Rhonda Buckholtz, CPC--Avoid 7 Common Medicare Billing Errors -- Here's How
Take a few simple steps to ensure clean claims and proper payments The Administrative Simplification Compliance Act requires that you electronically submit all initial Medicare claims for reimbursement as of Oct. 16, 2003 (except from small providers with limited exceptions). Of course, what this means in our world is not always simple. Processing the changes and information that come our way on a daily basis is difficult, and claim resubmission can be a constant frustration. But it doesn't have to be difficult if you know where to quickly find the information. CMS has come a long way in instructing our carriers regarding how to process claims and also, unfortunately, when to return them to us for errors. The following is a list of the most common errors encountered by Medicare and some tips on how you can avoid them. You can discover more about these on the CMS Web site (www.cms.gov) in the To ensure proper claim payment, you must append the correct alphabetical suffix to each HICN. And you should never use hyphens or dashes in the number.
2. Line item 32 requires that you indicate the place where the provider actually rendered the service to the patient, including the name and address -- and a valid ZIP code -- for all services unless it was in the patient's home.
Be aware 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. In addition, using the term "same" in these blocks is not allowed. On the other hand, a star route number is not a deliverable address, and RD numbers are no longer valid. If rural routes still exist in your area, the correct number should be preceded by RR, and then the box number.
3. Include the referring or ordering physician's name and UPIN on the claim.
You must include this information in item 17 and 17a on all diagnostic services, including consultations. Don't forget the new requirements for using National Provider Identifiers (NPIs). When you bill services for more than one provider within your group, you must put the individual provider number in item 24k because item 33 can accept only one individual provider number. Also, make sure the provider number on the claim is accurate and that it belongs to the group. For example, when you submit 99283 (
5. Diagnosis codes you use may be either invalid or truncated.
If a carrier considers diagnosis codes invalid, this is usually because the coder is adding an extra digit to make it five digits. All codes are not created equal. Make sure to code to the highest level of specificity.
Tip: You should update your encounter forms every year. The best time to do this is Oct. 1 of every year when the new diagnosis codes become effective.
Claims are being submitted with deleted procedure codes. AMA updates CPT every year in November to take effect Jan. 1, so make sure you're using the most up-to-date codes and modifiers. Did you find yourself in one of the above scenarios? It is not uncommon for any of us to be making one (or several) of the above-mentioned mistakes. Not having a global picture of where things are coming from or why we have to do things a certain way can be frustrating. We must hold ourselves accountable to our providers and to our carriers by submitting clean and accurate claims the first time around. Most of our larger carriers have posted their versions of clean claim requirements on their Web sites for us to now follow, and finding exactly what we're looking for is much easier for us. Being proactive by doing your research and learning the requirements of your different carriers can enable your practice to enjoy a consistent cash flow that allows for a sense of satisfaction and stability. --
HICN Is a Must-Have
Get the Full Address
Don't Omit UPIN/NPI
4. E/M procedure codes and the place of service (POS) do not match.
Make Sure You Have All the Digits
6. Procedure code or modifier was invalid on the date of service.
7. When Medicare is the secondary payer, you must complete items 11, 11a, 11b and 11c each and every time.
