Medicare Rejection as Annual Threapy cap limit and service was hospice election period

Q: We are receiving reject reason code 76474, so what steps can we take to avoid this reason code?
A: You are receiving this reason code when the patient has met the Medicare annual therapy cap limit for the calendar year.
• Confirm the beneficiary’s physical and occupational therapy cap information via the following:
• Interactive voice response (IVR) system
• Main menu select option 5 for Eligibility, then select option 3 for physical and occupational therapy information.
or
• Secure Provider Online tool (the SPOT) the Eligibility/Benefits Inquiry page, if the required beneficiary information is entered, the Benefits/Eligibility submenu will be visible and more beneficiary information/history will be accessible for example Deductibles/Caps with the following:
• Beneficiary’s Occupational Therapy information:
• Calendar Year -- the calendar year associated with the used dollar amount that has been applied to the capitation limit for occupational therapy services.
• Used Amount -- the used dollar amount that has been applied to the capitation limit for occupational therapy services for the calendar year indicated.
• Beneficiary’s Physical and Speech Therapy information:
• Calendar Year -- the calendar year associated with the used dollar amount that has been applied to the capitation limit for physical and speech therapy services.
• Used Amount -- the used dollar amount that has been applied to the capitation limit for physical and speech therapy services for the calendar year indicated.
• Refer to the Rehabilitation Services specialty page designed specifically for rehabilitation service providers.


Q: We are receiving reject reason code C7010. What steps can we take to avoid this reason code?

A: You are receiving this reason code when the beneficiary was/is enrolled in a hospice election period for the date of service(s).
• Confirm the beneficiary’s eligibility via direct data entry (DDE), interactive voice response (IVR) system, or Secure Provider Online Tool (the SPOT)
• If the information is invalid
Contact the hospice provider and ask them to submit their last claim for the beneficiary with occurrence code 42 and the date of disenrollment. Once the records are deleted or updated, refile the claim to Medicare
• If the information is valid and the services provided to the beneficiary are related to their terminal condition for hospice services
Refile the claim with the hospice provider listed on the beneficiary’s records
• If the information is valid and the services provided to the beneficiary are not related to their terminal condition for hospice services
Refile the claim with a condition code 07 (treatment of non-terminal condition for hospice patient)
SPOT Users:
• Select the Hospice/Home Health link from the Benefits/Eligibility submenu

Denial Action on Medicare code MA61, MA27, N256, MA112 AND M79

Beneficiary name and/or Medicare number
MA61: Missing/incomplete/invalid Social Security number or health insurance claim number (HICN).
MA36: Missing /incomplete/invalid patient name.
MA27: Missing/incomplete/invalid entitlement number or name shown on the claim.

• Review and make a copy of patient’s Medicare card for file and verify eligibility. For additional information, click here for beneficiary eligibility Frequently Asked Questions (FAQs).
• Enter patient’s name on claim as indicated on Medicare card.

• Include spaces and special characters if indicated on Medicare card. Exception: PC-ACE software currently does not accept special characters; enter space instead.
• Enter patient’s HICN exactly as indicated on Medicare card.


Billing entity/provider
N256: Missing/incomplete/invalid billing provider/supplier name.
N257: Missing/incomplete/invalid billing provider/supplier primary identifier.
N258: Missing/incomplete/invalid billing provider/supplier address.
MA112: Missing/incomplete/invalid group practice information.

• Refer to Item(s) 33 and/or 33A on the claim form. These are required fields. Enter the billing provider/supplier name, address and zip code in Item 33, and the billing provider’s, or group’s, NPI in Item 33A.



Charges on claim
M79: Missing/incomplete/invalid charge.

• Refer to Item 24F on the claim form. Medicare does not pay for services when a charge is not indicated. Enter a charge for each service listed on the claim..

Viscosupplementation therapy for knee Documentation Requirements

The medical records must document that the patient has symptomatic osteoarthritis of the knee, the nature of the symptoms and the functional limitations. Radiographic confirmation in the form of an x-ray report and/or notation in the record must accompany the clinical description. The frequency of injections and the dosage given must be clearly indicated. The response to treatment must also be noted. Repeat courses of viscosupplementation in the absence of documentation of response to the previous course of treatment will be considered not reasonable and necessary and not subject to coverage. The record should also indicate whether one or both knees are being treated and in the former instance, which knee is being treated.

The medical record must include documentation that supports that conservative therapy was attempted prior to viscosupplementation therapy. If conservative therapy and/or corticosteroid injections were contraindicated or failed, the reason(s) must be supported in the documentation submitted for review.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Additional dosage(s) may be reviewed for medical necessity when the patient receives more than the recommended number of injections. In addition, a single course of treatment of either of these medications should be given no more than once every six months.

Medication: Supartz
Weekly Dosage/Injections per week: 25 mg/1
Total Dosage: 125 mg
Duration of Treatment: 5 weeks/single course of treatment per knee

Medication: Synvisc/Hyalan G F
Weekly Dosage/Injections per week: 16 mg/1
Total Dosage: 48 mg
Duration of Treatment: 3 weeks/single course of treatment per knee

Medication: Hyalgan
Weekly Dosage/Injections per week: 20 mg/1
Total Dosage: 100 mg
Duration of Treatment: 5 weeks/single course of treatment per knee

Medication: Orthovisc
Weekly Dosage/Injections per week: 30 mg/1
Total Dosage: 90-120 mg
Duration of Treatment: 3-4 weeks/single course of treatment per knee

Medication: Euflexxa
Weekly Dosage/Injections per week: 20 mg/1
Total Dosage: 60 mg
Duration of Treatment: 3 weeks/single course of treatment per knee

Medication: *Synvisc-one/Hyalan
Weekly Dosage/Injections per week: N/A
Total Dosage: 48 mg
Duration of Treatment: One time/single course of treatment

Medication: *Gel-One®
Weekly Dosage/Injections per week: N/A
Total Dosage: 30 mg
Duration of Treatment: One time/single course of treatment

Medication: Monovisc TM
Weekly Dosage/Injections per week: N/A
Total Dosage: 88 mg
Duration of Treatment: One time/single injection (the effectiveness of Monovisc™ has not been established for more than one course of treatment)

Arthrography to provide guidance for injections will not be covered. Therefore, the billing of CPT code 73580 (Radiologic examination, knee, arthrography, radiological supervision and interpretation) and 27370 (Injection of contrast for knee arthrography) or similar services will not be covered when billed with HCPCs codes J7321, J7323, J7324, J7325, J7326 or J7327. The course of treatment should consist of the use of one agent. The use of one agent should be used for the entire course of treatment. Therefore, initiating a course of treatment with one agent, then switching before completion to a different agent is considered not medically reasonable and necessary. Example: Treatment is initiated with Synvisc. After the application of two doses, the provider switches to Synvisc-one. The Synvisc-one would not be considered medically reasonable and necessary.

It is not expected that routine imaging for the purpose of needle guidance would be required. Therefore, routine use of fluoroscopy may result in a pre- payment medical review of records. Documentation should provide justification when imaging is performed for the purpose of needle guidance. The use of hand held ultrasound devices are not separately reimbursed.


* Synvisc-one/Hyalan and Gel-One® are administered as a single intra-articluar injection per course of treatment.

Medicare appeal some common question Part 2

http://www.insuranceclaimdenialappeal.com/2016/03/medicare-appeal-some-common-question.html

Q: Can we resubmit a claim that was denied by the recovery audit contractor (RAC) if we determine the incorrect code was submitted?
A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service


Q: What are the reason code ranges for claims when they have denied?
A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a “5”. If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a “7”, which is a non-medical denial.


Q: Can I resubmit or adjust a claim when an appeal is processing?
A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.
Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.

Revised fact sheet on the appeals process
The Medicare Appeals Process external pdf file fact sheet (ICN 006562) was revised and is now available in a downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers, in addition to including more information on available appeals-related resources

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf

Good cause for extension of the time limit for filing appeals

The time limit for filing a request for redetermination may be extended in certain situations. Generally, providers, physicians, or other suppliers are expected to file appeal requests on a timely basis. A request from the provider, physician, or other supplier to extend the period for filing the request for redetermination would not be routinely granted.

Note: A finding by the contractor that good cause exists for late filing for the redetermination does not mean that the party is then excused from the timely filing rules for the reconsideration.
Good cause may be found when the record clearly shows, or the beneficiary alleges, that the delay in filing was due to one of the following:

• Circumstances beyond the beneficiary’s control, including mental or physical impairment (e.g., disability, extended illness) or significant communication difficulties;

• Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (the Centers for Medicare & Medicaid (CMS), the contractor, or the Social Security Administration) to the beneficiary (e.g., a party is not notified of her appeal rights or a party receives inaccurate information regarding a filing deadline);

Note: Whenever a beneficiary is not notified of his/her appeal rights or of the time limits for filing, good cause must be found.

• Delay resulting from efforts by the beneficiary to secure supporting evidence, where the beneficiary did not realize that the evidence could be submitted after filing the request;

• When destruction of or other damage to the beneficiary’s records was responsible for the delay in filing (e.g., a fire, natural disaster);

• Unusual or unavoidable circumstances, the nature of which demonstrates that the beneficiary could not reasonably be expected to have been aware of the need to file timely;

• Serious illness which prevented the party from contacting the contractor in person, in writing, or through a friend, relative, or other person;

• A death or serious illness in his or her immediate family; or

• A request was sent to a government agency in good faith within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired.

Note: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to timely submit appeals or other information is not grounds for finding good cause for late filing. Also, good cause does not exist where the provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.

Chiropractic Manipulative Treatment: Duplicate Denials

Denial Reason, Reason/Remark Code(s) 

• CO-18 - Duplicate Service(s): Same service submitted for the same patient, same date of service by
same doctor will be denied as a duplicate
• CPT codes: 98940, 98941, 98942

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 (IVR) unit.

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 by selecting the 'Introducing Online Provider Services' 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
• Specific instructions for accessing claim status information through OPS are available in the OPS User Manual.

Please note:
• Only one chiropractic manipulative treatment will be allowed per day

Beneficiary Eligibility Denials

Denial Reason, Reason/Remark Code(s)
• PR-26: Expenses incurred prior to coverage
• PR-27: Expenses incurred after coverage terminated

Resolution/Resources: Verify patient eligibility prior to submitting claims to Medicare through the Palmetto GBA Online Provider Services (OPS) tool or Interactive Voice Response (IVR) unit.

Online Eligibility 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 by selecting the 'Introducing Online Provider Services' graphic on the top of any of our main state 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
• Specific instructions for accessing beneficiary eligibility information through OPS are available in the OPS User Manual