Optometry Coding & Billing Alert

Published on Fri Jun 20, 2008 PDF

Question: We are getting denials from Medicare saying they can't see box 32 in our claim forms. I-ve checked the name, address and provider numbers, and they are all correct. Why are we getting these denials, and how can we avoid them?

North Carolina Subscriber

Answer: If you-re sure you-ve included the proper name, address and NPI information on the claim, you-re likely falling victim to ZIP code errors. Effective Oct. 1, 2007, CMS started requiring that you bill with a nine-digit ZIP code on claims for physicians and providers who supply services in ZIP code areas that cross payment localities.

Where it goes: You should put the nine-digit ZIP code in box 32 of the CMS-1500 claim form or its electronic field equivalent.

The following services and locations would be the only exceptions to this new billing requirement, according to CMS:

- services provided in ZIP code areas that do not cross payment localities

- services provided in place of service "Home" (POS code 12) or any places of service that carriers consider the same as "Home" (which vary by payer, but may consist of such POSs as Group Home [14]).

Check yourself: If you should be submitting a nine-digit ZIP code on your claim but you only use the five-digit ZIP code, your carriers will return the claim as unprocessable every time. If an insurer returns your claim as unprocessable, check your denial reason against the following Remittance Advice and Remark codes:

- Reason Code 16 -- Claim/service lacks information that is needed for adjudication. Additional information is supplied using remittance advice remark codes whenever appropriate.

- Remark Code MA130 -- Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

- Remark Code MA114 -- Missing/incomplete information on where the services were furnished.

-- Answers to You Be the Expert, Reader Questions and Build a Better Business reviewed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas.