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. See the Listing of Top 10 Claim Submission Errors December 2008 on the WPS Medicare Website.

I bill my claims through DDE, how do I correct my claim in RTP for reason code 32511?
For providers with DDE access, action can be taken to correct claims in RTP status. Here is the process:
- Access DDE.
- Access claims that edited with Reason Code 32511.
- Go to page 2 of the claim and press the F11 key (map171E).
- Correct the claim by entering data in any of the three NDC fields that are blank
- Press the F9 key.
After the claim is corrected and stored, the claim receipt date will reset and the claim will continue processing.

Refer to Correctly Edited Claims on the WPS Medicare Website.

I submitted a hardcopy adjustment on a claim that previously rejected due to other insurance coverage. The adjustment is now editing with reason code 77730 stating that the MSP record on Common Working File (CWF) is still showing Medicare as secondary payer. Who do I contact to update CWF?
As the provider, you are responsible for checking the MSP screen on Common Working File (CWF) to ensure the information is accurate. If the information is correct, you may proceed with requesting your adjustment. If the screen is incorrect, you must call the Coordination of Benefits Contractor (COB) at 1-800-999-1118 to update the CWF. Once the screen has been updated by (COB) you may proceed with requesting your adjustment. Until this has been done by COB, our MSP Department is unable to adjust the denied claims and unable to assist you. However, if you do not have access to CWF you may contact the MSP Department at 1-866-518-3284 and we will check CWF for you. You can find out more information on MSP Adjustments on the WPS Medicare Website.

I have an outpatient (13X) claim that line denied with reason code W7040 stating that a component of comprehensive procedure was billed without an appropriate modifier. What do I need to do to get this line to process?
To get the claim to process you will need to check the NCCI tables to see if a modifier is appropriate, and then add the appropriate modifier is allowed. The Medicare Claims Processing Manual is in reference to the modifier explanation.

The NCCI tables allow you to check your codes and determine if a modifier is allowed. When accessing the tables, you will need to select the appropriate code range for your claim.

I submitted an 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. See the Listing of Top 10 Claim Submission Errors December 2008 on the WPS Medicare Website and scroll down to Reason Code 77745.

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.

I have a claim that denied for C7010. How do I get my claim to process?
The facility must bill the hospice for the services approved by the hospice. If the services were not approved, the beneficiary is responsible for the payment. If the beneficiary has revoked this benefit, the hospice must request that the records be updated to reflect the correct revocation indicator. If the revocation indicator is '0', you need to contact hospice to update the indicator to '1' indicating hospice has been revoked.

I have a claim that denied for N5052 saying common working file records indicate the beneficiary's name and health insurance claim number do not match. What do I need to do to get this claim to process?
The providers will need to verify the information on the beneficiary's Medicare card. Then correct and resubmit the claim with the correct information to match the beneficiary's Medicare card.

I have an outpatient claim (13X) that rejected with reason code C7113 stating an inpatient stay is less than 4 days from my outpatient claim. If I remove the diagnostic services from my outpatient claim, will this allow my claim to process?
Yes, if all diagnostic services are removed from the claim this will allow the claim to process. See the Medicare Claims Processing Manual for more information.

What HCPC Codes are used to bill for the administration of the Influenza A (H1N1) vaccine?
The Influenza A (H1N1) virus has been identified as an additional type of influenza. The H1N1 virus vaccine will be provided to Medicare Part B beneficiaries as an additional preventive immunization service. Medicare will pay for the administration of the H1N1 vaccine. The Centers for Medicare & Medicaid Services (CMS) has created two new HCPCS codes for H1N1, effective for dates of service on and after September 1, 2009:
- G9141-Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
- G9142---Influenza A (H1N1) vaccine, any route of administration.
See Special Edition MLN Matters Article SE0920 .

Where can I find the Medicare Physician Fee Schedule (MPFS) amount for HCPCS code 97001?
The Medicare physician fee schedule is located on the CMS Website ; you can find the 97001 HCPCS code on the link below.

Visit the CMS Website
Scroll down & choose "All" in the View Items per page
Click Go
Click on the correct year
Open the file and click on "PPRRVUXX"

Where can I find an updated list of adjustment reason codes?
An updated list can be found on the Washington Publishing Company Website .

If we did not receive our Electronic Remittance Advice (ERA), who should we contact?
Starting October 17, 2005, the Customer Service Area no longer accepted telephone requests for duplicate remittance advices. Providers that need to obtain a duplicate remittance advice will have the following options for obtaining duplicate electronic or paper copies: Providers that receive their remittance advice electronically (ERA) have up to thirty days from the original ERA date to contact the Medicare Systems Area and request a duplicate electronic copy of their ERA. All requests must be faxed to 402-351-6188 on your company letterhead to the Medicare EDI Department. If the ERA is over 30 days old, we will not be able to provide an electronic copy. Instead, providers on ERA will have to mail or fax a request for a paper copy of their ERA. Providers can fax their duplicate remittance advice request to 402-351-8047 or mail their request to the following address assigned for their state:

IA	KS	MO	NE
WPS Medicare Part A General Correspondence P.O. Box 7665 Madison, WI 53707-7665	WPS Medicare Part A General Correspondence P.O. Box 7576 Madison, WI 53707-7576	WPS Medicare Part A General Correspondence P.O. Box 8890 Madison, WI 53708-8890	WPS Medicare Part A General Correspondence P.O. Box 8799 Madison, WI 53708-8799

Can patient status 04 be used when a patient is discharged from an Acute Hospital and is admitted to an assisted living facility?
No, the patient status 04 is to be used when a patient is discharged/transferred to an Intermediate Care Facility (ICF). See CMS Transmittal R1718CP .

In regards to the H1N1 vaccine administration in a Rural Health Clinic (RHC) setting, should we be maintaining a log of administrations for cost reporting purposes?
The H1N1 is a type of influenza virus. You would bill the H1N1 vaccine just the same as you would the Type A influenza vaccine.

Independent and provider-based RHCs and Federally Qualified Health Clinics (FQHCs) do not include charges for influenza virus and pneumococcal vaccines on Form CMS-1450. Administration of these vaccines does not count as a visit when the only service involved is the administration of influenza virus and/or pneumococcal vaccine(s). If there was another reason for the visit, the RHC/FQHC should bill for the visit without adding the cost of the influenza virus and pneumococcal vaccines on the claim. FI/A/B MACs pay at the time of cost settlement and adjust interim rates to account for this additional cost if they determine that the payment is more than a negligible amount. See the Medicare Claims Processing Manual .

We received a Remittance Advice that had financial adjustments PL/935 on it. Where can I find a list of these codes and their descriptions?
The PL/935 is a medical review adjustment which can be medical review post pay adjustments, medical review probes, or appeals. You can find information regarding the 935 on Transmittal 141. The code on the remittance advice to identify the 935 adjustments is N469. You can find the description of the N469 in the Remittance Advice Remark Codes field on the Washington Publishing Company Website .

Is there an edit for once in a lifetime procedures?
No, there are currently no edits in the Fiscal Intermediary Standard (or Shared) System (FISS) for once in a lifetime procedures.

Is there guidance from WPS Medicare on the reporting of medication that was appropriately discarded from single use vials? Are we required to bill modifier JW with the discarded units?
CMS encourages physicians, hospitals and other providers to schedule patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner. However, if a physician, hospital or other provider must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded along with the amount administered, up to the amount of the drug or biological as indicated on the vial or package label. When processing all drugs except those provided under the Competitive Acquisition Program for Part B drugs and biologicals (CAP), local contractors may require the use of the modifier JW to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. This modifier will provide payment for the discarded drug or biological. The JW modifier is not used on claims for CAP drugs. See the Medicare Claims Processing Manual .

May NPPs who are employed by the facility bill for medically necessary visits?
Payment may be made for the services of Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) who are employed by a SNF or NF when their services are rendered to facility residents. If NPs and CNSs employed by a facility opt to reassign payment for their professional services to the facility, the facility can bill the appropriate Medicare Part B carrier under the NPs' or CNSs' PINs for their professional services. Otherwise, the NPs or CNSs who are employed by a SNF or NF bill the carrier directly for their services to facility residents.

On the other hand, Physician Assistants (PAs) who are employed by a SNF or NF cannot reassign payment for their professional services to the facility because Medicare law requires the employer of a PA to bill for the PA's services. Hence, the facility must always bill the Part B carrier under the PA's PIN for the PA's professional services to facility residents.

How is the billing for a Critical Access Hospital (CAH) Swing Bed provider handled when a patient is sent to another hospital for a test that they could not provide?
CAH swing beds are exempt from SNF consolidated billing; however, they do need to follow the direction in the CMS Internet Online Manual 100-4, Chapter 3, Section 10.4 on bundling hospital charges. These charges should be included on the 18x type of bill. See the Medicare Claims Processing Manual .

Page Last Updated: Monday, 22-Feb-2010 11:08:07 CST