Billing and Coverage FAQs - Part A
1. We have several claim adjustments editing for reason code 30905 stating there is no record of processing an original for this adjustment. How can I correct these claims?
This edit should not be received unless an incorrect Document Control Number (DCN) was used on the adjustment. To correct his you will need to verify the Health Insurance Claim (HIC) number, cross reference DCM, 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.
2. Several claims that I submitted hit a reason code N5052 stating that Common Working File (CWF) records indicate the beneficiary's name and health insurance claim number do not match. How can I correct these claims?
This error is created when a beneficiary name and/or number is submitted and there is not an exact match on CWF. To correct this issue you should verify the information on the beneficiary's Medicare card. Once you have the correct information it should be resubmitted.
3. 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.
For more information:
- 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 to Section 180.4
4. I have several claims that are editing with reason code 74566 stating that only one unit per encounter should be billed for Current Procedural Terminology (CPT) code 36430 regardless of number of IV bags administered. Only one unit was billed for CPT code 36430. What do I need to do to get these claims to process through the system?
There was a system issue where these claims were inappropriately editing. The system was correct on 04/03/08. If you still have claims in a TB9997 status location, you will need to F9 to store you claims.
5. I am J5 Nebraska provider and I have a claim that line rejected for reason code 5PNCD because the diagnosis on the claim does not support the medical necessity of the service. After further review, I determined that the wrong diagnosis was billed. How can I get this line to process?
The 5PNCD was a reason code, with WPS the reason code used by your previous contractor, WPS the corresponding code is 54NCD. If a claim denies with a reason code 54NCD, and you determine that the ICD-9 code is not correct, you may submit a hardcopy adjustment with the correct ICD-9 code. Nebraska providers should submit hardcopy adjustment requests to the following address:
WPS Medicare
Claims Department
PO Box 8799
Madison, WI 53708-8799
6. I work for a doctor's office in the state of Iowa. I have a couple of questions regarding physician billing. What number should I be calling?
You would need to contact WPS Part B customer service at (866) 503-3807. Wisconsin Physicians Service (WPS) Part A does not process doctor's claims.
7. What does it mean when a Local Coverage Determination (LCD) is SUPERCEDED?
SUPERCEDED documents mean there is a more recent version of this particular document. WPS Medicare loads the LCDs into the MCD when there is an update to the policy. CMS has a particular schedule that the carriers must adhere to when they submit these updates. Once the LCD has been updated, the link to the policy is then revised as well, but this is done automatically by the database. After the revision goes "Live" (typically happens on a Thursday), the link that is available on the WPS Medicare Website needs to be revised as well. If it is not, then the policy comes up as "SUPERCEDED." If you find a LCD that states "SUPERCEDED", you can scroll down to the bottom of the policy to the section entitled: "Other Versions" and you will be able to find the current version.
8. I have a claim that keeps hitting reason code M5052, which states that beneficiary master records are located at another host site. Is there anything I need to do to get this claim to process?
Claims in location M5052 are searching for the beneficiary information on Common Working File (CWF). There are several CWF host sites where beneficiary information is stored; therefore, multiple host sites may need to be checked until the record is located. This process can take several days as the claim will automatically re-cable by the system to the next host site until the beneficiary record is located and the claim is processed. If the beneficiary record it is not located at any of the host sites, CWF will return a message to us indicating there is a problem with the beneficiary's name and/or Medicare number. If CWF provides a corrected Medicare number we will update the claim, otherwise, the claim will be denied with reason code 30715.
9. 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?
CMS established units of service edits referred to as Medically Unlikely Edits (MUEs). An MUE is defined as an edit that tests claim lines for the same beneficiary, HCPCS code, date of service, and billing provider against a criteria number of units of service. Providers should determine why the claim was returned, correct the error, and resubmit the corrected claim if appropriate.
For more information, visit http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5603.pdf 
10. I need to verify how many days are available for a patient. How can I get this information?
You can obtain beneficiary eligibility and check your claims status and reimbursement information through the IVR system, at 1-866-518-3291. For instructions on using the IVR, go to
http://www.wpsmedicare.com/mac/selfservice/ivr.shtml.
Page Last Updated: Monday, 09-Jun-2008 13:18:39 CDT
