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.

Medicare New Edit - new patient CPT billed two times within three years

Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for a New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years

Note: This article was revised on June 4, 2013, to reflect the revised CR8165 issued on May 31. The article shows a revised list of new patient CPT codes and an added list of established patient CPT codes on page 2. Also, the CR release date, transmittal number, and the Web address for accessing CR8165 have been revised. All other information remains the same.

Provider Types Affected 

This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action Needed 

This article is based on Change Request (CR) 8165 which informs Medicare contractors about changes to Medicare's Common Working File (CWF) system that will detect erroneous billings when there are two new patient Current Procedure Terminology (CPT) codes being billed within a three year period of time by the same physician or physician group.

Make sure that your billing staffs are aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes.

The Recovery Auditors, under contract with the Centers for Medicare & Medicaid Services (CMS), are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The Recovery Auditors have identified claims with "New Patient" Evaluation and Management (E&M) services to have improper payments, because the new patient services have been billed two or more times within a 3-year period by the same physician or physician group. The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.7 provides that “Medicare interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E&M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit.”

Can we submit paper document along with Electronic claim initial submission to Medicare?

Yes. Effective October 1, 2012, First Coast Service Options Inc. (First Coast) implemented the PWK (paperwork) segment of the X12N version 5010. PWK allows for voluntary submission of supporting documentation with a 5010 version electronic claim.

PWK is a segment within the 2300/2400 Loop of the 837 Professional and Institutional electronic transactions that provides the link between electronic claims and additional documentation. PWK allows providers to submit electronic claims that require additional documentation and, through the dedicated PWK process, have the documentation imaged to be available during the claims adjudication. Eliminating the need for costly development and allowing providers and Medicare contractors to utilize efficient, cost-effective Electronic Data Interchange or EDI technology will create a significant cost savings.

Although PWK ultimately will allow electronic submission of additional documentation, the October implementation only allows for submission of additional documentation via mail and fax (PWK 02 segment, BM [by mail] and FX [by fax] qualifier, respectively).

First Coast has made available a fax/mail coversheet that providers or trading partners shall use to submit the unsolicited additional documentation. The First Coast fax/mail coversheet is an interactive form posted to our website. Providers or trading partners may complete required data elements and are then able to print a hardcopy of the form to mail or fax with their documentation. Modifications to the fax/mail coversheet are not permitted. Separate forms are provided for Part A and B for Florida, Puerto Rico, and the U.S. Virgin Islands. First Coast has also provided secure faxination numbers for those providers or trading partners who elect to fax the additional documentation.

First Coast is requiring the following section of the form to be completed with valid information to ensure the paperwork documentation is appended to the pending claim in our system: ACN (Attachment Control Number (submitted in the PWK06 segment)), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary's health insurance claim number (HICN)/Medicare number, Billing provider's name and NPI (national provider identifier).

First Coast will return PWK coversheets with missing or inaccurate data. The coversheet will be returned based on how it was received (fax or mail).

• Note: First Coast will not return any paperwork documentation that accompanies a rejected PWK coversheet; nor will the documentation be used for adjudication of the claim.

PWK documentation may not be submitted prior to submission of a claim. Submitters must send all relevant PWK data at the same time for the same claim. Thus, if the claim was submitted with multiple PWK iterations, all PWK data for the claim must be submitted together under one coversheet.

shall we bill patients if Medicare denied the service

Billing Medicare Patients for Services Which May Be Denied

Medicare patients may be billed for services that are clearly not covered. For example, routine physicals or screening tests such as total cholesterol are not covered when there isno indication that the test is medically necessary. However, when a Medicare carrier is likely to deny payment because of medical necessity policy (either as stated in their written Medical Review Policy or upon examination of individual claims) the patient must be informed and consent to pay for the service before it is performed. Otherwise, the patient

has no obligation to pay for the test.

An Advance Beneficiary Notice (ABN), sometimes called a patient waiver form, is used to document that the patient is aware that Medicare may not pay for a test or procedure and has agreed to pay the provider in the event payment is denied. Each ABN must be specific to the service provided and the reason that Medicare may not pay for the service. Blanket waivers for all Medicare patients are not allowed.

Since both LMRPs as well as the new NCD for A1c include frequency limits, an ABN is appropriate any time the possibility exists that the frequency of testing may be in excess of stated policy. For example, if an A1c test may have been performed by another provider less than three months ago for a patient with uncomplicated diabetes, it would be prudent to obtain a signed ABN.