Part B Insider (Multispecialty) Coding Alert

Published on Tue Sep 22, 2020 PDF

Double check provider information before submitting claims.

There’s no denying that Medicare billing can be challenging, especially when a seemingly miniscule error can lead to unprocessable claims. Plus, hassles and confusion often ensue for the person tasked with fixing the claim.

We’ve put together a tough question and answer set on three common claims’ issues that plague Part B practices. Read on for detailed advice from the experts.

Know This CMS-1500 Rule

Question 1: Is it OK to scribble on a CMS-1500 claim form?

Answer 1: No. “Never write on a CMS-1500 form,” cautions Carolyn Henson with NGS Medicare in the August 25 webinar “Reducing Unprocessable Claim Rejections.” Unfortunately, the Part B Medicare Administrative Contractor (MAC) sees that a lot, Henson says.

The Centers for Medicare & Medicaid Services (CMS) explicitly outlines the dos and don’ts for the CMS-1500 in Chapter 26, Section 30 of the Medicare Claims Processing Manual, indicates Part B MAC WPS GHA. In fact, “claims that do not meet the CMS-1500 form specification requirements may be rejected and returned as unprocessable denials,” warns WPS online guidance.

Tip: Whether you’re typing up a paper version of CMS-1500 or plugging data into the electronic form, there are a few standards to keep in mind. You should not insert special characters like hyphens, parentheses, dittos, or dollar signs, NGS says. Bolding, underlining, and italicizing are also forbidden.

In addition, you should stick with one font type throughout; Times New Roman is preferred, according to WPS.

Understand the Basics on Unprocessable Claims

Question 2: Is it a good idea to appeal an unprocessable claim?

Answer 2: No. Not only is it not a good idea; it’s not possible.

If a claim is deemed unprocessable, the reopening unit won’t be able to handle it. “The CMS Internet-only Manual describes an unprocessable claim as any claim with incomplete or missing required information or any claim that contains complete and necessary information; however, the information provided is invalid,” NGS’ Gail O’Leary says. “Such information may either be required for all claims or required conditionally.”

Remark code: If your remittance advice lists MA130 as the reason code, then you know that the claim is unprocessable and a new claim needs to be submitted with correct and complete information.

Important: If your claim is rejected, “there are no appeal rights on this type of denial, because your claim was never actually processed, so there is nothing to appeal,” O’Leary explains. “Your only option is to correct your errors and resubmit the claim for processing.”

Check All Providers’ Specifics Before Submission

Question 3: What is one of the top reasons claims are registered unprocessable?

Answer 3: According to NGS, 29 percent of the Part B MAC’s claims were rejected due to provider data errors. Some of the top reasons include:

• Incorrect National Provider Identifiers (NPIs)
• Nicknames for the various providers instead of actual names
• Wrong organization listed
• Dates that don’t match the medical record
• Incorrect place of service (POS)

Tip: Before you submit Part B claims, you should review the documentation and identify the specifics on the referring, ordering, rendering, or attending physician. This includes cross referencing the providers’ information with the medical record and what’s in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).

Next, you may want to log into one of CMS’ many resource sites, NGS advises. These include the following:

• Data sets: For Medicare’s ordering and referring data files, you can check out the data sets, which offer a wealth of information on providers that can help you pinpoint claims data. Find out more at https://data.cms.gov.
• NPPES: If you need to make a query or differentiate NPI data, the National Plan and Provider Enumeration System (NPPES) is your best bet. NPPES “assigns NPIs, maintains and updates information about healthcare providers with NPIs, and disseminates the NPI Registry and NPPES Downloadable File,” says CMS. Log into NPPES at https://nppes.cms.hhs.gov/#/.
• POS code set: Your billing team may need to revisit Medicare’s POS code set for professional claims, NGS suggests. Check out CMS guidance on POS codes at www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.
• MAC website: You may want to look at your MAC’s guidance on filling out both the paper and electronic versions of the CMS-1500. Each jurisdiction has helpful online tools and interactive systems to guide you through the process.