1st Quarter FY12 Phone Correspondence FAQs

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  1. Do all Skilled Nursing Facility claims have to bill in sequential order?
  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?
  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?
  4. I have a claim that rejected with reason code 38038 indicating it was for a duplicate submission, but the claim was a separate and distinct visit. How can I get this claim processed?
  5. I have a claim that was returned in status location TB9997 for reason code 70007. How do I get my claim to process?
  6. My claim is editing for reason code 38092, where can I find information on billing multiple laboratory panels on the same claim?
  7. I have a claim that returned for reason code 12206. How can I get my claim to process?
  8. I have a claim that returned in status location TB9997 for reason code 38031. How can I correct my claim?
  9. I have a claim that is editing for reason code 39012. What information is needed to correct my claim?
  10. I have a roster bill with diagnosis V048 orV0382, the claim is editing with 32200 reason code, how do I get my claim to process?
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  1. 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. Internet Only Manual (IOM), Publication 100-4, Chapter 6Adobe Portable Document Format, Section 40.

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  3. 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(external link). To find the correct list you will need to choose the correct year on the left had side of the web page for the date of service of the claim in question.

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  1. 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, hospital, and nursing homes, are required to obtain and use NPIs in connection with all of their HIPPA standard health care transactions. These include claims; eligibility inquiries and responses; claim status inquires 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 1-(866) 518-3253

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  1. I have a claim that rejected with reason code 38038 indicating it was for a duplicate submission, but the claim was a separate and distinct visit. How can I get this claim processed?

    According to the IOM Publication 100-4, Chapter 4Adobe Portable Document Format, Section 180.4, hospitals subject to Outpatient Perspective Payment System (OPPS) report Condition Code G0 (zero) on Form Locator (FL) 24-30 (or the corresponding electronic location) on the UB04 when multiple medical visits occur on the same day, in the same revenue center, but the visits were distinct and constituted independent visits.

    An example of such a situation would be a beneficiary going to the emergency room twice on the same day, once in the morning for a broken arm and later in the same day for chest pain.

    Multiple medical visits on the same day in the same revenue center may be submitted on separate claims. Hospitals should report condition code G0 on the second claim. Appropriate reporting of Condition Code G0 allows for accurate payment under OPPS in this situation. The Outpatient Code Editor (OCE) contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.

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  1. I have a claim that was returned in status location TB9997 for reason code 70007. How do I get my claim to process?

    Providers must verify their units being billed for HCPCS codes J0878 & J0583. Providers must contact the correction line for verification or to change their number of units billed.

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  3. My claim is editing for reason code 38092, where can I find information on billing multiple laboratory panels on the same claim?

    A listing of HCPC laboratory panel codes can be found in the IOM Publication 100-4, Chapter 16Adobe Portable Document Format, Sections 90.2 and 90.3.

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  1. I have a claim that returned for reason code 12206. How can I get my claim to process?

    Inpatient type of bill 11X, 21X or 18X and adjustments: The number of covered and non covered days billed are not equal to the number of days between the from and through dates.

    • If the patient status is not 30 the through dates of the claim is not counted.
    • If the patient status is a 30 the through date is counted.
    • If the from and through dates match, the claim must show one day.
    • Same day transfers must be counted as a non covered day.
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  3. I have a claim that returned in status location TB9997 for reason code 38031. How can I correct my claim?

    Verify the claim is an actual duplicate claim. If this is a second medical visit that occurred on the same day in the same revenue center but the visits were distinct and constituted independent visits, then check the IOM Publication 100-4, Chapter 4Adobe Portable Document Format, Sections 170 and 180.4 for proper billing instructions. Correct the claim and resubmit.

    If the claim is not a distinct and constituted independent visit then add the charge to the previously processed claim.

    If this is the third medical visit that occurred on the same day in the same revenue center that is a distinct and constituted independent visit, the IOM has been checked, and the second and third claims have a "G0" (zero)condition code, contact the correction line to verify that the third claim was correctly billed. If the claim is not a distinct and constituted independent visit, then add the charges to the previously processed claim.

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  5. I have a claim that is editing for reason code 39012. What information is needed to correct my claim?

    On page four of the claim, in the "Remarks" section, type verbatim one of the following four justification reasons on the first line:

    • Justify: MSP involvement;
    • Justify: SSA involvement;
    • Justify: PRO review involvement;
    • Justify: Other involvement.

    Any other remarks should start on the next line. There should be no other information on the first line. Once remarks have been added store (F9) the claim.

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  1. I have a roster bill with diagnosis V048 orV0382, the claim is editing with 32200 reason code, how do I get my claim to process?

    When a claim is billed with the following bill types, 13x, 14x, 22x, 23x, 24x, 34x, 71x, 72x, 74x, 75x, 83x, and 85x and the diagnosis code on the claim are either V048 or V0382 then the condition code A6 must be present.

    IOM Publication 100-4, Chapter 18Adobe Portable Document Format, Sections 10 - 10.3.2

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Page Last Updated: Monday, 30-Apr-2012 13:57:56 CDT