Wiki Duplicate denials please help!

[lisaevans]

Hi! I'm pretty new to gastro billing/coding and I have an issue. Medicare HMO's deny our professional claim as a duplicate to our ASC claim (or vice versa) on a regular basis. They recoup on paid claims for this reason, too. We have to bill the HMO's the same way that we bill Medicare, so both claims go out on a CMS-1500. What, if anything, can I do to prevent this denial from occurring? In many instances my appeal of the duplicate denial or recoupment is denied, as well, even though I explain it to the "T" with examples. Please help! Thanks!!

 

[bdobyns]

Look into billing the ASC claims out on the UB-04 (UB-92 Electronic equivalent) with the type of bill code 831 for ASC, that should eliminate your problem. If this is not possible review your ASC contracts to ensure that you can bill the facility on the CMS-1500 form but you will need to utilize the SG modifier to let the carrier know that you are billing for the ASC.

 

[bridgettrager1]

Make sure you check box24J and 33A on the CMS 1500 to make sure your NPI is in both box.es It has been my experience when changing the form from a UB 04 to a CMS 1500 sometimes it will put the referring provider's NPI in 33A instead of your facility, especially if it is Advantx. You can also tell if this has happened by looking at your EOB to see if the correct NPI is on it. Also, if you have a secondary claim cross from Medicare, depending on the carrier, you may have to refile the secondary on a UB 04. Hope this helps.

 

[lisaevans]

Thank you!