Novitas identified the top Medicare claim submission errors for Texas the first quarter of 2013. These three on the list are new compared with those reported in December 2012. Here are tips on how to avoid the errors (explanation of Medicare benefits message numbers are in parentheses):
- “Patient/insured health identification number and name do not match.” (140) Verify the name and number as they appear on the patient’s red, white, and blue Medicare card, and double-check that the patient’s health insurance claim number (also on the card) was keyed in correctly. Periodically updating your patients’ information can help avoid this type of error.
- “Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.” (45) This code is associated with the multiple-procedure payment reduction for selected therapy services. See MLN Matters No. MM7050 (PDF).
- “The benefit for this service is included in the payment/allowance for another service or procedure that has already been adjudicated.” (97) Verify whether the service being billed is bundled into payment for another service, is considered part of a global surgical package, or is part of a more comprehensive service already billed. Refer to the Medicare National Correct Coding Initiative (NCCI) edits and guide (PDF). The edits update quarterly so make sure you are using the current physician edits. You will find them under Related Links section of the NCCI edits page.
TMA’s payment advocacy staff report that in a recent conference call, Medicare officials stressed the ongoing problem of duplicate claims. Be sure to allow Novitas sufficient time to process a claim before submitting a second. You can check claim status through the interactive voice response (IVR) system at (855) 252-8782 to see if a claim was paid or is currently being processed.
You also can identify duplicate claims through the IVR, which will tell you about claims on file for a date of service. After listening to a duplicate-claim denial, say “next claim” to hear the status of the next claim for this date. Keep listening to each duplicate claim until you hear the status of the original claim denial. Consult the IVR Guides if you need help navigating the system.
Should You Resubmit or Appeal?
When you receive a Medicare claim rejection from Novitas (code MA130), it means the claim contains information that is incomplete or invalid. There are no appeal rights. You should submit a new claim with correct and complete information.
MA130 — “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is not able to be processed. Please submit a new claim with the complete / correct information.”
You will receive a Medicare claim denial (code MA01) if the service or procedure billed was deemed the not medical necessary/not covered under Medicare. For these claims, you have the right to appeal.
MA01 — “If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.”
Remember LCDs, NCDs
When billing for Medicare services, be sure to follow Novitas’ local coverage determinations (LCDs) (select the “JH” region, and search by code and/or term) and CMS’ national coverage determinations (NCDs). You also can search for retired LCDs from TrailBlazer Health Enterprises, the previous Medicare contractor for Texas. When searching archived LCDs, select the appropriate date of service, and choose “Retired — Trailblazer Health Enterprises, LLC (04402, MAC — Part B)” from the drop-down menu. In addition, refer to the CMS Internet Only Manuals (IOM) for specific Medicare billing and coverage information, as well as Novitas’ Medical Policy Center for additional resources.
If you have questions or need guidance on a Medicare claim, call the TMA Billing and Coding hotline at (800) 880-1300, ext. 1414, to talk to a TMA reimbursement specialist, or email firstname.lastname@example.org. Also, ask your county medical society about scheduling a free TMA 30-Minute Billing Cure session in your area.
Need coding and documentation training for you or your staff? TMA Practice Consulting can bring a two-hour training session to you. It covers medical necessity, evaluation and management documentation guidelines, modifiers, and more, and 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 July 9, 2013
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