Medicare Claim Errors: The Easy and the Common

Filing your Medicare claims correctly the right way every time saves time and money. Fortunately, correcting a simple mistake on a Medicare claim is easy. However, if your practice is among those making the most common errors Novitas has identified that result in rejected claims, you might need to invest in some training to avoid the resulting headaches.

The Easy 

If you need to correct a minor error on a claim, such as adding a modifier, you can do it with a phone call to Novitas, the Medicare contractor for Texas. Your claim will be corrected that day. Call (855) 252-8782, Monday through Friday, 8 am-4 pm (CT) to change such elements as: 

  • The number of services or units,
  • Diagnosis,
  • Certain modifiers (or add or delete them),
  • Procedure code,
  • Date of service, and
  • Place of service.

You may correct up to 10 claims per phone call. To get to the claims correction line at the above phone number, press 1 or say “claims” when prompted; at the next prompt, press 2 or say “claim correction.” You will need the following information to correct your claim:

  • The provider’s National Provider Identifier, provider transaction access number, and taxpayer identification number;  
  • Internal control number; and
  • Date of service.

If the claim is correctable, it is added to the shopping cart list. Otherwise, you will be given the reason why it is not correctable. Note that you cannot use the claims correction line to:

  • Add a procedure code or line of service to a claim (you’ll need to file a new claim for that), or 
  • Request services requiring the review of medical documentation or involving limitation of liability (requires a written appeals request).  

The Most Common 

Novitas identified the six top claim submission errors for Texas for December 2012. They are as follows (explanation of Medicare benefits message numbers are in parentheses), with tips on how to avoid them.

  1. “Noncovered charge(s).” (96) When you are not sure if a service is covered, refer to the Centers for Medicare & Medicaid Services Internet Only Manual, 100-02, Chapter 16 (PDF), General Exclusions from Coverage.
  2. “These are noncovered services because this is not deemed a ‘medical necessity’ by the payer.” (50) Be sure to follow Medicare guidelines, and national coverage determinations  and Novitas JH local coverage determinations (LCDs) for the service billed.
  3. “Duplicate claim/service.” (18) To prevent duplicate denials, allow Novitas sufficient time to process a claim before submitting a second. You can check claim status through the interactive voice response system at (855) 252-8782 to see if a claim was paid or is currently being processed.
  4. “Claim not covered by this payer/contractor.” (109) Another Medicare contractor processes or pays this service (e.g., a durable medical equipment, hospice-related, or Medicare Advantage service). You must send the claim to the correct payer/contractor.
  5. “Payment is adjusted when performed/billed by a provider of this specialty.” (172) This is most likely a scope-of-practice error; i.e., a nonphysician practitioner (NPP) providing services outside of his or her scope of practice. Refer to TMA’s Delegation of Duties webpage to help verify if the service is within the NPP’s scope. Also, check the Novitas JH LCDs for coverage information; they often indicate if any special certification is required for a service. If you believe the service should be covered, submit a redetermination stating why.
  6. “Claim denied as patient cannot be identified as our insured.” (31) Verify the name and Medicare number as it appears on the patient’s Medicare card.

Need help with coding and documentation in your practice? TMA Practice Consulting can bring a two-hour Coding and Documentation Training session to you. The session covers medical necessity, evaluation and management documentation guidelines, modifiers, and more. The training offers up to 2 AMA PRA Category 1 Credits™ per physician in the practice. For more information, email TMA Practice Consulting or call (800) 523-8776.

Published March 12, 2013

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