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 July 1, 2006 to July 31, 2006 shows the top 10 errors to be as follows: 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. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PAYMNT SRCE CD NOT = MA LOOP : 2000B SEGMENT: SBR ELEMENT: 09 QUALIFIER: RESOLUTION: THE VALUE 'MA' IS REQUIRED FOR MEDICARE PART A. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 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). * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ICD9 PRIN PROC CODE INVALID FOR TOB LOOP: 2300 SEGMENT: HI ELEMENT: 01 QUALIFIER: BP RESOLUTION: THE ICD-9-CM PROCEDURE CODES WERE NAMED AS THE HIPAA STANDARD CODE SET FOR INPATIENT HOSPITAL PROCEDURES. THE HCPCS/CPT CODES WERE NAMED AS THE HIPAA STANDARD CODE SET FOR PHYSICIAN SERVICES AND OTHER HEALTH CARE SERVICES. THE FOLLOWING BILL TYPES ARE CONSIDERED INPATIENT: 11X, 12X, 18X, 21X, 22X, 41X. THE FOLLOWING BILL TYPES ARE CONSIDERED OUTPATIENT: 13X, 14X, 23X, 24X, 32X, 33X, 34X, 71X, 72X, 73X, 74X, 75X, 76X, 81X, 82X, 83X, 85X. THE VALID QUALIFIER FOR ICD-9-CM (INPATIENT) CODES IS BR. THE VALID QUALIFIER FOR HCPCS/CPT (OUTPATIENT) CODE IS BP. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PRIN DIAG CODE INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BK ADMIT DIAG CODE INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BJ PAT REASON FOR VISIT IS INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: ZZ OTH DIAG CODE INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BF 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.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * ATTN ETQ MUST BE 1 LOOP: 2310A SEGMENT: NM1 ELEMENT: 02 QUALIFIER: 71 RESOLUTION: WHEN REPORTING A QUALIFIER OF 71 FOR THE ATTENDING PHYSICIAN, THE ENTITY TYPE QUALIFIER (ETQ) NEEDS TO BE 1 FOR PERSON.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * PAYMNT SRCE CD INVALID/MISSING DATA LOOP : 2320 SEGMENT: SBR ELEMENT: 09 QUALIFIER: RESOLUTION: IF OTHER PAYERS ARE IDENTIFIED AS MAKING PAYMENT ON THE CLAIM OR IF REPORTING COB DATA, THE VALUE IN SBR09 MUST BE A VALID VALUE AS IDENTIFIED IN THE 837 IMPLEMENTATION GUIDE.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * Watch the Medicare Information Resource Supplement 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. |
