Rendering Provider NPI to PIN Relationship

Verify the correct NPI as assigned by the enumerator on the confirmation letter was reported. Verify the correct legacy number is listed in the “other identification numbers” field on the enumerator confirmation letter. Also verify that all other information matches exactly with legacy number. If not, go to Enumerator at: https://NPPES.cms.hhs.gov to add/revise the legacy number/information.

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

Deactivated Provider

Medicare will deactivate and identify providers who have not billed claims after four (4) consecutive quarters. Providers need to contact Customer Care at 1-888-855-4346 to reactivate their provider number.

9 Digit Zip Code required and not present or invalid

Medicare contractors have been directed to determine payment locality for services paid under the MPFS and anesthesia services by using the ZIP code on the claim of where the service was performed. CMS realizes that some ZIP codes fall into more than one payment locality. The CMS ZIP code file uses the convention of the United States Postal Service, which assigns these ZIP codes into dominant counties. In some cases, though the service may actually be rendered in one county, but per the ZIP code it is assigned into a different county. This causes a payment issue when each of the counties has a different payment locality and therefore a different payment amount.  

Make certain that your billing staffs are aware that Medicare requires the submission of nine-digit ZIP codes for services paid under the MPFS and anesthesia services, when the services are provided in those ZIP code areas listed in CR5208. Zip codes affected by this requirement can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5208.pdf