10 Tips for Clean Claims
- By Renee Dustman
- In Billing
- May 1, 2023
- No Comments
Don’t let avoidable errors muck up your revenue cycle.
A clean claim is one that does not require the payer to investigate or develop the claim before it can fully process it. The claim is received on time, passes all edits, is appended with any required medical evidence and supporting documentation, and includes all the basic information necessary for the payer to adjudicate the claim.
Here are 10 tips for ensuring your Medicare Part B claims are squeaky clean.
1 – Credential Providers
Providers and suppliers of durable medical equipment must have a national provider identifier (NPI) and be enrolled in Medicare before they can bill Medicare. For details, see Medicare Program Integrity Manual, Pub. 100-08, Chapter 15 – Medicare Enrollment.
2 – File the Right Claim Form
Part B claims are submitted electronically or via the CMS-1500 paper form. The Administrative Simplification Act requires providers to submit claims electronically unless they meet an exception such as fewer than 10 full-time employees, roster billers, dental claims, etc.
Use the Centers for Medicare & Medicaid Services (CMS) Administrative Simplification Compliance Act Self Assessment tool to determine if you are required to submit claims electronically (see Resources for link).
3 – Get the Dates Right
You can use either a six- or eight-digit format (MMDDYY or MMDDCCYY) for all dates, but be consistent. The exception is the patient’s birthdate, which must always be eight digits. Regardless of whether you use six or eight digits, on the CMS-1500, you must enter a space between the month, day, and year (e.g., 05|01|23 or 05|01|2023).
Generally, you must enter the exact date a service is rendered. For care plan oversight, enter the last date of the month or the date on which at least 30 minutes of time was completed. For home health certification dates of service, enter the date the physician or nonphysician practitioner (NPP) completed and signed the plan of care.
4 – Know Your Options
On the CMS-1500 claim form, there are fields that are required, conditional, and optional. There are also fields that must be left blank. For example, items 1-8 are patient demographics and are required fields. Not only must you complete these fields, you must also make sure to enter the information exactly as it appears on the patient’s Medicare card.
An example of a conditional field is item 17. All physicians and NPPs who order services or refer Medicare beneficiaries must complete fields 17 and 17b. If Medicare policy requires it, you will alternatively use these fields to enter the name of the supervising physician for the service(s) rendered and their NPI. Leave 17a blank.
Block 19 of the CMS-1500 claim form (or electronic equivalent) is another required field when reporting Not Otherwise Classified (NOC) codes. You must enter the description of the NOC code into block 19 or the claim will be denied.
Reporting information in the shaded areas located in fields 17a, 24j, 32b, and 33b could cause your claim to be rejected, according to Novitas Solutions, a Medicare Administrative Contractor (MAC).
5 – Identify Who’s on First
Medicare cannot pay a claim that has already been paid or is expected to be paid by a primary plan. When Medicare is the secondary payer, submit the claim to the primary payer first. On the CMS-1500, enter the primary payer’s information in fields 4, 6, 7, 10, and 11-11c (11d is not required). If Medicare is the primary payer, enter “None” in field 11.
6 – Sequence and Point to Diagnosis Codes Correctly
Field 21 on the CMS-1500 claim form is where you list the diagnosis codes related to line items in block 24. It’s important to list the diagnoses in order of priority. Also make sure the diagnosis code reference letter in block 24E points to the correct diagnosis code in field 21.
Tip: ICD-10-CM codes appear in your code book or coding software with decimal points (eg., 59.01). Do not use a period or any other special character on the CMS-1500 claim form.
It’s a good idea to run claims through a “scrubber” before submitting them to the payer. Scrubber software can be used to catch problems that could keep your claims from being held or denied.
7 – Check Units of Service
A common billing error is calculating the number of units incorrectly. Read the code descriptors carefully — some indicate “per day,” which means that only one unit can be billed on the date of service no matter how many times the service was performed that day.
8 – Identify the Billing and Rendering Providers
If the billing provider is different from the provider who is rendering the services, note both on the claim. On the CMS-1500 claim form, enter the rendering provider’s NPI in the lower unshaded portion of 24j and the billing provider’s information and NPI in fields 33 and 33a.
9 – Don’t Forget the Signature!
The patient or authorized representative must sign and date the claim unless the signature is on file. The patient’s signature or the statement “signature on file” authorizes payment of medical benefits to the physician or supplier.
10 – File Claims on Time
Submit claims to the MAC no later than 12 months, or one calendar year, after the date the services were furnished. For exceptions, see Medicare Claims Processing Manual, Pub. 100-04, Chapter 1, Section 70.7.
Mark your calendars! 2024 is a leap year, which means claims for services furnished on Feb. 29, 2024, must be filed by Feb. 28, 2025, to be considered timely.
CMS Administrative Simplification Compliance Act Self Assessment;
Medicare Claims Processing Manual, Pub. 100-04, Chapter 1, Sections 70.7, 80.2; www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf
Medicare Program Integrity Manual, Pub. 100-08, Chapter 15 – Medicare Enrollment; www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c10.pdf
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