Monday, June 21, 2010

CO 18 Denial code - Insurance claim denied as duplicate -

Claim denied as Duplicate - CO18

Description:

Claims submitted are exact duplicates of previous claims submitted. Claims are often denied as duplicates for the following reasons:

* The claim was previously processed (i.e., no payment made, allowed amount applied to deductible on the initial claim). The provider re-files the claim to "correct" it. The second claim submitted is considered a duplicate, as the initial claim was processed correctly.

* The provider automatically re-files the claim to seek payment if the initial claim has not been paid within 30 days.


Action:

1. if the reason for non-payment is in question, call Provider Services to verify the claim's processing information. Do not refile a claim until you know a new claim is necessary.

2. Check the claim status before re-filing a new claim; the claim could be pending in the Medicare system for payment or for additional information necessary to complete processing. Again, call Provider Services to check claim status before re-filing.


Clinical Laboratory Procedures: Duplicate Denials


Denial Reason, Reason/Remark Code(s)

CO-18 - Duplicate Service(s): Same service submitted for the same patient

CPT codes: 36415, 80048, 80053, 80061, 83036, 84443, 85610

Resolution/Resources

First: Verify the status of your claim before resubmitting. Use the Palmetto GBA eServices tool or call the Palmetto GBA Interactive Voice Response (IVR) unit.


All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.

Access the introductory article to learn more by selecting the 'Introducing eServices' graphic on the top of any of our main contract Web pages

Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.

Billing services and clearinghouses should contact their provider clients to gain access to the system

CPT modifier 91 may be submitted to identify an identical laboratory test for the same patient on the same date.

This modifier may not be submitted when tests are rerun to confirm initial results due to testing problems with specimens or equipment, or for any other reason when a normal, one-time, reportable result is all that is required

This modifier may not be used when other codes describe a series of test results (e.g., glucose tolerance tests)

For clinical laboratory tests ordered by an ESRD facility: these tests must be submitted with CPT modifier 91 if any single service (same CPT code) is ordered for the same patient, and the specimen is collected more than once in a single day, and the service is medically necessary

CPT modifier 91 must be submitted with services that meet these criteria, regardless of whether the test is also submitted with HCPCS modifiers CD, CE or EF

Any line item on a claim that meets these criteria and is submitted with CPT modifier 91 will be included into the calculation of the 50/50 rule

After calculation of the 50/50 rule, services used to determine the payment amount may not exceed 22

Preventing duplicate claim denials

Providers are responsible for all claims submitted to Medicare under their provider number. Preventable duplicate claims are counterproductive and costly, and continued submission to Medicare may lead to program integrity action.

Please share this information with your billing companies, vendors and clearing houses: Claim system edits search for duplicate, suspect duplicate and repeat services, procedures and items within paid, finalized, pending and same claim details in history. Duplicate claims and claim lines are automatically denied. Suspect duplicate claims and claim lines are suspended and reviewed by the Medicare administrative contractor (MAC) to make a determination to pay or deny. Click here for additional information.

Medicare correct coding rules include the appropriate use of condition codes and modifiers. When you submit a claim for multiple instances of a service, procedure or item, the claim should include an appropriate modifier to indicate that the service, procedure or item is not a duplicate. Note that the modifier should be added to the second through subsequent line items for the repeat service, procedure or item. An example is listed below. In many instances, this will allow the claim to process and pay, if applicable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable.

Review your billing procedures and software, and use appropriate modifiers, as applicable. The following are examples of modifiers that may be used on your claim to identify that the service, procedure or item is not a duplicate.

• Modifier 59: Service or procedure by the same provider, distinct or independent from other services, performed on the same day. Services or procedures that are normally reported together but are appropriate to be billed separately under certain circumstances

• The Centers for Medicare & Medicaid Services (CMS) established four new modifiers, effective January 1, 2015, to define subsets of modifier 59.


• Modifier 76: Repeat service or procedure by the same provider, subsequent to the original service or procedure.

• Modifier 91: Repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.

• Example: Laboratory submits Medicare claim for four glucose; blood, reagent strip tests (CPT� code 82948).

Line 1: 82948
Line 2: 82948 and modifier 91
Line 3: 82948 and modifier 91
Line 4: 82948 and modifier 91

• Modifiers RT (right side) and LT (left side): Append applicable modifier to the procedure code, even if the diagnosis indicates the exact site of the procedure.

• Example: Provider submits Medicare claim for diagnosis code M1711 (unilateral primary osteoarthritis, right knee) and/or diagnosis code M1712 (unilateral primary osteoarthritis, left knee). Modifier RT should be added to the procedure code billed with diagnosis code M1711. Modifier LT should be added to the procedure code billed with diagnosis code M1712.

Note: All claims submitted to Medicare should be supported by documentation in the patient’s medical record.


Duplicate Denials

To reduce receiving duplicate denials, submit one claim with all billed services for one member, one date of service when rendered by same provider. If you bill for
multiple dates of service, please ensure all billable services are listed for the dates of service.

The exception to these guidelines apply when the service(s) include:

• Different procedure codes

• Different modifiers

• Different NDC numbers

• Different place of service (POS)

• Billing by provider of different specialty

All services billed on a UB-04 form need to be listed on one claim form. Multiple claim form submissions will be denied as duplicate.



How to submit corrected Medical claims for Acute/Dual/CRS/DD:

Corrected claims can be submitted electronically by placing a frequency type code of ‘7’ (replacement of prior claim/correction) in the appropriate loop/segment
of the 837p transaction to payor ID # 03432.

• Corrected claims can be submitted on paper, with a Reconsideration Form and the Resubmission code 7 (replacement of prior claim/correction) and original claim
number located in box 22 of the CMS-1500 claim form to:

UnitedHealthcare Community Plan

P.O. Box 5290
Kingston, NY 12402-5290

• Submit corrected claims electronically with attachments via Optum Cloud Dashboard.

Use the EDI Issue Reporting Form available at UHCCommunityPlan.com under Electronic Data Interchange (EDI) left for EDI-specific issues.

Call UnitedHealthcare Community Plan at 800-842-1109 or EDI Support at

800-210-8315, or email ac_edi_ops@uhc.com.

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