4th Quarter FY11 Phone Correspondence FAQs

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  1. Are Critical Access Hospitals (CAH) required to utilize the G0 condition code?
  2. Do all Skilled Nursing Facility claims have to bill in sequential order?
  3. How do I correct a claim that rejected for 51MUE?
  4. Can I submit an adjustment on a denied claim that has been medically reviewed?
  5. We submitted a claim that rejected for reason code U538H stating that these charges were overlapping an incarceration period. We contacted the beneficiary and verified the beneficiary was not incarcerated at the time of the service. How do we get this corrected?
  6. We have several claims editing with reason code 19201 stating that when the receipt dates is on or after 05/23/08 the attending physician National Provider identifier (NPI) and name must be present. How do I correct these claims?
  7. I have a claim that denied for C7010, How do I get my claim to process?
  8. 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?
  9. How do I get the liability, no-fault, or worker's compensation record updated in Common Working File?
  10. I have a claim that is editing with reason code W7050 stating that the service is non-covered based on statutory exclusion. I am trying to bill HCPCS code A9270 for a self-administered drug denial. How should I be billing this?

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  1. Are Critical Access Hospitals (CAH) required to utilize the G0 condition code?

    No. The G0 condition code is used only for OPPS claims. A CAH is not subject to OPPS. Since CAHs are exempt from OPPS, they would need to bill all of their dates of service on the same claim.

    Internet Only Manuals (IOM) Publication 100-4, Chapter 4Adobe Portable Document Format, Section 180.4.

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  2. Do all Skilled Nursing Facility claims have to bill in sequential order?

    Yes, all claims need to be billed in sequential order. If the claim is not billed in sequential order, the claim will deny for 38119. The system is looking for the prior processed claim.

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  1. How do I correct a claim that rejected for 51MUE?

    Providers can adjust a claim that rejected for 51MUE to lower the units billed. Adjustments must be sent in hardcopy with condition code D9 and the following remark in the remarks section of the claim verbatim: Units. If the units are correct, the provider will need to submit an appeal with documentation to support medical necessity. Please see the Appeals page for more information.

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  1. Can I submit an adjustment on a denied claim that has been medically reviewed?

    No, if the entire claim was denied and currently has a "D B9997" status then you must submit an appeal for the denied claim.

    If line item(s) in the claim has/have been denied with a 50000 range reason code (medical review was done on the line in question) and this is what you are adjusting, you must submit an appeal for the denied service.

    If a claim has a line denial with a 50000 range reason code and you are trying to adjust other lines (not the line with the denial code) you should submit your request via DDE with your corrections and show the denied service as non covered as they appear on the processed claim. If you do not have DDE access a hard copy adjustment would need to be submitted.

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  2. We submitted a claim that rejected for reason code U538H stating that these charges were overlapping an incarceration period. We contacted the beneficiary and verified the beneficiary was not incarcerated at the time of the service. How do we get this corrected?

    If the dates of incarceration (INCR) on the Common Working File (CWF) are incorrect, the provider will have to contact the State Department of Corrections to verify the actual dates. If the information is not updated on CWF, then you will need to contact the CMS Regional Office (RO) in your region to have this updated.

    Once CWF has been updated to show the correct incarceration dates the RO will notify our office. At that time we will initiate the reprocessing of all claims that were impacted as a result of the incorrect incarceration dates.

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  3. We have several claims editing with reason code 19201 stating that when the receipt dates is on or after 05/23/08 the attending physician National Provider identifier (NPI) and name must be present. How do I correct these claims?

    As of May 23, 2008, the NPI which is a single, ten-digit identification number that replaced all other health care provider identifiers-including Medicare provider identification numbers and Unique Physician Identification Numbers (UPINs)--used on Medicare claims and all other payers' standard health care transactions. All health care providers, including individual physicians and practitioners, and organizations such as group practices, hospitals, and nursing homes, are required to obtain and use NPIs in connection with all of their HIPAA standard health care transactions. These include claims; eligibility inquiries and responses; claim status inquiries and responses; referrals; and remittance notices.

    To correct the claim, you will need to add the correct NPI and corresponding physician name to the claim. If the UPIN is present, remove the UPIN number. If you have DDE you can make your corrections through the DDE system. If you do not have DDE you can contact the correction line and they will add the information for you.

    The phone number for the correction line is (866) 518-3253.

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  4. 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 update to reflect the revocation indicator. If the revocation indicator is '0', you need to contact hospice to update the indicator to'1' indication it has been revoked.

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  5. 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.

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  6. How do I get the liability, no-fault, or worker's compensation record updated in Common Working File?

    If your provider number is on file with the Coordination of Benefits (COB) and you want to update a liability, no fault or worker's comp record you will need to contact the lead contractor assigned by the COB. The COB should be able to give the provider the name and number of the contractor who can update this record. CMS has assigned certain states (where the patient currently lives) to each Medicare office that initiates for subrogation. This will happen when a patient is involved in a slip/fall, auto accident, malpractice, or worker's comp injury.

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  7. I have a claim that is editing with reason code W7050 stating that the service is non-covered based on statutory exclusion. I am trying to bill HCPCS code A9270 for a self-administered drug denial. How should I be billing this?

    Providers should bill self-administered drugs with revenue code 637 as non-covered charges with HCPC A9270 along with modifier GY (Item or Service Statutorily Excluded or Does Not Meet the Definition of Any Medicare Benefit).

    Publication 100-4, Chapter 1Adobe Portable Document Format, Section 60.4.2.

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Page Last Updated: Monday, 30-Apr-2012 13:57:55 CDT