Friday, September 30, 2016

Billing tips for Laboratory claims in CMS 1500

 For independent laboratory claims:

1. Involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if the claim does not contain a validation from the prescribing physician that any laboratory service(s) performed were conducted at home or in an institution by entering the appropriate annotation in item 19 (i.e., “Homebound”). (Remark code MA116 is used.)

2. If the name, address, and ZIP Code where the test was performed is not entered in item 32, if the services were performed in a location other than the patient’s home or physician’s office. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.

3. When a diagnostic service is billed as an anti-markup service and the service is purchased from another billing jurisdiction, the billing physician or supplier must submit the name, address, and ZIP Code of the performing physician or supplier in Item 32, and the NPI of the performing physician or supplier in Item 32a. If Items 32 and 32a are not entered, remark code MA114 is used.


For all laboratory services, if the services of a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a. or if the NPI is not entered in item 17b. of the Form CMS-1500. (Remark code N264 or N286 is used.)

 For laboratory services performed by a participating hospital-leased laboratory or independent laboratory in a hospital, clinic, laboratory, or facility other the patient’s home or physician’s office (including services to a patient in an institution), if the name, address, and ZIP Code of the location where services were performed is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.


For all laboratory work performed outside a physician’s office, if the claim does not contain a name, address, and ZIP Code for where the laboratory services were performed in item 32 or if the NPI is not entered into item 32a of the Form CMS-1500 if the services were performed at a location other than the place of service home – 12. (Use Remark code MA114)


For all physician office laboratory claims, if a 10-digit CLIA laboratory identification number is not present in item 23. This requirement applies to claims for services performed on or after January 1, 1998. (Remark code MA120 is used.)

Tuesday, September 27, 2016

Billing tips for dialysis patient capitation payment - code N290

For physicians who maintain dialysis patients and receive a monthly capitation payment:

1. If the physician is a member of a professional corporation, similar group, or clinic, and the NPI is not entered into item 24J of the Form CMS-1500. (Remark code N290 is used.)

2. If the name, address, and ZIP Code of the facility other than the patient’s home or physician’s office involved with the patient’s maintenance of care and training is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.

B. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or ASC) and the group’s name, address, and ZIP Code is not entered in item 33 or if the NPI is not entered in item 33a of the Form CMS-1500, if their personal NPI is not entered in item 24J of the Form CMS-1500. (Remark code MA112 is used.)

C. For durable medical, orthotic, and prosthetic claims, if the name, address, and ZIP Code of the location where the order was accepted were not entered in item 32. (Remark code MA 114 is used.)


E. For routine foot care claims, if the date the patient was last seen and the attending physician’s NPI is not present in item 19. (Remark code N324 or N253 is used.)

F. For immunosuppressive drug claims, if a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist was used and their name is not present in items 17 or 17a., or if the NPI is not entered in item 17b. of the Form CMS-1500. (Remark code N264 or N286 is used.)

Saturday, September 24, 2016

Remark code MA114 - CMS 1500 Item 32 - Facility address tips to print

If the name, address, and ZIP Code of the facility where the service was furnished in a hospital, clinic, laboratory, or facility other than the patient’s home or physician’s office is not entered in item 32 (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered. (Remark code MA114 is used.)

Effective for claims with dates of service on or after October 1, 2007, the name, address, and 9-digit ZIP Code of the service location for services paid under the Medicare Physician Fee Schedule and anesthesia services, other than those furnished in place of service home – 12, and any other places of service A/B MACs treat as home, must be entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1. (Remark code MA114 is used.)

Effective for claims with dates of service on or after October 1, 2007, for claims received that require a 9-digit ZIP Code with a 4 digit extension, a 4-digit extension that matches one of the ZIP9 file or a 4-digit extension that can be verified according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1 must be entered on the claim. (Remark code MA114 is used.)

Effective January 1, 2011, for claims processed on or after January 1, 2011, on the Form CMS-1500, the name, address, and 5 or 9-digit ZIP code, as appropriate, of the location where the service was performed for services paid under the Medicare Physician Fee Schedule and anesthesia services, shall be entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1 for services provided in all places of service. (Remark code MA114 is used.)

Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of the ASC X12 837 professional electronic claim format for services payable under the MPFS and anesthesia services when rendered in POS home (or any POS they consider home) if submitted without the service facility location. (Remark code MA114 is used.)

Tuesday, September 20, 2016

UB 04 Clean claim submission

UB-04 clean claim submission - Minimum required field

The UB-04 form (previously known as the UB-92 and CMS-1450 claim forms) captures essential data elements for providers of services in institutional/inpatient/facility settings. The form can be used to bill Medicare fiscal intermediaries, Medicaid state agencies and health plans/insurers. The required elements of a clean claim must be  complete, legible and accurate.

In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the UB-04 claim form.

• Provider’s name, address and telephone number (field 1);
• Patient control number (field 3);
• Type of bill code (field 4);
• Provider’s federal tax ID number (field 5);
• Statement period (beginning and ending date of claim period) (field 6);
• Patient’s name (field 8);
• Patient’s address (field 9);
• Patient’s date of birth (field 10);
• Patient’s gender (field 11);
• Date of admission (field 12);
• Admission hour (field 13);
• Type of admission (e.g. emergency, urgent, elective, newborn) (field 14);
• Source of admission code (field 15);
• Patient-status-at-discharge code (field 17);
• Value code and amounts (fields 39-41);
• Revenue code (field 42);
• Revenue/service description (field 43);
• HCPCS/Rates (current CPT or HCPCS codes are required) (field 44);
• Service date (field 45), (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required);
• Units of service (field 46);
• Total charge (field 47);
• HMO or preferred provider carrier name (field 50);
• Type 2 main NPI number (field 56);
• Subscriber’s name (field 58);
• Patient’s relationship to subscriber (field 59);
• Insured’s Unique ID (field 60);
• Principal diagnosis code (ICD-10 codes are required effective 10/1/15) (field 67);
• Rendering provider Type 1 NPI (field 76-79); and
• Attending physician ID (field 76-79).


Data elements: Unless otherwise agreed by contract, the data elements contained in this paragraph are necessary for claims filed by physicians or providers if circumstances exist which render the data elements applicable to the specific claim being filed. The applicability of any given data element contained in this paragraph is determined by the situation from which the claim arose.

(1) Discharge hour (UB-04, field 16), is applicable if the patient was an inpatient, or was admitted for outpatient observation;

(2) Condition codes (UB-04, fields 18-28 are applicable if the CMS UB-04 manual contains a condition code appropriate to the patient’s condition;

(3) Occurrence codes and dates (UB-04, fields 31-34), are applicable if the CMS UB- 04 manual contains an occurrence code appropriate to the patient’s condition;

(4) Occurrence span code, from and through dates (UB-04, field 36), is applicable if the CMS UB-04 manual contains an occurrence span code appropriate to the
patient’s condition;

(5) HCPCS/Rates (UB-04, field 44), is applicable if Revenue Code description used does not adequately describe service provided or if Medicare is a primary or
secondary payer;

(6) Prior payments – payer and patient (UB-04, field 54), is applicable if payments have been made to the physician or provider by the patient or another payer or
subscriber, on behalf of the patient or subscriber, or by a primary plan;

(7) Diagnoses codes other than principle diagnosis code (UB-04, fields 67), is applicable if there are diagnoses other than the principle diagnosis and ICD-10
code is required effective 10/1/15;

(8) Ambulance trip report, submitted as an attachment to the claim; and

(9) Anesthesia report is applicable to report time spent on anesthesia services.

Saturday, September 17, 2016

Form CMS-1500 Items Affected the reporting


Item 3 - Patient’s Birth Date

Item 9b - Other Insured’s Date of Birth

Item 11a - Insured’s Date of Birth

Note that 8-digit birth dates, when provided, must be reported with a space between month, day, and year (i.e., MM_DD_CCYY). On the Form CMS-1500, the space between month, day, and year is delineated by a dotted, vertical line.

If a birth date is provided in items 3, 9b, or 11a, and is not in 8-digit format, carriers must return the claim as unprocessable. Use remark code N329 on the remittance advice. For formats other than the remittance, use code(s)/messages that are consistent with the above remark codes.

If carriers do not currently edit for birth date items because they obtain the information from other sources, they are not required to return these claims if a birth date is reported in items 3, 9b, or 11a. and the birth date is not in 8-digit format. However, if carriers use date of birth information on the incoming claim for processing, they must edit and return claims that contain birth date(s) in any of these items that are not in 8-digit format.

For certain other Form CMS-1500 conditional or required date items (items 11b, 14, 16, 18, 19, or 24A.), when dates are provided, either a 6-digit date or 8-digit date may be provided.

If 8-digit dates are furnished for any of items 11a., 14, 16, 18, 19, or 24A. (excluding items 12 and 31), carriers must note the following:
• All completed date items, except item 24A., must be reported with a space between month, day, and year (i.e., MM_DD_CCYY). On the Form CMS-1500, the space between month, day, and year is delineated by a dotted, vertical line;

• Item 24A. must be reported as one continuous number (i.e., MMDDCCYY), without any spaces between month, day, and year. By entering a continuous number, the date(s) in item 24A. will penetrate the dotted, vertical lines used to separate month, day, and year. Carrier claims processing systems will be able to process the claim if the date penetrates these vertical lines. However, all 8-digit dates reported must stay within the confines of item 24A;

• Do not compress or change the font of the “year” item in item 24A. to keep the date within the confines of item 24A. If a continuous number is furnished in item 24A. with no spaces between month, day, and year, you will not need to compress the “year” item to remain within the confines of item 24A.;

• The “from” date in item 24A. must not run into the “to” date item, and the “to” date must not run into item 24B.;

• Dates reported in item 24A. must not be reported with a slash between month, day, and year; and

• If the provider of service or supplier decides to enter 8-digit dates for any of items 11b, 14, 16, 18, 19, or 24A. (excluding items 12 and 31), an 8-digit date must be furnished for all completed items. For instance, you cannot enter 8-digit dates for items 11b, 14, 16, 18, 19 (excluding items 12 or 31), and a 6-digit date for item 24A. The same applies to those who wish to submit 6-digit dates for any of these items.


Carriers must return claims as unprocessable if they do not adhere to these requirements.

Wednesday, September 14, 2016

Teaching Physician Criteria billing critical care


In order for the teaching physician to bill for critical care services the teaching physician must meet the requirements for critical care described in the preceding sections. For CPT codes determined on the basis of time, such as critical care, the teaching physician must be present for the entire period of time for which the claim is submitted. For example, payment will be made for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes. (See IOM, Pub 100-04, Chapter12, § 100.1.4)


1. Teaching

Time spent teaching may not be counted towards critical care time. Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching
physician as critical care or other time-based services. Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted toward critical care time.

2. Documentation

A combination of the teaching physician’s documentation and the resident’s documentation may support critical care services. Provided that all requirements for critical care services are met, the teaching physician documentation may tie into the resident's documentation. The teaching physician may refer to the resident’s documentation for specific patient history, physical findings and medical assessment. However, the teaching physician medical record documentation must provide substantive information including: (1) the time the teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching physician. The medical review criteria are the same for the teaching physician as for all physicians.


Unacceptable Example of Documentation:


“I came and saw (the patient) and agree with (the resident)”.

Acceptable Example of Documentation:

"Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care."

Saturday, September 10, 2016

what provider can do after termination from Medicare ?


 Readmission to Medicare Program After Involuntary Termination

After the involuntary termination of its agreements, a health facility cannot participate again as a provider unless:

• The reasons for termination of the prior agreement have been removed, and

• There is reasonable assurance that they will not recur.

The RO makes the final decision as to whether the facility is eligible for readmission. In doing so, it reviews the case in its entirety and makes the final decision regarding the following:

• Correction of deficiencies upon which the termination was based;

• Reasonable assurance of continued compliance, and

• Reasonable assurance of availability of information pertinent to reasonable cost reimbursement.

The RO will then process the case in the same way as an initial certification.


 Effective Date of Provider Agreement


Since one of the key issues is whether the facility has furnished “reasonable assurance” that the reasons for termination will not recur, the provider agreement cannot be effective before the date on which “reasonable assurance” is deemed to have been provided.

Generally, a facility will be required to operate for a period of 60 days without recurrence of the deficiencies that were the basis for the termination. The provider agreement will be effective with the end of the 60-day period. If corrections were made before filing the new request for participation, the period of compliance before filing the new request will be counted as part of the 60-day period; however, in no case can the effective date of the provider agreement be earlier than the date of the new request for participation.

Exceptions to the 60-day period of compliance will be made where:

• Structural changes have eliminated the reasons for termination. “Reasonable assurance” will be considered established as of the date such structural changes were completed. The effective date will be that date or the date of filing the new request to participate, whichever is later.

• "Reasonable assurance” is not established even after 60 days of compliance, because of the facility’s history of misrepresentation or of making temporary corrections and then relapsing into the old deficiencies that were the basis for termination. The effective date in such cases would be the earliest date after 60 days at which “reasonable assurance” is deemed to have been established, or the filing date of the new request to participate, whichever is later.



 Fiscal Considerations in Provider Readmission to Medicare Program After Involuntary Termination

Upon being notified that a terminated provider has filed a request for participation, the RO telephones the FI which previously serviced the facility and requests information concerning any unresolved financial problems (e.g., an overpayment that must be recovered) so that the RO can determine whether such issues must be resolved before the facility is permitted to participate.

The RO also contacts the FI that will service the facility upon readmission (this may be either the FI which previously serviced the facility or another FI) and asks it to make sure that the facility has made adequate provisions for furnishing the financial and accounting data required under the participation agreement. Where termination was based on fiscal considerations, either entirely or in combination with deficiencies in health and safety factors, the FI will also be requested to check and report on whether the deficiencies have been corrected. This report should include:

• The basis for believing that the deficiencies that led to termination of the provider agreement have (or have not) been corrected.

• If corrected, a description of:

o When and how this was done;

o The evidence showing compliance has existed for a sufficient period of time; and

o The FI’s reasons for concluding that the deficiencies will not recur.

• A description of any other fiscal and reimbursement problems and the basis of believing these should (or should not) affect certification of the facility.

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