Tuesday, November 11, 2014

provider identifying qualifiers box 17

This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare contractors (carriers, A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors
(DME/MACs)) for services provided to Medicare beneficiaries.

This change request (CR) 8509 revises the current CMS 1500 claim form instructions to
reflect the revised CMS 1500 claim form, version 02/12.

The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

• DN - Referring Provider
• DK - Ordering Provider
DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.

Friday, November 7, 2014

Electronic Billing Guide: Submitting Medical Documentation for Part A/B 5010 Electronic Claims

Submitting Medical Documentation For Part A/B 5010 Electronic Claims

Under the Health Insurance Portability and Accountability Act (HIPAA), claims for reimbursement by the Medicare Program must be submitted electronically, except where waived, even for claims with attachments. The process for accepting medical documentation and attaching it to the electronic claim has been improved due to our imaging system. The Claim Supplemental Information segment (PWK) is used whenever paper documentation has been sent for an electronic claim. When sending an electronic claim that contains an attachment, follow these rules to submit the attachment for your electronic claim:

Maintain the appropriate medical documentation on file for electronic (and paper) claims.
Complete the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * form. For accurate processing of your claim(s), please complete all requested information in capital letters and avoid contact with the edge of the boxes.

Important tips to keep in mind when faxing medical records for electronic claims:

•    Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
•    The narrative field on the claim is to be utilized in situations where sufficient information for the documentation of a procedure/modifier can be provided without sending the medical records. When additional information cannot be contained in the narrative of the claim, additional documentation (medical records) may be submitted via mail or fax.
•    Only fax documentation for one patient per cover sheet. The cover sheet is for Part A or B electronic claims.
•    Clearly write the: Attachment Control Number, Internal Control Number (ICN/DCN), Patient Name, Health Insurance Claim (HIC) Number, Date of Service, Total Claim Billed Amount, National Provider Identification (NPI) Number, Contact Information, and State Where Services Were Provided on the cover sheet.  Failure to submit all items requested will result in documentation being returned and could delay claim processing.
•    The fax/mail cover sheets are not to be modified.
•    Only the first iteration of the PWK, at either the claim level and/or line level, will be considered for adjudication.
•    Submitters must send ALL relevant PWK data at the same time for the same claim.
•    After submitting the electronic claim, locate the ICN/DCN number on the 277CA claims acknowledgement report.  The ICN/DCN is located in the 2200D REF segment.
•    Fax the cover sheet and medical documentation to (877) 439-5479. You may fax documentation any time after claim submission, including the same day. Faxing is available 24 hours a day, 7 days a week. Faxes should be sent within seven calendar days of your electronic claim submission.
Novitas Solutions strongly recommends faxing your medical documentation. If you are not able to fax your documentation, mail the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * and all pertinent medical documentation within ten calendar days of your electronic claim submission.

In the Claim Supplemental Information Segment (PWK) of the electronic claim:
•    Select the appropriate Report Type Code for the medical documentation. For information on what codes are needed in the PWK segment.
•    Use the By Fax or By Mail option for the Attachment Transmission Code
•    Enter AC for the Identification Code Qualifier
•    Report the Attachment Control Number - This number may be assigned by your software or can be any number you chose including the patient account number or other identifying number.
Note: Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
Technically Speaking, Claim Supplemental Information (PWK) is reported as follows:

Data Element    Segment
Attachment Report Type Code    2300 or 2400 - PWK01
Attachment Transmission Code    2300 or 2400 - PWK02
Identification Code Qualifier    2300 or 2400 - PWK05
Attachment Control Number    2300 or 2400 - PWK06

Friday, October 10, 2014

NPI AND PTAN Difference and Relationship - complete review

This article explains the difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN). There are no policy changes in this article.

All providers and suppliers who provide services and bill Medicare for services provided to Medicare beneficiaries must have an NPI. Upon application to a Medicare Administrative Contractor (MAC), the provider or supplier will also be issued a
Provider Transaction Access Number (PTAN). While only the NPI can be submitted on claims, the PTAN is a critical number directly linked to the provider or supplier’s NPI.

Providers and suppliers receiving requests to revalidate their enrollment information have asked the Centers for Medicare & Medicaid Services (CMS) to clarify the differences between the NPI and the PTAN.

National Provider Identifier (NPI)

The NPI is a national standard under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification provisions.

• The NPI is a unique identification number for covered health care providers.
• The NPI is issued by the National Plan and Provider Enumeration System (NPPES).
• Covered health care providers and all health plans and health care clearinghouses must use the NPI in the administrative and financial transactions (for example, insurance claims) adopted under HIPAA.

• The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The NPI does not carry information about healthcare providers, such as the state in which they live or their medical specialty. This reduces the chances of insurance fraud.

• Covered providers and suppliers must share their NPI with other suppliers and providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

Since May 23, 2008, Medicare has required that the NPI be used in place of all legacy provider identifiers, including the Unique Physician Identification Number (UPIN), as the unique identifier for all providers, and suppliers in HIPAA standard transactions.

You should note that individual health care providers (including physicians who are sole proprietors) may obtain only one NPI for themselves (Entity Type 1 Individual). Incorporated individuals should obtain one NPI for themselves (Entity Type 1
Individual) if they are health care providers and an additional NPI(s) for their corporation(s) (Entity Type 2 Organization). Organizations that render health care or furnish health care supplies may obtain NPIs (Entity Type 2 Organization) for their organizations and their subparts (if applicable).

For more information about the NPI, visit the NPPES website at https://nppes.cms.hhs.gov/NPPES/Welcome.do on the CMS website.

Provider Transaction Access Number (PTAN)

A PTAN is a Medicare-only number issued to providers by MACs upon enrollment to Medicare. When a MAC approves enrollment and issues an approval letter, the letter will contain the PTAN assigned to the provider.

** The approval letter will note that NPI must be used to bill the Medicare program and that PTAN will be used to autheniticate the provider when using MAC self help tools such as IVR , internet portal , online application etc.

** The PTAN's use should generally be limited to the provider's contacts with their MAC

Where can I find my PTAN?

You can find your PTAN by doing any one of the following:

1. View the letter sent by your MAC when your enrollment in Medicare was approved.

2. Log into Internet-based PECOS. Click on the “My Enrollments” button and then “View Enrollments”. Locate the applicable enrollment and click on the “View Medicare ID Report” link which will list all of the provider or supplier’s active
PTANs in one report.

3 The provider (or, in the case of an organizational provider, an authorized or delegated official) shall send a signed written request on company letterhead to your MAC; include your legal name/legal business name, national provider identifier
(NPI), telephone and fax numbers.

Relationship of the NPI to the PTAN

The NPI and the PTAN are related to each other for Medicare purposes. A provider must have one NPI and will have one, or more, PTAN(s) related to it in the Medicare system, representing the provider’s enrollment. If the provider has relationships with one or more medical groups or practices or with multiple Medicare contractors, separate PTANS are generally assigned.

Together, the NPI and PTAN identify the provider, or supplier in the Medicare program. CMS maintains both the NPI and PTAN in the Provider Enrollment Chain & Ownership System (PECOS), the master provider and supplier enrollment system.

Wednesday, September 24, 2014

New Physician Specialty Code for Interventional Cardiology

This MLN Matters® Article is intended for physicians, non-physician practitioners, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

CR 8812, from which this article is taken, provides notice that the Centers for Medicare & Medicaid Services (CMS) is establishing a new physician specialty code for Interventional Cardiology. The CR is also changing the description of specialty code 62, and updating the names associated to specialty codes 88 and 95. Make sure your billing staffs are aware of these changes.

Physicians who enroll in the Medicare program self-designate their Medicare physician specialty on the Medicare enrollment application (CMS-855B) or via the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS). Non-physician practitioners who enroll with Medicare are assigned a Medicare specialty code. These Medicare physician/non-physician practitioner specialty codes describe the specific/unique types of medicine that physicians and non-physician practitioners (and certain other suppliers) practice. They become associated with the claims that physician or non-physician practitioners submit; and are used by CMS for programmatic and claims processing purposes.

CR 8812 establishes a new physician specialty code for Interventional Cardiology (C3). CR8812 is also removing the word “Clinical” from the description of specialty code 62 (Psychologist (Billing Independently)), and is changing the description of specialty code 88 to “Unknown Provider,” and of specialty code 95 to “Unknown Supplier”. The changes to the descriptions for codes 88 and 95 align their names with their intended usages.

Sunday, August 24, 2014

Date format in CMS 1500 forms

Required Data Element Requirements

1 - Paper Claims
The following instruction describes certain data element formatting requirements to be followed when reporting the calendar year date for the identified items on the F9+o203 rm CMS-1500:
• If birth dates are furnished in the items stipulated below, then these items must contain 8-digit birth dates (MMDDCCYY). This includes 2-digit months (MM) and days (DD), and 4-digit years (CCYY).
Form CMS-1500 Items Affected by These Reporting Requirements:

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.

Wednesday, February 19, 2014

Sample new CMS 1500 CLAIM form

Now we can enter 12 DX in single claim.

See the below changes in the format of 21 BLOCK

Thursday, January 23, 2014

Box #21, ICD 10 entering on CMS 1500 new form

Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties (i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All narrative diagnoses for nonphysician specialties shall be submitted on an attachment.

Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to October 1, 2014, on either the old or revised version of the CMS-1500 claim form.

For form version 08/05, report a valid ICD-9-CM code. Enter up to four diagnosis codes.

For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).

• The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:

 Indicator Code Set 
 9 ICD-9-CM diagnosis
0 ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)

• If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.

• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

• Do not insert a period in the ICD-9-CM or ICD-10-CM code.
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