National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Response to Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals Claims When the Medicare System Common Working File (CWF) 69XD Error Code is Received

Provider Types Affected
Participating CAP physicians and other providers billing Medicare carriers or Medicare Administrative Contractors (A/B MAC) for Part B drugs and biologicals under the Competitive Acquisition Program (CAP)

Provider Action Needed
Impact to You
If you submit the same prescription order number more than once on a single CAP claim, your carrier or A/B MAC will return the entire claim as unprocessable.

What You Need to Know
CR 5658, from which this article is taken, instructs carriers and A/B MACs to return as unprocessable CAP claims received with duplicate prescription order numbers.

What You Need to Do
Make sure that your billing staff is aware that they should not submit the same prescription order number more than once on a CAP claim, nor should they use the JW modifier on CAP claims, per CR5658.

Background
Carriers and A/B MACs receive an error code when the same prescription order number is submitted more than once on a CAP claim. This inclusion of duplicate prescription order numbers on a single claim can happen, for example, when:

• The provider is coding wastage of the drug using the JW modifier, and has repeated the prescription order number on the wastage line;
• The units provided for the drug exceed 999 and the balance of the units are coded on an additional line with a repeat of the prescription order number; or
• The provider has submitted more than one line on the same claim with the same or different dates of service using the same prescription order number (even when the units do not exceed 999).

In response to this error code, carriers and A/B MACs will return the claims as unprocessable, using the following Remittance Advice Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC) messages:

• CARC 16: Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remark codes whenever appropriate. This change to be effective April 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).
• Message MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.
• New RARC N389: Duplicate prescription number submitted.
• RARC M16: Please see our website, mailings, or bulletins for more details concerning this policy/procedure/decision.

In order to resolve the issue of units that exceed 999, the Centers for Medicare & Medicaid Services (CMS) will be working with the approved CAP vendor to issue additional prescription order numbers when the units of the drug exceed 999.

Finally, CR 5658 rescinds (from CR 4309, issued on February 17, 2006) the instructions that addressed applying the unused drug modifier (JW) to indicate billing for the unused portion of a single-use drug product under the CAP. Claims for drugs provided under CAP submitted with the JW modifier will be treated as unprocessable. This CR does not affect the use of the JW modifier for non CAP claims.

Additional Information
You can find the official instruction, CR5658, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1313CP.pdf 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.

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: MM5658
Related Change Request (CR) #: 5658
Related CR Release Date: July 23, 2007
Effective Date: August 23, 2007
Related CR Transmittal #: R1313CP
Implementation Date: August 23, 2007

News Flash – PQRI Tool Kit Available
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) Tool Kit is now available. To access the Tool Kit, visit the PQRI Web page at http://www.cms.hhs.gov/PQRI on the CMS Web site, then go to the PQRI Tool Kit section. To access all of the other resources you need to assist in successful reporting, go to the Educational Resources section of the previously mentioned Web site.