Denial code B9 - Hospice: Non-Attending Physician Denials

Denial Reason, Reason/Remark Code(s) 

• PR-B9: Patient is enrolled in a Hospice
• Procedures: All, especially CPT code 99308, 99309 and 99232

Resources/Resolution 

• Determine whether the patient has elected hospice benefits prior to submitting claims to Medicare
• You may verify eligibility through the Palmetto GBA Interactive Voice Response (IVR) unit or online though an ANSI 270/271 transaction
• If the patient has elected hospice benefits, refer to 'Hospice Benefits and Medicare Part B' section below

Hospice Benefits and Medicare Part B

• Medicare beneficiaries entitled to hospital insurance (Part A) who have terminal illnesses and a life expectancy of six months or less have the option of electing hospice benefits in lieu of standard Medicare coverage for treatment and management of their terminal condition

• When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner

• Claims from the attending physician for services provided to hospice-enrolled patients may be submitted to Palmetto GBA with HCPCS modifier GV. This is true regardless of whether the care is related to the patient’s terminal illness. HCPCS modifier GV signifies that:

o The service was rendered to a patient enrolled in a hospice

o The service was provided by a physician or nonphysician practitioner identified as the patient’s 'attending physician' at the time of that patient’s enrollment in the hospice program

• If the service was provided by a physician employed by the hospice, HCPCS modifier GV may not be submitted

• If the service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, HCPCS modifier GV may not be submitted

Online Eligibility Verification

CMS offers real-time Internet-based eligibility transactions as an alternative to the IVR. These ANSI 270/271 transactions are processed through the CMS data center. Providers and clearinghouses must be authenticated by CMS before conducting these transactions. Telecommunications software is also required in order to access the CMS network.

Steps to obtain access for Internet eligibility (270/271) transactions:

• Access the CMS HIPAA Eligibility Transaction System (HETS)
• From the left navigation menu, select Sign Up Now
• In order to obtain access to the CMS 270/271 Medicare Eligibility transaction from the Medicare

Data Communication Network (MDCN), you must access and complete the Trading Partner Agreement and Access Form

o This agreement outlines security and privacy procedures for the Medicare beneficiary database. Complete all the information on the form electronically and click on the appropriate assurances. If you do not consent to the terms of the agreement, the access process will be terminated.

o If you check the appropriate boxes of the agreement and supply the information requested, a copy of the completed form will be electronically submitted to the CMS 270/271 Medicare Eligibility Integration Contractor (MEIC) for security authentication

o The access process will then continue, and you will be directed to complete the MDCN Connectivity Form. This form must be submitted electronically in order for you to be connected to the 270/271 eligibility database.

• CMS will ensure that all necessary information is provided on the forms and ensure the complete connectivity to the 270/271 application. The MEIC will be responsible for contacting the clearinghouses, providers and trading partners to authenticate the accessing entity's identity. Once authentication has been completed, the MEIC will provide you with a submitter ID that must be used on all 270/271 transactions. Testing will be coordinated by the MEIC. After successful testing, 270 production inquiries may be sent in real-time.


Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?

A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.


When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

E/M Service: Similar Services from Multiple Providers in the Same Group - Denial code M86, B14

Denial Reason, Reason/Remark Code(s) 
• M86: Service denied because payment already made for same/similar service(s) within set time frame
• B14 (CO): Only one visit or consultation per physician per day is covered
• CPT Codes: 99213, 99214, 99231, 99232, 99233 and 99291

Resolution/Resources
First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Palmetto GBA Online Provider Services (OPS) tool or by calling the Palmetto GBA Interactive Voice Response unit (IVR).

Online Claim Status Verification through OPS 
• 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: Click on the 'Introducing Online Provider Services' graphic on the top of any of our main contract Web pages

• One important consideration: 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
• Specific instructions for accessing claim status information through OPS are available in the OPS User Manual.

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. When more than one E/M service is provided to the same patient on the same date by more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. Physicians in the same group practice but who are in different specialties or subspecialties may bill and be paid without regard to their membership in the same group.

• On electronic claims the documentation record could be used to specify the subspecialty of the provider when more than one service has been billed by multiple providers in the same group
• On electronic claims the documentation record could be used to explain why treatment was needed by a different provider in the same group

• Attachments (e.g., signed office notes, signed progress notes, etc.) for paper claims must identify the patient’s name, Health Insurance Claim number, date of service and other pertinent information (e.g., subspecialty of the billing provider):

o Attachments must be a full page (8 ½ x 11)

• On appeal, signed medical records (e.g., progress notes, history and physical notes, office notes, etc.) may be sent as evidence to show why more than one visit was submitted on the same date either by similar providers from different groups or different providers with different subspecialties from the same group

• On appeal, the identification of the providers’ subspecialty, when more than one provider from the same group is billing for E/M services to the same patient on the same date, can be helpful in explaining why multiple providers were needed

We strongly encourage all providers and their staff members to become familiar with the E/M Documentation Guidelines, which were developed jointly by CMS and the American Medical Association.

• Take advantage of free training offered by Palmetto GBA clinical education staff to learn more about how to understand and apply the E/M Documentation Guidelines. To view a list of upcoming workshops, select Learning and Education from the left side of the Web page and then select Workshops.

• Conduct internal audits of documentation versus code selections, especially for E/M services

• Consider using a standardized 'scoring tool' for consistency in applying the E/M Documentation Guidelines. Palmetto GBA publishes one such tool on our website, although there are many others from which to choose.

• Review the E/M Documentation Guidelines on the CMS website

Documentation needed to qualify for timely filing limit exceptions

Section 6404 of the Patient Protection and Affordable Care Act (the Affordable Care Act or ACA) reduced the maximum period for submission of all Medicare fee-for-service claims to no more than 12 months -- one calendar year -- after the date of service. This policy is effective for services furnished on or after January 1, 2010; claims for services furnished prior to that date were required to be submitted no later than December 31, 2010.

Effective on/after January 1, 2016, providers must utilize the new reopening process (TOB XXQ) when the need for correction is discovered beyond the claim timely filing limit; an adjustment bill (TOB XX7) is not allowed.

In an effort to streamline and standardize the process for claim reopening with the ‘Q” frequency code and adjustment reason codes (ARC), the Centers for Medicare & Medicaid Services (CMS) issued MLN Matters® article MM8581 external pdf file.

CMS released special edition MLN Matters® article SE1426 external pdf file to assist providers with coding instructions and billing scenarios for submitting requests to reopen claims that are beyond the claim filing timeframe.

(NOTE: The Administrative Billing Errors category is being removed from the process below, you must utilize the new reopening process to correct claims with dates of service beyond the timely filing limit. Please refer to the MLN Matters referenced above for complete information on the new reopening process.)

The following exceptions apply to the time limit for filing initial Medicare claims:
• Retroactive Medicare entitlement
• Retroactive Medicare entitlement involving state Medicaid agencies
• Retroactive disenrollment from a Medicare Advantage plan or program of all-inclusive care for the elderly (PACE) provider organization

Retroactive Medicare entitlement
• An official letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement, and
• Documentation describing the service(s) furnished to the beneficiary and the date of the furnished service(s), or
• If an official Social Security Administration (SSA) letter cannot be provided, First Coast Service Options, Inc. (First Coast) will check the Common Working File (CWF) database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify retroactive Medicare entitlement.
Retroactive Medicare entitlement involving state Medicaid agencies (state buy-in)
• Documentation showing the date that the state Medicaid agency recouped money from the provider/supplier, and
• Documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (i.e., the official letter to the beneficiary), and
• Documentation verifying the service/s furnished to the beneficiary and the date of the furnished service(s).
Retroactive disenrollment from a Medicare Advantage plan or PACE provider organization
• Evidence of prior enrollment of the beneficiary in an MA plan or PACE provider organization, and
• Evidence that the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization, and
• The effective date of the disenrollment; and
• Documentation showing the date the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

Customer service process for time limit exceptions

First Coast has undertaken an initiative to provide an easier mechanism for handling requests from providers to extend the timely filing requirement on claims that exceed the provision. Effective January 1, 2016, as previously mentioned, the Administrative Billing Errors category has been removed from the process listed below. The following guidelines remain the same for all other requests from providers to extend the timely filing extension on their claims:
• Medicare providers must complete the Request for Telephone Claim Override Timeliness Form for Part A, attach the appropriate documentation and a brief explanation of the reason for delayed filing. A limit of one form can be submitted per fax request. Fax the request to 904-361-0693. Click here to access the form pdf file. Note: If any part of the form is not legible, the timely filing limit for your claim(s) will not be overridden.

• First Coast written inquiry representatives will retrieve the documentation, review it, and issue an approval or disapproval letter to the provider in response to the timely filing request. Be advised that this process could take up to 45 business days to complete. Do not call the contact center.
If a claim filing extension is granted, the approval letter will instruct the provider to file a new claim. The unique approval number, provided in the approval letter, and the date of the approval letter must be included in the remark section of the claim.

Additionally, the approval letter will include a date by which the new claim must be filed. Once the claim is filed, the approval number entered on the remark line and the receipt date of the claim will be compared to the list of approved numbers. If this information matches, the claims timely filing edit will then be overridden on the applicable claim. It is important to note that other edits may fail on the claim which may require that providers correct their billing and resubmit the claims.
If a claim filing extension is not granted, the reason for not granting the extension will be outlined in the letter.

It is important that the above outlined process be followed in its entirety as any deviations could result in documentation being returned and added delays in approvals.

Access the timely filing request form pdf file

http://medicare.fcso.com/Forms/233051.pdf

cliam reopening via IVR - Medicare

Telephone reopening requests via the IVR

The First Coast Service Options’ Part B interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.

Features

• This enhancement is designed to make your requests easier and faster to process. Requests for telephone reopenings via the IVR will process the next day.

• Using this self-service feature will result in faster receipt of any applicable payments.

• The hours of availability are beyond the hours of availability for a customer service representative (CSR).

• Bonus -- The number of telephone reopening requests via the IVR are unlimited within the allotted 30-minute timeframe.

Types of reopenings available via the IVR

The following types of reopening requests are not available through a CSR; you must call the IVR for the following types of requests:

• Change date of service and quantity billed
• Change diagnosis code
• Add, delete, change modifier (except modifiers listed below)
• History corrections – including entitlement, Medicare Secondary Payer, Medicare Advantage Plan change in status or update to the patients records
• Change procedure code (can also change billed amount)
• Change quantity billed (can also change billed amount)
• Change ordering or referring provider information
Types of reopenings that cannot be performed via the IVR
• Previously adjusted claims
• Pending claims
• Non-assigned claims
• Claims for certain drug codes (listed below)

CPT®/HCPCS drug codes not allowed via the IVR
J0200	J0390	J0395	J0520	J0735	J1094	J1700
J1710	J1885	J1960	J1990	J2323	J2440	J2670
J2760	J3490	J3590	J7130	J7184	J7199	J7310
J7326	J7628	J7629	J7648	J7658	J7659	J7683
J7684	J8499	J9165	J9201	J9217	J9219	J9270
J9357	J9999	Q0144	Q2027	Q2034	Q2035	Q2036
Q2037	Q2038	Q2039	Q2045	Q2046	90654	90655
90656	90657	90658	90659	90660	90667	90668
90715	90724	90779	96549

• Request on claims containing the following modifiers, or requests to add or change these modifiers: 21, 22, 24, 51, 52, 53, 56, 62, 66, 99, CC, GA, GY, GZ, or SG, or WU.
Information you must have when calling the IVR for a reopening
• Provider’s National Provider Identifier (NPI), Tax Identification Number (TIN), and Provider Transaction Access Number (PTAN)
• Beneficiary’s last name and first Initial
• Beneficiary’s Medicare health insurance claim (HIC) number
• Beneficiary’s date of birth
• Caller’s name and 10-digit telephone number (3-digit area code and 7-digit number)
• Date of service
• Internal Control Number (ICN) -- can be obtained from your provider remit notice or the IVR when receiving a claim status
• Item(s) or service(s) at issue
• Reason for request
• New/revised information

IVR takes your request -- what’s next?
• IVR will confirm the request at the end of the call.
• If the request is approved, you will receive a letter and new remittance advice notice.
• If the request cannot be processed, a letter will be sent advising the provider of our decision.
• If the request would create an overpayment situation, the IVR will advise you to submit your request via a written redetermination form.

IVR hours of availability for telephone reopenings
• The IVR is available for requests for telephone reopenings from 7:00 a.m. to 6:30 p.m. Monday through Friday, and Saturday 7:00 a.m. to 3:00 p.m. ET.
• The toll-free Part B telephone number is 1-877-847-4992

Additional information
• No limit to the number of calls per day.
• Please have the information listed under “Information You Must Have When Calling the IVR for A Reopening” available when calling for an IVR reopening.
• Additional IVR instructions are available via our IVR Part B operating guide.

Medicare appeal some common question - Part 1

Q. Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim?

A. Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696 external link). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.

Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.
The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:

• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.

Q: During the appeal process, at what point can additional records be submitted?

A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery audit contractor (RAC) determination, the RAC will forward the medical records they received to the affiliated contractor, or First Coast Service Options Inc.

Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?
A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.


Q: What does the term “amount in controversy” mean?
A: The amount in controversy (AIC) is the amount in dispute, at a minimum, that you must have for the administrative law judge (ALJ) and judicial review levels in the appeal process.

: Is there a resource for providers or beneficiaries that outline what services or items can be appealed?
A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the resource listed below.

Medicare file Limit Q & A

Claims timely filing guidelines FAQ
Q: What are the claims timely filing guidelines? How can I prevent claim denials and/or rejects for untimely filing?

A: Per Section 6404 of the Patient Protection and Affordable Care Act (ACA), Medicare fee-for-service (FFS) claims for services furnished on or after January 1, 2010, must be filed within one calendar year from the date of service. Claims with dates of service January 1, 2010, and later, received more than one calendar year (12 months) from the date of service will be denied or rejected.

Key points to remember

For all claims:

• Claims with a date of service of February 29 must be filed by February 28 of the following year to be considered filed timely.
• Electronic claims -- The electronic data interchange (EDI) system accepts claims 24/7; however, claims received after 6:00 p.m., or on weekends/holidays, are considered received the next business day.
• Paper claims -- Timeliness is calculated based on contractor receipt date, not the postmark date of when the claims are mailed, so please allow time for mailing.

For Part A claims:

• For institutional claims with span dates of service (i.e., a "from" and "through" date span on the claim), the "through" date is used to determine the date of service for claim timely filing.

Exceptions allowing extension of time limit:
• Exceptions to the 12-month timely filing period are outlined in the Center for Medicare & Medicaid Services (CMS) Internet-only manual (IOM) Medicare Claims Processing Manual, Chapter 1 external pdf file.


• Click here http://medicare.fcso.com/Claim_submission_guidelines/233057.asp  view the documentation needed to qualify for Part A exceptions.

Medicare denial claim reopen from SPOT

Claim reopening: Request types

What types of changes may I include in a claim reopening request? May I change more than one field on each line item? Can I add or remove line items?

The only form of claim reopening request that may be submitted through the SPOT is a Part B clerical reopening.

• If a line item of a claim is considered eligible for reopening, corrections may be made to the following fields:
• Date of Service (DOS)
• Diagnosis Code (primary)
• Procedure Code
• Modifier
• Units Billed
• Only one Claim Reopening Request type may be selected for each eligible line item, and the type of request is determined by the primary field to be corrected.
• Some types of requests may allow the editing of more than one field (i.e., primary and secondary fields). However, the primary field is based upon the request type selected, and the primary field is always a required field.

    Claim Reopening: Request types and tips

Claim Reopening Request Type	Primary Field(s) (Required)	Secondary Field (Optional)	Comments
Edit DOS From	DOS From	N/A	DOS From date may not be later than DOS To date.
Edit DOS To	DOS To	N/A	DOS To date may not be earlier than DOS From date
Edit DOS Both	DOS From	N/A	Both DOS fields must be changed
	and DOS To
Edit Diagnosis Code	Diagnosis Code	N/A	The primary diagnosis code may be changed.
Edit Procedure Code	Procedure Code	Billed Amount	The replacement code must be one that may be used in a claim reopening request.
Add Modifier	Modifier	N/A	Only one modifier may be added, and it must be one that may be used for a reopening request.
	(first available field)
Edit Modifier	Modifier	N/A	Only one modifier may be replaced, and it must be one that may be used for a reopening request.
	(any modifier field that contains a value)
Delete Modifier	Modifier	N/A	Only one modifier may be deleted.
	(any modifier field that contains a value)
Edit Units Billed	Units Billed	DOS From, DOS To, Billed Amount	Anesthesia providers must use units and not minutes when adjusting units billed. The conversion factor is 1 unit = 15 minutes. For example, 75 minutes would be entered as 5 units (75/15=5 units).

            Limitations to claim reopenings on the SPOT

• Multiple request types (e.g., Edit Procedure Code and Add Modifier) may not be utilized for the same eligible line item
• Line items may not be added or removed
• History corrections (e.g., updates to beneficiary information or status) may not be submitted
• Rendering provider’s NPI may not be changed
• Claim reopening requests submitted through the SPOT must be filed within one year of the receipt of the initial determination
• Multiple modifiers, procedure codes, or diagnosis codes may not be added through the SPOT
• Claim reopening requests without any changes may not be submitted through the SPOT