note: Changed as of 6/01
CO71
Primary Payer amount. Note: Deleted as of 6/00. Use code 23.
CO72
Coinsurance day. (Handled in QTY, QTY01=CD) Note: Inactive for 003040
CO73
Administrative days. Note: Inactive for 003050
CO74
Indirect Medical Education Adjustment.
CO75
Direct Medical Education Adjustment.
CO76
Disproportionate Share Adjustment.
CO77
Covered days. (Handled in QTY, QTY01=CA) Note: Inactive for 003040
CO78
Non-Covered days/Room charge adjustment.
CO79
Cost Report days. (Handled in MIA15) Note: Inactive for 003050
CO8
The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Changed as of 6/02
CO80
Outlier days. (Handled in QTY, QTY01=OU) Note: Inactive for 003050
CO81
Discharges. Note: Inactive for 003040
CO82
PIP days. Note: Inactive for 003040
CO83
Total visits. Note: Inactive for 003040
CO84
Capital Adjustment. (Handled in MIA) Note: Inactive for 003050
CO85
Interest amount.
CO86
Statutory Adjustment. Note: Inactive for 004010, since 6/98. Duplicative of code 45.
CO87
Transfer amount.
CO88
Adjustment amount represents collection against receivable created in prior overpayment. Note: Inactive for 004050.
CO89
Professional fees removed from charges.
CO9
The diagnosis is inconsistent with the patient's age.
CO90
Ingredient cost adjustment.
CO91
Dispensing fee adjustment.
CO92
Claim Paid in full. Note: Inactive for 003040
CO93
No Claim level Adjustments. Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
CO94
Processed in Excess of charges.
CO95
Benefits adjusted. Plan procedures not followed. Note: Changed as of 6/00
CO96
Non-covered charge(s).
CO97
Payment is included in the allowance for another service/procedure. Note: Changed as of 2/99
CO98
The hospital must file the Medicare claim for this inpatient non-physician service. Note: Inactive for 003040
CO99
Medicare Secondary Payer Adjustment Amount. Note: Inactive for 003040
COA0
Patient refund amount.
COA1
Claim denied charges.
COA2
Contractual adjustment.
COA3
Medicare Secondary Payer liability met. Note: Inactive for 004010, since 6/98.
COA4
Medicare Claim PPS Capital Day Outlier Amount.
COA5
Medicare Claim PPS Capital Cost Outlier Amount.
COA6
Prior hospitalization or 30 day transfer requirement not met. Note:
COA7
Presumptive Payment Adjustment Note:
COA8
Claim denied; ungroupable DRG
COB1
Non-covered visits. Note:
COB10
Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Note:
COB11
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. Note:
COB12
Services not documented in patients' medical records. Note:
COB13
Previously paid. Payment for this claim/service may have been provided in a previous payment. Note:
COB14
Payment denied because only one visit or consultation per physician per day is covered. Note: Changed as of 2/01
COB15
Payment adjusted because this procedure/service is not paid separately. Note: Changed as of 2/01
COB16
Payment adjusted because `New Patient' qualifications were not met. Note: Changed as of 2/01
COB17
Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. Note: Changed as of 2/01
COB18
Payment denied because this procedure code/modifier was invalid on the date of service or claim submission. Note: Changed as of 2/01
COB19
Claim/service adjusted because of the finding of a Review Organization. Note: Inactive for 003070
COB2
Covered visits. Note: Inactive for 003040
COB20
Payment adjusted because procedure/service was partially or fully furnished by another provider. Note: Changed as of 2/01
COB21
The charges were reduced because the service/care was partially furnished by another physician. Note: Inactive for 003040
COB22
This payment is adjused based on the diagnosis. Note: Changed as of 2/01
COB23
Payment denied because this provider has failed an aspect of a proficiency testing program. Note: Changed as of 2/01
COB3
Covered charges. Note: Inactive for 003040
COB4
Late filing penalty.
COB5
Payment adjusted because coverage/program guidelines were not met or were exceeded. Note: Changed as of 2/01
COB6
This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. Note: Changed as of 2/01
COB7
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Changed as of 10/98
COB8
Claim/service not covered/reduced because alternative services were available, and should have been utilized.
COB9
Services not covered because the patient is enrolled in a Hospice.
COD1
Claim/service denied. Level of subluxation is missing or inadequate. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD10
Claim/service denied. Completed physician financial relationship form not on file. Note: Inactive for 003070, since 8/97. Use code 17.
COD11
Claim lacks completed pacemaker registration form. Note: Inactive for 003070, since 8/97. Use code 17.
COD12
Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Note: Inactive for 003070, since 8/97. Use code 17.
COD13
Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Note: Inactive for 003070, since 8/97. Use code 17.
COD14
Claim lacks indication that plan of treatment is on file. Note: Inactive for 003070, since 8/97. Use code 17.
COD15
Claim lacks indication that service was supervised or evaluated by a physician. Note: Inactive for 003070, since 8/97. Use code 17.
COD18
Inactive for 4010 as of 2/99.
COD19
Claim service lacks physician/operative or other supporting documentation (inactive as of version 5010; use code 16).
COD2
Claim lacks the name, strength, or dosage of the drug furnished. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD21
This (these) diagnosis (es) is (are) missing or is (are) invalid.
COD3
Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD4
Claim/service does not indicate the period of time for which this will be needed. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD5
Claim/service denied. Claim lacks individual lab codes included in the test. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD6
Claim/service denied. Claim did not include patient's medical record for the service. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD7
Claim/service denied. Claim lacks date of patient's most recent physician visit. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD8
Claim/service denied. Claim lacks indicator that `x-ray is available for review.' Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COW1
Workers Compensation State Fee Schedule Adjustment Note: New as of 2/00
CR A2
Contractual adjustment (inactive for 004060; use code 45 with group code CO).
CR07
The procedure/revenue code is inconsistent with the patients gender.
CR1
Deductible amount.
CR10
The diagnosis is inconsistent with the patients gender.
CR100
Payment made to patient/insured/responsible party.
CR102
Major medical adjustment.
CR104
Managed care withholding.
CR107
Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
CR109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CR11
The diagnosis is inconsistent with the patients gender.
CR112
Payment adjusted as not furnished directly to the patient and/or not documented.
CR119
Benefit maximum for this time period or occurrence has been reached.
CR121
Indemnification adjustment.
CR125
Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
CR127
Coinsurance - major medical.
CR129
Payment denied. Prior processing information appears incorrect.
CR13
The date of death precedes the date of service.
CR131
Claim specific negotiated discount.
CR133
The disposition of the claim/service is pending further review.
CR137
Payment/reduction for surcharges, assessments, allowances, or health related taxes.
CR144
Incentive adjustment, e.g., preferred product/service.
CR145
Premium payment withholding.
CR148
Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
CR149
Lifetime benefit maximum has been reached for this service/benefit category.
CR150
Payment adjusted because the payer deems the information submitted does not support this level of service.
CR151
Payment adjusted because the payer deems the information submitted does not support this many services .
CR16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
CR165
Payment denied/reduced for absence of, or exceeded, referral .
CR17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever .appropriate. This change to be effective 4/1/07: at least one remark code
CR170
Payment adjusted when performed/billed by a provider of this type of provider.
CR172
Payment adjusted when performed/billed by a provider of this specialty.
CR179
Payment adjusted because the patient has not met the required waiting requirements.
CR18
Duplicate claim/service.
CR180
Payment adjusted because the patient has not met the required residency requirements.
CR183
The referring provider is not eligible to refer the service billed.
CR185
The rendering provider is not eligible to perform the service billed.
CR187
Health savings account payments.
CR19
Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
CR2
Coinsurance amount.
CR20
Claim denied because this injury/illness is covered by the liability carrier.
CR21
Claim denied because this injury/illness is the liability of the no-fault carrier.
CR22
Payment adjusted because this care may be covered by another payer per coordination of benefits.
CR23
Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.
CR24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
CR26
Expenses incurred prior to coverage.
CR27
Expenses incurred after coverage terminated.
CR29
The time limit for filing has expired.
CR3
Copayment amount.
CR30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
CR31
Claim denied as patient cannot be identified as our insured.
CR32
Our records indicate that this dependent is not an eligible dependent as defined.
CR33
Claim denied - insured has no dependent coverage.
CR34
Claim denied - insured has no coverage for newborns.
CR35
Lifetime benefit maximum has been reached.
CR38
Services not provided or authorized by designated (network/primary care) providers .
CR39
Services denied at the time authorization/precertification was requested.
CR4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
CR40
Charges do not meet qualifications for emergent/urgent care.
CR42
Charges exceed our fee schedule or maximum allowable amount.
CR45
Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
CR46
This (these) service (s) is (are) not covered.
CR47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
CR48
This (these) procedure (s) is (are) not covered.
CR49
These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CR5
The procedure code/bill type is inconsistent with the place of service.
CR50
These are noncovered services because this is not deemed a "medical necessity" by the payer.
CR51
These are noncovered services because this is a preexisting condition.
CR52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
CR54
Multiple physicians/assistants are not covered in this case.
CR55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CR56
Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
CR57
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
CR58
Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
CR59
Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
CR6
The procedure/revenue code is inconsistent with the patient's age.
CR62
Payment denied/reduced for absence of, or exceeded, precertification/authorization.
CR63
Correction to a prior claim.
CR7
The procedure/revenue code is inconsistent with the patients gender.
CR85
Interest amount.
CR88
Adjustment amount represents collection against receivable created in prior overpayment.
CR9
The diagnosis is inconsistent with the patients age.
CR94
Processed in excess of charges.
CR95
Benefits adjusted. Plan procedures not followed.
CR96
Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
CR97
Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
CRA1
Claim/service denied. At least one remark code must be provided; may be comprised of either the remittance advice remark code or NCPDP reject reason code.
CRA2
Contractual adjustment (inactive for 004060; use code 45 with group code CO).
CRA6
Prior hospitalization or 30-day transfer requirement not met.
CRB1
Noncovered visits.
CRB10
Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
CRB11
Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
CRB12
Services not documented in patient's medical records.
CRB13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
CRB14
Payment denied because only one visit or consultation per physician per day is covered.
CRB15
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.
CRB16
Payment adjusted because "new patient" qualifications were not met.
CRB18
Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
CRB20
Payment adjusted because procedure/service was partially or fully furnished by another provider.
CRB22
This payment is adjusted based on the diagnosis.
CRB3
Covered charges.
CRB5
Payment adjusted because coverage/program guidelines were not met or were exceeded.
CRB6
This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
CRB7
This provider was not certified/eligible to be paid for this procedure/service on this date of service.
CRB9
Services not covered because the patient is enrolled in hospice.
CRD19
Claim/service lacks physician/operative or other supporting documentation .
CRD21
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
PR02
Coinsurance amount.
PR07
The procedure/revenue code is inconsistent with the patients gender.
PR1
Deductible amount.
PR10
The diagnosis is inconsistent with the patients gender.
PR100
Payment made to patient/insured/responsible party.
PR104
Managed care withholding.
PR107
Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
PR109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
PR11
The diagnosis is inconsistent with the procedure.
PR111
Not covered unless the provider accepts assignment.
PR112
Payment adjusted as not furnished directly to the patient and/or not documented.
PR117
Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
PR119
Benefit maximum for this time period or occurrence has been reached.
PR125
Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
PR126
Deductible - major medical.
PR127
Coinsurance - major medical.
PR129
Payment denied. Prior processing information appears incorrect.
PR13
The date of death precedes the date of service.
PR131
Claim specific negotiated discount.
PR133
The disposition of the claim/service is pending further review.
PR136
Claim adjusted based on failure to follow prior payer's coverage rules.
PR137
Payment/reduction for regulatory surcharges, assessments, allowances, or health related taxes.
PR138
Claim/service denied. Appeal procedures not followed or time limits not met.
PR140
Patient/insured health identification number and name do not match.
PR141
Claim adjustment because the claim spans eligible and ineligible periods of coverage.
PR145
Premium payment withholding.
PR147
Provider contracted/negotiated rate expired or not on file.
PR149
Lifetime benefit maximum has been reached for this service/benefit category.
PR15
Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
PR150
Payment adjusted because the payer deems the information submitted does not support this level of service.
PR151
Payment adjusted because the payer deems the information submitted does not support this many services .
PR156
Flexible spending account payments.
PR16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
PR167
This (these) diagnosis (es) is (are) not covered.
PR17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever .appropriate. This change to be effective 4/1/07: at least one remark code
PR170
Payment denied when performed/billed by this type of provider.
PR171
Payment denied when performed/billed by this type of provider in this type of facility.
PR172
Payment adjusted when performed/billed by a provider of this specialty.
PR177
Payment denied because the patient has not met the required eligibility requirements.
PR179
Payment adjusted because the patient has not met the required waiting requirements.
PR18
Duplicate claim/service.
PR180
Payment adjusted because the patient has not met the required residency requirements.
PR183
The referring provider is not eligible to refer the service billed.
PR184
The prescribing/ordering provider is not eligible to prescribe/order the service billed.
PR185
The rendering provider is not eligible to perform the service billed.
PR19
Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
PR2
Coinsurance amount.
PR20
Claim denied because this injury/illness is covered by the liability carrier.
PR21
Claim denied because this injury/illness is the liability of the no-fault carrier.
PR22
Payment adjusted because this care may be covered by another payer per coordination of benefits.
PR23
Payment adjusted due to the impact of prior payer's) adjudication including payments and/or adjustments.
PR24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
PR26
Expenses incurred prior to coverage.
PR27
Expenses incurred after coverage terminated.
PR28
Coverage not in effect at the time the service was provided.
PR29
The time limit for filing has expired.
PR3
Copayment amount.
PR30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
PR31
Claim denied as patient cannot be identified as our insured.
PR32
Our records indicate that this dependent is not an eligible dependent as defined.
PR33
Claim denied - insured has no dependent coverage.
PR34
Claim denied - insured has no coverage for newborns.
PR35
Lifetime benefit maximum has been reached.
PR38
Services not provided or authorized by designated (network/primary care) providers .
PR39
Services denied at the time authorization/precertification was requested.
PR4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
PR40
Charges do not meet qualifications for emergent/urgent care.
PR42
Charges exceed our fee schedule or maximum allowable amount.
PR45
Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
PR46
This (these) service (s) is (are) not covered.
PR47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
PR48
This (these) procedure (s) is (are) not covered.
PR49
These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
PR5
Procedure code/bill type is inconsistent with the place of service.
PR50
These are noncovered services because this is not deemed a "medical necessity" by the payer.
PR51
These are noncovered services because this is a preexisting condition.
PR52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
PR54
Multiple physicians/assistants are not covered in this case.
PR55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
PR56
Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
PR57
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
PR58
Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
PR59
Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
PR6
The procedure/revenue code is inconsistent with the patient's age.
PR62
Payment denied/reduced for absence of, or exceeded, precertification/authorization.
PR63
Correction to a prior claim.
PR7
The procedure/revenue code is inconsistent with the patients gender.
PR8
The procedure code is inconsistent with the provider type/specialty (taxonomy) .
PR87
Transfer amount.
PR9
The diagnosis is inconsistent with the patients age.
PR92
Claim paid in full.
PR94
Processed in excess of charges.
PR95
Benefits adjusted. Plan procedures not followed.
PR96
Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
PR97
Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
PRA1
Claim/service denied. At least one remark code must be provided; may be comprised of either the remittance advice remark code or NCPDP reject reason code.
PRA2
Contractual adjustment (inactive for 004060; use code 45 with group code CO).
PRA6
Prior hospitalization or 30-day transfer requirement not met.
PRB1
Noncovered visits.
PRB11
Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
PRB12
Services not documented in patient's medical records.
PRB13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
PRB14
Payment denied because only one visit or consultation per physician per day is covered.
PRB15
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.
PRB16
Payment adjusted because "new patient" qualifications were not met.
PRB18
Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
PRB20
Payment adjusted because procedure/service was partially or fully furnished by another provider.
PRB22
This payment is adjusted based on the diagnosis.
PRB5
Payment adjusted because coverage/program guidelines were not met or were exceeded.
PRB6
This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
PRB7
This provider was not certified/eligible to be paid for this procedure/service on this date of service.
PRB8
Claim/service not covered/reduced because alternative services were available and should have been utilized.
PRB9
Services not covered because the patient is enrolled in hospice.
PRD19
Claim/service lacks physician/operative or other supporting documentation .
PRD21
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

Medicare is asking that everyone learn the new Electronic Remittance Advice coding system and identify your own answers prior to calling their Customer Service department. Sounds like a easy task but we all know a live human being can usually give us more information then what we find on the Explanation of Benefits.

However if we all cut back on our in-coming phone calls maybe Medicare can save some money and be around for when I retire...


Additional Medical Billing and Codingquestions are answered here: Online Medical Coding and Billing Courses


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