MIR-2007 04B, April 2007

Common Billing Errors to Avoid when Billing Medicare Carriers (SE0712)

Provider Types Affected
Physicians and providers billing Medicare carriers for services provided to Medicare beneficiaries

Provider Action Needed
This special edition article includes some general information regarding the most frequent errors that are found in claims submitted to Medicare carriers. The article is intended to help you correctly complete your Medicare claims so they will not be denied, rejected, or delayed because of incorrect or incomplete information.

Background
The Administrative Simplification Compliance Act and its implementing regulation (42 CFR 44.32, http://www.gpoaccess.gov/cfr/retrieve.html ), require that all initial claims for reimbursement under Medicare be submitted electronically as of October 16, 2003 (except from small providers with limited exceptions).

All Medicare providers, except for small providers defined in regulation, must bill Medicare electronically. A “small provider” is defined in the Federal Register (42 CFR 424.32(d)(1)(vii), http://www.gpoaccess.gov/cfr/retrieve.html ). To simplify, Medicare will consider all physicians, practitioners, facilities, or suppliers with fewer than 10 full time employees (FTEs) that bill a Medicare carrier or DMERC to be small. Providers that qualify as “small” automatically qualify for waiver of the requirement that their claims be submitted to Medicare electronically. Those providers are encouraged to submit their claims to Medicare electronically, but are not required to do so under the law. Small providers may elect to submit some of their claims to Medicare electronically, but not others. Submission of some claims electronically does not negate their small provider status nor obligate them to submit all of their claims electronically.

COMMON BILLING ERRORS
The following list includes common billing errors that you should avoid when submitting your claims to Medicare carriers:

• The patient cannot be identified as a Medicare patient. Always use the Health Insurance Claim Number (HICN) and name as it appears on the patient’s Medicare card.
• Item 32 (and the electronic claim equivalent) requires you to indicate the place where the service was rendered to the patient including the name and address –including a valid ZIP code – for all services unless rendered in the patient’s home. Please be advised that any missing, incomplete, or invalid information recorded in this required field will result in the claim being returned or rejected in the system as unprocessable. Any claims received with the word “SAME” in Item 32 indicating that the information is the same as supplied in Item 33 are not acceptable. (NOTE: References to an item number, such as item 32, refer to paper claim forms. However, note that the whenever an article number is used in this article, the related concept and information required also applies to equivalent fields on electronic claims.)
• The referring/ordering physician’s name and UPIN were not present on the claim. Please keep in mind this information is required in Item 17 and 17a on all diagnostic services, including consultations. In addition, be aware of the new requirements for use of National Provider Identifiers (NPIs). To learn more about NPIs and how to obtain your NPI, see the MLN Matters article SE0679 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0679.pdf on the CMS Web site. Also, see the MLN Matters articles SE0555, SE0659, and MM4203 for important information regarding CMS’s schedule for implementing the NPI. The articles are at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0555.pdf , http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0659.pdf , and http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4023.pdf , respectively.
• Evaluation and management (E/M) procedure codes and the place of service do not match. An incorrect place of service is being submitted with the E/M procedure code. (Example: Procedure code 99283, which is an emergency room visit, is submitted with place of service 11, which is office).
• Please keep in mind, when billing services for more than one provider within your group, that you must put the individual provider number in Item 24K, as Item 33 can only accept one individual provider number. Also, please make sure the provider number on the claim is accurate and that it belongs to the group. (Also, remember that as of May 23, 2007, NPIs are to be used.)
• Diagnosis codes being used are either invalid or truncated. Diagnosis codes are considered invalid usually because an extra digit is being added to make it five digits. Please remember not all diagnosis codes are five digits. Please check your ICD-9-CM coding book for the correct diagnosis code.
• Procedure code/modifier was invalid on the date of service. Remember that, as of January 1, 2005, CMS no longer provides a 90-day grace period for billing discontinued CPT/HCPCS codes. (Note: Please read the Medicare provider bulletins, especially at the end of each year, as Medicare list all the additions, deletions, and code changes for the following year.)
• Claims are being submitted with deleted procedure codes. This information can also be found in the Current Procedural Terminology (CPT) Book. It is important to be using a current book.
• When Medicare is secondary, Item 11, 11a, 11b, and 11c must be completed.

BILLING TIPS
The following topics will assist you with correct billing and help you complete and submit error free claims:

A. Provider Numbers
Individual vs. Group PIN - Use the individual rendering provider identification number (PIN) on each detail line. Make sure the group number, when applicable, corresponds to the appropriate individual PIN. When a physician has more than one PIN (private practice, hospital, etc.), use the appropriate PIN for the services rendered. A rendering provider number, if not a solo number, must always belong to the group number that is billing. Electronic submitter ID numbers (not UPINs) should be entered in place of the PIN (group or individual). When billing any service to Medicare, if you have doubts as to which provider number to use, please verify with your carrier. (Remember to use NPIs on claims as of May 23, 2007.)

"Zero-Filling" - Do not substitute zeros or a submitter identification number where a Medicare PIN, UPIN, or NPI is required.

B. Health Insurance Claim (HIC) Numbers
HIC Accuracy – Your carrier receives numerous claims that are submitted with invalid or incorrect HIC numbers. These claims require manual intervention and can sometimes result in beneficiaries receiving incorrect EOMB information. Please be certain the HIC number you are keying is entered correctly, and is also the HIC that belongs to the patient (based on what is on his/her Medicare card) for which you are billing.

HIC Format - A correct HIC number consists of nine numbers immediately followed by an alpha suffix. Take special care when entering the HIC number for members of the same family who are Medicare beneficiaries. A husband and wife may have a HIC number that share the same Social Security numerics. However, every individual has their own alpha suffix at the end of the HIC number. In order to ensure proper claim payment, it is essential that the correct alpha suffix is appended to each HIC. No hyphens or dashes should be used.

"Railroad Retirees" - Railroad Retirement HIC numbers generally have two alpha characters as a prefix to the number. These claims should be billed to United Health Care Insurance Company, at this address:

Palmetto Government Benefit Administrators
Railroad Medicare Services
P.O. Box 10066
Augusta , GA 30999-0001

C. Name Accuracy
Titles should not be used as part of the name (e.g., Dr., Mr., Rev., M.D., etc.). Be sure to use the name as it appears on the patient’s Medicare card.

Non-Medicare Claims - Do not send claims for non-Medicare beneficiaries to your Medicare carrier.

D. Complete Address
U.S. Postal Addressing Standards - It is very important to meet the U.S. Postal addressing standards. Patient and provider information must be correct. This is necessary so that checks and Medicare Summary Notices (MSNs) or remittance notices arrive at the correct destination. It is also to ensure the quickest service to your office.

• A deliverable address may contain both a street name and number or a street name with a Post Office (P.O.) Box number.
• A P.O. Box by itself is acceptable.
• A Rural Route (RR) number must be with a box number. Note: It is incorrect to key P.O. in front of the box number when given with a rural route.
• A star route number is not a deliverable address. Use highway contract route (HC) instead of star route.
• RD numbers are no longer valid. If there are rural routes still existing in your area, the correct number should be preceded by RR, then the box number.
• A box number or a RR number by itself is not deliverable.
• A street name without a number can not be delivered.
• Do not use % or any other symbol when denoting an "in care of" address. C/O is appropriate.
• As always, no commas, hyphens, periods, or other special characters should be used.

Nursing Home or Skilled Nursing Facility Address - For a facility such as a nursing home or skilled nursing facility, it is preferred that a street name and number be supplied. In some cases, this information is not available, but if it is, please use it. Please verify the accuracy of your address before you send this information.

Apartment Complex - An apartment complex (words such as apartments, towers, or complex indicate such) should contain a street address and an apartment number. Again, this information is not always available, but should always be used when it exists.

Development Center / Trailer Park - If a development center or trailer park is given, it should contain the street address and number, if that information is part of the complete address.

" No Street Address" (NSA) - NSA (No Street Address) is not acceptable. This is not a deliverable address.

Changes to Provider Address - Please notify your carrier in writing of any address changes for your office practice.

E. Diagnosis and Procedure Codes
Make sure you keep current with valid diagnosis and procedure codes. HIPAA requires that Medicare conform to these standard code sets reported codes must be valid as of the date of service. Remember that Medicare can no longer allow a grace period for using deleted codes.

Additional Information

Medicare Claims Processing Manual
The Medicare Claims Processing Manual (Publication 100-04) contains detailed instructions on Medicare’s claims processes and detailed information on preparation and submission of claims. This manual is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.

MLN Matters
MLN Matters is a series of articles that CMS prepares especially for providers. These articles provide information on new and/or deleted procedure and diagnosis codes, changes to the Medicare Physician Fee Schedule and other changes that impact physicians and providers. These articles are available at http://www.cms.hhs.gov/MLNMattersArticles/ on the CMS Web site.

Listservs
Listservs are electronic mailing lists that CMS uses to get new information into the hands of physicians and providers as quickly as possible. To get your Medicare news as it happens, join the appropriate listserv(s) at http://www.cms.hhs.gov/apps/mailinglists/ on the CMS Web site.

If you have any questions, please contact your carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Flu Shot Reminder

It’s Not Too Late to Give and Get a Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember - influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: SE0712
Related Change Request (CR) # N/A
Effective Date: N/A

Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.