Top Claims Submission Errors

Surname and Health Insurance Claim Number(HIC) do not match Social Security Administration (SSA) records

or

Sex and first initial disagree with SSA records

National Government Services receives numerous claims that are submitted with invalid or incorrect Health Insurance Claim (HIC) numbers. These claims require manual intervention and can sometimes result in beneficiaries receiving incorrect Medicare Summary Notice (MSN) 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. Also, keep in mind you must enter the beneficiary’s name EXACTLY as it is indicated on their Medicare card.

Performing provider not on file

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.)

Invalid Unique Provider Identification Number (UPIN)

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.

Date(s) of service prior to effective date or after end date of procedure codes

Claims are being submitted with deleted procedure codes. This information can be found in the Current Procedural Terminology (CPT) Book. It is important to use current CPT book.

The Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set Rule require providers to use the medical code set that is valid at the time that the service is provided.

CMS will no longer allow a 90-day grace period for providers to learn about the discontinued HCPCS codes. Providers should be aware that effective January 1, 2005, Carriers no longer accept discontinued HCPCS codes for dates of service January 1 through March 31 of the current year (beginning in 2005) that are submitted prior to April 1. In addition, effective January 1, 2005, CMS will no longer allow a 90-day grace period for discontinued codes resulting from any mid-year HCPCS updates.

In order for providers to know about the new, revised, and discontinued numeric CPT-4 codes for the upcoming year, they should obtain the American Medical Association’s CPT-4 coding book that is published each October. CMS posts on its Web site the annual alpha-numeric HCPCS file for the upcoming year. The CMS Web site to view the annual HCPCS update is http://www.cms.hhs.gov/providers/pufdownload/anhcpcdl.asp .

Physicians, providers, and suppliers should be aware that Medicare systems will reject discontinued codes, beginning on January 1 of each year if the codes were not effective on the date of service. Such claims will be returned to the submitter for correction.

Modifier invalid

Check the validity of the procedure code/modifier combination in the following resources (this is not an all inclusive list):

• Current Procedural Terminology (CPT) guidelines
• National Government Services (NGS) Local Cover Determination if applicable.
• CMS Physician Fee Schedule Look up located on CMSs website. http://www.cms.hhs.gov/PFSlookup  

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. )

Zip code not on file, detail-jurisdictional pricing

Item 32 (and the electronic claim equivalent) require 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.

CLIA number invalid

Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988, establishing quality standards for all non-research laboratory testing performed on specimens derived from humans for the purpose of providing information for the diagnosis, prevention, treatment of disease, or impairment of, or assessment of health. CLIA requires that laboratories performing these types of tests be certified by the Secretary of the Department of Health and Human Services (DHHS).

Report the CLIA number in Item 23 of the CMS-1500 claim form or its electronic equivalent for each line of service rendered.

Physical therapy claims

Physical Therapy claims must be submitted with the appropriate modifier

GN Services delivered under an outpatient speech-language pathology plan of care

GO Services delivered under an outpatient OT plan of care

GP Services delivered under an outpatient PT plan of care

Multiple performing providers

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 24J on the CMS 1500 (08/05), 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.)