Monday, January 18, 2016

Hospital part A Denial reason code 31816, 37544 and N5252 - what should we do ?

Q: We are receiving a return to provider (RTP) reason code 31816, so what steps can we take to avoid this reason code?

A: You are receiving this reason code when the claim contains any of the following evaluation/re-evaluation therapy codes 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004, and the claim is billed without the functional G-code(s) and the appropriate modifier(s).

Effective July 1, 2013, outpatient therapy providers are required to report a combination of two non-payable G-codes to show the beneficiary’s functional limitations (i.e., G8978 and G8979). In addition, each G-code must contain the appropriate therapy modifier(s) to indicate Physical/Occupational (PT/OT) or Speech Language (SLP) therapy (i.e., GP, GO, GN), along with the severity modifier (i.e., CJ) to indicate the severity/complexity for that measure.

Note: It is required to report the current and projected goal status for each of the G-codes at the onset of a therapy episode of care, every 10th treatment day, and then the goal and discharge status when the patient is discharged or to end the reporting for one functional limitation as needed.

Q: We are receiving a return to provider (RTP) reason code 37544, so what steps can we take to avoid this reason code?

A: A claim adjustment was submitted with condition code D1 to specify that there were changes in the charges. However, the line item and total charges on the adjustment are the same as the original claim.
• Condition code D1 is used when charges are the only change on the claim
• Condition code D1 should not be used even though other claim change reasons frequently change charges

We are receiving return to provider (RTP) reason code 38119. So what steps can we take to avoid this reason code

: You are receiving this reason code when SNF (skilled nursing facilities) or non-PPS (prospective payment system) inpatient claims are not submitted in the same sequence in which the services are furnished.
• RTP occurs when the SNF inpatient claims are billed “out of sequence”
• SNF claims must be billed sequentially and only after the prior claim has been properly adjudicated
• If your prior claim has not finalized, then wait for the prior claim to finalize before resubmitting this claim
• The claim with this reason code does not directly follow the "through" date of the previous paid claims for this patient from this provider, the "from" date must be the day after the "through" date on the prior bill
• In some instances, the claim that is out of sequence may be in process; you can check claim status via: the Secure Provider Online Tool (the SPOT), the toll-free interactive voice response (IVR) pdf file for Florida Medicare Part A at 1-877-602-8816, and also online, via direct data entry (DDE) pdf file, immediately after the claim is entered/updated
• Verify that the “admission date,” "from" date, and patient's health insurance claim number (HICN) on claim(s) to make sure they have been correctly reported
• If admission and "from" dates, as well as HICN, were reported correctly, you must submit prior month's claim
• Prior claim must have processed correctly and appear on your remittance advice (RA) before this claim can be processed. Once prior claim has shown on RA, submit next monthly claim.
• Do not include charges that were billed on an earlier bill

Q: My claim was “returned to provider” (RTP) for reason code N5052. How can I prevent claims from being returned for this reason code?
A: Check beneficiary eligibility prior to submitting claims to Medicare. Click here for ways to verify beneficiary eligibility. When completing the claim, make sure the patient’s name and HIC number are submitted exactly as they appear on the Medicare card.
For name corrections/updates to a beneficiary’s record, the beneficiary must contact the Social Security Administration (SSA).

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