American College of Physicians: Internal Medicine — Doctors for Adults ®

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Avoid the most common claims errors in Medicare billing

From the April ACP Internist, copyright 2013 by the American College of Physicians

By Debra Lansey

Periodically, the Medicare Administrative Contractors (MACs) name the top claims errors their organizations have encountered. Although the MACs provide claims processing services in different geographic regions, they see similar trends across the country.

There are many components to health insurance claims, so physician practices should always review the Medicare remittance advice for additional messages that will explain why any individual claim was rejected. In some instances, there may be more than one message that explains why the claim was rejected. Claims that are rejected or cannot be processed will also have an additional message on the remittance.

Avoid the most common claims errors in Medicare billing

The following list represents some of the most common errors seen on Medicare claims, which likely also occur on claims sent to private payers.

The claim is missing information that is needed for processing and/or payment. Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim cannot be processed. Please submit a new claim with complete/correct information.

This message directs physicians to the appeal rights for the individual claim along with the message to submit the claim with corrected information. The practice’s next steps are to review the claim carefully, research the patient record to determine the missing information, and then resubmit the claim in a timely fashion.

The claim is a duplicate claim for service.

MACs define a duplicate claim as when a physician resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same physician to the same beneficiary for the same service/item for the same date(s) of service. If the original claim is in a processing status at the MAC, do not resubmit the claim; the second claim will be denied as a duplicate.

Review your practice’s billing process to avoid automatic resubmissions of claims. If claims are repeatedly and significantly rebilled, the Medicare system could potentially identify a physician as an abusive biller, or it could result in an investigation for fraud if a pattern of duplicate billing is identified.

Pay close attention to your remittance advice to determine if the denied claim(s) should be resubmitted or appealed. Make sure that your billing staff or third-party billing service knows the Medicare payment floors and claims filing rules.

The referring physician’s primary identifier is missing or is invalid.

If it’s applicable, be sure that the referring physician’s National Provider Identifier (NPI) is present on the claim. If the service was ordered or referred by a physician, the NPI of the referring/ordering physician should be listed in item 17b of the CMS-1500 form.

The place of service code (POS) is invalid or inconsistent with the billed procedure code.

To avoid this type of error, physicians should verify that they are reporting the POS code that applies to the setting in which the service was provided and that the submitted procedure code is compatible with that POS. For example, office or other outpatient services (CPT codes 99201-99215) should be billed with POS codes 11 (office) or POS code 22 (outpatient hospital). Home-based services (CPT codes 99341-99350) should be billed with POS code 12 (home).

The claim lists an invalid patient name.

Remember to submit claims with the patient’s name listed exactly as it appears on his or her Social Security card. This includes any prefixes, suffixes, apostrophes, hyphens or spaces. If the beneficiary has had a name change that is not reflected on the Social Security card, the name still has to be submitted as on the card until an update has been made with the Social Security Administration.

More information about how to comply with Medicare coding rules and how to avoid errors is available at the website of each of the Medicare Administrative Contractors; once there, conduct a search for “claims errors.”

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Additional resources

Claim Adjustment Reason Codes (CARCs): Washington Publishing Company.

Place of service (POS) codes: For a complete listing of place of service codes and definitions, refer to the current CPT code book, or to the CMS Internet Online Manual, Pub.100-04, Medicare Claims Processing, Chapter 26, Section 10.

Avoiding duplicate claims: Medicare Learning Network (MLN) Special Edition article SE0415 titled “Reminder to Stop Duplicate Billings,” April 29, 2004.

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