Medicare Information Resource, Issue 2007-2A:What's Preventing Your Electronic Claims From Being Accepted?

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MIR-2007-2A, February 2007

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 837Implementation 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 December 01, 2006 to December 31, 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 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 URRENT 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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PRIN DIAG CODE INVALID

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

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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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 CCEPTABLE 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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STMT FROM DATE INVALID/MISSING DATE

LOOP: 2300 SEGMENT: DTP ELEMENT: 03 QUALIFIER: 434

RESOLUTION: THE CLAIM STATEMENT DATE IS REQUIRED AND MUST BE IN EITHER A SINGLE DATE FORMAT (CCYYMMDD) OR A DATE RANGE FORMAT (CCYYMMDD-CCYYMMDD).

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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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OTH PRV UPIN REQUIRED

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

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NPI# - INVALID

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

RESOLUTION: WHEN SUBMITTING THE LEGACY PROVIDER NUMBER IN THE 2310E LOOP, THE ‘1G’ QUALIFIER MUST BE USED. USING ANY OTHER LEGACY QUALIFIER, INCLUDING THE ‘1C’ QUALIFIER MAY CAUSE AN NPI ERROR BECAUSE THE SYSTEM DOES NOT RECOGNIZE ‘IC’ LEGACY PROVIDER AND PERCEIVES THAT THE NPI WAS THE ONLY IDENTIFIER SUBMITTED. IF THAT NPI IS NOT ON THE CMS CROSSWALK, THE ‘NPI# - INVALID’ ERROR WOULD THEN OCCUR.

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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 Out of Balance" posted on 09/18/06 on our Web site for INFORMATION ON HOW TO BALANCE CLAIMS CORRECTLY.

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DATE RANGE INVALID AT LINE LEVEL FOR TOB

LOOP: 2400 SEGMENT: DTP ELEMENT: 03 QUALIFIER:

RESOLUTION: UNLESS THE CLAIM IS A DRUG CLAIM, THE DTP02 SHOULD BE EQUAL TO ‘D8’. THE ‘RD8’ QUALIFIER SHOULD NOT BE USED FOR ANY TYPE OF BILL THAT IS NOT A DRUG CLAIM.

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Watch the Medicare Information Resource (MIR) for our monthly analysis of IG errors and visit our Web site at www.NGSMedicare.com where we will be posting our findings in the future to help you improve the acceptance rate of your claim submissions.