Issue 2006-05, May 2006

What’s Preventing Your Electronic Claims From Being Accepted?

Institutional EDI regularly identifies the most frequent errors on electronically submitted claims. These edits are ANSI 837 Implementation Guide edits that prevent claims from being accepted into FISS. You would see these errors on your Inbound Reject Report.

Analysis of claims submitted from March 21, 2006 to April 18, 2006 shows the top 10 errors to be as follows:

PAYMNT SRCE CD NOT = MA

LOOP: 2000B SEGMENT: SBR ELEMENT: 09 QUALIFIER:

RESOLUTION: THE VALUE ‘MA’ IS REQUIRED FOR MEDICARE PART A.

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OTH DIAG CODE INVALID

LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BF

PRIN DIAG CODE INVALID

LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BK

ADMIT DIAG CODE INVALID

LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BJ

RESOLUTION: THE PHYSICIAN SHOULD CODE THE ICD-9-CM CODE THAT PROVIDES THE HIGHEST DEGREE OF ACCURACY AND COMPLETENESS. IN THE CONTEXT OF ICD-9-CM CODING, THE “HIGHEST DEGREE OF SPECIFICITY” REFERS TO ASSIGNING THE MOST PRECISE ICD-9-CM CODE THAT MOST FULLY EXPLAINS THE NARRATIVE DESCRIPTION OF THE SYMPTOM OR DIAGNOSIS. CONCERNING LEVEL OF SPECIFICITY, ICD-9-CM CODES CONTAIN EITHER 3, 4, OR 5-DIGITS. IF A 3-DIGIT CODE HAS 4-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 3-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION. IF A 4-DIGIT CODE HAS 5-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 4-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION.

UPDATED ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER IN APRIL/MAY OF EACH YEAR AS PART OF THE PROPOSED CHANGES TO THE HOSPITAL INPATIENT PROSPECTIVE PAYMENT SYSTEM, AND ARE EFFECTIVE EACH OCTOBER FIRST. PHYSICIANS, PRACTITIONERS, AND SUPPLIERS MUST USE THE CURRENT AND VALID DIAGNOSIS CODE THAT IS IN EFFECT BEGINNING OCTOBER 1, 2005. AFTER THE ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER, CMS PLACES THE NEW, REVISED, AND DISCONTINUED CODES ON THE FOLLOWING WEB SITE: HTTP://WWW.CMS.HHS.GOV/MEDLEARN/ICD9CODE.ASP THE UPDATED ICD-9-CM DIAGNOSIS CODES CAN ALSO BE VIEWED AT THE NATIONAL CENTER FOR HEALTH STATISTICS (NCHS) WEB SITE AT: HTTP://WWW.CDC.GOV/NCHS/ICD9.HTM.

PROVIDERS WITH AN OMNIPRO LOGON SHOULD USE INQUIRIES/ICD-9 IN FISS TO DETERMINE IF THE DIAGNOSIS YOU INTEND TO USE IS VALID BEFORE SUBMITTING THE CLAIM.

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DEPENDENT TO SUBSCRIBER IS NOT ALLOWED

LOOP: 2000C SEGMENT: PAT ELEMENT: 01 QUALIFIER:

RESOLUTION: THE ENCOMPASSING LOOP (2000C/HL SEGMENT) IS NEVER USED FOR MEDICARE. THE SUBSCRIBER AND THE PATIENT ARE ALWAYS THE SAME AND REPORTED IN THE 2000B LOOP (SUBSCRIBER LEVEL).

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SRCE ADMISSION CANNOT BE SPACES

LOOP: 2300 SEGMENT: CL1 ELEMENT: 02 QUALIFIER:

RESOLUTION: REQUIRED FOR ALL INPATIENT ADMISSIONS. REQUIRED ON MEDICARE OUTPATIENT REGISTRATIONS FOR DIAGNOSTIC TESTING SERVICES. VALID VALUE IS A NUMERIC CODE INDICATING THE SOURCE OF THE ADMISSION. FOR EMERGENCY, ELECTIVE OR OTHER TYPE OF ADMISSION: 1-PHYSICIAN REFERRAL, 2-CLINIC REFERRAL, 3-HMO REFERRAL, 4-TRANSFER FROM A HOSPITAL, 5-TRANSFER FROM A SKILLED NURSING FACILITY, 6-TRANSFER FROM ANOTHER HEALTH CARE FACILITY, 7-EMERGENCY ROOM, 8-COURT/LAW ENFORCEMENT, 9-INFORMATION NOT AVAILABLE.

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ATTN PHYS UPIN REQUIRED

LOOP: 2310A SEGMENT: REF ELEMENT: 02 QUALIFIER:

RESOLUTION: ALL CLAIMS THAT LIST A PHYSICIAN WHO HAS RENDERED SERVICES MUST INCLUDE THE PHYSICIAN’S UPIN. IF A PHYSICIAN DOES NOT HAVE HIS OR HER OWN UPIN AND IS IN THE PROCESS OF OBTAINING ONE, CMS ALLOWS THE USE OF “OTH000” AS A “SPECIAL USE” UPIN. “NPP000” IS NOT A VALID UPIN.

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TAXONOMY CODE IS INVALID

LOOP: 2310A SEGMENT: PRV ELEMENT: 03 QUALIFIER:

RESOLUTION: BEGINNING WITH ANSI ASC 837 VERSION 4010 A1, PRV SEGMENT IN BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION LOOP IS OPTIONAL IN INSTITUTIONAL CLAIMS. IF NOT REQUIRED FOR YOUR BILLING SITUATION, ELIMINATE THE SEGMENT COMPLETELY. IF USED, ENSURE THAT YOU ARE USING A VALID TAXONOMY CODE. A LIST OF VALID TAXONOMY CODES AS WELL AS OTHER CODE SETS CAN BE OBTAINED FROM WWW.WPC-EDI.COM.

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PAT REASON FOR VISIT IS INVALID

LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: ZZ

RESOLUTION: THE PHYSICIAN SHOULD CODE THE ICD-9-CM CODE THAT PROVIDES THE HIGHEST DEGREE OF ACCURACY AND COMPLETENESS. IN THE CONTEXT OF ICD-9-CM CODING, THE “HIGHEST DEGREE OF SPECIFICITY” REFERS TO ASSIGNING THE MOST PRECISE ICD-9-CM CODE THAT MOST FULLY EXPLAINS THE NARRATIVE DESCRIPTION OF THE SYMPTOM OR DIAGNOSIS. CONCERNING LEVEL OF SPECIFICITY, ICD-9-CM CODES CONTAIN EITHER 3, 4, OR 5-DIGITS. IF A 3-DIGIT CODE HAS 4-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 3-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION. IF A 4-DIGIT CODE HAS 5-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 4-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION.

UPDATED ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER IN APRIL/MAY OF EACH YEAR AS PART OF THE PROPOSED CHANGES TO THE HOSPITAL INPATIENT PROSPECTIVE PAYMENT SYSTEM, AND ARE EFFECTIVE EACH OCTOBER FIRST. PHYSICIANS, PRACTITIONERS, AND SUPPLIERS MUST USE THE CURRENT AND VALID DIAGNOSIS CODE THAT IS IN EFFECT BEGINNING OCTOBER 1, 2005. AFTER THE ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER, CMS PLACES THE NEW, REVISED, AND DISCONTINUED CODES ON THE FOLLOWING WEB SITE: HTTP://WWW.CMS.HHS.GOV/MEDLEARN/ICD9CODE.ASP. THE UPDATED ICD-9-CM DIAGNOSIS CODES CAN ALSO BE VIEWED AT THE NATIONAL CENTER FOR HEALTH STATISTICS (NCHS) WEB SITE AT: HTTP://WWW.CDC.GOV/NCHS/ICD9.HTM.

PROVIDERS WITH AN OMNIPRO LOGON SHOULD USE INQUIRIES/ICD-9 IN FISS TO DETERMINE IF THE DIAGNOSIS YOU INTEND TO USE IS VALID BEFORE SUBMITTING THE CLAIM.

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PAT REL 2 INS CANNOT BE SPACES

LOOP: 2000B SEGMENT: SBR ELEMENT: 02 QUALIFIER:

RESOLUTION: VALID VALUE IS 18. FOR MEDICARE, THE SUBSCRIBER IS ALWAYS THE SAME AS THE PATIENT. CLAIMS CONTAINING DATA IN THE PATIENT HIERARCHICAL LEVEL (2000C LOOP) WILL NOT BE PROCESSED.

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Watch the Medicare News Updates for our monthly analysis of IG errors and visit our Web site at www.empiremedicare.com, where we will be posting our findings in the future to help you improve the acceptance rate of your claim submissions.