Tuesday, November 21, 2017

BCBS denial code list

Reason codes, and the text messages that define those codes, are used to explain why a claim may not have been paid in full. For instance, there are reason codes to indicate that a particular service is never covered by Medicare, that a benefit maximum has been reached, that non-payable charges exceed the fee schedule, or that a psychiatric reduction has been made. Under the standard format, only reason codes approved by the American National Standards Institute (ANSI) Insurance Subcommittee and Medicare-specific supplemental messages approved by CMS may be used.

The ANSI reason codes were designed to replace the large number of different codes used by health payers in this country, and to relieve the burden of medical providers to interpret each of the different coding systems. Although reason codes and CMS message codes will appear in the body of the remittance notice, the text of each code that is used will be printed at the end of the notice to facilitate interpretation. The approximately 10,000 different messages used by Medicare carriers nationwide have been reduced to fewer than 400 messages. The standard messages may expand or change occasionally as the need arises, but CMS plans to limit the frequency of such changes.

Code Description

01 Deductible amount.
02 Coinsurance amount.
03 Co-payment amount.
04 The procedure code is inconsistent with the modifier used, or a required modifier is missing.
05 The procedure code/bill type is inconsistent with the place of service.
06 The procedure/revenue code is inconsistent with the patient’s age.
07 The procedure/revenue code is inconsistent with the patient's gender.
08 The procedure code is inconsistent with the provider type/specialty (taxonomy).
09 The diagnosis is inconsistent with the patient's age.
10 The diagnosis is inconsistent with the patient's gender.
11 The diagnosis is inconsistent with the procedure.
12 The diagnosis is inconsistent with the provider type.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using remittance advice remarks codes whenever appropriate.
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
23 Payment adjusted because charges have been paid by another payer.
24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
25 Payment denied. Your stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Benefit maximum has been reached.
36 Balance does not exceed co-payment amount.
37 Balance does not exceed deductible.
38 Services not provided or authorized by designated (network) providers.
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract.
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/legislated fee arrangement.
46 This (these) service(s) is (are) not covered.
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
48 This (these) procedure(s) is (are) not covered.
49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
50 These are non-covered services because this is not deemed a "medical necessity" by the payer.
51 These are non-covered services because this is a pre-existing condition.
52 The referring/prescribing provider is not eligible to refer/prescribe/order/perform the service billed.
53 Services by an immediate relative or a member of the same household are not covered.
54 Multiple physicians/assistants are not covered in this case.
55 Claim/service denied because procedure/ treatment is deemed experimental/ investigational by the payer.
56 Claim/service denied because procedure/ treatment has been deemed “proven to be effective” by the payer.
57 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day’s supply.
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
59 Charges are reduced based on multiple surgery rules or concurrent anesthesia rules.
60 Charges for outpatient services with this proximity to inpatient services are not covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
62 Payment denied/reduced for absence of, or exceeded, precertification/ authorization.
63 Correction to a prior claim.
64 Denial reversed per Medical Review.
65 Procedure code was incorrect. This payment reflects the correct code.
66 Blood deductible.
67 Lifetime reserve days.
68 DRG weight.
69 Day outlier amount.
70 Cost outlier. Adjustment to compensate for additional costs.
71 Primary payer amount.
72 Coinsurance day.
73 Administrative days.
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days.
78 Non-covered days/Room charge adjustment.
79 Cost report days.
80 Outlier days.
81 Discharges.
82 PIP days.
83 Total visits.
84 Capital Adjustment.
85 Interest amount.
86 Statutory Adjustment.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior overpayment.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim paid in full.
93 No claim level adjustments.
94 Processed in excess of charges.
95 Benefits adjusted. Plan procedures not followed.
96 Non-covered charges.
97 Payment is included in the allowance for another service/procedure.
98 The hospital must file the Medicare claim for this inpatient non-physician service.
99 Medicare Secondary Payer Adjustment amount.
100 Payment made to patient/insured/responsible party.
101 Predetermination. Anticipated payment upon completion of services or claim adjudication.
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount).
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not paid or identified on the claim.
108 Payment adjusted because rent/purchase guidelines were not met.
109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
113 Payment denied because service/procedure was provided outside the United
States or as a result of war.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or cancelled.
116 Payment denied. The advance indemnification notice signed by the patient
did not comply with requirements.
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period has been reached.
120 Patient is covered by a managed care plan.
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment.
124 Payer refund amount – not our patient.
125 Payment adjusted due to a submission/billing error(s). Additional information
is supplied using the remittance advice remarks codes whenever appropriate.
126 Deductible – Major Medical.
127 Coinsurance – Major Medical.
128 Newborn’s services are covered in the mother’s allowance.
129 Payment denied. Prior processing information appears incorrect.
130 Claim submission fee.
131 Claim specific negotiated discount.
132 Prearranged demonstration project adjustment.
133 The disposition of this claim/service is pending further review.
134 Technical fees removed from charges.
135 Claim denied. Interim bills cannot be processed.
136 Claim adjusted. Plan procedures of a prior payer were not followed.
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
138 Claim/Service denied. Appeal procedures not followed or time limits not met.
139 Contracted funding agreement. Subscriber is employed by the provider of the services.
140 Patient/Insured health identification number and name do not match.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142 Claim adjusted by the monthly Medicaid patient liability amount.
143 Portion of payment deferred.
144 Incentive adjustment, e.g., preferred product/service.
145 Premium payment withholding.
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
147 Provider contracted/negotiated rate expired or not on file.
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
A0 Patient refund amount.
A1 Claim denied charges.
A2 Contractual adjustment.
A3 Medicare Secondary Payer liability met.
A4 Medicare Claim PPS Capital Day Outlier Amount.
A5 Medicare Claim PPS Capital Cost Outlier Amount.
A6 Prior hospitalization or 30 day transfer requirement not met.
A7 Presumptive Payment Adjustment.
A8 Claim denied; ungroupable DRG.
B1 Non-covered visits.
B2 Covered visits.
B3 Covered charges.
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B8 Claim/service not covered/reduced because alternative services were available, and should not have been utilized.
B9 Services not covered because the patient is enrolled in a Hospice.
B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
B12 Services not documented in patient’s medical records.
B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14 Payment denied because only one visit or consultation per physician per day is covered.
B15 Payment adjusted because this service/procedure is not paid separately.
B16 Payment adjusted because "new patient" qualifications were not met.
B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. B18 Payment denied because this procedure code/modifier was invalid on the
date of service or claim submission.
B19 Claim/service adjusted because of the finding of a Review Organization.
B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
B21 The charges were reduced because the service/care was partially furnished by another physician.
B22 This payment is adjusted based on the diagnosis.
B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
D1 Claim/service denied. Level of subluxation is missing or inadequate.
D2 Claim lacks the name, strength, or dosage of the drug furnished.
D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
D4 Claim/service does not indicate the period of time for which this will be needed.
D5 Claim/service denied. Claim lacks individual lab codes included in the test.
D6 Claim/service denied. Claim did not include patient's medical record for the service.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.
D8 Claim/service denied. Claim lacks indicator that "x-ray is available for review”.
D9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
D10 Claim/service denied. Completed physician financial relationship form not on file.
D11 Claim lacks completed pacemaker registration form.
D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
D14 Claim lacks indication that plan of treatment is on file.
D15 Claim lacks indication that service was supervised or evaluated by a physician. W1 Workers Compensation State Fee Schedule Adjustment.

Wednesday, November 15, 2017

Nebulizer cpt code list - A7017, A7018, A7007

For a DME item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Nebulizers require an in-person or face-to-face interaction between the beneficiary and their treating physician prior to prescribing the item, specifically to document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. A dispensing order is not sufficient to provide these items. A WOPD (written order prior to delivery) is required.

Detailed documentation requirements are outlined in Nebulizer LCD

HCPCS Code Description

A4217 Sterile water/saline, 500 ml
A4218 Sterile saline or water, metered dose dispenser, 10 ml
A4619 Face tent
A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable
A7004 Small volume nonfiltered pneumatic nebulizer, disposable
A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable
A7006 Administration set, with small volume filtered pneumatic nebulizer
A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor
A7008 Large volume nebulizer, disposable, prefilled, used with aerosol compressor (noncovered per LCD) A7009 Reservoir bottle, non-disposable, used w/ large volume ultrasonic nebulizer (noncovered per LCD)
A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 feet
A7011 Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet
A7012 Water collection device, used with large volume nebulizer
A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator
A7014 Filter, nondisposable, used with aerosol compressor or ultrasonic generator
A7015 Aerosol mask, used with DME nebulizer
A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer
A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen
A7018 Water, distilled, used with large volume nebulizer, 1000 ml
A7525 Tracheostomy mask, each
G0333 Pharmacy dispensing fee for inhalation drug(s); initial 30-day supply as a beneficiary
J2545 Pentamidine isethionate, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 300 mg
J7604* Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram
J7605 Arformoterol, inhalation solution, FDA approved final product, non-compounded, administered through DME, unit dose form, 15 micrograms
J7606 Formoterol fumarate, inhalation solution, FDA approved final product, noncompounded, administered through DME, unit dose form, 20 micrograms
J7607* Levalbuterol, inhalation solution, compounded product, administered through DME, concentrated form, 0.5 mg
J7608 Acetylcysteine, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per gram
J7609* Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg
J7610* Albuterol, inhalation solution, compounded product, administered through DME, concentrated form, 1 mg
J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg
J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg
J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg
J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg
J7615* Levalbuterol, inhalation solution, compounded product, administered through DME, unit dose, 0.5 mg


QUESTIONS AND ANSWERS

Q: Is a large volume ultrasonic nebulizer (HCPCS E0575) covered by Medicare?

A: A large volume ultrasonic nebulizer offers no proven clinical advantage over a pneumatic compressor and nebulizer and will be denied as not reasonable and necessary.


Q: Are compound inhalation solutions covered by Medicare?

A: CMS revoked coverage of compounded inhalation solutions in 2007.


Q: Are there any restrictions around nebulizers and home oxygen use?

A large volume pneumatic nebulizer (HCPCS E0580) and water or saline (HCPCS A4217 or A7018) are not separately payable and should not be separately billed when used for beneficiaries with rented home oxygen equipment.


Medical Records

If the claim includes a nebulizer with compressor (E0570), the medical records include a face-to-face examination by the treating physician that meets the following requirements: The examination occurred within 6 months prior to the date of the written order that was obtained prior to delivery; and

The examination documents that the beneficiary was evaluated and/or treated for a condition that supports the need for a nebulizer with compressor in order to administer inhalation drugs.

A date stamp or similar indicator verifies that the supplier received a copy of the F2F note on or before the date of delivery.

Continued Medical Need for the Equipment/Accessories/Supplies is Verified by Either:

A refill order from the treating physician dated within 12 months of the date of service under review; or

A change in prescription dated within 12 months of the date of service under review; or

A medical record, dated within 12 months of the date of service under review, that shows usage of the item. Claims for a Small Volume Ultrasonic Nebulizer (E0574)

A small volume ultrasonic nebulizer is reasonable and necessary to administer treprostinil inhalation solution only (See Treprostinil/Iloprost Inhalation Solution Checklist). Claims for code E0574 used with other inhalation solutions will be denied as not reasonable and necessary. Claims for HCPCS Code E1399 (Miscellaneous Equipment or Accessories)

The claim includes a clear description of the item including:

The manufacturer’s name,

The model name/number,Pricing information, and An explanation of medical necessity. Claims for HCPCS Code J7699 (NOC Nebulizer Drug Code)

The claim is accompanied by:

Detailed order information as described in the written order requirements,

A clear statement of the number of ampules/bottles of solution dispensed, and Documentation of the medical necessity of the drug for that beneficiary.

It is expected that the beneficiary’s medical records will reflect the need for the care provided. These records are not routinely submitted to the DME MAC but must be available upon request. Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and review the appropriate medical records and maintain a copy in the beneficiary’s file.

Additionally, while the nebulizer drug LCD does not require suppliers who only provide the nebulizer to keep a file copy of the written order for the drug(s), it is strongly recommended that the supplier do so. In the event of a claim audit by the DME MAC, CERT, or ZPIC contractor, documentation the supplier will be required to submit in order to verify the medical necessity for the nebulizer will include a copy of the detailed written order for the drug(s). Failure to provide the written order in a timely manner could result in denial of the nebulizer claim and an overpayment assessment.

Wednesday, October 11, 2017

Wheelchair CPT code list


Procedure Code Description Rate

E1037 TRANSPORT CHAIR, PEDIATRIC SIZE

E1038 TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

E1039 TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS

E1161 MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

E1229 WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED

E1231 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

E1232 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM

E1233 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

E1234 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

E1235 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

E1236 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM

E1237 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

E1238 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM


K0001 STANDARD WHEELCHAIR $491.58

K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR $626.04

K0003 LIGHTWEIGHT WHEELCHAIR $685.35

K0004 HIGH-STRENGTH, LIGHTWEIGHT WHEELCHAIR $1,202.76

K0005 ULTRA LIGHTWEIGHT WHEELCHAIR $1,697.86

K0006 HEAVY DUTY WHEELCHAIR $959.40

K0007 EXTRA HEAVY-DUTY WHEELCHAIR $1,365.57

K0008 CUSTOM MANUAL WHEELCHAIR BASE $0.00

K0009 OTHER MANUAL WHEELCHAIR BASE $0.00

K0010 STANDARD-WEIGHT FRAME MOTORIZED, POWER WHEELCHAIR $3,258.81

K0011 STANDARD WEIGHT FRAME MOTORIZED POWER WHEELCHAIR WITH $4,051.80

K0012 LIGHTWEIGHT PORTABLE MOTORIZED POWER WHEELCHAIR $2,485.62

K0013 CUSTOM MOTORIZED POWER WHEELCHAIR $0.00

K0014 OTHER MOTORIZED POWER WHEELCHAIR BASE $0.00

K0015 DETACHABLE NONADJUSTABLE HEIGHT ARMREST ,EACH $143.83

K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST , BASE EACH $40.45

K0018 DETACHABLE ADJUSTABLE HEIGHT ARMREST ,UPPER PORTION EACH $22.60

K0019 ARM PAD , EACH $12.94

K0020 FIXED, ADJUSTABLE HEIGHT ARM REST , PAIR $36.78

K0037 HIGH MOUNT FLIP-UP FOOTREST , EACH $38.12

K0038 LEG STRAP, EACH $19.22

K0039 LEG STRAP H-STYLE , EACH $42.65

K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH $59.10

K0041 LARGE SIZE FOOTPLATE , EACH $41.89

K0042 STANDARD SIZE FOOTPLATE , EACH $28.84

K0043 FOOT REST LOWER EXTENSION TUBE , EACH $15.45

K0044 FOOTREST , UPPER HANGER BRACKET , EACH $13.17

K0045 FOOTREST , COMPLETE ASSEMBLY $44.82

K0046 ELEVATING LEGREST LOWER EXTENSION TUBE , EACH $15.45

K0047 ELEVATING LEGREST UPPER HANGAR BRACKET , EACH $60.53

K0050 RATCHET ASSEMBLY $25.73

K0051 CAM RELEASE ASSEMBLY , FOOTREST OR LEGREST , EACH $41.64

K0052 SWING AWAY DETACHABLE FOOTRESTS , EACH $73.18

K0053 ELEVATING FOOTRESTS ARTICULATING (TELESCOPING) , EACH $80.75

K0056 SEAT HEIGHT LESS THAN 17" OR LESS THAN OR EQUAL TO 21" FOR A HIGH STRENGTH LT-WGT OR ULTRA LT-WGT WHEELCHAIR $87.34

K0065 SPOKE PROTECTORS, EACH $40.82

K0069 REAR WHEEL ASSEMBLY COMPLETE WITH SOLID TIRES, SPOKES OR MOLDED , EACH $91.77

K0070 REAR WHEEL ASSEMBLY COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDER, EACH $168.21

K0071 FRONT CASTER ASSEMBLY COMPLETE, WITH PNEUMATIC TIRE, EACH $100.33

K0072 FRONT CASTER ASSEMBLY COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACH $60.40

K0073 CASTER PINLOCK, EACH $31.96

K0077 FRONT CASTER ASSEMBLY COMPLETE, WITH SOLID TIRE,EACH $54.05

K0098 DRIVE BELT FOR POWER WHEELCHAIR $20.91

K0105 IV HANGER, EACH $91.31

K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED $0.00

K0148 HYDROGEL DRESSING, EACH $4.92

K0195 ELEVATING LEG RESTS, PAIR (FOR USED WITH CAPPED RENTAL WHEELCHAIR BASE) $161.19

K0267 REPLACEMENT BATTERY, ANY TYPE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, $6.10

K0455 INFUSION PUMP USED FOR UNINTERRUPTED ADMINISTRATION OF EPOPROSTENOL $0.00

K0462 TEMPORARY REPLACEMENT FOR PATIENT OWNED EQUIPMENT BEING REPAIRED, ANY TYPE $0.00

K0552 SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACH $2.44

K0601 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE, 1.5 VOLT, EACH $1.02

K0602 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE, 3 VOLT, EACH $5.84

K0603 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, ALKALINE, 1.5 VOLT, EACH $0.52

K0604 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 3.6 VOLT, EACH $5.58

K0605 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 4.5 VOLT, EACH $13.41

K0606 AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS, GARMENT TYPE $0.01

K0607 REPLACEMENT BATTERY FOR AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT TYPE ONLY, EACH $178.38

K0608 REPLACEMENT GARMENT FOR AUTOMATED EXTERNAL DEFIBRILLATOR, EACH $111.31

K0609 REPLACEMENT ELECTRODES FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT TYPE ONLY, EACH $740.29

K0669 WHEELCHAIR SEAT OR BACK CUSHION, NO WRITTEN CODING VERIFICATION FROM SADMERC $0.00

K0730 CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM $1,583.30

K0733 POWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASS $23.91

K0734 SKIN PROTECTION WHEELCHAIR SEAT CUSHSION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH $284.98

K0735 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH $362.62

K0736 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH $287.32

K0737 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH $363.73

K0738 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CLYLINDERS; $464.67

K0739 REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT OTHER THAN OXYGEN EQUIPMENT REQUIRING THE SKILL OF $13.56

K0800 POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND

INCLUDING 300 POUNDS $1,023.30

K0801 POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT 301 TO 450 POUNDS $1,649.76

K0802  POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS $1,867.01

K0806 POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND

INCLUDING 300 POUNDS $1,237.91

K0807 POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS $1,878.39

K0808 POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS $2,906.27

K0812 POWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIED $0.00

K0813 POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO $2,171.16

K0814 POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAIN'S CHAIR, PATIENT WEIGHT CAPACITY UP TO AND $2,779.02


K0815 POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 $3,164.67


Medicare Guidelines - HMO

For example, if a beneficiary received a manual wheelchair under a HMO/Managed Care plan, he or she would need to meet Medicare coverage criteria and documentation requirements for manual wheelchairs. He or she would have to obtain a Certificate of Medical Necessity (CMN), and would begin an entirely new rental period, just as a beneficiary enrolled in FFS, to obtain a manual wheelchair for the first time.

Customized items are rarely necessary and are rarely furnished. In accordance with 42 CFR Section 414.224, in order to be considered a customized item, a covered item (including a wheelchair) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of a physician and be so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes. For example, a wheelchair that is custom fabricated or substantially modified so that it can meet the needs of wheelchair-confined, conjoined twins facing each other is unique and cannot be grouped with any other wheelchair used for the same purpose. It is a one-of-a-kind item fabricated to meet specific needs. Items that are measured, assembled, fitted, or adapted in consideration of a patient’s body size, weight, disability, period of need, or intended use (i.e., custom fitted items) or have been assembled by a supplier or ordered from a manufacturer who makes available customized features, modification or components for wheelchairs that are intended for an individual patient’s use in accordance with instructions from the patient’s physician do not meet the definition of customized items. These items are not uniquely constructed or substantially modified and can be grouped with other items for pricing purposes. The use of customized options or accessories or custom fitting of certain parts does not result in a wheelchair or other equipment being considered as customized. The item must be uniquely constructed using raw materials or there must be  a necessary, substantial modification to the base equipment (e.g., wheelchair frame) for the item to be considered a customized item.

The definition of customized DME set forth in regulations at 42 CFR Section 414.224 is based on the longstanding definition of customized DME used in making decisions regarding when to make individual payment determinations outside the normal process for calculating customary and prevailing charges under the reasonable charge payment methodology used for DME prior to 1989. Public Law 101-508, Omnibus Budget Reconciliation Act (OBRA), November 5, 1990 (104 Stat. 1388-79) amended the criteria for treatment of wheelchair as ‘a customized item at section 1834 (a) (4) of the Social Security Act by adding a clause that in case of a wheelchair furnished on or after January 1, 1992, the wheelchair shall be treated as a customized item if the   wheelchair has been measured, fitted, or adapted in consideration of the patient’s body size, disability period of need, or intended use, and has been assembled by a  supplier or ordered from a manufacturer who makes available customized features, modification or components for wheelchairs that are intended for an individual  patient’s use in accordance with instructions from the patient’s physician. The amendment further noted that this clause applied only to items furnished on or after  January 1, 1992, unless the Secretary developed specific criteria before that date for the treatment of wheelchairs as customized items for purposes of section 1834(a)  (4) of the Social Security Act (in which case the amendment made by such clause would not become effective.’ CMS issued an interim final rule on December 20, 1991 (56  FR 65995) to announce the decision not to use the optional definition of customized wheelchairs in section 1834 (a) (4) of the Act and add a new section 414.224 to 42  CFR to provide in regulation criteria that must be met for a covered item to be considered a customized item for payment purposes. The final rule (58 FR 34919) was  published on June 30, 1993.

Effective May 1, 1991, suppliers must give beneficiaries entitled to electric wheelchairs the option of purchasing them at the time the supplier first furnishes the item. DME MACs or A/B MACs (HHH) make no rental payment for the first month for electric wheelchairs until the supplier notifies the MAC that it has given the beneficiary the option of either purchasing or renting. Information contained in Exhibit 2 may be furnished to beneficiaries by suppliers to help them make a rent/purchase decision. MACs provide copies of Exhibit 2 to suppliers. Payment must be on a lump-sum fee schedule purchase basis where the beneficiary chooses the purchase option. If the beneficiary declines to purchase the electric wheelchair initially, MACs make rental payments in the same manner as any other capped rental item, including the instructions in §30.5.2.

If you need an electric wheelchair prescribed by your doctor, you may already know that Medicare can help pay for it. Medicare requires (specify name of supplier) to give you the option of either renting or purchasing it. If you decide that purchase is more economical, for example, because you will need the electric wheelchair for a long  time, Medicare pays 80 percent of the allowed purchase price in a lump sum amount. You are responsible for the 20 percent coinsurance amounts and, for unassigned  claims, the balance between the Medicare allowed amount and the supplier's charge. However, you must elect to purchase the electric wheelchair at the time your medical  equipment supplier furnishes you the item. If you elect to rent the electric wheelchair, you are again given the option of purchasing it during your 10th rental month.

If you continue to rent the electric wheelchair for 10 months, Medicare requires (specify name of supplier) to give you the option of converting your rental agreement to a purchase agreement. This means that if you accept this option, you would own the medical equipment. If you accept the purchase option, Medicare continues making rental payments for your equipment for 3 additional rental months. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After these additional rental payments are made, title to the equipment is transferred to you. You have until (specify the date one month from the date the supplier notifies the patient of this option) to elect the purchase option. If you decide not to elect the purchase option, Medicare continues making rental payments for an additional 5 rental months, a total of 15 months. After a total of 15 rental months have been paid, title to the equipment remains with the medical equipment supplier; however, the supplier may not charge you any additional rental amounts.

Elevating/stair climbing power wheelchairs are class III devices. Suppliers billing the DMERCs must submit claims for the base power wheelchair portion of this device using HCPCS code K0011 (programmable power wheelchair base) with modifier KF for claims submitted on or after April 1, 2004, with dates of service on or after January 1, 2004. For claims with dates of service on or after January 1, 2004, the elevation feature for this device should be billed using HCPCS code E2300 and the stair climbing feature for this device should be billed using HCPCS code A9270.

Regional home health intermediaries (RHHIs) will not be able to implement the KF modifier until January 1, 2005. Therefore, for claims with dates of service prior to January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code E1399. For claims with dates of service  on or after January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code K0011 with modifier KF.

The fee schedule amounts for K0011 with and without the KF modifier appear on the fee schedule file referenced at www.cms.hhs.gov/providers/pufdownload/default.asp#dme. For claims with dates of service prior to January 1, 2005, RHHIs should pay claims for stair climbing wheelchair bases billed with code E1399 using the fee schedule amounts for K0011 with the KF modifier. All other claims for programmable power wheelchair bases should be paid using the fee schedule amounts for K0011 without the KF modifier.

The DMEPOS fee schedules are updated on an annual basis in accordance with the statute and regulations. The update process for the DMEPOS fee schedule is located in Pub.100-04, Medicare Claims Processing Manual, chapter 23, section 60. Payment on a fee schedule basis is required for certain durable medical equipment (DME) by §1834(a) of the Social Security Act. Section1834(a)(1)(F)(ii) of the Act mandates adjustments to the fee schedule amounts for certain DME items furnished on or after January 1, 2016, including wheelchair accessories and seat and back cushions, in areas that are not competitive bid areas, based on information from competitive bidding programs (CBPs) for DME.

Providers/suppliers must use modifier “KU” for claims submitted on or after July 1, 2016, with dates of service on or after January 1, 2016, and before January 1, 2017, for any HCPCS code describing a wheelchair accessory or seat or back cushion when furnished in connection with a Group 3 complex rehabilitative power wheelchair.

Effective July 1,

2017, CMS has taken into consideration the exclusion at section 1847(a)(2)(A) of the Act to revise the policy. As a result, payment for these items furnished in connection with a Group 3 complex rehabilitative power wheelchair and billed with the KU modifier will be based on the unadjusted fee schedule amounts updated in accordance with section 1834(a)(14) of the Act.

The payment amount for a given service or item, whether rented or purchased, must be consistent with what is reasonable and medically necessary to serve the intended purpose (See the Medicare Benefit Policy Manual, Chapter 15). Additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. Thus, where a service or item is medically necessary and covered under the Medicare program, and the patient wishes to obtain such deluxe features, the payment is based upon the payment amount for the kind of service or item normally used to meet the intended purpose (i.e., the standard item.) Usually this is the least costly item. DME MACs may, of course, determine that the payment amount for a more expensive service or item is reasonable when the additional expense is for an added feature that is medically necessary in a given case. For example, a more expensive item may be medically necessary where a patient in a weakened condition needs a poweroperated wheelchair or a power-operated vehicle that may be appropriately used as a wheelchair since the patient is not strong enough to operate a manual wheelchair.

Diagnosis Codes - Listed in the first space is the diagnosis code that represents the primary reason for ordering this item. Additional diagnosis codes that would further describe the medical need for the item (up to 3 codes) are also listed. A given CMN may have more than one item billed, and for each item, the primary reason for ordering may be different. For example, a CMN is submitted for a manual wheelchair (K0001) and elevating leg rests (K0195). The primary reason for K0001 is stroke, and the primary reason for K0195 is edema.

Power wheelchair additional documentation requirements re: make and model name/number

There must be no requirement that all claims for power wheelchairs include the make and model name/number of the wheelchair separate from the claim or the CMN. The CMN, an OMB approved information collection form, can be used to collect this information. Specifically, DME MACs can require that the make and model name/ number of the power wheelchair be included in Section C of the CMN. Section C requires the supplier to include a narrative description of the items, options and accessories ordered.

EXCEPTION: Medicare makes a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the “from” date or anniversary date defined below.

For capped rental items of durable medical equipment (DME) where the DME supplier submits a monthly bill, the date of delivery (“from” date) on the first claim must be the “from” or anniversary date on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months

A beneficiary rents a wheelchair beginning on January 1. The DME MAC determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair. The beneficiary enters a covered a hospital on February 15 and is discharged on April 5. In this example, Medicare pays for the entire month of February, because the patient was in the home for part of the month. However, the DME MAC denies the claim for March, because the patient was in a covered hospital stay for the entire month.

Because the anniversary date (“from” date) of the monthly bill was April 1, and the patient was still in the covered hospital stay on that date, the DME supplier must not submit another claim until April 5 (the date of discharge). April 5 becomes the new anniversary date (“from” date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.

A beneficiary rents a wheelchair beginning December 15. On January 1, the patient enters a hospital and is discharged on January 31.

In this example, the DME MAC denies the claim dated January 15. The supplier submits a new claim dated January 31, which becomes the anniversary date for billing purposes. The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date. The February claim would be dated February 28 because there is no 31st day in February.

For capped rental DME items where the DME supplier submits a monthly bill, the date of delivery (the “from” date) on the first claim must be the “from”, or “anniversary date”, on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated on the 15th of the following months (October 15, November 15, etc.).

The following instructions discuss DME payment when the DME is furnished during a month in which the beneficiary spends part of the month in a SNF, and part of the month in his or her own home. In accordance with DME payment policy, Medicare will make separate payment for a full month for DME items in such situations, provided the beneficiary was in the home on the “from” date or “anniversary date” defined above.

A beneficiary rents a wheelchair beginning on January 1. The DME MAC determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair. The beneficiary enters a covered Part A stay in a SNF on February 15 and is discharged on April 5. In this example, Medicare will make payment for the entire month of February, because the patient was in the home for part of the month. However, the DME MAC will deny the claim for March, because the patient was in a covered Part A stay in the SNF for the entire month.

Because the anniversary date (“from” date) of the monthly bill was April 1, and the patient was still in the covered Part A stay in a SNF on that date, the DME supplier must not submit another claim until April 5 (the date of discharge). April 5 becomes the new anniversary date (“from” date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period. The supplier should annotate the claim to indicate that the patient was in a SNF on the first claim with the new anniversary date.

Friday, September 8, 2017

Getting Authorization for inpatient hospital visit

INPATIENT HOSPITAL AUTHORIZATION REQUIREMENTS

The information in this section applies to instate and borderland hospitals. Information regarding out-ofstate hospital authorization requirements can be found in the Out-of-State/Beyond Borderland Providers subsection of this chapter.

All inpatient admissions must be medically necessary and appropriate, and all services must relate to a specific diagnosed condition. In the event that an inpatient stay is deemed medically inappropriate or unnecessary, either through a pre-payment predictive modeling review or a post-payment audit, providers are allowed to submit an outpatient claim for all outpatient services and any inpatient ancillary services performed during the inpatient stay. Elective admissions, readmissions, and transfers for surgical and medical inpatient hospital services must be authorized through the Admissions and Certification Review Contractor (ACRC). The physician/dentist should refer to the Prior Authorization Certification Evaluation Review (PACER) subsection of this chapter for specific requirements.

Medically inappropriate or unnecessary inpatient admissions may be resubmitted as outpatient claims for all outpatient services and any inpatient ancillary services performed during the inpatient stay. When an inpatient claim is deemed medically inappropriate or unnecessary through a pre-payment predictive modeling review or a post-payment audit, hospitals are allowed to submit a hospital outpatient Type of Bill (TOB) 013X for all outpatient services and any inpatient ancillary services performed during the inpatient stay. Examples of services related to medically inappropriate or unnecessary inpatient admission include:

** all elective admissions, readmissions, and transfers that are not authorized through the PACER system;

** admissions or readmissions which have been inappropriately identified as emergent/urgent;

** selected ambulatory surgeries inappropriately performed on an inpatient basis; and

** any other inpatient admission determined to have not been medically necessary. Medicaid does not cover inpatient hospital admissions for the sole purpose of:

** Cosmetic surgery (unless prior authorized)

** Custodial or protective care of abused children

** Diagnostic procedures that can be performed on an outpatient basis

** Laboratory work, electrocardiograms (ECGs), electroencephalograms (EEGs), and diagnostic x-rays

** Observation

** Occupational Therapy (OT)

** Patient education

** Physical Therapy (PT)

** Routine dental care

** Routine physical examinations not related to a specific illness, symptom, complaint, or injury

** Speech pathology

** Weight reduction or weight control (unless prior authorized)

If Medicaid does not cover the services of the physician/dentist or hospital, the physician/dentist or hospital must not bill the beneficiary, a member of the beneficiary's family, or other beneficiary representative.


PRIOR AUTHORIZATION CERTIFICATION EVALUATION REVIEW (PACER)

Elective admissions, all readmissions within 15 days of discharge, continued stays (when appropriate), and all transfers for surgical or medical inpatient hospital services to and from any hospital enrolled in the Medicaid program require authorization through the ACRC. This includes transfers between a medical/surgical unit and an enrolled distinct part rehabilitation unit of the same hospital. All cases are screened using the Medicaid approved Severity of Illness/Intensity of Services (SI/IS) criteria sets and the clinical judgment of the review coordinator. An ACRC physician/dentist makes all adverse decisions. The ACRC performs medical/surgical and rehabilitation admission, readmission, and transfer reviews through the PACER system and assigns PACER numbers.

The attending/admitting physician/dentist or representative is responsible for obtaining the PACER number before admitting, readmitting, or transferring the beneficiary, with exceptions as noted below. (Refer to the Directory Appendix for PACER authorization contact information.) The physician/dentist is responsible for providing the PACER number to the admitting hospital. The PACER number is issued on the day that the admission is approved by the ACRC. This number is valid for the entire medical or surgical admission unless otherwise noted in this section. PACER authorization must be requested prior to the admission of the beneficiary. Physicians/dentists are asked to provide the procedure code(s) when a surgical admission/readmission is requested.

Authorization through the ACRC for the hospital admission does not remove the need for prior authorization (PA) required by Medicaid for specific services. The PA for the service must be obtained before the ACRC authorization is requested.

Approval of an admission only confirms the need for services to be provided on an inpatient hospital basis. Payment for the admission is subject to eligibility requirements, readmission, and third party liability (TPL) reimbursement policy, along with any pre- and post-payment determinations of medical  necessity.

If an admission, readmission, transfer, or continued stay is not approved, MDHHS does not reimburse for services rendered.


Reconsiderations The attending physician/dentist or the hospital may request reconsideration of the adverse determination of the ACRC regarding the need for admission, readmission, transfer, or continued stay. This reconsideration right applies regardless of the current hospitalization status of the beneficiary. Reconsiderations must be requested within three business days of the adverse determination. (Refer to the Directory Appendix for ACRC contact information.) If requested by the ACRC, the provider must provide written documentation. The provider is notified of the reconsideration decision within one business day of receipt of the request or the date of receipt of written documentation. If the initial adverse determination is overturned, the adverse determination is considered null and void. If the initial adverse determination is upheld or is modified in such a manner that some portion of the hospital care is not authorized, the hospital is liable for the cost of care provided from the date of the initial determination, unless this determination is overturned in the Medicaid appeals
process.

Technical Denials If the provider fails to request a PACER number on a timely basis, the provider should make this request as soon as the omission is noted. When the provider contacts the ACRC by telephone with an untimely request, the review coordinator sends the provider a form to complete, explaining the circumstances of the untimely request. If upon review of this written documentation the untimeliness is waived, the case is reviewed for medical necessity and the appropriateness of the admission, readmission, or transfer. If approved, the ACRC gives the provider a PACER number. If the untimeliness issue is not approved, the attending physician/dentist and the hospital are notified in writing within 24 hours of the decision. The physician/dentist or hospital may request further review of the ACRC decision by Medicaid relative to timeliness.


If the ACRC does not authorize the admission or the continued stay for an admission and the beneficiary remains in the hospital for one or more days after Medicaid payment is not authorized, the hospital is at risk of Medicaid nonpayment for those days. The provider may request post-discharge review by the ACRC, regardless of whether reconsideration was requested on the case, in writing within 30 calendar days of the discharge from the hospital. A copy of the medical record must accompany the post-discharge review request.

Post-discharge review is conducted for only those days that were not authorized during the telephone review. The ACRC informs the provider, in writing, of the ACRC decision within 14 calendar days of the receipt of the request and documentation. If some or all of the previously nonauthorized days are approved, a new PACER number is issued and included in the notification of the decision. If the initial adverse determination is upheld, the notification includes the previously issued PACER number. If the provider is dissatisfied with the decision of the ACRC, the decision may be appealed.

The hospital may bill Medicaid only for the days authorized by the ACRC. If the ACRC has made an adverse determination and issued a final PACER number, the hospital  may submit a claim with this PACER number for only the authorized days while the
case is in the reconsideration, post-discharge review, or formal appeals process. Submission of such a claim does not imply acceptance of the ACRC determination.


A. ADMISSIONS/READMISSIONS/TRANSFERS THAT REQUIRE A PACER NUMBER

The following require a PACER number:

** All elective admissions.

** All readmissions within 15 days of discharge (including newborns). [NOTE: If a beneficiary is readmitted to the same hospital within 15 days for a related (required as a consequence of the original admission) condition, Medicaid considers the admission and the related readmission as one episode for payment purposes. The related admissions must be combined on a single claim. No PACER number is issued for continuation of care.]

** All transfers for medical/surgical services to and from any hospital enrolled in the Medicaid program (including newborns).

** Transfers between a medical/surgical unit and an enrolled distinct part rehabilitation unit of the same hospital.

** Authorization of continued stays in freestanding and distinct part rehabilitation units.



B. ADMISSIONS/READMISSIONS/TRANSFERS THAT DO NOT REQUIRE A PACER NUMBER

The following do not require a PACER number:

** Emergent/urgent inpatient hospital admissions. (All transfers and 15-day readmissions to the same or a different hospital do require PACER through the ACRC.)

** All admissions and transfers to distinct-part psychiatric units or freestanding psychiatric hospitals and all continued stays in a psychiatric unit/hospital. (Authorization must be obtained through the local Prepaid Inpatient Health Plan (PIHP)/Community Mental Health Services Program (CMHSP).)

** Obstetrical patients admitted for any delivery.

** Newborns admitted following delivery.

** Admissions of beneficiaries who are eligible for CSHCS only.
** Medicaid beneficiaries enrolled in a Medicaid Health Plan (MHP). (Authorization must be obtained through the MHP.)

** When a beneficiary is admitted to a hospital that is not enrolled with the Michigan Medicaid Program.

** When a beneficiary becomes Medicaid eligible after the admission, readmission, transfer, or certification review period. (When Medicaid eligibility is determined retroactively, "Retroactive Eligibility" must be entered in the Remarks section of the inpatient hospital claim.)

** Medicare Part A beneficiaries.

** Commercial insurance coverage for admissions, readmissions, transfers, or continued stays.



PACER READMISSIONS

To be separately reimbursable, all readmissions (whether to the same or a different hospital) for hospital services must be prior authorized through the ACRC. The request for a PACER number for an elective readmission, whether to the same or a different hospital, must be made prior to readmission. The request for a PACER number for an emergent/urgent readmission to the same hospital must be made by the next business day following the readmission. The request for a PACER number for an emergent/urgent readmission to a different hospital must be made prior to the beneficiary's discharge from a transferring hospital. Medicaid defines readmission, for purposes of review, as any admission/hospitalization of a beneficiary within 15 days of a previous discharge, whether the readmission is to the same or a different hospital.

If the hospital intends to combine an admission and a readmission into a single episode for DRG payment purposes, the ACRC should not be contacted for a separate PACER number for the readmission.

Before contacting the ACRC, the provider should assemble as much information as possible regarding the medical condition of the beneficiary upon the first discharge and at the time of the readmission. When contacted for a PACER number, the ACRC either:

** Agrees that the original admission and the readmission are unrelated, as well as medically necessary, and issues a PACER number so that the stays may be billed and paid separately by the same hospital;

** Authorizes a readmission to a different hospital as medically necessary and issues a PACER number;

** Asks the caller to obtain additional information and call back no later than the next business day; or

** Questions the relatedness of two stays at the same hospital or the medical necessity for the readmission and refers the call to a physician/dentist advisor who may issue or deny a PACER number.

If a PACER number is not provided for a readmission due to relatedness (required as a consequence of the original admission), the hospital must combine the two stays into a single episode for DRG payment purposes (using the Leave of Absence revenue code 0180 for the time between discharge and readmission), or request reconsideration of the ACRC physician/dentist advisor's decision within three business days. If the initial admission has already been billed, the hospital must submit a claim
replacement to combine the two stays.

If it is determined a readmission is medically unnecessary, the hospital may only bill for the first admission.


PACER TRANSFERS

If a beneficiary needs to be transferred, authorization for the transfer must be obtained through the ACRC. Authorization for a transfer is granted only if the transfer is medically necessary and the care or treatment is not available at the transferring hospital. Transfers for convenience are not considered.

Transfers include the following situations:

** Transfer from one inpatient hospital to another.

** Transfer from one unit of an inpatient hospital to another unit of the same hospital (i.e., distinctpart rehabilitation unit).

The following describes the appropriate requestor and timeframes for transfer authorization:

** Elective transfers – the transferring physician/dentist or designee must obtain authorization prior to transfer.

** Emergent/urgent transfers – the authorization must be obtained by the transferring physician/dentist no later than the next business day, or by the receiving physician/dentist or hospital before discharge.

If the transfer is approved, a PACER number is issued. The receiving hospital must use this PACER number when billing. The transferring hospital continues to use the original PACER number if a PACER number was required for the admission.

Monday, August 7, 2017

Top 50 Billing Error Reason Codes With Common Resolutions


Description Common Resolutions 

0453 Enrolled in HMO or an Encounter Claim for F. F. S. Verify the enrollee eligibility and bill the claim to the appropriate
carrier.

0302 Duplicate of History File Record, Same Provider, Same Dates of Service Provider has already received payment for this date of service. Review your prior remittance to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline *Note- make sure the prior remittance’s provider number matches the number of the remit with the denied claim


0301 Duplicate Payment Request-Same Provider, Same Dates of Service Provider has already received payment for this date of service. Review your prior remittances to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline *Note- make sure the prior remittance’s provider number matches the number of the remittance with the denied claim

0318 Enrollee not eligible on DOS Claim will deny if the client is not eligible during dates of service billed. Check enrollee eligibility status through MediCall to verify eligibility on the date of service being rendered. If the enrollee is not eligible no payment will be received from Virginia Medicaid. If upon verification you find that the client is now eligible on that date of service resubmit the claim.

1393 No Srvc Taxonomy Code on the Claim Verify that the servicing provider taxonomy code was on the claim.

0309 Services Not Covered Verify the client’s eligibility on our Medicall system. If the client is eligible, contact the Provider Helpline to verify that the client is enrolled in the program for which services were billed.

0313 Enrollee is covered by private insurance, refer to third party information of this R/A

Our system indicates that there is a primary carrier, which needs to be billed prior to Medicaid. This carrier is now listed on your remittance advice under the claims information for that particular client. Please refer to this other coverage information which should be billed as primary.

*NOTE: If the client states there is no other coverage then they will need to contact their case worker at the Department of Social Services to have this information corrected

0732 Servicing Provider Invalid Verify the 10 digit number entered for the servicing provider.

0155 Procedure Requires Authorization The procedure/revenue code billed requires a preauthorization and there is no PA number on the claim. You must get preauthorization from the appropriate area depending on the service being provided. The preauthorization number received is required on the claim.

0039 Qualified Medicare Beneficiary Only Enrollee. Medicaid coverage limited to deductible and coinsurance.

Qualified Medicare Beneficiary (QMB) Only clients are eligible only for payment of Medicare premiums, deductibles, and coinsurance. If a QMB Only claim is denied by Medicare then there will be no reimbursement by Medicaid.

0983 Enrollee Not on File Verify the enrollee’s Medicaid ID number.

0456 Enrollee Not Covered for this ServiceVerify the enrollee is covered for the service you are billing.

0485 Authorization by Medallion PCP Not Indicated The members primary care provider must authorize services

0308 Your payment request was filedpast the filing time limit without acceptable documentation

Virginia Medicaid is mandated by federal regulations to require the initial submission of all claims (including accident cases) within 12 months from the date of service. Medicaid is not authorized to make payment on claims submitted after the 12 month timely filing limit, except under the conditions listed in the Providers Manual Chapter V pgs 2-3. For additional details regarding the timely filing regulations, please reference the appropriate Provider Manual, Chapter 5 0022 Servicing Provider is Not Eligible to Bill this Payment Request Type

The servicing provider billed on the claim is not eligible to bill this claim.

1357 NPI Servicing Provider Not on File

Verify the 10 digit NPI entered for the servicing provider.

0385 Re-bill on Title XVIII Invoice If the claim is being submitted to Medicaid for deductible and coinsurance secondary to Medicare’s payment, and the claim to Medicare was submitted in a CMS-1500 format, then the claim to Medicaid must be submitted on a Title XVIII claim format.

0028 Admit Date Missing or Invalid UB 04–. The admit date must be numeric without any dashes or slashes.

0367 This enrollee is covered by Medicare part B, Rebill on Title 18 Medicaid requires claims be submitted on a Title 18 for Medicare Part B deductible and coinsurance. See Medicaid Memo dated 3/18/04.

0161 Authorization Not Valid for Dates of Service

The payment request's from and thru dates of service must fall within the PA's begin and end dates. CMS – 1500 and UB-04: Please verify the correct PA number was entered.

0731 Servicing Provider Not Eligible on DOS

The servicing provider was not eligible on the date of service. Contact Provider Enrollment Unit.

0370 Wrong Procedure Code Billed Check your claim to verify that the correct/valid procedure code was billed, if you feel the code is correct call the Provider Helpline to verify the code billed

0757 Servicing Provider Can Not be a Group Provider

The servicing provider number used on your claim can’t be a group NPI number.

0756 Billing Provider is not a Group Provider

The billing provider must be enrolled as a group provider. Contact Provider Enrollment

0730 Servicing Provider Not a Member of the Group

The servicing provider is not a member of the group provider, Contact Provider Enrollment

0480 Not CLIA Certified to perform procedure

Check that the CLIA number used on the claim is certified to perform the procedure.

0129 Revenue Code Not Covered UB 04 – Verify that the revenue code being billed is valid for the provider type and service

0026 Covered Days Missing or Invalid

UB 04 – Value code 80, enter the number of covered days for inpatient hospitalization or the number of days for re-occurring out-patient claims. The format for value code is digit: do not format the number of covered or non-covered days as dollar and cents.

0004 Enrollee ID Missing or Not in Valid Format

Verify the enrollee number for eligibility. The twelve digit enrollee number should appear as it is on the Medicaid Card.
0734 Covered Days Entered is greater than the Statement Period The covered days entered cannot exceed the difference between the from and thru dates.

1370 Invalid Present on Admission Flag

This requirement only applies to inpatient facility claims. The locator for the POA is right after the diagnosis code. A POA indicator is required for the primary, secondary and the external reason code. Review all diagnosis codes on the claim to assure the POA indicator was used. For more detail, please refer to the Hospital Manual, Chapter 5


0157 Approved Authorization Not on File The procedure billed requires authorization and the authorization is not on file. Verify that the authorization number on the claim is the correct authorization for the service billed.

0162 Number of procedures exceeds number authorized The number of units or visits billed is greater than the number of units or visits authorized on the PA

0191 Provider Referral Required The procedure code entered on the CMS-1500 or the revenue code on the UB-04 requires a referral, Verify the correct provider number is entered correctly on the claim.

0178 Invalid Diagnosis Code The primary diagnosis is not valid. Please verify that the diagnosis code is valid and is in the correct format.

0179 Invalid Discharge Status for Type Bill UB-04 –Enter the code indicating the disposition or discharge status of
the patient at the end service for the period covered on this bill (If the third position of type of bill is 2 or 3 the discharge status should be 30. If the third position of type of bill is 1 or 4 the discharge status should not be 30.

0014 Billed Amount Missing or Invalid CMS-1500 – Billed charges should be on each line. Do not use a decimal point.

UB-04 – The billed charges must be numeric without spaces.

0017 Missing Former Reference Number The original Internal Control Number (ICN) for claims that are being submitted to adjust or void the original PAID claim must be provided.

0055 The Type of Bill Missing or Invalid UB 04 –Type of Bill - Enter the code as appropriate

0077 Adjustment Denied - Original Payment Request Already Adjusted/Voided

An adjustment or void request cannot be submitted for a payment that has been previously adjusted or voided.

0110 Diagnosis Code Does Not Agree with Age The diagnosis given is not compatible with the enrollee's age.

0119 Service Period Not Equal Accommodation Days UB 04 - If a revenue code(s) is billed for accommodation or room and
board, the service units billed for the revenue code(s) must be equal to the number of days covered by the from-thru dates of service for the payment request.

0158 Enrollee Disagrees with Authorization

The authorization number used on the claim is not for the same enrollee as billed.

0160 Procedure Disagrees with Authorization The procedure billed on the claim is not the same procedure that has been authorized.

0352 Only Paid Payment Requests Can be Adjusted/Voided Only paid payment requests can be adjusted or voided. If the claim
previously denied, you must submit the claim as a new c laim.

0364 Primary carrier payment equals or exceeds DMAS’ allowed amount The claim was submitted with COB code indicating there was a primary carrier which paid on this claim and that the primary carrier’s payment to you equaled or exceeded Medicaid’s allowed amount. DMAS will not reimburse you if the primary carrier payment exceeds the Medicaid allowed amount.

0035 Missing/Invalid Type of Accommodation Code UB 92 –,Enter the total number of covered accommodation days or
ancillary units of service where appropriate. Th s number is equal to the number of covered days.

0352 Only Paid Payment Requests Can be Adjusted/Voided Only paid payment requests can be adjusted or voided. If the claim previously denied, you must submit the claim as a new claim.

0015 Primary Carrier Pay Missing or Invalid

CMS-1500 – our records show there is a primary carrier and no TPLinformation is on the claim.

UB-04: if claim was submitted with a COB code of ‘83’ (primary carrier billed and paid) under ‘code’, the payment made by the primary carrier must be under ‘amount.”


Popular Posts