What is claim check edit

Claim Check

The TRICARE West Region contract uses a version of the McKesson HBOC ClaimCheck® product

to review non-Outpatient Prospective Payment System (non-OPPS) claims on a prepayment basis for unbundling. ClaimCheck is an automated product that contains specific auditing logic designed to evaluate professional billing for CPT coding appropriateness and to eliminate overpayment.

The current Web-based version (ClaimCheck 8.5) has the ability to read up to four modifiers on each claim line, as well as the ability to handle HCPCS codes the same way as CPT codes.

ClaimCheck Edits

You should follow CPT coding guidelines to prevent claim denials due to ClaimCheck editing. Any edits made by ClaimCheck will be explained by a message code on the provider remittance advice.

ClaimCheck includes the following edit categories:

•  Age Conflicts

•  Alternate Code Replacements

•  Assistant Surgeon Requirements

•  Billed Date(s) of Service

•  Cosmetic Procedures

•  Duplicate and Bilateral Procedures

•  Gender Conflicts

•  Incidental Procedure

•  Modifier Auditing

•  Mutually Exclusive Procedure

•  Preoperative (pre-op) and Postoperative (post-op) Auditing Billed

•  Procedure Unbundling

•  Unlisted Procedures

The complete set of code edits is proprietary and, as such, cannot be released to the general public.

 ClaimCheck Appeals

ClaimCheck findings are “allowable charge determinations” and, as such, are not appealable.

However, participating providers do have recourse through medical review. Issues appropriate for

medical review include:

•  Requests for verification that the edit was  correctly applied to the claim 

•  Requests for an explanation of ClaimCheck  auditing logic 

•  Situations in which you submit additional documentation substantiating that unusual circumstances existed

Billing tips to submit Global Maternity claims V22.0 - V22.2

Global Maternity Claims

Global maternity involves the billing process for maternity-related claims for a beneficiary. Once a beneficiary has been diagnosed as pregnant, all charges related to the pregnancy are grouped under one global maternity diagnosis code.

These diagnosis codes will be listed as the primary diagnosis when billing. Figure 8.1 on the following page lists examples of these codes.

 

 

Global Maternity Diagnosis Code Examples

V22 Normal pregnancy 

V22.0 Supervision of normal first pregnancy 

V22.1 Supervision of other normal pregnancy 

V22.2 Pregnant state, incidental 

 

When beneficiaries are referred for specialty obstetric care, prior authorization must be obtained

for both outpatient and inpatient services.

How to bill Lab, radiology and Venipuncture code with Modifier 26

Lab and Radiology Billing

When submitting claims for laboratory or radiology services rendered in a hospital setting, inpatient or outpatient, and you are a professional provider, use modifier 26 to indicate that you are billing for the professional component only. The hospital will submit claims for the technical component.

When submitting claims for laboratory or radiology services rendered in an office setting and you are a professional provider, indicate whether or not you are billing for the global fee or only the professional component. Use modifier 26 to indicate you are billing for the professional component only if sending the sample to a laboratory. You should also check “yes” in Box 20 of the CMS-1500 or 837 transaction. This allows payment to the laboratory for the technical component. If you don’t use a modifier and don’t indicate “yes” in Box 20 of the CMS-1500, you will be paid the

global fee. Should the laboratory subsequently bill for the technical component, that claim

will be denied.

Note: Clinical labs billing for services for inpatient hospital patients must bill the facility, not TRICARE, for the lab tests. Repeated failure to follow this rule will cause the clinical lab to have all claims returned to them without processing.

Foot Care service - Medicare coverage

Treatment of Subluxation of Foot

Subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons ligaments, or muscles of the foot. Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.

However, medical or surgical treatment of subluxation of the ankle joint (talo-crural joint) is covered. In addition, reasonable and necessary medical or surgical services, diagnosis, or treatment for medical conditions that have resulted from or are associated with partial displacement of structures is covered. For example, if a patient has osteoarthritis that has resulted in a partial displacement of joints in the foot, and the primary treatment is for the osteoarthritis, coverage is provided.

B. Exclusions from Coverage

The following foot care services are generally excluded from coverage under both Part A and Part B.

1. Treatment of Flat Foot

The term “flat foot” is defined as a condition in which one or more arches of the foot have flattened out. Services or devices directed toward the care or correction of such conditions, including the prescription of supportive devices, are not covered.

All point about Signature on File filed box 12 on CMS 1500

Signature-on-File Requirements

When a TRICARE beneficiary has signed a Release of Information statement, you should indicate “signature on file” in Box 12 of the CMS-1500. A new signature is required every year for professional claims submitted on a CMS-1500 and for every admission for claims submitted on a UB-04.

If the beneficiary is under age 18, the parent or legal guardian should sign the claim. However, a beneficiary under the age of 18 may sign the claim form if the beneficiary is (or was) the spouse of an active duty service member (ADSM) or retiree, or if the services are related to venereal disease, drug or alcohol abuse, or abortion

  

In situations when a beneficiary is mentally incompetent or physically incapable, the person signing should either be the legal guardian or, in the absence of a legal guardian, a spouse or parent of the beneficiary. See the Important Provider Information section of this handbook

for more information about the release of patient information.

If the beneficiary is deceased, and you do not have a valid signature-on-file agreement, you

must submit one of the following: 

•  A claim form signed by the legal representative of the estate.

•  Documentation accompanying the claim form to show the person signing is the legally appointed representative.

•  If no legal representative has been appointed, the parent, spouse, or next of kin may sign the claim form. The signer must provide a statement that no legal representative has been appointed. The statement should contain the date of the beneficiary’s death and the signer’s relationship to the beneficiary.

How to submit the claim for unlisted procedure ?

Billing with Unlisted Procedures

Some procedures may not be found in any level of Healthcare Common Procedure Coding System (HCPCS). Typically, these are services that are rarely provided, or are unusual, variable, or unlisted procedures. In order for TriWest to make an appropriate benefit determination, prior authorization for all unlisted codes is required. If the unlisted code is approved, claims must be submitted with a description of the service/item or a National Drug Code (NDC) and will be reimbursed according to the TriWest Fee Schedule found at www.triwest.com/provider under the “Reimbursement Rates” link.

Claims submitted with unlisted codes that do not have prior authorization will be denied. If claims are received with documentation but were not authorized, reimbursement will be reduced by at least 10 percent for noncompliance with the authorization requirement.

Timely Filing

Network providers, by virtue of their contracts with TriWest, should make their best efforts to file all claims within 30 days. TRICARE requires that all claims be submitted to TriWest no later than one year after the date the services were provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility. Professional services billed by the facility must be submitted within one year from the date of service or one year from the date of discharge for an inpatient admission.

Enrolling ERA and EFT with Tricare

Electronic Remittance Advice

The electronic remittance advice (ERA) can help improve the workflow and  productivity of your business office. Available through WPS, the ERA can be automatically loaded into your accounts receivable system, depending upon your software. ERA offers a secure and reliable alternative to manually posting claim adjudication information to your accounts receivable software program and allows you more time to focus on patient care.

The ERA is the electronic equivalent of the provider remittance advice,  containing the same information about claims payments, deductibles, and cost-

shares. It also provides details on how your patients’ claims were paid and, when applicable, why they were denied. WPS generates an ERA as soon as a TRICARE claim is processed.

Depending on your practice management system and internal workflow, ERA can improve your business office’s productivity by:

•     Eliminating the need to manually enter and process paper remittance advices

•     Eliminating errors associated with manual entry

 •     Saving time and costs associated with filing and storing paper remittance advices

Who can appeal against insurance denial claims

Proper Appealing Parties

•     The TRICARE beneficiary (including minors)

•     The non-network participating (accepts  assignment) provider of services

•     A non-network participating (accepts assignment) provider appealing a readmission/preprocedure denial (when services have not been rendered)

•     A provider who has been denied approval as a TRICARE-authorized provider or who has been terminated, excluded, suspended, or otherwise sanctioned

•     A person who has been appointed in writing by the beneficiary to represent them in the appeal

•     An attorney filing on behalf of a beneficiary

How Medicare fee schedule calculation happen

MEDICARE PHYSICIAN FEE SCHEDULE

Medicare Part B pays for physician services based on the MPFS, which lists the more than 7,000 covered services and their payment rates. Physician services include the following: Office visits; Surgical procedures; and A range of other diagnostic and therapeutic services.

Physician services are furnished in all settings including

: Physicians’ offices;

Hospitals;

Ambulatory Surgical Centers;

Skilled Nursing Facilities and other post-acute care settings;

 Hospices;

 Outpatient dialysis facilities;

 Clinical laboratories; and

 Beneficiaries’ homes

Payment rates for an individual service are based on three components:

1) Relative Value Units (RVU)

The three separate RVUs that are associated with the calculation of a payment under the MPFS are:

Work RVUs reflect the relative levels of time and intensity associated with furnishing a physician fee schedule service and account for more than 50 percent of the total payment associated with a service. By statute, all work RVUs must be examined no less often than every five years.

Practice expense (PE) RVUs reflect the costs of maintaining a practice such as renting office space, buying supplies and equipment, and staff costs. PE RVUs account for approximately 45 percent of the total payment associated with a given service.

 Malpractice RVUs represent the remaining portion of the total payment associated with a service.

How to avoidReferral/Prior Authorization Request Delays or rejection

The following guidelines will help expedite your referral and authorization requests:

•     Submit an online request or, if that option is not available to you, use the TRICARE Patient Referral/Authorization Form for any TRICARE Prime beneficiary requiring a specialty care referral or a prior authorization for any TRICARE West Region beneficiary who requires prior

authorization for services on the Prior Authorization List

     Submit complete online referral and authorization requests with physician documentation and all clinical indications, including laboratory/ radiology results related to the requested service. Attach relevant documentation to your online request. If you have an electronic medical management system, you may also copy/paste from that system into your online request. If you are unable to submit your requests online, submit a complete and legible TRICARE

Patient Referral/Authorization Form by fax.

•     If you submit referrals and authorizations online on a regular basis, please use a Request Type profile that includes your requested codes.

* TriWest has online user guides to help you select the correct Request Type profile. TriWest has more than 100 profiles and using them will eliminate any code range issues. If you cannot use a profile, TriWest limits code ranges (low and high) to 10 codes. If the code range is more than 10 codes, the user will get an error indicating that the “allowable” code range has been exceeded and will have to put in a code range less than 10 codes. The user will not be able to enter the request until there is an acceptable code range.

•     Be specific about the requested services and provide the most appropriate procedure and  diagnosis codes. Requests for DME also require complete information on applicable codes. A reasonable range is acceptable.

Include National Drug Codes (NDCs) for medication requests.

•     Make sure the correct ICD-9 and Current Procedural Terminology (CPT®) code(s) are included. Include clinical documentation for services on the Prior Authorization List.

Be sure to clearly reference your contact information, particularly the fax number to which TriWest should respond. Incomplete

forms may slow the process.

•     When pictures are needed to support the requested service, the preferred method of submission is to use the online referral and authorization tool

and attach a digital photograph to the request.

Pictures sent via fax do not transmit clearly and may delay the process while

TriWest requests and awaits receipt of originals.

•     Generally, approvals are active for 180 days, unless otherwise indicated on the referral/ authorization approval letter. If the servicing provider is unable to provide the approved services prior to the expiration of the referral,

a new referral/authorization request must be submitted. If it has been 180 days or more since the initial approved request for the same diagnosis, the PCM should request the new referral/authorization. If the specialist has obtained a referral from the PCM within 180 days, the specialist may make the request

for services related to the same diagnosis.

If the servicing provider wishes to add additional procedural or treatment codes to the approved referral or authorization, then a new referral/

authorization request must be submitted covering the additional requested services.

•     Verify the beneficiary’s demographic information (sponsor’s Social Security number, address, date of birth, etc.) and include it on the request form.

•     When using the fax process, you only need to fax your referral or authorization request once, if you have confirmed that you faxed the referral

to the correct number and have a confirmation from your fax machine. Re-faxing creates duplicate requests and delays processing. You may check the status of your request online at any time if you are registered with

www.triwest.com/provider, regardless of whether the request was submitted online or by fax. You may also call 1-888-TRIWEST (1-888-874-9378) if you have not received a response within five days.

BCBS covered chriopractice CPT list

CPT Code                               Description

Supervised Modalities The application of a modality that does not require direct (one-on-one) patient contact by the provider.
64550	Application of surface (transcutaneous) neurostimulator

97012	Traction, mechanical

97014	Electrical stimulation (unattended)

97016	Vasopneumatic devices

97018	Paraffin bath

97022	Whirlpool
97024	Diathermy (e.g., microwave)
97028	Ultraviolet
Constant Attendance Modalities The application of a modality that requires direct (one-on-one) patient contact by the provider.
97032	Electrical stimulation (manual)

97033	Iontophoresis

97034	Contrast baths
97035	Ultrasound

97036	Hubbard tank

Therapeutic Procedures Physician or therapist required to have direct (one-on-one) patient contact. Therapeutic procedure, one or more areas, each 15 minutes.

97110	Therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112	Neuromuscular reeducation of movement, balance, coordination, kinesthetic senses, posture, and/or proprioception for sitting and/or standing activities

97113	Aquatic therapy with therapeutic exercises

97116	Gait training (includes stair climbing)

97124	Massage, including effleurage, pertissage and/or tapotement (stroking, compression, percussion)

97140	Manual therapy techniques, one or more regions, each 15 minutes

97150	Therapeutic procedure(s), group (2 or more individuals)
97530	Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
97535	Self-care/home management training (e.g., ADL), each 15 minutes

Tests and Measurements (Requires direct on-on-one patient contact)

97750	Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes
Orthotic Management and Prosthetic Management

97760	Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
97762	Checkout for orthotic/prosthetic use, established patient, each 15 minutes
Acupuncture
97810	Without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97811

Without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)