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J5 MAC Part A Providers serving beneficiaries in Iowa, Kansas, Missouri and Nebraska

Billing and Coverage FAQs

1. I have an outpatient claim that denied with reason code C7080 because the dates of service fall within the dates of service of an inpatient hospital claim (i.e. the outpatient date is 09/15/08 and the inpatient claim is from 09/01/08 through 09/20/06). What do I do?

All items and non physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of whether they are subject to PPS. Therefore, your services will need to be billed directly to the hospital where the patient was an inpatient.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under Guidance click on "Manuals"
Under Manuals Overview on the left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 3
Scroll down to 10.4
http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf

2. I have a claim that has line denials for reason code C7251 stating that my outpatient claim is overlapping a Skilled Nursing Facility (SNF) inpatient (21X) claim. How can I tell whether this service is on the consolidated billing exclusion list?

A list of exclusions for consolidated billing can be found on CMS Website under Consolidated Billing.

Go to http://www.cms.hhs.gov/
Click on "Medicare"
Under "Billing"
Click on "Consolidated Billing"
Click on the correct billing year
http://www.cms.hhs.gov/SNFConsolidatedBilling/

3. I submitted an adjustment on a claim that line rejected for 54NCD. I forgot to put any information in the remarks field and now the claim has returned back to me for reason code 37537 stating that provider has submitted an adjustment on a rejected claim/line and no remarks are present. How do I correct my claim?

To correct your claim in Direct Data Entry (DDE) you would need to update the remarks field and F9 the claim.

Providers that do not have DDE can contact our Corrections line to update the remarks field.

4. I submitted a cancel (XX8) on a claim and it returned back to me for reason code 30955 stating that the cross reference Document Control Number (DCN) is invalid. How do I correct my cancel?

This edit should not be received unless an incorrect Document Control Number (DCN) was used on the adjustment. To correct this you will need to verify the Health Insurance Claim (HIC) number, cross reference DCN, dates of service and/or provider number. Once the correct DCN has been obtained, the original incorrect adjustment should be suppressed and a new adjustment request with the correct DCN should be submitted.

5. We have received several claim denials with reason code W7009 stating non-covered service, line item denial. After further review it was determined that we submitted one item as non-covered with the GY modifier and the whole claim has denied. How do I get my claim to process?

Previously there was an issue with some claims inappropriately rejecting with reason code W7009. This has been corrected. You would continue to bill with the GY modifier and charges non-covered and it should process appropriately.

6. We are a Critical Access Hospital (CAH) that provides outpatient physical therapy. Is it appropriate for us to bill two 85X claims with the same dates of service for physical therapy?

No. Since CAH are exempt from OPPS billing regulations you would need to bill all of their dates of service on the same claim.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the left side, click on "Internet-Only Manuals"
Under Publications click on 100-4
Under Downloads click on "Chapter 4"
Scroll down and search for Section 180.4
http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf

7. I am billing a claim for non-End Stage Renal Disease (ESRD) services. On one of the lines I am billing HCPC code J0885 with the EC modifier. Is this appropriate billing and is there reimbursement for that HCPC code?

This is appropriate billing for non-ESRD services. Reimbursement may not be given in the following circumstances:

Effective for claims with dates of service on and after January 1, 2008, non-ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EC (ESA, anemia, non-chemo/radio) shall be denied when any one of the following diagnosis codes is present on the claim:

any anemia in cancer or cancer treatment patients due to folate deficiency (281.2),
B-12 deficiency (281.1, 281.3),
iron deficiency (280.0-280.9),
hemolysis (282.0, 282.2, 282.9, 283.0, 283.2, 283.9-283.10, 283.19), or
bleeding (280.0, 285.1),
anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML) (205.00-205.21, 205.80-205.91); or
erythroid cancers (207.00-207.81).

Effective for claims with dates of service on and after January 1, 2008, contractors shall deny non-ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EC (ESA, anemia, non-chemo/radio) for:

any anemia in cancer or cancer treatment patients due to bone marrow
fibrosis,
anemia of cancer not related to cancer treatment,
prophylactic use to prevent chemotherapy-induced anemia,
prophylactic use to reduce tumor hypoxia,
patients with erythropoietin-type resistance due to neutralizing antibodies; and
anemia due to cancer treatment if patients have uncontrolled hypertension.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 17
Sections 80.9 - 80.12
http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf

8. I am a biller for Method II Critical Access Hospital. Can we bill for physicians charges if they waive their rights to bill to the Medicare carrier?

The individual practitioner must certify, using the Form CMS 855R, if he/she wishes to reassign their billing rights. The CAH must then forward a copy of the 855R to the intermediary and the appropriate carrier, must have the practitioner sign an attestation that clearly states that the practitioner will not bill the carrier for any services rendered at the CAH once the reassignment has been given to the CAH. This "attestation" will remain at the CAH.

For CAHs that elected the optional method before November 1, 2003, the provision is effective beginning on or after July 1, 2001. For CAHs electing the optional method on or after November 1, 2003, the provision is effective for cost reporting periods beginning on or after July 1, 2004. Under this election, a CAH will receive payment from their intermediary for professional services furnished in that CAH's outpatient department. Professional services are those furnished by all licensed professionals who otherwise would be entitled to bill the carrier under Part B.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 4
Sections 250.2
http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf

9. I have a claim that rejected for reason code 34002 stating that this beneficiary has coverage through an employer's group health plan that is primary over Medicare. We show that Medicare is the primary insurance. Common Working File (CWF) has been updated to show that Medicare is primary. Can I adjustment my claim now that CWF is updated?

If CWF has been updated, you can request an adjustment to the original claim. Please do not request a cancel on the original claim. Only an adjustment should be completed on a rejected MSP claim.

http://www.wpsmedicare.com/
Click on Part A
Under Medicare Areas
Click on "More Areas"
On left hand side Under Medicare Secondary Payer
Click on "Frequently Asked Questions"
Scroll down to the correct question needed
Answers to Frequently Asked Questions about Medicare Secondary Payer

10. Where can I find out how many Diabetes Self Management Training (DSMT) hours a beneficiary has used?

DDE providers can find the DSMT information on page 6 (Preventive Services) of Health Insurance Query- A (HIQA).

Providers that do not have access to HIQA can contact Customers Service to verify this information.

11. I am searching for the new RUGS rates that go into effect on 10/01/2008. Where can I go to find this information?

You can find the new RUGs rates in the 8/8/08 Federal Register on Page 46428-46429.

Federal Register Link
Click on the link below, and then scroll to page 46428
http://edocket.access.gpo.gov/2008/pdf/E8-17948.pdf

12. I need some clarification on the condition code 44. If we have a patient that discharges on Sunday and then on Monday morning the utilization review committee determines that the patient does not meet Inpatient criteria. Can we bill an outpatient claim with the condition code 44?

Condition Code 44 cannot be used in this circumstance. In order for the condition code 44 to be used the following conditions must be met:

The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
The hospital has not submitted a claim to Medicare for the inpatient admission;
A physician concurs with the utilization review committee's decision; and
The physician's concurrence with the utilization review committee's decision is documented in the patient's medical record.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 1
Scroll down to section 50.3
http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf

13. Where are the retired Local Coverage Determinations (LCDs) located at on the WPS Website?

All retired policies are available on CMS' Website. CMS outlines the process that allows the MAC contractor to retire an LCD. Following these guidelines, if we did not think the LCD met a PIM requirement based on our experience, we retired it and sent it to CMS for final approval. CMS approved all of our recommendations to retire LCDs. We ended up with a much more manageable number of J5 LCDs. All retired policies are available on CMS' Website. As of today, not all of these policies show an end date. We are currently working with CMS to resolve that issue. When any policy is retired, the provider should use the information in the Internet-Only Manual (IOM) located on CMS' Website. The IOM holds all of CMS's guidelines and should always be used in lieu of a policy.

http://www.wpsmedicare.com/
Click on Part A=
Click on Policy/Coverage
On left hand side click on Local Coverage Determinations
Local Policies (LCD)

14. Are we required to obtain documentation of a face-to-face evaluation prior to providing a sleep study?

The documentation of the physician face-to-face office visit is necessary documentation to support medical necessity of the sleep study and conformity to the conditions of coverage for Medicare. It is the testing facilities responsibility to produce this documentation in the event of a review of services. The pre-procedure information is vital in determining medical necessity.

15. We are a Method II Critical Access Hospital. This year we qualify for the CRNA pass-through payments. Where can I find out how to bill for this service?

The Provider Billing Requirements for Method II Receiving the CRNA Pass-through can be found in Medicare Claims Processing Manual 100-04, Chapter 4, Section 250.3.3.2.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 4
Scroll down to section 250.3.3.2
http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf

16. Can the new Advance Beneficiary Notice (CMS-R-131) be revised to suit our needs?

The CMS-R-131 can be used now; however; is not required until March 1, 2009. Once it is required there are certain preparation requirements that you must meet. Those requirements are defined within the ABN-G and ABN-L webpage by clicking on "Revised ABN CMS-R-131 Form and Instructions."

http://www.cms.hhs.gov/bni
Click on FFS ABN-G and ABN-L
Click on Revised ABN CMS-R-131 Form and Instructions

17. Our facility is a Part A outpatient rehabilitation facility. Do we need a signed signature on each plan of cares or can the doctor stamp his name?

Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-08
Under Downloads click on Chapter 3
Scroll down to section 3.4.1.1
http://www.cms.hhs.gov/manuals/downloads/pim83c03.pdf

18. In the November Communiqué, you list revisions to the Colonoscopy LCD. Included in those revisions are new ICD-9 codes. What dates of service are these new ICD-9 codes effective for?

The ICD-9 codes are effective with claims submitted with dates of service on or after 10/01/2008, WPS Medicare will cover the new 2009 ICD-9-CM codes for the policies (LCDs) listed. The listed changes to these effected policies will be posted to the CMS Medicare Coverage Database (MCD) after 10/01/2008.

http://www.wpsmedicare.com/
Click on Part A MAC
Under publications
Click on "Communiqué Archive"
Under 2008
Click on November
Go to page 19
Communiqué

19. We are a Part A outpatient rehabilitation facility. Are we required to bill all of our outpatient therapy services on one claim?

Yes. Repetitive Part B services furnished to a single individual by providers that bill FIs/A/B MACs shall be billed monthly (or at the conclusion of treatment). Consolidating repetitive services into a single monthly claim reduces CMS processing costs for relatively small claims and in instances where bills are held for monthly review. A listing of services repeated over a span of time and billed with the following revenue codes are defined as repetitive services can be found at the below manual reference.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 1
Scroll down to section 50.2.2
http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf

20. What number do we call to have our FISS Direct Data Entry (DDE) password reset?

You should call 1-866-518-3251 for password resets.

http://www.wpsmedicare.com/
Click on Part A MAC
Under Self Service
Click on "More Self Service"
On left hand side
Click on "Direct Data Entry (DDE) Part A only"
Scroll down to DDE Contact Information
http://www.wpsmedicare.com/j5macparta/selfservice/dde.shtml

21. I have an outpatient claim that denied with reason code C7050 because the dates of service fall within the dates of service of an inpatient hospital claim. What do I do?

To correct the claim, you will need to adjust the inpatient claim to add the charges from the outpatient claim.

22. I have a claim that rejected for reason code 39721 stating that the requested non-medical information was not received timely. How do I correct this claim?

To have this claim considered for payment, please submit a new claim with the requested information.

23. I submitted a MSP claim. The claim returned to me for reason code 77745 stating that Medicare's primary. How can I correct my claim?

Verify CWF to determine who is primary. If Medicare is primary and you have received payment from the other insurance, refund the payment to that insurer. If primary payment was not received from the other insurance, remove all the other insurance information from the claim and resubmit.

http://www.wpsmedicare.com/
Click on J5 MAC: Iowa, Kansas, Missouri, Nebraska Providers
Click on Medicare Areas
Click on Claims
Click on Top 10 Claim Submission Errors
Click on View a listing of Top 10 Claim Submission Errors December 2008
Scroll down to reason code 77745
The Top Ten Claim Submission Errors (Part A)

24. I have a claim editing for reason code 31715 stating that the units of service are exceeding the medically reasonable daily allowance. What do I need to do to get this claim to process?

To correct your claim, verify units and resubmit the claim.

http://www.wpsmedicare.com/
Click on J5 MAC: Iowa, Kansas, Missouri, Nebraska Providers
Click on Medicare Areas
Click on Claims
Click on Top 10 Claim Submission Errors
Click on View a listing of Top 10 Claim Submission Errors December 2008
View reason code 31715
The Top Ten Claim Submission Errors (Part A)

25. I have a claim that returned back to me for reason code W7072 stating to remove or update the non-billable HCPCS code(s). How can I find out which HCPCS code on my claim is non-billable?

In order to find out which HCPCS on the claim are non-billable you will need to check the Federal Register Addendum B to see which HCPC code has a status indicator of a B or M.

Go to http://www.cms.hhs.gov/
Click on Medicare
Under Medicare Fee-for-Service Payment
Click on Hospital Outpatient PPS
On left side click on Addendum A and Addendum B Updates
Scroll down & choose "All" in the View Items per page
Click Go
Click on Addendum B for the appropriate date of your claim.
http://www.cms.hhs.gov/HospitalOutpatientPPS/AU/list.asp?intNumPerPage=all&submit=Go

26. I have a claim that returned back to me for reason code 32206 stating that the revenue code is invalid for this type of bill. Where can I verify what revenue codes are valid for the type of bill?

You can verify the correct revenue code in the Internet-Only Manual, Medicare Claims Process Manual Publication 100-04 Chapter 25 on CMS' Website.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 25
Scroll down to section 75.4-Form locator 42
http://www.cms.hhs.gov/manuals/downloads/clm104c25.pdf

27. I have a claim that rejected for reason code T5052 stating that Common Working File (CWF) records indicate the beneficiary record is not on file. The claim was billed with the wrong Health Insurance Claim (HIC) number. Can I resubmit my claim with the correct HIC number?

Yes, the claim needs to be resubmitted with the correct HIC number.

28. I have an inpatient Part A SNF claim that rejected for reason code 11503 stating that admission date is greater than 30 days after the through date of the qualifying hospital stay. This patient was admitted more than 30 days after their 3-day qualifying hospital stay because their condition prevented them from being able to begin treatment. How do I bill this claim?

When billing for this situation you need to add condition code 56 to the claim. This condition code is used to indicate that the patient's SNF admission was delayed more than 30 days after the hospital discharge due to the patient's condition which made it inappropriate to begin active care within that period.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 25
Scroll down to section 75.2 - Form Locators 16-30
http://www.cms.hhs.gov/manuals/downloads/clm104c25.pdf

29. I have a claim that returned back to me with reason code 31153 stating that therapy revenue codes 42X, 43X and 44X must be billed with an appropriate HCPCS modifier of GN, GO or GP. How do I correct my claim?

Modifiers are used to identify therapy services whether or not financial limitations are in effect. You will need to add the appropriate modifiers to your claim and F9.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 5
Section 20.1
http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf

30. I have a claim that rejected with reason code 34293 stating that the beneficiary has coverage through an employer group health plan that is primary to Medicare. The claim was rejected by the group health plan. How do I indicate this on my claim?

If the group health plan denied the claim use an Occurrence Code 24 with the date the primary insurance denied the claim, use the appropriate value code with a $0.00 dollar amount. The primary payer code should be a "C" with the primary insurance name and the secondary line should show a payer code "Z" and Medicare. Include in remarks the reason the primary insurance denied the claim (i.e., insurance denied services not covered).

31. Where can I find physical therapy documentation guidelines information?

Physical Therapy documentation guidelines can be found on the WPS Website under the Medical Review area.

http://www.wpsmedicare.com/
Click on J5 MAC: Iowa, Kansas, Missouri, Nebraska Providers
Click on Medicare Areas
Click on MR/CERT
Click on Medical Review
Under Medical Review Information, Click on Documentation Guidelines
Scroll down and click on Documentation Guidelines File
Scroll down to Therapies (Physical, Occupational and Speech)
http://www.wpsmedicare.com/j5macparta/business/partamrdocguidefulldoc.shtml

32. Where can I find information on how to bill the shingles vaccine?

The Shingles Vaccine is not a covered under Part B, however may be covered under Part D.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under Guidance
Click on Transmittals
Under Transmittals
Click on "2007 Transmittals
Scroll down & choose "All" in the View Items per page
Click Go
Click on "SE0727"
http://www.cms.hhs.gov/Transmittals/2007Trans/list.asp

33. We have had several claims reject because our mammography certification is not on file. How can we get these claims to process?

The Mammogram Certification will need to be faxed in to WPS Medicare, Attention Tineisha Whitehead at 402-351-8796. Once certification has been updated the claim can be re-billed.

34. Do the daily nursing notes for a Skilled Nursing Facility (SNF) have to be done by a Registered Nurse (RN) or can they be done by a Licensed Practical Nurse (LPN)?

Skilled nursing and/or skilled rehabilitation services are those services, furnished pursuant to physician orders, that:

Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and
Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-02
Under Downloads click on Chapter 8
Scroll down to section 30.2.1
http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf

35. Where can I find a list of the 2009 inpatient only procedures?

The 2009 inpatient only procedures can be found on the Federal Register Addendum B with a status indicator of C.

36. We had a patient come to our acute hospital from a SNF. They were receiving Part A benefits at the time and received a blood transfusion which will be billed with HCPC code 36430. Is this HCPC code excluded from consolidated billing?

No, HCPC code 36430 would be included in the inpatient stay.

Go to http://www.cms.hhs.gov/
Click on Medicare
Under Billing
Click on "SNF Consolidated Billing"
Under Overview
Click on the appropriate year for your claim dates of service
http://www.cms.hhs.gov/SNFConsolidatedBilling/

37. We are a Critical Access Hospital (CAH) and are providing patients with cardiac rehabilitation services. Should these services be billed monthly or daily?

Only facilities that are subject to OPPS are required to bill repetitive services monthly, since CAHs are not subject to OPPS they do not have to bill monthly.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 1
Scroll down to section 50.2.2
http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf

38. Are pain medications administered post-operative separately billable on an inpatient acute (11X) claim?

Pain medications are included in the DRG payment for inpatient claims. Beneficiary cost-sharing is limited to statutory deductibles, coinsurance, and payment for noncovered items and services.

Go to http://www.cms.hhs.gov/ Click on "Regulations and Guidance" Under "Guidance" click on "Manuals" Under Manuals Overview on the left side, click on "Internet-Only Manuals" Under Publications click on 100-04 Under Downloads click on Chapter 3 Scroll down to section 20 A.-General http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf

39. We have a patient who came into our Acute Hospital with chest pain. During the course of treatment we repeated the cardiac enzymes test 3 times resulting in 3 venipunctures. Are we able to bill for all 3 of these venipunctures?

No, only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 16
Scroll down to section 60.1
http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf

40. If the admitting physician agrees that a patient should have been placed in observation instead of being admitted as an inpatient, does the case still have to go to Utilization Management (UM) Committee to agree before utilizing the condition code 44?

Yes, the UM committee still needs to agree that services did not meet inpatient criteria before condition code 44 can be utilized.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 1
Scroll down to section 50.3
http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf

Page Last Updated: Wednesday, 17-Feb-2010 14:07:58 CST

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