Claim rejected as Duplicated claim - What are the possible ways to find outcome?

Q: My claim rejected, or was returned to provider, as a duplicate of another claim. Can I resubmit the claim? What steps can I take to avoid duplicate claims?

A: Claim system edits are in place to detect duplicate services. The edits search within paid, finalized, pending, and same claim details in history. This means that unless applicable modifiers and/or condition codes are included in your claim, the edits detect duplicate and repeat services within the same claim, and/or based on a previously submitted claim.

The following reject reason codes are commonly seen with this edit:
• 38005 -- This claim is a duplicate of a previously submitted inpatient claim
• 38031 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim
• 38035 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim for the same provider
• 38038 – This claim is a possible duplicate of a previously submitted claim
• 38200 -- This is an exact duplicate of a previously submitted claim

The following return to provider (RTP) reason codes are commonly seen with this edit:
• 38032 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim
• 38037 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim

Your claim rejected as a duplicate, because one or more of the following items matched the original claim:

• Health Insurance Claim Number (HICN), provider number, type of bill (TOB)--all three positions of any TOB, statement coverage from and through dates, at least one diagnosis or line item date of service, revenue code, HCPCS code, and/or total charges (0001 revenue line).

To prevent duplicate claims, verify status of claim prior to filing.

1. If you use direct data entry (DDE) pdf file, access the beneficiary's HIC number to verify the history of claims submitted and the status/location of those claims. Note: you cannot see claims submitted by other facilities.
2. Check status of claims via the Secure Provider Online Tool (SPOT).
3. Contact the interactive voice response (IVR) pdf file system by calling (877) 602-8816. There are three breakdowns available: claim status, return to provider and pending claims.
4. Review the remittance advice for the history of the beneficiary's claims.

In addition, if your claim includes repeat services or supplies, append modifiers and/or condition codes, as applicable. For a complete list of coding resources, refer to the Medicare Billing: 837I and Form CMS-1450 Fact Sheet external pdf file

If you submit claims via the electronic data interchange (EDI) gateway, you are provided with confirmation when the batch of claims is received. Please wait for this confirmation, instead of resubmitting the batch of claims. If you make one change to one claim in the batch but resubmit the entire batch, all the claims go to the fiscal intermediary shared system (FISS), resulting in duplicate claims. Do not resubmit the entire batch; resubmit corrected claims only.

Note: If a third party vendor, billing service, or clearinghouse submits claims on your behalf, contact them to ensure they are not resubmitting entire batches of claims as described above. In addition, occasional software glitches can cause the resubmittal of an entire batch. Be aware that these software or vendor issues reflect directly upon the provider and are problematic, at best, and considered possible abuse, at worst.

Listed below are some recommendations, when additional action is required to correct your claim(s):
• You have two options when the original processed claim needs to be updated or corrected.
1. Adjust the original processed claim (TOB xx7) and resubmit.
2. Cancel the original processed claim (TOB xx8) and submit a new claim, but you must wait for the cancelled claim to finalize before the new claim is submitted.
• If two claims were submitted at the same time and resulted in duplicates against each other, submit a new claim.
• If the rejected claim is an exact duplicate to a previously processed/finalized claim, no action is necessary.

Submitting worker compensation claim electronically - what are the attachement required to submit

Electronic Bill Attachments


(a) Required reports and/or supporting documentation to support a bill as defined in Complete Bill Section 3.0 shall be submitted in accordance with this section. Unless otherwise agreed by the parties, all attachments to support an electronically submitted bill must either have a header or attached cover sheet that provides the following information:

(1) Claims Administrator - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224. Loop 2010BB, NM103.

(2) Employer - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2010BA, NM103.

(3) Unique Attachment Indicator Number - the Unique Attachment Indicator Number shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2300, PWK Segment: Report Type Code, the Report Transmission Code, Attachment Control Qualifier (AC) and the unique Attachment Control Number. It is the combination of these data elements that will allow a claims administrator to appropriately match the incoming attachment to the electronic medical bill. Refer to the Companion Guide Chapter 2 for information regarding the Unique Attachment Indicator Number Code Sets.

(4) Billing Provider NPI Number – the number must be the same as populated in Loop 2010AA, NM109. If the provider is ineligible for an NPI, then this number is the provider?s atypical billing provider ID. This number must be the same as populated in Loop 2010AA, REF02.

(5) Billing Provider Name.

(6) Bill Transaction Identification Number – This shall be the same number as populated in the ASC 005010X222, 005010X223, or 005010X224 transactions, Loop 2300 Claim Information, CLM01.

(7) Document type – use Report Type codes as set forth in Appendix C of the Companion Guides.

(8) Page Number/Number of Pages the page numbers reported should include the cover sheet.

(9) Contact Name/Phone Number including area code.

(b) All attachments to support an electronically submitted bill shall contain the following information in the body of the attachment or on an attached cover sheet:

(1) Patient?s name
(2) Claims Administrator?s name
(3) Date of Service
(4) Date of Injury
(5) Social Security number (if available)
(6) Claim number (if available)
(7) Unique Attachment Indicator Number
(c) All attachment submissions shall comply with the rules set forth in Section One – 3.0 Complete Bills and Section Three – Security Rules. They shall be submitted according to the protocols specified in the Companion Guide Chapter 8 or other mutually agreed upon methods.

(d) Attachment submission methods:

(1) FAX

(2) Electronic submission – if submitting electronically, the Division strongly recommends using the ASC X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) transaction set. Specifications for this transaction set are found in the Companion Guide Chapter 8. The Division is not mandating the use of this transaction set. Other methods of transmission may be mutually agreed upon by the parties.

(3) E-mail – must be encrypted


(e) Attachment types
(1) Reports
(2) Supporting Documentation
(3) Written Authorization
(4) Misc. (other type of attachment)

Coding a Professional Claim

Procedure Modifier and Diagnosis Codes

A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. Inclusion of a complete and accurate list of diagnosis codes associated with the patient at the time of the encounter, including chronic conditions not necessarily treated at the time of the encounter, is part of correctly coding an encounter. It ensures that we can best match patients with appropriate care and disease management programs and members are properly classified by risk programs. We encourage you to purchase current copies of CPT, HCPCS, and ICD 10 CM code books.

Unlisted Procedure Codes

Report an unlisted code only if unable to find a procedure code that closely relates to or accurately describes the service performed. Whenever you submit an unlisted code, you must include a written description of the services with the claim. Unlisted codes require documentation and therefore should not be submitted electronically; the exception is unclassified HCPCS drug codes (refer to Unclassified Drugs).

Modifiers

A modifier provides a physician with the means to indicate that a service/procedure is altered by some specific circumstance, but not changed in its definition or code. By modifying the meaning of a service, modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions can be found in the most current CPT and HCPCS coding books.

When multiple modifiers are necessary for a single claim line, modifiers should be submitted in the order that they affect payment.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit a claim payment appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation.

Modifiers may be used to indicate that:

• A service or procedure has both a professional and technical component

• A service or procedure was performed by more than one physician and/or in more than one location

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual events occurred

What are the forms need to submit with worker compensation claims

3.0 Complete Bills;

(a) To be complete a submission must consist of the following:

(1) The correct uniform billing form/format for the type of health care provider.

(2) The correct uniform billing codes for the applicable portion of the OMFS under which the services are being billed.

(3) The uniform billing form/format must be filled out according to the requirements specified for each format in Appendix A and/or the Companion Guide. Nothing in this paragraph precludes the claims administrator from populating missing information fields if the claims administrator has previously received the missing information.

(4) A complete bill includes required reports and supporting documentation specified in subdivision (b).

(b) All required reports and supporting documentation sufficient to support the level of service or code that has been billed must be submitted as follows:

(1) A Doctor?s First Report of Occupational Injury (DLSR 5021), must be submitted when the bill includes Evaluation and Management services and a Doctor?s First Report of Occupational Injury is required under Title 8, California Code of Regulations § 9785.

(2) A PR-2 report or its narrative equivalent must be submitted when the bill is for Evaluation and Management services and a PR-2 report is required under Title 8, California Code of Regulations § 9785.

(3) A PR-3, PR-4 or their narrative equivalent must be submitted when the bill is for Evaluation and Management services and the injured worker?s condition has been declared permanent and stationary with permanent disability or a need for future medical care. (Use of Modifier – 17.)

(4) A narrative report must be submitted when the bill is for Evaluation and Management services for a consultation.

(5) A report must be submitted when the provider uses the following Modifiers – 22, – 23 and – 25.

(6) A descriptive report of the procedure, drug, DME or other item must be submitted when the provider uses any code that is payable “By Report”.

(7) A descriptive report must be submitted when the Official Medical Fee Schedule indicates that a report is required.

(8) An operative report is required when the bill is for either professional or facility Surgery Services fees.

(9) An invoice or other proof of documented paid costs must be provided when required by the OMFS for reimbursement.

(10) Appropriate additional information reasonably requested by the claims administrator or its agent to support a billed code when the request was made prior to submission of the billing. (This does not prohibit the claims administrator from requesting additional appropriate information during further bill processing.)

(11) For paper bills, any written authorization for services that may have been received by the physician.

(c) For paper bills, if the required reports and supporting documentation are not submitted in the same mailing envelope as the bill, then a header or attachement cover sheet as defined in Section One – 7.3 for electronic attachments must be submitted.

How to resolve when denial received on two provider submitting on DOS ?

My inpatient claim is overlapping a home health episode with the same date(s) of service. How can I resolve this?

A: Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services, as beneficiaries cannot receive home care while they are institutionalized. Beneficiaries cannot be institutionalized and receive home care simultaneously.
• Verify dates of service on your claim
• If dates of service are incorrect, correct your claim and resubmit.
• If dates of service are correct, it is recommended that you contact the home health agency and ask them to correct their claim.
• Edit exclusions:
• The inpatient claim admission date is the same as the home health agency transfer/discharge date
• The inpatient claim discharge date is the same as the home health agency admission date
• The inpatient claim dates are between the occurrence span code 74 ‘From’ date and the day following the occurrence span code ‘Through’ date


Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

ICD 10 CODE for Osteopenia - M85.811 - M85.871 Bone density and structure

The Centers for Medicare & Medicaid Services (CMS) will implement Change Request  (CR) 9252 on January 4, 2016, effective October 1, 2015. (See related MLN Matters® article MM9252.) This CR establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for Bone Mass Measurement studies according to the requirements set forth in National Coverage Determination (NCD) 150.3. CR9252 and  accompanying spreadsheet inadvertently omitted the condition of osteopenia and the ICD- 10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of bone density and structure. The codes and conditions identified within this subcategory are considered covered indications for bone mass measurement under NCD 150.3 and providers should report theseappropriately according to medical documentation. Additional guidance and education as to the updated complete list of covered indications will be forthcoming as CMS continues to review this issue and the systems updates required.

Background

Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for CR 5521/NCD 150.3, dated May 11, 2007, when reported with CPT code 77080. (See related MLN Matters article MM5521.) The accompanying Benefit Policy Manual, Publication 100-02, chapter 15, section 80.5.6, Beneficiaries Who May Be Covered, includes: 2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.

Under ICD-10-CM, the term “Osteopenia” is indexed to ICD-10-CM subcategory M85.8- Other specified disorders of bone density and structure, within the ICD-10-CM Alphabetic Index. The codes within this subcategory were inadvertently omitted from the CMS spreadsheet that accompanied CR 9252 containing the list of covered conditions and corresponding diagnosis codes. These are considered covered for NCD 150.3 indications.

Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.

** M85.811 Other specified disorders of bone density and structure, right shoulder

** M85.812 Other specified disorders of bone density and structure, left shoulder

** M85.821 Other specified disorders of bone density and structure, right upper arm

** M85.822 Other specified disorders of bone density and structure, left upper arm

** M85.831 Other specified disorders of bone density and structure, right forearm

** M85.832 Other specified disorders of bone density and structure, left forearm

** M85.841 Other specified disorders of bone density and structure, right hand

** M85.842 Other specified disorders of bone density and structure, left hand

** M85.851 Other specified disorders of bone density and structure, right thigh

** M85.852 Other specified disorders of bone density and structure, left thigh

** M85.861 Other specified disorders of bone density and structure, right lower leg

** M85.862 Other specified disorders of bone density and structure, left lower leg

** M85.871 Other specified disorders of bone density and structure, right ankle and

foot

** M85.872 Other specified disorders of bone density and structure, left ankle and foot

** M85.88 Other specified disorders of bone density and structure, other site

** M85.89 Other specified disorders of bone density and structure, multiple sites

Provider Enrollment - Some basic question on ownership and disclosing information

What does disclosing entity mean?

Disclosing Entity means a Medicaid provider (other than an individual practitioner), or a fiscal agent.

What does Publicly Owned mean?

In the United States, a publicly owned corporation is one whose shares are traded on public stock exchanges. Generally, anyone may purchase shares in such a corporation.

What does Privately Owned mean?

A privately owned corporation does not offer or trade its shares to the public on public stock exchanges.

What if there are no owners who have a 5% or more controlling interest in a publicly owned company?

In the PEAP system you would indicate YES where it states: “If the provider entity is a publicly held corporation and no person owns 5% or more of the corporation, you must select "Yes," and you must provide information for board members, agent(s) and managing employee(s). (Local, county and state government entities must select "No.")

”

What does managing employee mean?

Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

What is the definition of an Agent?

Any person who has been delegated the authority to obligate or act on behalf of a provider.

What does ownership or controlling interest mean?

Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity.

A person with an ownership or controlling interest means a person or corporation that—

a. Has an ownership interest totaling 5% or more in a disclosing entity;

b. Has an indirect ownership interest equal to 5% or more in a disclosing entity;

c. Has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity;

d. Owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5% of the value of the property or assets of the disclosing entity;

e. Is an officer or director of a disclosing entity that is organized as a corporation or is a partner in a disclosing entity that is organized as a partnership.

What does indirect ownership interest mean?

Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

Can a CEO be listed as a board member? 

Yes, if he/she serves on the board.

I have a physician who is owner and board member and who has also designed a component that is used in surgical procedures. Should I disclose that information, as he receives royalties for that, and we bill Medicaid for that component?

Yes.

What if I have a board member who is also an owner? How should I enter this person’s information?

The board member must be listed as both.

How do I know what my taxonomy code is?

You can obtain your taxonomy code from the letter you received to begin your revalidation. This letter also provided your Case Number for entering the Provider Enrollment Application Portal (PEAP).

What is a subcontractor?

(1) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or (2) An individual, agency, or organization with which an intermediary or carrier has entered into a contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicare agreement.

Q: What steps can be taken to identify claims that overlap with another provider?

A: If you receive an overlap reason code, you can do one of the following:

• Verify your claims submitted through direct data entry (DDE) pdf file

• Option -1 (inquiry menu), then option -12 (claims summary), and key in the beneficiary’s health insurance claim (HIC) number, your provider number, and press enter

• Review the list of claims submitted to identify those with identical dates of service, and validate they were submitted accurately

• Verify eligibility for home health episodes and hospice election from the ELGA and/or ELGH screens

• Verify the beneficiary/eligibility tab submenu on the secure provider online tool (SPOT)

• Home health episode start and end date, and the servicing provider’s NPI

• Hospice election effective and termination date, revocation code and the servicing provider’s NPI

• Click here to learn more about the SPOT

• NPI registry lookup external link enables you to search for the provider’s information

• Verify additional eligibility information from the submenu on the interactive voice response (IVR)

• Hospice effective and termination dates (if applicable), and the servicing provider’s ID

• Home health effective and termination dates (if applicable), and the servicing provider’s ID

• Skilled nursing facility (SNF) effective and termination dates (if applicable), and the servicing provider’s ID

BILLING Guideline for CPT Code 59425, 59409, S5100 and T1023

Incomplete Antepartum Care 

Service CPT

Billing for Incomplete Antepartum Care

59425 When billing for four to six prenatal visits
59426 When billing for seven or more prenatal visits with or without an initial visit


Billing for Multiple Deliveries For additional babies: 59409, 59514, 59612, or 59620   Modifier - 51 and 59


Oral and Maxillofacial Surgery

Do not use CPT procedure code 41899, as this is an unspecified code and will cause delay in payment for services

Locum Tenens and Reciprocal Billing
Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement.
Q6 - Service furnished by a locum tenens physician


S5100 Day Care Services, Adult
1 Unit = 15 minutes
U2 modifier is no longer required when billing this service code.
POS -  12 Home 99 Other (Community)

Billing Presumptive Eligibility (PE) Determinations

T1023 to bill for PE determination

Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit

90471 to 90474 - If there is a significant, separately identifiable service, performed, at the time of the vaccine administration, an appropriateE/M code may also be billed with modifier 25