Preventive Service Claims Erroneously Denied

The Centers for Medicare & Medicaid Services (CMS) says it has identified a Medicare claims processing system issue that is causing certain preventive services rendered in the outpatient hospital setting to be processed incorrectly. The following information provides the action that will be taken by Medicare claims administration contractors:

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  • Hospital Outpatient Prospective Payment System (OPPS) claims containing surgical procedure codes 10000-69999 with the PT modifier submitted on type of bill (TOB) 13X with dates of service on or after Jan. 1, 2011, are being suspended due to deductibles being incorrectly applied. Medicare contractors have been instructed to hold claims impacted by this problem. A software correction is scheduled for July 2011.
  • Hospital OPPS claims with dates of service on and after Jan. 1, 2011 containing hepatitis B vaccine administration HCPCS Level II code G0010 are incorrectly receiving deductible and coinsurance. Medicare contractors have been instructed to hold claims impacted by this problem. A software correction is scheduled for July 2011.
  • Hospital outpatient (13X TOB) claims with dates of service on or after Jan. 1, 2011, containing CPT® codes 90740, 90743, 90744, 90746, and 90747 are not being paid. Medicare contractors have been instructed to hold claims impacted by this problem until a correction is implemented. A software correction is scheduled for this month.

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