Procedure codes with modifier 22 - Medicare internal issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule. First Coast Service Options (First Coast) is currently identifying the impacted claims and will begin to initiate adjustment action on all impacted claims within the next two weeks. Note: only claims previously reviewed by our medical staff having met medical necessity requirements to allow above the fee schedule will be adjusted. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue. First Coast apologizes for any inconvenience this issue has caused.

Issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule.

Resolution

First Coast is currently identifying the impacted claims and will begin to initiate adjustments on all impacted claims within the next two weeks. Claims having met medical necessity requirements will be changed to an unlisted surgical procedure code (modifier 22 will be appended to the related unlisted surgical procedure) to allow payment above the Medicare physician fee schedule. First Coast began utilizing this process July 11, 2014, for all surgical procedure billed with the 22 modifier that met medical necessity requirements for additional payment.

Receipt Date - Medicare definition

The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim). The receipt date is used to: determine if the claim was timely filed , determine the “payment floor” for the claim , determine the “payment ceiling” on the claim  and, when applicable, to calculate interest payment due for a clean claim that is not timely processed, and to report to CMS statistical data on claims, such as in workload reports.

A paper claim that is received by 5:00 p.m. on a business day, or by closing time if the contractor routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the contractor does not open the envelope which contains the claim or does not enter the claims data into the claims processing system until a later date. A paper claim that is received after 5:00 p.m., or after the contractor’s routine close of business between 4:00 p.m. and 5:00 p.m., is considered as received on the next business day.

A paper claim is considered as received if it is delivered to the contractor’s place of business by the U.S. Postal Service, picked up from a P.O. box, or is otherwise delivered to the contractor’s place of business by its routine close of business time. If the contractor uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box at least once per business day unless precluded on a particular day by the emergency closing of its place of business or that of its postal box site.

Procedure codes with modifier 22

 An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule. First Coast Service Options (First Coast) is currently identifying the impacted claims and will begin to initiate adjustment action on all impacted claims within the next two weeks. Note: only claims previously reviewed by our medical staff having met medical necessity requirements to allow above the fee schedule will be adjusted. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue. First Coast apologizes for any inconvenience this issue has caused.

Issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule.

Electronic vs. Paper Billing - basic overview from Molina insurance

Medicaid  claims  that  are  secondary  to  insurance  or  Medicare  coverage,  including  Medicare HMOs, may be billed electronically either through electronic vendors or through Molina’s web portal.  Contact the EDI Help Desk for access to submitting claims on the web portal.

Medicare Primary Claims 

Many Medicare primary claims crossover to Medicaid automatically from the Medicare Part A and Part B carriers through the Coordination of Benefits Agreement (COBA), but some do not.  Claims that do not crossover, and therefore must be billed separately by providers include:

*** Outpatient claims from Part A Medicare carriers (such as NGS)

*** Long Term Care (LTC) claims from Part A Medicare carriers 

*** Anesthesia claims from Part B Medicare carriers (on crossover, these are rejected because

claims are billed in “minutes” not “units”)

*** Claims processed by Medicare HMOs.

All of these types of claims may be billed electronically to Medicaid.  Medicare paid amounts, deductible amounts, and coinsurance amounts are required for Medicare approved services and Medicare Action Codes are required for services denied by Medicare.  This information is re-quired at the claim line level for professional services billed on the 837P format and at the head-er level for institutional services billed on the 837I format.  

***  Allowed amount, paid amount, deductible, and co-insurance information must be billed in the Medicare segments, not the TPL segments, or the claim will not process correctly.