Billing issues FAQs
Why did I receive a duplicate denial on my remittance advice (ANSI code CO-18) when I have never received payment or denial on the claim? I made a minor mistake on a claim I submitted. Do I need to request an appeal to correct a minor error or omission on a claim? Our claims are being returned as unprocessable, with remark code N34 Incorrect claim form/format for this service. What should we be doing differently? I purchased the technical component (TC) of a diagnostic service. How do I indicate this information when I complete 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? 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?Q: Why did I receive a duplicate denial on my remittance advice (ANSI code CO-18) when I have never received payment or denial on the claim?
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 has been sent to the provider and the provider resubmits the claim, instead of responding promptly to the letter (e.g., regarding a National Provider Identifier (NPI) mismatch).
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: 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 floor is the waiting period for payment of clean claims mandated by the Centers for Medicare & Medicaid Services (CMS). 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 a claim which stops in the system for any error or development is no longer considered a clean claim and may not process within these time frames.
Remember: Providers have an obligation under law to conform to the requirements of the Medicare program. Billing which 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.
(Last Modified 10/23/08)
Sources: CMS Internet-Only Manual (IOM) Publication 100-04 Medicare Claims Processing Manual, Chapter 1, Sections 80.2.1.1 & 80.2.1.2; CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 4, Section 4.2.1.
A: FCSO offers a FREE Web-based training (WBT) course pertaining to duplicate claims.
• To access the Duplicate Claims – Part B WBT, visit our FCSO Medicare Training Web site www.fcsomedicaretraining.com 
. Click here for additional details concerning our FCSO Medicare Training Web site.
. Click here for additional details concerning our FCSO Medicare Training Web site.FCSO also offers FREE educational sessions throughout the year, focused on particular billing issues you may be experiencing. These may include webcasts or seminars on avoiding duplicate claims for Part B.
(Last modified 11/17/08)
Source: Top Part B Denials data for August & September 2008
Q: I made a minor mistake on a claim I submitted. Do I need to request an appeal to correct a minor error or omission on a claim?
A: No, you do not have to request an appeal to correct a minor error or omission. A clerical error reopening can be initiated via the telephone or in writing. In many cases, the denied service(s) can simply be resubmitted.
Note: An enhancement is now available on the Part B Interactive Voice Response unit (IVR). This enhancement allows you to request a single-line clerical reopening of certain claims without contacting customer service. Click here for additional details.
(Last modified 11/26/08)
Source: Medicare Customer Service and Appeals Center
A: Frequently asked questions (FAQs) that directly address coding issues are posted to this Web site at: http://www.floridamedicare.com/Part_B/FAQs/index.asp.
• Upon accessing this link, separate categories will be listed, many of which address proper use of codes pertaining to a variety of billing scenarios.
Note: FAQs are also posted to the CMS Web site at http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php 
. Using the search function will allow you to narrow your search to coding issues.
. Using the search function will allow you to narrow your search to coding issues.FCSO Medicare provider Web site; CMS Web site
A: The FCSO Medicare training Web site has multiple FREE online learning/Web-based training (WBT) modules, one of which is titled “Introduction to Global Surgery.” This site can be reached at www.fcsomedicaretraining.com .
.Information regarding global surgery is also available in the CMS Internet-only manual (IOM) Publication 100-04, Chapter 12, Section 40 (http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf 
).
).(Last Modified 11/05/08)
FCSO online learning; CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Section 40
(Last Modified 11/05/08)
Q: Our claims are being returned as unprocessable, with remark code N34 Incorrect claim form/format for this service. What should we be doing differently?
A: Your claims contain inconsistently-formatted dates, which will cause claims to be returned as unprocessable with remark code N34.
All dates indicated in the Physician/Supplier Information section of a claim must be either in a 6-digit (MM|DD|YY) or 8-digit (MM|DD|CCYY) format. Dates appearing in items 14 (Date of Current Illness, Injury, Pregnancy), 16 (Dates Patient is Unable to Work in Current Occupation), 19 (Narrative or Comment field), and 24A (Date(s) of Service), or the electronic equivalents, must be consistent in their format. Consistency must be maintained throughout the entire claim to avoid an unprocessable return.
• Example: A 6-digit date in the Date of Current Illness field and an 8-digit date in the Date of Service field would result in an unprocessable claim.
Review your office protocol for reporting date(s) and ensure that all of your claims are submitted either with 6-digit or 8-digit dates throughout.
For more information regarding CMS-1500 claim requirements, refer to the CMS-1500 FAQs.
Useful Tips
• Before submitting claims, perform a quality check to ensure all dates appear in the same format.
• Take our FREE Web-based training course on Unprocessable Claims – Part B through our provider training Web site www.fcsomedicaretraining.com 
.
.(Last modified 10/23/08)
Source: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 26, Sections 10 & 10.4
Q: I purchased the technical component (TC) of a diagnostic service. How do I indicate this information when I complete the claim?
A: Providers purchasing the TC or interpretation (PC) of certain diagnostic tests from a separate entity would submit a separate claim for the purchased service.
First, complete the outside lab information (Item 20 or the electronic equivalent) for all purchased diagnostic services, indicating the amount that was paid for the service.
Next, enter the address of the location where the service was actually rendered in the service facility location information area (paper claim form Item 32 or electronic equivalent) and indicate the NPI of the provider who actually rendered the service in the service facility location ID area (Item 32a or electronic equivalent). For Medicare’s purposes, Item 32a is used only when reporting purchased diagnostic tests (PDT) or interpretations.
Points to remember for all PDT service claims:
• An NPI is required for all PDT claims.
• If an NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in Item 32b or electronic equivalent), claims will be returned as unprocessable.
• Note: The NPI should not be reported for providers outside the local jurisdiction (Florida). Instead, the purchasing provider would report their own NPI. The NPI is still reported for providers rendering PDT services within the state.
• Example: If you purchase services performed in a facility in Boca Raton, you would report the Boca Raton provider’s address and NPI. If you purchase a diagnostic service from a mobile provider out of Georgia, you report the physical location where services were performed and your NPI, since the mobile provider is outside of Florida.
• Do not complete Item 32b. If any information is entered, the claim will be rejected or returned as unprocessable.
• Refer to the CMS-1500 FAQ regarding service facility location information (item 32) for additional completion details.
Note: Since only one address can be billed per claim, do not include the PC on a claim with a purchased TC or vice versa. Failure to submit a separate claim for each component will result in the claim being returned as unprocessable.
(Last Modified 10/15/08)
Source: CMS IOM Pub. 100-04, Chapter 1, Section 30.2.9; Ch. 13, Section 20.2.4; Ch. 26 Section 10.4; CR 5543 - Implementation of Carrier Jurisdictional Pricing Rules for All Purchased Diagnostic Service Claims; CR 5858 – Medicare Fee For Service Legacy Provider IDs Prohibited on Form CMS-1500 and Form CMS-1450 (UB-04) Claims; CR 6093 – Reporting National Provider Identifiers (NPI) for Secondary Providers
Q: For therapy services, should the treatment encounter notes capture total timed code treatment minutes and total treatment time?
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:
18 minutes of therapeutic exercise (97110)
13 minutes of manual therapy (97140)
10 minutes of gait training (97116)
8 minutes of ultrasound (97035)
13 minutes of manual therapy (97140)
10 minutes of gait training (97116)
8 minutes of ultrasound (97035)
Total treatment time: 49 minutes.
How to bill for the above example:
Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of time units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed). You should still document the ultrasound in the treatment notes.
(Last Modified 2/27/08)
Source: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 5, Section 20.2
Source: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 5, Section 20.2
Q: 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 claim form?
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.
) 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.
(Last Modified 09/23/08)
Source: CMS IOM Pub. 100-04, Chapter 26, Sections 10.4 & 10.5; CMS Place of Service Code Database.
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.
(Last Modified 09/23/08)
Source: CMS IOM Pub. 100-04, Chapter 26, Sections 10.4 & 10.5; CMS IOM Pub. 100-08, Chapter 4, Sections 4.2 & 4.6.2; CMS Place of Service Code Database.
Q: After the 60-day period, can the locum tenens physician take a day off and the 60-day period begin again?
A: CMS guidelines state that a regular physician may bill for the services of a locum tenens physician provided the following guidelines are met:
1. The regular physician is unable to provide visit services
2. The Medicare beneficiary has arranged for or seeks to receive services from the regular physician
3. The regular physician pays the locum tenens for services on a per diem or similar fee-for-time basis
4. The substitute physician does not provide services over a continuous period longer than 60 days.
• The only exception to the 60-day limit on substitute physician billing is for physicians called to active duty in the Armed Forces for services furnished from January 1, 2008 through June 30, 2008. Under section 116 of the “Medicare, Medicaid, and SCHIP Extension Act of 2007” (MMSE), enacted on December 29, 2007, a physician called to active duty may bill for substitute physician services from January 1, 2008 through June 30, 2008 for longer than the 60-day limit.
5. The Q6 modifier should be submitted on the claim
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.
(Last Modified 09/23/08)
Source: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, Section 30.2.11
Q: I am a physician or non-physician practitioner employed by a group and also maintaining a private practice. How is my National Provider Identifier (NPI) number reported differently on a claim when billing as an individual versus billing as part of a group?
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:
Claims submitted on or after January 2, 2007
Type of Claim |
Submission Method |
NPI Billing Instructions |
|---|---|---|
Individual/Solo Practice |
Paper |
Individual NPI is placed in Item 33a of the CMS-1500 (08/05). |
Individual/Solo Practice |
Electronic |
The individual NPI number should be submitted in the billing provider loop (2010AA, NM109 with an XX qualifier in the NM108 element). |
Group |
Paper |
Individual NPI is placed in the lower portion of Item 24J and group NPI is placed in Item 33a of the CMS-1500 (08/05). |
Group |
Electronic |
The group NPI number should be submitted in the billing provider loop (2010AA, NM109 with an XX qualifier in the NM108 element) and the individual NPI number should be submitted in the rendering provider loop (2310B, NM109 with an XX qualifier in the NM108 element). |
(Last Modified 09/23/08)
Source: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 26, Section 10.4; HIPAA ASC X12N 837 Professional guide – 4010/4010A Part B flat file; CMS Medicare Learning Network (MLN) Special Edition Article SE 0725
Q: On the Advance Beneficiary Notice (ABN) form, is the completion of the estimated cost field required?
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.
(Last Modified 9/27/07)
Source: CMS IOM Pub. 100-04, Chapter 30, Section 50.5.7
