Why did I receive a duplicate denial on my remittance advice (ANSI code 18) when I have never received payment or denial on the claim?

For therapy services, should the treatment encounter notes capture total timed code treatment minutes and total treatment time?

Where can I find information on billing the correct place of service (POS) code and where do I enter the code on the CMS-1500 form?

How is reimbursement affected by the place of service (POS) code billed on a claim?

After the 60-day period, can the locum tenens physician take a day off and the 60-day period begin again?

I am a physician or non-physician practitioner who is employed by a group and also maintaining a private practice. How is my National Provider Identifier (NPI) number reported on the claim differently when billing as an individual versus billing as part of a group?

On the Advance Beneficiary Notice (ABN) form, is the completion of the estimated cost field required?

A: Duplicate denials occur when a provider submits more than one claim for the same patient and the claim includes identical information such as date of service, type of service, procedure code, place of service, and billed amount. A claim may be denied as a duplicate when an Automated Development System (ADS) letter regarding a National Provider Identifier (NPI) mismatch has been sent to the provider and the provider resubmits the claim instead of responding promptly to the letter.

Prior to resubmitting any claim, a provider should check the status of the original claim by using the Provider Contact Center’s Interactive Voice Recognition (IVR) system by calling (877) 847-4992. Always allow at least two weeks (10 business days) after submitting a claim before using the IVR to check claim status. This action will prevent unnecessary delays in the processing of claims.

Please note that when a provider resubmits a claim before the original claim has finished processing, the duplicate claim denial may appear on a remittance advice before the finalized original claim does. This is because duplicate claims do not process through the Common Working File (CWF), and therefore are not held on the “payment floor.” The “payment floor” is a Centers for Medicare & Medicaid Services (CMS)-mandated waiting period for payment of clean claims. This waiting period is currently 13 days for Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant Electronic Media Claim (EMC) submissions and 28 days for paper claims, with payment made no sooner than day 14 or 29, as applicable. Many providers mistakenly assume that all clean claims are paid on the payment floor date; however, the payment floor date is actually the earliest day after the day of receipt of the clean claim that payment may be made. The Medicare Part B contractor has up to 30 days to process clean claims without paying interest to the provider. It is also important to note that if a claim stops in the system for any error or development, it is no longer considered a clean claim and may not process within these time frames.

Remember that providers have an obligation under law to conform to the requirements of the Medicare program. Billing that appears to be a deliberate application for duplicate payment for the same services or supplies in an attempt to get paid twice may be considered fraudulent. Providers are responsible for claims submitted to Medicare on their behalf by vendors and/or clearinghouses. Ultimately, Medicare holds the provider of service accountable for duplicate claim submission.

A: Yes, it is a requirement that the total timed code treatment minutes and total treatment time is captured in the treatment encounter notes. However, the amount of time for each specific intervention/modality provided to the patient is not required, as it is indicated in the billing. The billing and the total timed code treatment minutes must be consistent and, in addition, the identification of each specific intervention/modality provided and billed, for both timed and un-timed codes, needs to be recorded.

Example:

How to bill for the above example:

A: The POS codes and definitions can be located in the CMS Internet Only Manual (IOM) Publication 100-04 Medicare Claims Processing Manual, Chapter 26, section 10.5 – Place of Service (POS) codes and definitions on page 19 (http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf ) and in the POS code database on the CMS Place of Service Codes Web page (http://www.cms.hhs.gov/PlaceofServiceCodes/03_POSDatabase.asp ). Please review both documents, as one may be more up to date than the other, due to possible revisions being made.

The POS code should be entered in Item 24B on the CMS-1500 (08/05) claim form.

It is important to ensure you bill the appropriate POS code on all claims to avoid potential overpayments. It is recommended you review your claims and systems for proper billing of the place of service codes. If you use an outside biller or clearinghouse, make sure they are billing all of your claims with the correct place of service code.

Remember: It is your responsibility to ensure your claims are billed correctly.

A: The POS codes entered in Item 24B on the CMS-1500 (08/05) claim form can greatly affect reimbursement.

If services are performed in a facility, billing an incorrect place of service (e.g. an office location) can cause an overpayment situation. Examples of billing errors causing overpayments are providers who service patients in hospital outpatient facilities. Even though the provider’s office is physically located within the department, the services are provided in the facility. The provider should bill a POS code of 22 (Hospital Outpatient), not POS 11 (Office).

The same is true for an Ambulatory Surgical Center (ASC). If the individual provider bills a service rendered during an ASC covered procedure, the service should be billed with POS 24 (ASC facility), not POS 11 (Office). Even though the provider’s actual physical office is located in the ASC, the service was provided in the facility. The rationale is, unlike a group practice or individual’s office, providers operating from facilities have little to no overhead. The facility typically pays the overhead costs. Therefore, billing the facility POS and lower rate is appropriate, as the provider doesn’t incur the facility costs. The facility is reimbursed when billing their services.

If billing an incorrect place of service were to occur on a regular basis, not only can it affect immediate finances, it may be considered program abuse or fraud. If a provider is found guilty of fraud, monetary and civil penalties may be incurred, including but not limited to possible incarceration.

It is important to enter the appropriate POS code on all claims to avoid potential overpayments. It is recommended you review your claims and systems for proper billing of the place of service codes. If using an outside biller or clearinghouse, make sure they are billing all of your claims with the correct place of service code.

Remember: It is your responsibility to ensure your claims are billed correctly.

A: CMS guidelines state that a regular physician may bill for the services of a locum tenens physician provided the following guidelines are met:

Note: If the regular physician requires the services of a locum tenens physician for a period longer than 60 days, then the substitute physician needs to enroll with the group. Otherwise the substitute physician taking a day off is not a consideration in the guidelines for locum tenens for establishing the 60-day period.

A: Billing individual and group NPIs is very similar to the previous process of billing with Provider Identification Numbers (PINs) and group numbers. However, there are distinct differences depending on how you submit claims to Medicare, whether electronic or paper.

Please refer to the chart below for instructions on submitting NPIs on your claims to Medicare:

A: Although CMS doesn’t mandate completion of the estimated cost field, it is in the best interest of the provider and the beneficiary to know the approximate costs. This enables the beneficiary to make an informed decision and should assist the provider when billing the patient if Medicare denies the charges.

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