WPS Medicare Provider Part B - Frequently Asked Questions

Frequently Asked Questions - Top 10 Phone Inquiries

WPS is please to publish FAQ's based upon topics we have identified as those generating a high volume of telephone inquiries to Customer Service. The following table lists ten reasons (by topic) our Medicare providers and their agents telephoned our call centers during February 2008.

Top 10 Reason Codes for Wisconsin, Illinois, Michigan, and Minnesota:
February 2008
(Excluding Claim Status and Eligibility Issues)

Description	Occurrences
Coding Errors/Modifiers	1,583
Duplicate Claim Denials	1,396
Address/Phone/Fax/Web Address	1,356
Contractual Obligation not Met - Claim Denials	1,069
CMS-1500 Claim Form Item	983
Appeals Process/Rights	937
Provider Information	916
Medicare Secondary Payer (MSP)	897
Submitted to Incorrect Program	894
Payment Explanation/Calculation	821

WPS Medicare publishes FAQs specifically developed to address Top 10 Inquiry Reasons from the previous month's reporting period. We hope the answers to the questions listed below assist you in reducing claims errors associated with these topics.

February

January

Contractual Obligation Not Met - Claim Denials

My claims are being denied stating "missing/incomplete/invalid information on where the services were furnished." Box 32 has the name and address listed, so why is Medicare denying my claims? (03/24/08)

ATP Amount / Check Information

I have three different providers for whom I need to obtain approved-to-pay and pending claims information, as well as check amounts and issue dates. What is my best way of getting this information? (03/24/08)

December

Coding Errors/Modifiers

How do I bill for a procedure that is performed bilaterally? (03/03/08)

Address/Phone/Fax/Web Address

Is there a telephone number where I can reach the EDI Department? (03/03/08)

November

Medicare Secondary Payer (MSP)

Why is my claim denying, stating that the beneficiary has another payee contractor? He states he only has Medicare. (03/03/08)

National Provider Identifier (NPI)

Why is my claim denying for invalid primary identifier? All the correct information is on claim. (03/03/08)

October

CMS-1500 Claim Form Item

What information is required in item 11 on the CMS-1500 claim form when Medicare is the primary insurance? (12/26/07)

September

Address/Phone/Fax/Web Address

I have a patient who is enrolled in the Medicare Advantage program through United Healthcare. Do you know how I can get their phone number? (09/04/07)

I have received notification that Medicare is monitoring my paper claims filing under the Administrative Simplification Compliance Act (ASCA). This states that I should be trying to file my claims electronically. Do you offer any type of guidance or software that can help me get started with electronic filing? We do not have a large volume of Medicare claims, but maybe we should file them electronically anyway. (09/04/07)

Coding Errors/Modifiers

Why did the chest x-ray (CPT 71010), on my claim deny? The doctor performed and interpreted it in the office, but my denial says the procedure is inconsistent with the place of service. (09/04/07)
Why are my therapy codes denying? I always bill therapy procedure codes and are paid for them; so, why are they denying now? (12/26/07)

Duplicate Claim Denial

I called the Interactive Voice Response (IVR) system to see if I could find out why I had not received payment on a claim I submitted. The IVR stated that the claim denied as a duplicate. What is going on? (09/04/07)
We continually receive duplicate denials on radiology services performed multiple times per day to a patient. Why? (12/26/07)

Payment Explanation/Calculation

Why was my claim paid at a lower allowed amount for surgery than what is shown on the Medicare fee schedule? (09/04/07)

August

Duplicate Claim Denials

My claims are being denied as duplicates when I do not have record that payment has been received. How long should I wait before I re-file the claims when I have not heard anything from Medicare? (10/08/07)

CMS-1500 Claim Form Item

In what field on the CMS-1500 claim form do I place the provider's National Provider Identifier (NPI) number(s)? (10/08/07)

Medicare Secondary Payer (MSP)

I received denials for a patient stating that Medicare cannot make payment for the date of service without an Explanation of Benefits (EOB) from the primary insurer. However, the patient states that Medicare is primary. Why are you denying? (10/08/07)

July

Address/Phone/Fax/Web Address

Our office began filing claims for services covered under the Physician Quality Reporting Initiative last month. We are not certain that the quality measures we reported are accurate. Is there a location where we may find additional information about this program? (09/04/07)

Appeals Process/Rights

What is the time limit for filing a written appeal of a denied service? (09/04/07)

Coding Errors/Modifiers

Our office is providing a service to a patient that Medicare lists as Non-covered. Do we need to supply the patient with an Advance Beneficiary Notice in order to collect from them? (09/04/07)

Medical Necessity

Medicare denied a procedure we billed as not medically necessary. When I went to your Website and looked at the policy for the procedure, the diagnosis on the claim is payable. Why is it being denied? (09/04/07)

February

Coding Errors/Modifiers

1.	Why is my claim for an Evaluation and Management (E/M) visit denied as bundled into another procedure, when I have billed the 25 modifier on the claim, which is needed since a surgery was performed on the same day as the E/M visit?
	The E/M service may be in the global period of another procedure. If the E/M service is unrelated to the previous procedure and significant, separately identifiable from the procedure performed on the same day both Modifier 24 and 25 may be necessary. The 24 modifier is appropriate if the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is also needed to identify that the E/M services is significant, separately identifiable from the minor surgery/procedure performed on the same day. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/ education/modifier_global_surg.pdf Posted (05/09/08)

CMS 1500 Claim Form Item

2.	How do I report an NPI on a CMS-1500 claim form when the provider is a sole practitioner?
	A sole practitioner should enter their NPI in box 33-a. This is different from a provider who is a member of a group. Providers who are members of a group must enter their individual NPI in box 24-j, and the group NPI in box 33-a You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/manuals/ downloads/clm104c26.pdf Posted (05/09/08)

Appeals Process/Rights

3.	If Medicare denies a service, do I have any appeal rights and, if so, what is the process to file an appeal?
	Part B providers and beneficiaries have 120 days to file a request for a redetermination from the date of receipt of the remittance notice or Medicare Summary Notice (MSN). This is the first level of appeal conducted by Medicare contractors, and it must be done in writing. If a claim was returned as unprocessable, a new claim should be submitted with additional or corrected information. A redetermination cannot be performed on unprocessable claims. You may find additional information on this topic at the following Websites: http://www.wpsmedicare.com/part_b/ business/appeal_howto.pdf and at http://www.cms.hhs.gov/OrgMedFFSAppeals/ Posted (05/09/08)

Provider Information

4.	Why was my claim returned indicating an incorrect primary identifier?
	Reference to the primary identifier usually means that you are billing something incorrectly regarding the billing/individual provider (number), in CMS 1500 claim form box 33-a, or box 24-j. This would indicate the Provider Transaction Access Number (PTAN) or NPI of the group or the individual performing provider. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/manuals/ downloads/clm104c26.pdf Posted (05/09/08)

Medicare Secondary Payer (MSP)

5.	My claim denied stating that the patient has other primary insurance; however, when I checked eligibility on the IVR it stated that Medicare is primary. Why is my claim being denied?
	Often times an MSP record is updated by the Coordination of Benefits Contractor (COBC) after a claim has been submitted and denied by Medicare. If you have verified that the records are updated to reflect Medicare as primary on the date of the denied service, then a new claim can be resubmitted. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/Provider Services/01_overview.asp Posted (05/09/08)

Payment Explanation/Calculation

6.	Why was the reimbursement for the claim I submitted reduced?
	There are several reasons whereby reimbursement levels can be reduced. For example, payments can be reduced based upon multiple surgery guidelines, when a secondary surgical procedure is billed with a "51" modifier. For surgical procedures which are appropriately billed as secondary, the reimbursement level is reduced to 50 percent of what that procedure would approve were it to be performed by itself. Similarly, an Evaluation and Management Code (E/M) billed the day of or the day before surgery is usually considered part of the surgical package, and reimbursement for it may be included in the reimbursement for the surgery itself. The Medicare Physician Fee Schedule Database (MPFSDB) offers additional information regarding this process. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/Transmittals/ Downloads/R28CP.pdf Posted (05/09/08)

January

Contractual Obligation Not Met - Claim Denials

1.	My claims are being denied stating "missing/incomplete/invalid information on where the services were furnished." Box 32 has the name and address listed, so why is Medicare denying my claims?
	The Centers for Medicare & Medicaid Services (CMS) has determined that some ZIP codes fall into more than one payment locality. Therefore, beginning October 1, 2007, Medicare requires the submission of a 9-digit ZIP code for services paid under the Medicare Physician Fee Schedule and anesthesia services when the services are provided in those ZIP codes which cross the lines of more than one payment locality. The requirement does not apply to services provided with the place of service Home. Change request (CR) 5208 issued on March 9, 2007 contains the list of ZIP codes that require the use of the full 9-digit ZIP code for claims with dates of service on or after October 1, 2007. This ZIP code list was updated by CR 5730. You may find additional information on this topic at the following Websites: CR5208 - http://www.cms.hhs.gov/mlnmattersarticles/ downloads/mm5208.pdf CR5730 - http://www.cms.hhs.gov/mlnmattersarticles/ downloads/mm5730.pdf Posted (03/24/08)

ATP Amount / Check Information

2.	I have three different providers for whom I need to obtain approved-to-pay and pending claims information, as well as check amounts and issue dates. What is my best way of getting this information?
	The WPS Medicare Website offers a number of self-service tools to assist providers and their agents in obtaining needed information. Among these tools, providers may access instructions for utilizing the Interactive Voice Response (IVR) unit. Providers can obtain approved-to-pay and pending claims information, as well as check amounts and paid dates via the Provider Summary option of the IVR. You may find additional information on this topic at the following Web address http://www.wpsmedicare.com/part_b/selfservice /contact_info.shtml Posted (03/24/08)

December

Coding Errors/Modifiers

1.	How do I bill for a procedure that is performed bilaterally?
	When a procedure is done bilaterally AND the Medicare Physician Fee Schedule Database (MPFSDB) indicator for the procedure is "1," report the procedure code once, append modifier 50 to it, and report it with one unit of service. Some procedures, even though they can be performed bilaterally, are not shown on the on the MPFSDB as having indicator "1" in the bilateral column. This means that they cannot be billed with modifier 50. Medicare carriers are not able to override such restrictions found on the MPFSDB. For procedures performed bilaterally which do not allow modifier 50, bill the service on two separate lines, and append modifier LT (for left) on the first line of service, and modifier RT (for right) on the second line of service. You may find additional information on this topic at the following Web address: http://www.wpsmedicare.com/part_b/education/modifiers.shtml Posted (03/03/08)

Address/Phone/Fax/Web Address

1.	Is there a telephone number where I can reach the EDI Department?
	The telephone number for Electronic Data Interchange (EDI) for all providers in Wisconsin, Illinois, and Michigan is 877-567-7261. Minnesota providers should call 866-380-4742. If you need to leave a message, please leave your name, telephone number, and submitter ID. A member of the EDI staff will return your call as soon as possible. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/selfservice/contact_info.shtml Posted (03/03/08)

November

Medicare Secondary Payer (MSP)

1.	Why is my claim denying, stating that the beneficiary has another payee contractor? He states he only has Medicare.
	The patient may have another insurance, primary over his Medicare, indicated on his master file. If so, he should contact the Coordination of Benefits Contractor, (COBC) at 800-999-1118 to have his files updated with the correct information. Once he has done so, you can resubmit your claims. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/COBGeneralInformation Posted (03/03/08)

National Provider Identifier (NPI)

1.	Why is my claim denying for invalid primary identifier? All the correct information is on claim.
	When a claim denies for invalid primary identifier, Medicare has identified that you have billed something incorrect in item 33-A. The incorrect data is most likely an incorrect NPI. Item 33-A should have the NPI of the billing provider, or that of the practice. If you are having problems with an incorrect NPI, you can go to the Website for the National Plan and Provider Enumeration System (NPPES) and contact the NPI Enumerator. They can direct you on how to obtain the correct provider or group numbers you need. You may also want to contact Provider Enrollment to see how your clinic and doctors are listed in Medicare's provider files. You may find additional information on this topic at the following Website: http://nppes.cms.hhs.gov/NPPES/Welcome.do Posted (03/03/08)

October

CMS-1500 Claim Form Item

1.	What information is required in item 11 on the CMS-1500 claim form when Medicare is the primary insurance?
	If Medicare is primary, enter the word "NONE" in this field and proceed to item 12 on the claim form. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/manuals/ downloads/clm104c26.pdf Posted (12/26/07)

September

Address/Phone/Fax/Web Address

1.	I have a patient who is enrolled in the Medicare Advantage program through United Healthcare. Do you know how I can get their phone number?
	Please refer to the CMS website. This Website has the most current listing of contact information, including phone numbers, for all Medicare Advantage plans. It is important to remember that Medicare Advantage plans work like a Health Maintenance Organization (HMO) program and replace traditional Medicare. Posted (09/04/07)


2.	I have received notification that Medicare is monitoring my paper claims filing under the Administrative Simplification Compliance Act (ASCA). This states that I should be trying to file my claims electronically. Do you offer any type of guidance or software that can help me get started with electronic filing? We do not have a large volume of Medicare claims, but maybe we should file them electronically anyway.
	It is important that all providers file their claims electronically, unless they meet one of the ASCA exceptions. Medicare offers free HIPAA-compliant billing software, named PC-Ace Pro 32. This is a "stand alone" software package that creates a patient database and allows your office to electronically submit Medicare Part B claims electronically. Please call our EDI Hotline at (877) 567-7261 for additional information. Minnesota providers should call (952) 885-2881, (952) 885-2882, or (952) 885-2811. Posted (09/04/07)

Coding Errors/Modifiers
1.	Why did the chest x-ray (CPT 71010), on my claim deny? The doctor performed and interpreted it in the office, but my denial says the procedure is inconsistent with the place of service.
	The claim Medicare received indicated a facility place of service code. Medicare cannot pay globally (professional and technical components combined) in a facility. If the correct place of service is office, the correct place of service code is "11." Either you can re-bill the claim with the correct place of service, or you can call the reopening hotline line, at the Provider Customer Service telephone number for the state in which you practice. Posted (09/04/07)

1.	Why are my therapy codes denying? I always bill therapy procedure codes and are paid for them; so, why are they denying now?
	In order to pay correctly, you must bill therapy procedure codes with a modifier. Wisconsin Physicians Service (WPS) Medicare outlines this instruction in medical policy PhysMed-001, page 34. By category, the appropriate therapy modifiers and their corresponding usage, are: GN, for Speech-Language Therapy GO, for Occupational Therapy GP, for Physical Therapy KX, for Specific, Required Therapy services You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/ policy/physmed-001.pdf Posted (12/26/07)

Duplicate Claim Denial
1.	I called the Interactive Voice Response (IVR) system to see if I could find out why I had not received payment on a claim I submitted. The IVR stated that the claim denied as a duplicate. What is going on?
	Claims deny as duplicate when they "hit" against another claim that was received but which has not finalized, or for which the approved amount was applied to deductible. Of course, claims will also deny as duplicate when we have paid the service previously. You should always wait until you receive your Remittance Notice before submitting another claim. Remember: it takes paper claims 30- 45 days to complete processing, and electronic claims take 14 days to complete processing. Posted (09/04/07)

We continually receive duplicate denials on radiology services performed multiple times per day to a patient. Why?
	A provider may perform multiple procedures, or "repeat procedures" to a patient on a single day. These are more common with radiology and clinical laboratory services. If Wisconsin Physicians Service (WPS) Medicare cannot accept multiple numbers of services (quantity billing), then the provider of service must bill separate line items for each service. Providers can apply modifier 76 (radiology or diagnostic services) or modifier 91(clinical laboratory services only) to the second and subsequent lines of service to avoid duplicate denials. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b /business/avoid_dup.shtml Posted (12/26/07)

Payment Explanation/Calculation
1.	Why was my claim paid at a lower allowed amount for surgery than what is shown on the Medicare fee schedule?
	With the procedures you are billing, Medicare bases reimbursement for the paid amount upon multiple surgery guidelines. To find out more specifics about multiple surgeries, please refer to National Coverage Provision (NCP) GSURG-001 on the Medicare Website. In addition, we frequently publish articles in our monthly newsletter, the Communiqué, which address this topic. Finally, the Medicare Physician Fee Schedule Database (MPFSDB) contains indicators which point to whether or not a given procedure code is subject to multiple surgery guidelines. When this applies, Medicare reduces reimbursement for second (and additional) procedures. You may find the MPFSDB on the CMS website. Posted (09/04/07)

August

Duplicate Claim Denials

1.	My claims are being denied as duplicates when I do not have record that payment has been received. How long should I wait before I re-file the claims when I have not heard anything from Medicare?
	Before re-filing a claim, allow sufficient time for the claim to reach Medicare, for the claim to process, and for the Provider Remittance Notice (PRN) to reach you. Claim processing time cannot be shorter than the "payment floor," which is 13 days for electronic claims, and 29 days for paper claims. This is the minimum amount of time that must elapse from the date Medicare receives the claim until the date Medicare issues a payment. Actual processing time may be longer. Also, before re-filing, carefully review your records, and access the Interactive Voice Response (IVR) system for claim status. When submitting a claim, send it in either a paper or electronic format, but not both. Please note that restrictions associated with both the Health Insurance Portability and Accountability Act (HIPAA) and the Administrative Simplification Compliance Act (ASCA) allow only certain providers to continue to submit paper claims. You may find additional information on duplicate claim denials on the WPS Website. Posted (10/08/07)

CMS-1500 Claim Form Item
1.	In what field on the CMS-1500 claim form do I place the provider's National Provider Identifier (NPI) number(s)?
	The CMS-1500 claim form utilizes multiple fields for different purposes when reporting provider's National Provider Identifiers (NPIs) to Medicare. Use field 17B for the ordering/referring providers' NPI. This replaces the Unique Physician Identification Number (UPIN), previously reported in this field. Field 24J (non-shaded area) is reserved for the rendering/performing providers' NPI. Field 32A is the service facility NPI; and 33A is the billing provider or group NPI. The reporting scenarios listed above are only a few of the many instances where billers need to report a provider's National Provider Identifier (NPI) on the CMS-1500 claim form. For a complete listing of all fields, and the information required, please refer to CMS's Internet Only Manual (IOM) 100-04, Chapter 26, Sections 10.2-10.4. Information specific to NPI is contained in Section 10.4. You can find these instructions on the CMS Website at http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf Posted (10/08/07)

Medicare Secondary Payer
1.	I received denials for a patient stating that Medicare cannot make payment for the date of service without an Explanation of Benefits (EOB) from the primary insurer. However, the patient states that Medicare is primary. Why are you denying?
	If Medicare files indicate that a patient has primary coverage through another insurer, and the patient indicates this is incorrect, the patient (or an authorized representative of the patient) can contact the Coordination of Benefits (COB) contractor and have their files updated. This process will take approximately 72 hours, after which time you may re-file claims. For additional information regarding the role of the COB, please refer to: http://www.cms.hhs.gov/COBGeneralInformation/ Posted (10/08/07)

July

Address/Phone/Fax/Web Address

1.	Our office began filing claims for services covered under the Physician Quality Reporting Initiative last month. We are not certain that the quality measures we reported are accurate. Is there a location where we may find additional information about this program?
	There is a tremendous amount of information available regarding the Physicians Quality Reporting Initiative (PQRI) on the CMS Website at http://www.cms.hhs.gov/PQRI. At this location, you will find the following: 2007 PQRI quality measures and the associated measure specifications the complete list of eligible professionals who may choose to participate new and revised Frequently Asked Questions Posted (09/04/07)

Appeals Process/Rights
1.	What is the time limit for filing a written appeal of a denied service?
	Part B providers and beneficiary's have 120 days to file a request for a redetermination from the date of receipt of the remittance notice or Medicare Summary Notice (MSN). This is the first level of appeal that Medicare contractor's conduct. You can find this information in the Internet Only Manual (IOM) 100-4, Chapter 29, Section 30.7 at the following Web address: http://www.cms.hhs.gov/manuals/downloads/clm104c29.pdf Posted (09/04/07)

Coding Errors/Modifiers
1.	Our office is providing a service to a patient that Medicare lists as Non-covered. Do we need to supply the patient with an Advance Beneficiary Notice in order to collect from them?
	No. CMS designed the Advance Beneficiary Notice (ABN) as a tool of communication between providers and their patients to be used when it is expected that Medicare will deny a service that may otherwise be paid. The two primary categories for which such denials occur are 1) diagnosis, and 2) frequency of service. If a service is statutorily Non-covered, the provider (or supplier) may always bill the patient. No written notification is required. Posted (09/04/07)

Medical Necessity
1.	Medicare denied a procedure we billed as not medically necessary. When I went to your Website and looked at the policy for the procedure, the diagnosis on the claim is payable. Why is it being denied?
	If a procedure is being denied as not medically necessary for a diagnosis that is found on a policy, go to the end of the policy to the Revision History Number/Explanation for your state to locate the revision date and the explanation of what was added or removed from the policy. Unless otherwise noted, the revision date is the effective date. If the date of service being denied is prior to the revision/effective date, the service will be denied. Medical necessity denials may also occur for services which are provided more frequently than is allowed. Posted (09/04/07)

Page Last Updated: Friday, 09-May-2008 17:01:32 CDT