How to use Medicare Part B Electronic Data Interchange (EDI) Hotline

A few years ago Medicare Health Insurance began requesting medical offices to submit all Medicare Health Insurance claims electronically to save processing costs. In order to handle the connection of software products to Medicare they created a department called the Electronic Data Interchange or EDI.

The EDI department has the right to kick out a claim before it comes through their claim processing system. If a medical claim is kicked out at the EDI level it is like the insurance carrier never received the medical claim in the first place.

If you have issues where you are sending Medicare Health Insurance claims and they are not appearing in the IVR or in the support line it means one of two things:

1. Your clearinghouse kicked out the claim for issues
2. The Medicare EDI department kicked out the claim for issues

I would first recommend viewing your EDI reports for the patient that Medicare Support was not able to find on file. Now that you have the report read the exclusion reason...

If you don't understand the denial reason you have 3 different options depending on how you are submitting the claim:

1. If you use a Practice Management software that is integrated with the medical claims clearinghouse you might want to contact them first to see how to resolve the issue.
2. If you use a Practice Management Software that is not integrated with the medical claims clearinghouse and you can contact your medical claims clearinghouse do so now. Ask them to pull the file and see why they can identify the claim is getting kicked out.
3. If you have a direct connection with Medicare Health Insurance follow the EDI Hotline Rules

To make a phone call to the EDI Hotline please have this information handy:
1. Submitter ID number. It can also be called Sender ID, User ID and/or Billing Location Code for providers sending to Medicare Health Insurance through Blue Cross of Michigan.

2. NPI number (National Provider Identifier) and can be found in the NPPES directory

3. Date you submitted the claim

4. Processed Date if report states "deleted"

Do not call Medicare's EDI Hotline until you have prepared all of this information. They are usually very nice in the EDI department but they are in a hurry so they need this information quickly.

EDI Hotline for Medicare Part Health Insurance Carriers: 877-567-7261


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

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Are Medicare payments looking smaller each month?

Is your HPSA/PSA incentive payment less than you think it should be? One reason could be that the 5% Physician Scarcity Area (PSA) Incentive Payment ended recently. It was effective for dates of service from January 1, 2005, through June 30, 2008.

Any services rendered after June 30, 2008, will not receive the PSA incentive payment. This change does not effect the Health Professional Shortage Area (HPSA) incentive payment.

PSA Overview:
Medicare will automatically pay this new bonus on a quarterly basis without the need for a modifier on the claim for services provided in zip code areas that:
*Fall fully within a county designated as a PSA; or
*Fall partially within a county designated as a PSA and are considered to be dominant for that county, based on a determination of the United States Postal Service; or
*Fall within a rural area of a metropolitan statistical area identified through the latest modification of the Goldsmith modification that is determined to be a PSA.

In some cases, a service may be provided in a county that is considered to be a PSA, but the zip code is not considered to be dominant for that area. In these cases, the bonus payment cannot be made automatically. To receive the bonus for such services, physicians will need to include the AR modifier to reflect a physician service provided in a PSA.

Some key points to remember regarding the PSA bonus are the following:

*Medicare will pay a five percent PSA bonus on a quarterly basis, and the bonus will be based on what Medicare actually paid not on the Medicare-approved payment amount.
*A single service may be eligible for the PSA bonus and the HPSA bonus, which is discussed later.
*Payment will be based on where the service is performed and not on the address of the beneficiary.
*The PSA bonus will be paid on services rendered on or after January 1, 2005 through December 31, 2007.
*Only the provider designations of General Practice (01), Family Practice (08), Internal Medicine (11), and Obstetrics/Gynecology (16) will be paid the bonus for the zip codes designated as primary care PSAs. All other physician provider specialties will be eligible for the specialty physician scarcity bonus for the zip codes designated as specialty PSAs.
*Dentists, chiropractors, podiatrists, and optometrists are not eligible for the physician scarcity bonus as either primary care or specialty physicians.
*Medicare will pay a five percent PSA bonus on a quarterly basis, and the bonus will be based on what Medicare actually paid not on the Medicare-approved payment amount.
*A single service may be eligible for the PSA bonus and the HPSA bonus, which is discussed later.
*Payment will be based on where the service is performed and not on the address of the beneficiary.
*The PSA bonus will be paid on services rendered on or after January 1, 2005 through December 31, 2007.
*Only the provider designations of General Practice (01), Family Practice (08), Internal Medicine (11), and Obstetrics/Gynecology (16) will be paid the bonus for the zip codes designated as primary care PSAs. All other physician provider specialties will be eligible for the specialty physician scarcity bonus for the zip codes designated as specialty PSAs.
*Dentists, chiropractors, podiatrists, and optometrists are not eligible for the physician scarcity bonus as either primary care or specialty physicians.
*Services submitted with the AR modifier will be subject to validation by Medicare.

HPSA Overview:
MMA Section 413(b) requires CMS to revise some of the policies that address HPSA bonus payments. Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act. In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. But keep in mind that if a zip code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.

MMA Changes
Effective January 1, 2005, you no longer have to include a modifier on claims to receive your HPSA bonus payment, which will be paid to you automatically, if you provide care in zip code areas that either:

*Fall entirely in a county designated as a full-county HPSA; or
*Fall entirely within the county, through a USPS determination of dominance; or
*Fall entirely within a partial county HPSA.

However, if you provide care in zip code areas that do not fall entirely within a full county HPSA or partial county HPSA, you must enter the AQ modifier on your claim to receive the bonus.

The following are the specific instances in which you will need to enter a modifier:

*When you provide services in zip code areas that do not fall entirely within a designated full county HPSA bonus area;
*When you provide services in a zip code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision;
*When you provide services in a zip code area that falls partially within a non-full county HPSA;
*When you provide services in a zip code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file.

To determine if you qualify to automatically receive the bonus payment, you can review the information provided on the CMS Web site. The HRSA website should be reviewed for the most recent designations. Physicians may also use the HRSA website designations when making the decision on whether or not to include the HPSA modifier on their claims.
Some points to remember include the following:

*Medicare carriers will continue to base your bonus on the amount you are actually paid (not the Medicare approved payment amount for each service) and will pay you the ten-percent bonus on a quarterly basis.
*The HPSA bonus pertains only to physician's professional services. Should you bill for a service that has both a professional and technical component, only the professional component will receive the bonus payment.
*The key to eligibility is not that your beneficiary lives in an HPSA nor that your office or primary location is in an HPSA, but rather that you actually render the service in an HPSA.
*A single service may be eligible for both the HPSA bonus payments and the physician scarcity bonus.
*To be considered for the bonus payment, you must include the name, address, and zip code of the location where the service was rendered on all electronic and paper claim submissions.
*Physicians should verify the eligibility of their area for a bonus before submitting services with a HPSA modifier for areas they think may still require the submission of a modifier to receive the bonus payment.
*Services submitted with the AQ modifier will be subject to validation by Medicare.

Do I need to use the "AR" Modifier?Check the automated pay zip code lists under under Primary Care or Speciality links first. If your zip code is on either list, you do not have to use the "AR" modifier.

Do I need to use the "AQ" Modifier?Areas eligible for payment via the AQ modifier must be verified using your local Carrier Web Sites

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

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Voluntary Refunds to Medicare and how to process in your medical office

As a biller you will come across times where Medicare overpaid and this can happen because of many different scenarios like:

• Overpaid on a Claim
• Patient wasn't treated but claim was submitted resulting in a need to refund
• Claim was billed under wrong provider
• Claim was double paid

If you ever find that you have received an overpayment from Medicare per your contract with medicare you are required to refund the overpayment ASAP. Voluntary refund checks payable to the Medicare program cannot be returned, regardless of the amount of the refund. If you need to refund Medicare, please verify you are sending the correct amount.

** WPS disclaimer: The acceptance of a voluntary refund in no way affects or limits the rights of the Federal Government or any of its agencies or agents to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.

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

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How to email Medicare with Personal Health Information

Well, to begin with you should know straight off to never send Patient Health Information by email especially to Medicare since this is a HIPAA issue. However, Medicare breaks it down by additional information that they request doctors/billing services please do not send through email. Also find out what information you can send by email so Medicare can find your patient.

Do not send the Beneficiary's Health Insurance Claim Number (HICN)
Do not send Protected Health Information (PHI)

Examples:

• Patient Name
• Patient Date of Birth
• Patient Social Security Number
• Patient Medicare ID#

What to send to Medicare through Email:

They ask that you please only send the ICN or Internal Control Number for the claim in question. This is all of the information WPS Medicare requires in order to find the patients information on their side.

Please do your part to protect your patients health information.

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

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Crossover Error Code Notification

If your providers received a crossover rejection letter dated October 17 2008 and containing rejection code N22223 please ignore these letters. These letters were sent in error and should be shredded.

WPS Medicare Part B accidentally sent Crossover Rejection letters dated on October 17th 2008 containing N22223 can be ignored and shredded. These were sent in error!


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

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Medicare Fee Schedules are not appealable

Medicare has released a notification stating that they are receiving a higher volume in appeal requests for services which Medicare paid the claim appropriately based on the set allowable fee schedule.

WPS Medicare wants medical providers to understand that for those who noticed the fee schedule change resulted in a payment reduction and are attempting to appeal that this is not an appealable option.

Per the Centers of Medicare and Medicaid Services (CMS) internet-Only Manual (IOM) Publication 100-4, Chapter 29, Section 200 C (3). This section states, Actions that are not initial determinations and are not appealable under this the Chapter include, but are not limited to, "Any issue regarding the computation of the payment amount of program reimbursement of general applicability for which CMS or a carrier has sole responsibility under Part B, such as the establishment of a fee schedule set forth in 42 CFR, part 414, subpart B or an inherent reasonableness adjustment pursuant to 42 CFR 405.502 (g).:

Please refer to the CMS IOM 100-4, Chapter 29 regarding appeals at the following Website address:http://www.cms.hhs.gov/manuals/downloads/clm104c29.pdf

Medical billers/collectors please forward this information on to your providers that bill to Medicare so they are aware of these changes. When they ask you to "collect" more on these fee schedules you will be able to explain why you can't.

Good Luck and Happy Billing!

For more articles about Medical Billing and Coding read this Over 250 Medical Billing and Coding Articles

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Kansas, Nebraska and Western Missouri Medicare Updates

RelayHealth was updated with new information regarding Wisconsin Physicians Service (WPS) about processing change to the Part B processing system for Kansas Medicare, Nebraska Medicare, and Western Missouri Medicare. The WPS change will allow for consistent processing for the Jurisdiction 5 Medicare Administrative Contractor (MAC) and automate many of the current manual processes allowing for more accurate and timely payment. These new changes will benefit providers and medical offices.

The change will affect claims processed November 1, 2008 and after.

The payors affected are listed below:
CPID# Insurance Carrier Name
2463 Kansas Medicare
1451 Nebraska Medicare
4451 Western Missouri Medicare

RelayHealth has identified the following items for you to be aware of with this change:
WPS Medicare Part B will have a system dark day on October 31, 2008
No customer service activity. The Provider Call Center representatives will not have system access.

* Interactive Voice Response (IVR) access will be available for registered C-Snap users.
* RelayHealth will send claims to WPS on October 31, 2008; however, claim processing will not begin until Monday November 3, 2008.
* WPS will output reports on Tuesday November 4, 2008. RelayHealth will output reports when they are received from WPS.

Please review your reports and expect an initial delay in processing of claims.

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

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2008 Correction Payment Fees for Clinical Laboratory Travel Codes P9603 and P9604 for Collection of Specimens

Medicare Part B insurance, will reimburse CLIA's for the services of a specimen collection and travel allowance of a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under Section 1833(h)(3) of the Social Security Act. Payment is made based on the clinical laboratory fee schedule.

The P travel codes allow for payment of the travel allowance either on a per mileage basis (P9603) or on a flat rate per trip basis (P9604). Payment of the travel allowance is made only if a specimen collection fee is also payable.

The travel allowance fee schedule is to help cover the estimated travel costs of collecting the specimen, including the laboratory technician’s salary and travel expenses.

The per flat rate trip basis P9604 is $9.55 and should be used for trips under 20 miles round trip. If your distance is longer than 20 miles round trip or you stop to pick up a Non-Medicare specimen in the same trip you will want to use the per mile P9603 $1.035 fee.

On August 1, 2008, the per mile allowance rate of $1.035 cents per mile was computed using the Federal mileage rate of $0.585 cents per mile for automobile expenses plus an additional $0.45 cents per mile to cover the technician’s time and travel costs. Medicare contractors have the option of establishing a higher per mile rate in excess of the minimum of $1.035 cents per mile if local conditions warrant it.

Under either method (i.e., flat or per mile travel allowance), when one trip is made for multiple specimen collections (e.g., at a nursing facility), the travel payment component is prorated based on the number of specimens collected on that trip (for both Medicare and non-Medicare patients) either at the time the claim is submitted by the laboratory or when the flat rate is set by the Medicare contractor.

Medicare Notice: Medicare will not reprocess your claims with the updated Fee Schedule pricing unless you bring it to their attention and ask that they reprocess the claim. It is also recommended to raise your charge fee sctructure for these two procedure codes P9603 and P9604.

Procedure Codes Affected:
P9603 Calendar Year 2008 $1.035 per mile
P9604 Calendar Year 2008 $9.55 per Flat-rate trip

Real Life Billing Scenarios

Example 1: On August 2, 2008, a ARUP laboratory technician travels 60 miles round trip from a lab located in SLC to a Ogden location, and back to the lab to draw a single Medicare patient’s blood. The total reimbursement would be $62.10 (60 miles x 1.035 cents a mile), plus the specimen collection fee.

Example 2: On August 2, 2008, a ARUP laboratory technician travels 40 miles from the SLC lab to a Medicare patient’s home to draw blood, and then travels an additional 10 miles to a non-Medicare patient’s home and then travels 30 miles to return to the SLC lab. The total miles traveled would be 80 miles. The claim submitted would be for one half of the miles traveled or $41.40 (40 x 1.035), plus the specimen collection fee.

Example 3: A ARUP laboratory technician travels from the SLC laboratory to a single Medicare patient’s home and returns to the SLC laboratory without making any other stops. The flat rate would be calculated as follows: 2 x $9.55 for a total trip reimbursement of $19.10, plus the specimen collection fee.

Example 4: A ARUP laboratory technician travels from the SLC laboratory to the homes of five patients to draw blood, four of the patients are Medicare patients and one is not. An additional flat rate would be charged to cover the 5 stops and the return trip to the SLC lab (6 x $9.55 = $57.30). Each of the claims submitted would be for $11.46 ($57.30 /5 = $11.46). Since one of the patients is non-Medicare, four claims would be submitted for $11.46 each, plus the specimen collection fee for each.

Example 5: A ARUP laboratory technician travels from the SLC laboratory to a nursing home and draws blood from 5 patients and returns to the laboratory. Four of the patients are on Medicare and one is not. The $9.55 flat rate is multiplied by two to cover the return trip to the laboratory (2 x $9.55 = $19.10) and then divided by five (1/5 of $19.10 = $3.82). Since one of the patients is non-Medicare, four claims would be submitted for $3.82 each, plus the specimen collection fee.

Note** At no time will a laboratory be allowed to bill for more miles than are reasonable or for miles not actually traveled by the laboratory technician.

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

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Payment witholding if providers who bill to Medicare owe the IRS

If you are in the medical billing industry and you receive Medicare EOB's or Remittance Advice reports that reflect a provider level adjustment code as "WU" please read the following message.

As of October 1, 2008 Medicare can withhold 15% of the providers payments and reimburse the IRS for any outstanding Taxes owed by the provider or facility of services. If you begin receiving WU codes in the PLB03-1 data field you can call the IRS toll free at 1-800-829-3903 number. This information will also be found in the PLB03-2 data field located on the Remittance Advice report.

*Note: Billers can not discuss tax issues with the IRS. Only the physician with the outstanding tax balance can speak with the IRS. Do not contact Medicare as they are instructed to collect by the IRS and will only stop doing so if the levy has been paid or other arrangements are made to satisfy the debt.

You maybe wondering why Medicare would take 15% of your payment and send it to the IRS. Well, the Taxpayer Relief Act of 1997, Section 1024, requires the IRS to reduce certain federal payments, including Medicare payments, to allow collection of overdue taxes.

In July 2000, the Treasury Department’s Financial Management Service and the IRS began the Federal Payment Levy Program (FPLP) which is authorized by Internal Revenue Code Section 6331 (h), as prescribed by Section 1024 of the Taxpayer Relief Act of 1997. Through this program, collection of overdue taxes through a continuous levy on certain federal payments is authorized. This includes federal payments made to contractors and vendors, including Medicare providers, doing business with the government.

IRS may reduce federal payments subject to the levy by 15 percent, or receive payment in full if it is less than 15 percent of the complete Medicare Insurance payment.

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Podiatrist and Medicare Claim Billing with 837 claims

Medicare is identifying that Podiatrists are having issues submitting clean claims using the ANSI 837 file format. If you are billing for a podiatrist that performs routine foot care services, and you are identifying lack of payment on Medicare claims please follow these suggestions:

1. Enter "Date Last Seen (DLS)" in Loop 2300 with the DTP segment and 304 Qualifier
- DLS is the most current date the patient was seen by the attending physician for the services rendered and is required on the claim

Example: DTP*304*D8*20080922~

- Date/Time Qualifier 304 must be included on the claim (used to convey dates associated with the information contained in the corresponding EB Loop)

2. Enter supervising/attending NPI in Loop 2310E, NM109 segment with a DQ indicator. XX will be in segment NM108.
- Supervising Providers Name must be submitted on the claim
- Entity Identifier Code must be DQ
- Supervising Provider UPIN must be submitted

Another note: If you received payment on claims submitted incorrectly (i.e. not billing this information in this format) Medicare is requesting that you refund all payments made and have the claims reprocessed under the correct format.

Learn more about Electronic Medical Billing and Coding at this site medical billings and health insurance claims

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Waived CLIA Tests for Medicare and approved by the FDA

If you are a certified CLIA facility, you know that the Centers for Medicare & Medicaid Services (CMS) only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, and if the laboratory claims are edited at the CLIA certificate level.


Once new waived tests are approved by the FDA they become valid for use. The new waived tests announced by CR 6179 (and their effective dates) are in the following table:


Note: QW modifier tells Medicare that these are waived tests and should always be billed on the claim with the correct procedure code.


CPT: Modifier Approved Date: Description:
87880 QW June 28, 2007 PSS World Medical Select Diagnostics Strep A Twist
87880 QW March 19, 2008 Jant Pharmacal Accutest Integrated Strep A Rapid Test Device
87880 QW March 19, 2008 Inverness Medical Biostar Acceava Strep A Twist
87880 QW April 8, 2008 Diagnostic Test Group Clarity Strep A Rapid Test Strips
80061 QW April 14, 2008 Abaxis, Piccolo xpress Chemistry Analyzer {Lipid Panel Reagent Disc} (Whole Blood)
82465 QW April 14, 2008 Abaxis, Piccolo xpress Chemistry Analyzer{Lipid Panel Reagent Disc} (Whole Blood)
83718 QW April 14, 2008 Abaxis, Piccolo xpress Chemistry Analyzer{Lipid Panel Reagent Disc} (Whole Blood)
84478 QW April 14, 2008 Abaxis, Piccolo xpress Chemistry Analyzer{Lipid Panel Reagent Disc} (Whole Blood)
82465 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
82947 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
82950 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
82951 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
82952 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
83718 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
84478 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
84450 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
84460 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Lipid Panel Plus Reagent Disc} (Whole Blood)}
82042 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
82150 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
82247 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
82977 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
84157 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
84075 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
84450 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
84460 QW April 14, 2008 Abaxis Piccolo xpress Chemistry Analyzer{Liver Panel Plus} (Whole Blood)
89300 QW June 12, 2008 SpermCheck Vasectomy
83520 QW June 13, 2008 HemoCue Albumin 201 System


In addition to this list the CR 6179 also announces that:
The new waived CPT/HCPCS code 87809 has been assigned to the infectious agent antigen detection by immunoassay with direct optical observation; adenovirus. The HCPCS code assigned to the Rapid Pathogen Screening PRS


Adeno Detector test has been changed to 87809QW with an effective date of January 1, 2008.


•The new waived CPT code, 83520QW has been assigned for the albumin test performed using the A HemoCue Albumin 201 System with an effective date of June 13, 2008.


•As of May 1, 2008, the following test systems are either discontinued or are no longer manufactured, and their names have been removed from the list of tests granted waived status under CLIA:oMetrika A1c Now for Prescription Home Use (K020234),oMetrika A1c Now™ - Professional Use (K000887),oMetrika A1c Now for Professional Use (K020235),oMetrika DRx® HbA1c (Professional Use Test System),oBayer DCA 2000 – glycosylated hemoglobin (Hgb A1c), andoBayer DCA 2000+ - glycosylated hemoglobin (Hgb A1c).


•The Bayer A1CNow+ {For Professional Use} was granted waived complexity categorization because of its home (over the counter) use. Effective May 1, 2008, the CPT code for Bayer A1CNow+ {For Professional Use} test system has been changed from 83036QW to 83037QW on the list of tests granted waived status under CLIA.

The attachment to CR 6179 includes the list of tests granted waived status under CLIA. The tests mentioned on the first page of this attachment (i.e., CPT codes: 81002, 81025, 82270, 82272, G0394, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.

If you have previously billed claims incorrectly resubmit them to your Medicare carrier or MAC and request them to review and reprocess your claims with these new changes.


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Updated Draft of MLN Matters on Limitation on Recoupment for Provider, Physicians and Suppliers Overpayment

On September 18, 2008 Medicare updated a MLN Matters Articles to clarify page 2 and delete unneccesary language on pages 5 & 9. For the full details of this updated document please visit:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6183.pdf

Background of this update:
Before the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) was enacted, a provider’s electing to appeal an overpayment determination did not affect Medicare’s prerogative to recover the debt. However, through an amendment of Title XVIII of the Social Security Act (the Act); MMA Section 935 changed this process, by adding a new paragraph (f) to section 1893 of the Act.

This amendment requires the Centers for Medicare & Medicaid Services (CMS) to change: 1) the way it recoups certain overpayments to providers, physicians and suppliers; and 2) how it pays interest to a provider, physician or supplier whose overpayment is reversed at subsequent administrative (Administrative Law Judge (ALJ)) or judicial levels of appeal.

CR 6183 describes these changes to the providers, physicians and suppliers overpayment recoupment process. Specifically, Section 1893 (f)(2)(a) of the Social Security Act protects providers physicians, and suppliers during the initial stages of the appeal process (both first level
appeal – contractor redetermination, and second level appeal -- Qualified Independent Contractor (QIC) reconsideration) by limiting the recoupment process for Medicare overpayments while the appeals process is underway.

It requires that when a valid first or second level appeal is received from a provider on an overpayment, subject to certain limitations (see below), CMS and its Medicare contractors may not recoup the overpayment until the decision on the redetermination and/or reconsideration has been rendered.

The article (link above) provides more detail and clarifies which overpayments are subject to limitation on recoupment and which types of overpayments are not subject to this limitation. Make sure that your billing staff are aware of these changes.

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Medicare as Secondary Insurance

Has your medical office ever received a request for repayment by the primary insurance carrier; the patient has a secondary insurance through Medicare but was never billed because the primary paid above Medicare's allowed amount so the balance was adjusted off?

Medicare has a 1 year timely filing policy giving most clients ample time to resolve claim issues and submit a clean claim. However; sometimes you will receive a primary insurance payment in full and 2 or 3 years later the insurance carrier will identify they weren't the primary insurance carrier and ask for a full refund. Now what do you do?

For Future Claims take these steps to make sure this never happens to you. Bill Medicare regardless how the primary insurance carrier paid (yes, even if they paid in full.)

• Submit all secondary claims to Medicare even if the primary paid in full
• The medical claim will reflect in Medicare's software to prove timely filing
• Patients might meet part of their deductible even if the primary paid in full and to ease your patients accounting bill the medical claim
• Medicare uses information on the medical claim and submits it to the National Claims Processing File
• If the primary insurance carrier requests a refund at any point you will know you are safe because you have proved timely filing with Medicare

But this has happened to me now - what can I do?

• Take a copy of the Refund Request, EOB's, Claim and any other kind of proof you can show to Medicare that you attempted to collect this correctly through the primary insurance carrier and submit to Medicare.
• If you receive a denial for late filing appeal asking Medicare to waive the claim timely file limit for good cause. Again attach any and all supporting documentation plus a really nice well written appeal letter.

Medicare has the option to evaluate and make a determination based on the supporting documentation.

Medicare states it the doctors responsibility to identify who the correct primary insurance carrier is. Although sometimes the primary insurance carriers are small companies that have slow or bad software programs and they don't update paperwork for weeks or months causing these kinds of issues....

1. Always contact the Interactive Voice Response (IVR) and verify files are update
2. Contact the Coordination of Benefit Contractor (COBC) (1-800-999-1118) and follow instructions if information is not correct.
3. Always bill Medicare as a secondary even if the primary insurance paid in full

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Key Words: Medicare as secondary insurance carrier, what happens if primary requests a refund and I never billed Medicare, timely filing, late filing, medical claims payment from Medicare, claim submission, bill all claims to Medicare regardless if paid in full, How to appeal Medicare denied claims, Claim Denial, Claim Collection, Coordination of Benefits, COBC, Primary payer, 1 year timely filing, medical claims, medical billing, IVR, proof of timely filing

Electronic Certificate of Medical Necessity

For medical practices that complete Certificates of Medical Necessity forms you can choose these options:

• Copied form mailed in with paper claim
• Faxed form
• Electronic claim transmission - CMN documentation sent electronically with claim.

Contact your Practice Management software or Clearinghouse to identify if they currently support the electronic claim transmission format. Also, be aware that your office should still complete a paper CMN form and keep in the patients chart files with the providers signature or scanned in the patients chart files with your PM software.

If claims are submitted electronically and DMERC feels that something has been falsified or is incorrect they can request a copy of the original signed documentation at any time. Your medical office will be required to supply the paper form at this time for claims payment.

To locate the CMN forms please visit: http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPage and follow these steps:

1. Check mark Show only items containing this word: Certificate

2. Click Show Items

**Everything will pull except for the DME Information Form - External Infusion Pump DME 09.03 (go back to the Show only items and enter DME 09.03 and click Show Items again)

All forms needed:

CMS 484 Certificate of Medical Necessity - Oxygen DME 484.03

CMS 846 Certificate of Medical Necessity - Pneumatic Compression Device DME 04.04B

DME 847 Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C

DME 848 Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B

CMS 849 Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A

CMS 854 Certificate of Medical Necessity - DME 11.02

CMS 10125 DME Information Form - External Infusion Pumps DME 09.03

CMS - 10252 Instructions for completing the Certificate of Data Destruction for Data aquired from the centers for Medicare & Medicaid Services

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Medicares Quarterly Updates - holding checks

The Centers for Medicare and Medicaid Services (CMS) requires and schedules standarda quarterly updates that each Medicare contractor must load into their claim processing system. These quarterly updates take place each January, April, July and October. The July 2008 update will take place the weekend of July 5th 2008. Medicare (CMS) will create a hold edit and place it in the system on July 1st 2008, to ensure that all claims submitted to Medicare on or after July 1, 2008, with 2008 dates of services, are held in the system until the July update has been completed.

Once Medicare confirms and validate that the system updates are processing correctly, they will start releasing the medical claims from the hold edit. Due to the volume of claims, it may take Medicare a few business days to release all claims from the hold edit.

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Medicare must verify who you are when calling

Medicare can not just talk with anyone so in order to get your question answered please call prepared to answer some questions. As of May 23, 2008 Medicare customer service will not be able to assist you until you verify the providers National Provider Identifier (NPI) (line 33A of the CMS-1500 claim form) and the Provider Transaction Access Number (PTAN) which appears on line 33B of the CMS-1500 claim form.

All providers who enrolled with Medicare before May 23, 2008 their PTAN is their legacy Medicare number. New providers enrolling in Medicare on or after May 23, 2008 will be assigned a PTAN as part of the Medicare enrollment process.

Medicare NPI exclusion edits

Correction: Edit should read as follows:
EDIT HU 0024C:INVALID CLAIM SRV FAC ID QUAL - IN LOOP 2310D(PROF) WHEN NM108 IS SENT IT MUST BE EQUAL TO XX

Update: RelayHealth has also implemented the following NPI edit for all Medicare Part A payors.
EDIT HU 0024C:INVALID CLAIM SRV FAC ID QUAL - IN LOOP 2310D(PROF) NM108 MUST BE EQUAL TO XX

RelayHealth will be implementing payor NPI changes on May 22, 2008 in preparation for the CMS requirements that will take effect on May 23, 2008. As part of this change, RelayHealth will be implementing the following NPI edits for all Medicare Part A and Part B payors.
The following edits apply to Medicare Part A payors:
EDIT HU 0022C:INVALID CLAIM REND PRV ID QUAL - IN LOOP 2310C(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0026C:INVALID CLAIM ATTEND PHY ID QUAL - IN LOOP 2310A(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0027C:INVALID CLAIM OPERATE PHY ID QUAL - IN LOOP 2310B(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0028D:INVALID SRV LINE REND PRV ID QUAL - IN LOOP 2420C(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0034D:INVALID SRV LINE ATTND PHY ID QUAL - IN LOOP 2420A(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0035D:INVALID SRV LINE OPER PHY ID QUAL - IN LOOP 2420B(INST), NM108 MUST BE EQUAL TO XX

The following edits apply to Medicare Part B payors:
EDIT HU 0021C:INVALID CLAIM REF PROV ID QUAL - IN LOOP 2310A(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0023C:INVALID CLAIM PUR SRV ID QUAL - IN LOOP 2310C(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0025C:INVALID CLAIM SUP PROV ID QUAL - IN LOOP 2310E(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0029D:INVALID SRV LINE PUR SRV ID QUAL - IN LOOP 2420B(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0031D:INVALID SRV LINE SUP PROV ID QUAL - IN LOOP 2420D(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0032D:INVALID ORDERING PROVIDER ID QUAL - IN LOOP 2420E(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0033D:INVALID SRV LINE REF PROV ID QUAL - IN LOOP 2420F(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0036D:INVALID PURCHASE SERVICE ID - FOR PROFESSIONAL CLAIMS, PS101 MUST BE 10 NUMERIC AND POSITION 1 MUST BE 1 OR 2 AND MUST PASS NPI CHECK DIGIT ROUTINE

Action Required: Please be aware of the Medicare Part A and Part B new edit requirements effective May 22, 2008.

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Billing NPI's may possibly require additional submitter numbers

RelayHealth would like to provide you with the following important information from Noridian Administrative Services EDISS Support regarding National Provider Identifier (NPI). Please read carefully and follow the specific instructions for your organizations.

Failure to update your Payor Assigned Submitter ID may cause payment delays.
EDI Support Services (EDISS) is issuing Submitter IDs (Payor Assigned Submitter IDs) in a one to one ratio with the Billing NPI, due to the transition from Medicare Provider Numbers to NPI in electronic claim submission. If you have one Billing NPI you will have one Submitter ID. If you have multiple Billing NPIs you will have multiple Submitter IDs. The way you enumerated determines the way Submitter IDs will be assigned. Refer to the following chart for examples:



For existing providers who have enumerated with multiple Billing NPIs for that one Medicare Billing Number: EDISS will fax you additional Submitter IDs for each billing NPI, if currently submitting claims with one Medicare Billing Number and one Submitter ID and have enumerated with multiple Billing NPIs for that one Medicare Billing Number.
The payors impacted are listed below:
CPID 1446 Nevada Medicare
CPID 1455 Alaska Medicare
CPID 1456 Arizona Medicare
CPID 1459 Oregon Medicare
CPID 1462 Washington Medicare
CPID 1469 Iowa Medicaid
CPID 1523 North Dakota Medicare
CPID 1527 Utah Medicare
CPID 2411 North Dakota Blue Shield
CPID 2453 North Dakota Medicare
CPID 2454 South Dakota Medicare
CPID 2458 Utah Medicare
CPID 2466 Wyoming Medicare
CPID 2467 Hawaii Medicare
CPID 2571 Iowa Medicaid
CPID 3521 Minnesota Medicare
CPID 3583 Wyoming Medicare
CPID 5515 Oregon Medicare
CPID 5521 Washington and Alaska Medicare
CPID 5546 Arizona Medicare
CPID 5581 Idaho Medicare
CPID 5589 South Dakota Medicare
CPID 7400 Montana Medicare
CPID 7489 Wyoming Blue Shield
Action Required: Providers must fax a copy of the Submitter IDs to RelayHealth at (916) 267-2963 to allow for set up in our system.


Submitter numbers are used to identify the client that is submitting the claims to the insurance carrier.

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Medicare claim billing

Medicare Notification:

PHYSICIAN (CLINIC) BILLING OF HCT OR HGB VALUES ON ERYTHROPOIESIS STIMULATING AGENT (ESA) CLAIMS

The following information must be submitted with each claim:

HCT or Hgb values:
For professional paper claims, test results are reported in item 19 of the Form CMS-1500 claim form. For electronic claims (837P), providers report the hemoglobin or hematocrit readings in Loop 2400 MEA segment. The specifics are MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results.

In other words, EMC claims should map the correct amounts to the correct field when billed as indicated in BR 5699.5: "Contractors shall require the most recent hematocrit or hemoglobin test results to be reported on claims submitted with HCPCS codes J0881, J0882, J0885, J0886, and Q4081. Hematocrit or hemoglobin test results are reported in the MEA03 segment Loop 2400 of the 837P or item 19 of the Form CMS-1500 claim form." (If the area above is blank, the claim will deny)

ICD-9 codes (For 4010A1 electronic format):
The ICD-9 code for the cause of the anemia must be placed in 2300 Loop, HI Segment for electronic claims (item 21, #1 for CMS 1500 forms) and a pointer of 1 in Loop 2400, SV1 segment for electronic claims (#1 in item 24E on the CMS 1500 form).

If you received an unprocessable denial, the claim can be resubmitted with the correct information.

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How to format out of country addresses for Medicare

OUT OF COUNTRY ADDRESSES & 837 4010 EMC PRE-PASS EDITING

The Electronic Media Claims (EMC) system reviews every claim for a number of pre-pass edits to ensure that claim data is valid. If a claim contains missing or incorrect information, one of two things will happen because of a pre-pass edit.

1. If an informational edit is in effect, the claim, batch, or file will process normally. The informational edit identifies the error and alerts the submitter in order to correct future claims.
2. If a delete edit is in effect, the claim, batch, or file will NOT process normally; it deletes from the claims processing system and alerts the submitter to the error.

Addresses are present in various loops in an electronic claim. For electronic claims, the state code is required and must be present and valid unless the country code is used. The state code edits set if N402 is present and is an invalid code OR if N402 = spaces AND N404 (Country Code) = spaces or a valid country code. Spaces or CAN are acceptable values. Alpha numeric zip codes are also acceptable.

Element Description
N401 City
N402 State
N403 Postal Code (Zip Code)
N404 County Code

Claims with a foreign address are subject to the mandatory electronic claims submission requirements for Medicare and are NOT an Administrative Simplification Compliance Act (ASCA) exception.

For a complete list of valid country codes, go to: http://unstats.un.org/unsd/methods/m49/m49alpha.htm


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