Medicare Information Resource, Issue 2007-1A:What’s Preventing Your Electronic Claims From Being Accepted?

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MIR-2007-1A, January 2007

What’s Preventing Your Electronic Claims From Being Accepted?

Institutional Electronic Data Interchange (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 November 01, 2006 to November 30, 2006 shows the top ten 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

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 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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DRG INVALID FOR OUTPATIENT

LOOP: 2300 SEGMENT: HI ELEMENT: 04 QUALIFIER: DR

RESOLUTION: DRG INFORMATION IS ONLY REQUIRED WHEN AN INPATIENT HOSPITAL IS UNDER DRG CONTRACT WITH A PAYER AND THE CONTRACT REQUIRES THE PROVIDER TO IDENTIFY THE DRG TO THE PAYER. DRG INFORMATION SHOULD NOT BE SENT FOR OUTPATIENT CLAIMS.

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PRIN DIAG CODE INVALID

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

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.

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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.

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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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 AN ICD-9-CM (INPATIENT) CODE IS BR. THE VALID QUALIFIER FOR A HCPCS/CPT (OUTPATIENT) CODE IS BP.

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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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NPI ID CODE IS NOT 10 NUMERIC DIGITS

LOOP: 2310A SEGMENT: NM1 ELEMENT: 09 QUALIFIER:

RESOLUTION: THE NPI SUBMITTED IN THE NM109 FOR THE ATTENDING PHYSICIAN MUST BE 10 NUMERIC DIGITS. ALPHA CHARACTERS ARE NOT VALID TO BE SUBMITTED AS AN NPI.

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OTH PRV UPIN REQUIRED

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

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PRIMARY PAYER CLAIM DOES NOT BALANCE

LOOP: 2320 SEGMENT: CAS ELEMENT: 01 QUALIFIER:

RESOLUTION: FOR CLAIMS SUBMITTED ON OR AFTER 12/11/2006 THIS EDIT IS A VALID EDIT. DURING THE ENTIRE MONTH OF NOVEMBER THERE WAS A PROBLEM IN STANDARD SYSTEM PROCESSING THAT CAUSED THIS ERROR TO ASSIGN FOR CLAIMS THAT DID INDEED BALANCE AS WELL AS TO ASSIGN FOR CLAIMS THAT DID NOT BALANCE. Please refer to Part A News item "MSP ut of Balance" posted on 09/18/06 on our Web site for INFORMATION ON HOW TO BALANCE CLAIMS CORRECTLY.

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Watch the Medicare Information Resource (MIR) 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.