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| CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. |
Advance Beneficiary Notices (ABNs) - Revised 12-2-02
The Centers for Medicare & Medicaid Services (CMS) has issued specific instructions regarding the usage of advance beneficiary notices (ABNs). CMS has also issued ABN forms that are approved by the Office of Management and Budget (OMB). These instructions and forms are effective December 2, 2002.
Providers who utilize ABNs should familiarize themselves with these instructions and utilize the new OMB-approved forms. For claims for items or services furnished on or after January 1, 2003, use of the GA modifier or occurrence code 32 on a claim form is permissible only in conjunction with ABN-G or ABN-L, form CMS-R-131.
For the online replicable copies of CMS-R-131 ABN forms (G & L) in PDF format, go to the CMS Beneficiary Notices Initiative (BNI) Web page at http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp. Do not replicate the forms in the exhibits section of Part I for actual use.
Billing Guides
These billing guides have been created to assist Medicare providers in the proper billing of Medicare claims.
The following guides are available from the Centers for Medicare & Medicaid Services (CMS) Web site:
Common Billing Errors - Revised 3-19-08
Below are some common reasons why claims are being rejected. Please refer to Pub. 100-04, Medicare Claims Processing Manual, Chapter 26 - Completing and Processing Form CMS-1500 Data Set and make note of these issues when submitting your claims. These errors apply to both the CMS-1500 claim items identified and their electronic claim equivalents.
- Item 32 (service facility location information) requires the name and address –including a valid ZIP code– for all services unless rendered in the patient’s home. Please be advised that any missing, incomplete, or invalid information recorded in this required field will result in the claim being returned or rejected in the system as unprocessable. Any claims received with the word “SAME” in Item 32 indicating that the information is the same as supplied in Item 33 are not acceptable.
- The referring/ordering physician's name and provider identifier were not present on the claim. Please keep in mind this information is required in Item 17 and 17a and/or 17b on all diagnostic services and consultations.
Item 17 - Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.
Item 17a - Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported until May 23, 2008, and MUST be reported if an NPI is not available.
Item 17b - Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available.
Note: Item 17a and/or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2008, and later, 17a is not to be reported, but 17b MUST be reported when a service was ordered or referred by a physician.
- Evaluation and management (E&M) procedure codes and the place of service do not match. An incorrect place of service is being submitted with the E&M procedure code. (Example: Procedure code 99283, which is an emergency room visit is submitted with place of service 11, which is office).
- When billing services for more than one provider within your group, you must put the individual provider identifier in Item 24J.
Item 24J - Prior to May 23, 2008, enter the rendering provider's PTAN in the shaded portion.
Effective May 23, 2008, and later, do not use the shaded portion. Effective March 1, 2008, you must enter the rendering provider's NPI number in the lower portion. It is important that the provider listed in 24J belongs to the group identified in item 33a.
- Diagnosis codes being used are either invalid or truncated. The invalid diagnosis codes are usually because an extra digit is being added to make it 5 digits. Please remember not all diagnosis codes are 5 digits. Please check your ICD-9-CM coding book for the correct diagnosis code.
- Please read the provider bulletins, especially at the end of each year, as we list all the additions, deletions, and code changes for the following year. Claims are being submitted with deleted procedure codes. This information can also be found in the CPT Book. It is important to be using a current book.
- Chiropractors need to complete Item 14 with the initial treatment date (MM/DD/CCYY).
- In Item 19, enter either a 6-digit (MM|DD|YY) or an 8-digit (MM|DD|CCYY) date patient was last seen and the UPIN (NPI when it becomes effective) of his/her attending physician when a physician providing routine foot care submits claims.
- When Medicare is secondary, Item 11, 11a, 11b, and 11c must be completed.
Tips for Correct Billing
Procedure Codes
Peer Review Organization (PRO) Numbers - For procedure codes that need prior approval, you need to enter the Peer Review Organization (PRO) number in the prior approval field. On most occasions, this field should be left blank. This is a rarely needed option that pertains to assistant surgery for ophthalmology procedures. The current codes requiring prior approval are: 66852, 66930, 66940, 66985, 66986.
Repeat Procedure on Same Day - When billing the same procedure codes with the same date of service, you must bill them on the same claim. Services that are "repeated" should be billed with the appropriate modifier (e.g., 76 or 77). If billed on two separate claims, they could be auto-denied as duplicate services.
"By Report" or "Not Otherwise Classified" - When using a BY REPORT or NOT OTHERWISE CLASSIFIED procedure code, please include a description of the procedure (for electronic claims; in the narrative or comment field section of your software).
Use CLIA Numbers Where Applicable - CLIA certification numbers are to be added to each detail requiring a CLIA number.
Days/Units Field - Days or units should be reported to reflect the number of services. Number of minutes is reported for anesthesia codes only. Anesthesiologists should not report "time" for E&M or surgical procedures.
Modifiers
(See also our Modifier Reference Guide for more information on modifiers.)
Modifiers Must Be Up to Date - Modifiers that are no longer valid should not be used (e.g., GB, Q1, WI). Modifiers should only be used on the applicable codes. On electronic claims, NEVER zero fill a modifier field. Modifiers should be placed in the first modifier field, and then the second modifier field. NEVER skip the first modifier field and place a modifier in the second modifier field. Anesthesiologists should not use anesthesia modifiers on surgical or E & M codes. You may refer to Medicare Part B Hotline Bulletins, HCPCS updates, and the Modifier Reference Guide (contact our office for a copy of this guide) for more information on modifiers.
More Than Two Modifiers - When three or more modifiers are needed for one particular detail line, use the 99 modifier. This lets us know that more than two modifiers are applicable. For electronic claims, use your narrative or comment field to include additional modifier information. For paper claims, use Item 19 to identify the modifiers that apply.
Provider Numbers
Facility Provider Field - Our office receives multiple claims each day that have to be manually corrected due to erroneous information in the facility provider field. This delays processing of your claims. There are ONLY two instances when this field should be used. These are assistant-at-surgery services and services rendered in a skilled nursing facility (POS 31). The provider number of the hospital or facility where the service was rendered should be entered into this field. Otherwise, leave this field blank.
Individual vs. Group PIN - Use the individual rendering provider identification number (PIN) on each detail line. Make sure the group number, when applicable, corresponds to the appropriate individual PIN. When a physician has more than one PIN (private practice, hospital, etc.), use the appropriate PIN for the services rendered. A rendering provider number, if not a solo number, must always belong to the group number that is billing. Electronic submitter ID numbers (not UPINs) should be entered in place of the PIN (group or individual). When billing any service to Medicare, if you have doubts as to which provider number to use, please verify with our office.
"Zero-Filling" - Do not substitute zeros or a submitter identification number where a Medicare PIN or UPIN is required.
Unique Physician Identification Numbers (UPINs) & Physician Name - When a UPIN is required, enter the referring physician's name, last name first, as well as the number.
Health Insurance Claim (HIC) Numbers
HIC Accuracy - Our office receives numerous claims that are submitted with invalid or incorrect HIC numbers. These claims require manual intervention by our office and can sometimes result in beneficiaries receiving incorrect EOMB information. Please be certain the HIC number you are keying is entered correctly, and is also the HIC that belongs to the patient for which you are billing.
HIC Format - A correct HIC number consists of 9 numbers immediately followed by an alpha suffix. Take special care when entering the HIC number for members of the same family who are Medicare beneficiaries. A husband and wife may have a HIC number that share the same Social Security numerics, however, every individual has their own alpha suffix at the end of the HIC number. In order to ensure proper claim payment, it is essential that the correct alpha suffix is appended to each HIC. No hyphens or dashes should be used.
Name Accuracy - Titles should not be used as part of the name (e.g., Dr., Mr., Rev., M.D., etc.).
"Railroad Retirees" - Railroad Retirement HIC numbers generally have two alpha characters as a prefix to the number. These claims should not be billed to us. You need to bill them to United Health Care Insurance Company, at this address:
Palmetto Government Benefit Administrators
Railroad Medicare Services
PO Box 10066
Augusta, GA 30999-0001
Non-Medicare Claims - Do not send claims for non-Medicare beneficiaries to the Upstate Medicare Division.
Complete Address
U.S. Postal Addressing Standards - It is very important to meet the U.S. Postal addressing standards. Patient and provider information must be correct in our system. This is necessary so that checks and Medicare Summary Notices (MSNs) or remittance notices arrive at the correct destination. It is also to ensure the quickest service from us to your office. (For a list of addresses here at UMD, please refer to our contact pages.)
- A deliverable address may contain both a street name and number or a street name with a P.O. Box number.
- A P.O. Box by itself is acceptable.
- A RR number must be with a box number. Note: It is incorrect to key P.O. in front of the box number when given with a rural route.
- A star route number is not a deliverable address. Use HC instead of star route.
- RD numbers are no longer valid. If there are rural routes still existing in your area, the correct number should be preceded by RR, then the box number.
- A box number or a RR number by itself is not deliverable.
- A street name without a number can not be delivered.
- Do not use % or any other symbol when denoting an "in care of" address. C/O is appropriate.
- As always, no commas, hyphens, periods, or other special characters should be used.
Nursing Home or Skilled Nursing Facility Address - For a facility such as a nursing home or skilled nursing facility, it is preferred that a street name and number be supplied. In some cases, this information is not available, but if it is, please use it. Please verify the accuracy of your address before you send us this information.
Apartment Complex - An apartment complex (words such as apartments, towers, or complex indicate such) should contain a street address and an apartment number. Again, this information is not always available, but should always be used when it exists.
Development Center / Trailer Park - If a development center or trailer park is given, it should contain the street address and number, if that information is part of the complete address.
"No Street Address" (NSA) - NSA (No Street Address) is not acceptable. This is not a deliverable address.
Changes to Provider Address - Please notify our Provider Enrollment Unit in writing of any address changes for your office practice.
Dates of Service - Revised 3-25-08
One Month Per Detail Line - In the Date of Service field, do not enter more than 1 month per detail. For example, you can not bill from July 1st through August 1st on the same detail line. Following is how to correctly bill it:
07/01/2007 - 07/31/2007 Quantity Billed = 310
08/01/2007 Quantity Billed = 010
The following is how it should not be billed:
07/01/2007 - 08/01/2007 Quantity Billed = 320
Date Spans - Only consecutive days within the same month can be spanned. For example, if you were billing consecutive hospital visits from January 1st to January 4th, the quantity billed should be 040. For example:
01/01/2008 - 01/04/2008 Quantity Billed = 040
Non-consecutive Days - If you are billing for January 1st, January 9th, and January 12th, which are not consecutive days, each day MUST be billed on a separate detail line. For example:
01/01/2008 Quantity Billed = 010
01/09/2008 Quantity Billed = 010
01/12/2008 Quantity Billed = 010
Do not bill:
01/01/2008 - 01/12/2008 Quantity Billed = 030
This is a common error which will cause a delay in claims processing. Another variation of this error is:
01/01/2008 - 01/04/2008 Quantity Billed = 030
Note: Providers and suppliers must report 8-digit dates in all date of birth fields (items 3, 9b, and 11a), and either 6-digit or 8-digit dates in all other fields (items 11b, 12, 14, 16, 18, 19, 24a, and 31).
Diagnosis Codes
Reference Only One Diagnosis Per Detail Line - It is very important to reference only one diagnosis code on each detail line. For each detail line, choose the diagnosis that is most relevant and most specific to the procedure on that line (e.g., reference diagnosis number 1, or 2, or 3, or 4; do NOT reference "1 and 2," or "1, 2, 3, and 4").
Medicare Secondary Payer (MSP) Claims Submission
Medicare Secondary Payer (MSP) claims tend to be confusing to many providers across the country. This chart answers common questions regarding Medicare as primary or secondary. Please refer to this chart when submitting claims that may require Medicare as secondary payer:
| Person with disability is under 65 Years of age and... |
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| The beneficiary is not covered under a large-group health insurance plan and does not have a spouse. |
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X |
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| The beneficiary is covered under a large-group health plan from a past or present employer; the employer has fewer than 100 employees; the beneficiary has no spouse. |
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X |
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| The beneficiary is covered under a large-group health plan by a past employer; the employer has more than 100 employees; the beneficiary has no spouse. |
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X |
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| The beneficiary is covered under a large-group health plan by a present employer; the employer has more than 100 employees; the beneficiary has no spouse. |
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X |
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X |
| The beneficiary is not covered under any large-group health plan by a past or present employer, but has a spouse or family member who is employed and has the beneficiary covered under the plan. The spouse’s or family member’s employer has fewer than 100 employees. |
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X |
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| The beneficiary is not covered under a large-group health plan, but has a spouse or family member who is currently employed and has the beneficiary covered under the plan. The spouse’s or family member’s employer has more than 100 employees. |
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X |
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X |
| The disabled child is covered under a parent’s contract; the employer has fewer than 100 employees. |
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X |
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| The disabled child is covered under a parent’s contract; the employer has more than 100 employees. |
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X |
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X |
| End Stage Renal Disease |
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| The beneficiary has coverage under a current or former employer and is entitled to Medicare solely on the basis of ESRD. |
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X |
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X |
| The beneficiary does not have any employer-group health coverage through self or family. |
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X |
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| Working Aged Beneficiary |
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| The beneficiary is not employed and does not have a spouse. |
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X |
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| The beneficiary is still employed and covered by an employer-group health plan; the employer has fewer than 20 employees. |
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X |
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| The beneficiary is still employed and covered by an employer-group health plan; the employer has more than 20 employees. |
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X |
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X |
| The beneficiary is not employed, but has a spouse or family member who is still employed and has the beneficiary covered under the employer-group health plan; the spouse’s employer has fewer than 20 employees. |
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X |
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| The beneficiary is not employed, but has a spouse or family member who is still employed and has the beneficiary covered under the employer-group health plan; the spouse’s employer has more than 20 employees. |
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X |
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X |
| Medicare does not usually pay for services related to the following statements because the diagnosis indicates that coverage may be provided by other insurers such as Auto Accident (AA); Black Lung (BL); Third Party Liability (TPL); or Workers’ Compensation (WC)* |
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| The beneficiary is involved in an AA or WC accident. The provider submits a claim with a diagnosis that IS related to the injury. |
X |
X |
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| The beneficiary is involved in an AA or WC accident. The provider submits a claim with a diagnosis that is NOT related to the injury. |
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X |
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| The beneficiary is involved in a TPL accident. The provider submits a claim with a diagnosis that IS related to the injury.** |
X |
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X |
| The beneficiary is involved in a TPL accident. The provider submits a claim with a diagnosis that is NOT related to the injury. |
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X |
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| The beneficiary receives Black Lung benefits. The provider submits a claim with a diagnosis that IS payable under BL. |
X |
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| The beneficiary receives Black Lung benefits. The provider submits a claim with a diagnosis that is NOT payable under BL. |
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X |
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* When determining whom to bill for Auto Accident (AA), Black Lung (BL), Third Party Liability (TPL), or Workers Compensation (WC) claims, refer to this table.
** If the provider chooses to bill the TPL insurer or file a lien against the potential settlement, he cannot also bill Medicare simultaneously. If he cannot collect from the TPL promptly, he must bill Medicare for a conditional payment. Claims submitted to the TPL payer prior to Medicare, that are subsequently denied by the TPL payer, are still subject to the Medicare timely requirements.
NOTE: Some beneficiaries may choose to be covered by Medicare or the Veterans’ Administration (VA) insurance. They cannot receive payment from both. For this reason, if a beneficiary is covered under VA insurance, Medicare cannot be billed, even as a secondary payer.
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