How to avoid or preventing duplicate denial OA 18

Exact duplicate claim/service

(DUPLICATE CHARGE PAID ?002XX ON CLAIM ?001XXXXXXXXX)

(DUPLICATE CHARGE OF CLAIM ?001XXXXXXXXX NOW BEING PROCESSED)

(THIS IS A DUPLICATE OF A CHARGE WE HAVE PROCESSED)

(MORE THAN 1 E/M SERVICE BILLED ON THE SAME DAY)

Resources/tips for avoiding this denial

Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.

• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.

• Click here to review article on new claim system edits regarding duplicate claims.

• Ensure necessary appropriate modifiers are appended to claim lines.

• Refer to the Modifier FAQs here on the First Coast Medicare provider website for additional information.

Preventing duplicate claim denials 

Effective July 1, 2013, new claim system edits may result in additional duplicate claim denials to your practice. Please share this information with your billing companies, vendors and clearing houses. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare contractors to enhance claim system edits to include same claim details in its history review of duplicate procedures and/or services. The edits will search within paid, finalized, pending and same claim details in history. This means that unless applicable modifiers are included in your claim, the edits will detect duplicate and repeat services within the same claim and/or based on a claim previously submitted.

To minimize a potential increase in duplicate claim denials, please review your billing software and procedures to ensure that you are billing correctly. Some services on a claim may appear to be duplicates when, in fact, they are not. Please ensure appropriate use of modifiers to identify procedures and services that are not duplicates. A complete list of modifiers can be found in the Current Procedural Terminology (CPT®) codebook. The following are a few examples of modifiers that may be used, as applicable, to identify repeat or distinct procedures and services on a claim:

• Modifier 76 may be used to indicate a repeat procedure or service by the same provider, subsequent to the original procedure or service.

• Modifier 91 may be used to indicate repeat clinical diagnostic laboratory tests.  This modifier is added only when additional test results are medically necessary on the same day.

• Modifier 59 may be used, as applicable, to identify procedures or services that are normally reported together but are appropriate to be billed separately under certain circumstances. Modifier 59 indicates a procedure or service by the same provider, distinct or independent from other services, performed on the same day.