Top 10 Phone Inquiries FAQs

Home MAC Provider Self-Service FAQs

WPS Medicare is pleased to publish FAQs based upon topics we have identified as those generating a high volume of telephone inquiries to Customer Service. The following table lists ten reasons (by topic) our Medicare providers and their agents telephoned our call centers during September 2008.

September

Top 10 Reason Codes for Iowa, Kansas, Missouri, and Nebraska:
September 2008

(Excluding Claim Status and Eligibility Issues)

Description	Occurrences
Coding Errors/Modifiers	2,575
Duplicate Claim Denials	1,922
Address/Phone/Fax/Web Address	1,835
Appeals: Status/Explanation/Resolution	1,811
Claim Denials – General	1,474
Medicare Secondary Payer (MSP)	1,371
Payment Calculation/Explanation	1,205
Contractual Obligation Not Met	865
Claim Overlap	858
CMS 1500 Claim Form	665

WPS Medicare publishes FAQs specifically developed to address Top 10 Inquiry Reasons from the previous months' reporting period. We hope the answers to the questions listed below assist you in reducing claims errors associated with these topics.

FAQs developed to address Top 10 Inquiry Topics:

Each month, WPS Medicare publishes Frequently Asked Questions (FAQs) we specifically develop to address Top 10 Inquiry Reasons. We hope the answers to the FAQs listed below assist you in reducing claims errors associated with these topics.

Global Surgery Period

1. What is the definition of the global surgery period? When does the global period begin for major and minor surgery? (11/24/08)

Hospital Discharge

1. If a provider is covering for another physician, and the other physician's patient is discharged, can a claim be submitted for a Hospital Discharge Day Management Service for the final visit? (11/24/08)

Routine Foot Care

1. Are routine foot care services ever covered by Medicare? Please elaborate. (11/24/08)

Emergency Room Services for Critical Care Patients

1. Can a provider bill an emergency room visit on the same date that they provide critical care to the same patient? (11/24/08)

August

Medically Unlikely Edits (MUEs)

1. What resources are available to providers related to Medically Unlikely Edits (MUEs)? (10/13/08)

National Disasters: Hurricanes

1. Where can I find questions and answers regarding hurricanes, and other national disasters that may affect the delivery of healthcare and Medicare? (10/13/08)

Physician Quality Reporting Initiative (PQRI)

1. How do I get my report for the PQRI bonus payment? (10/13/08)

July

CLIA Waived Tests, QW Modifier

1. Do all lab codes require a QW Modifier? (10/13/08)

Physician Quality Reporting Initiative (PQRI) Bonus, Bonus Check

1. What if a provider doesn't agree with the amount of the bonus payment shown on the 2007 PQRI CMS report? (10/13/08)

Co-surgery/Co-surgeons

1. Does Medicare pay for co-surgeons? Why would a co-surgery claim deny? (10/13/08)

June

National Provider Identifier (NPI)

1. I tried to use the Interactive Voice Response (IVR) and was unable to obtain any information, because my NPI and PTAN numbers did not match. I'm using the group PTAN and the individual NPI and they are linked. Why would I receive this message? (08/11/08)
2. Why are my claims denying for the billing provider? We only have one doctor. (08/11/08)

Modifiers

1. I am receiving a denial of "invalid procedure code/modifier combination" on my claim. I billed an Evaluation and Management (E/M) code with a 78 modifier. Why would this deny? (08/11/08)

Submitted to Incorrect Program

1. Why are my claims denying for another contractor? (08/11/08)

May

Medicare Secondary Payer (MSP)

1. My electronic claim denied stating that other insurance was primary over Medicare; however, I included the primary insurance allowed and paid amounts on the claim. Why would it deny? (06/30/08)

Modifiers

1. Why has my claim rejected? The remittance advice states that the reimbursement for this service is included in another payment. (06/30/08)

Appeals Process/Rights

1. If Medicare denies a redetermination request, what is the next step to further appeal the decision? (06/30/08)

Submitted to Incorrect Program

1. Why are my claims being denied by another contractor? How could I have known this would happen? (06/30/08)

April

CMS 1500 Claim Form

1. Can you direct me on how to fill out my CMS 1500 claim form? I am receiving denials related to where I enter my provider information. (06/23/08)

Appeals: Status/Explanation/Resolution

1. I submitted a written redetermination request to Medicare several weeks ago. The Interactive Voice Response (IVR) system is not providing me with a status of this request. How can I verify the status of my appeal, and how long should I wait for a response? (06/23/08)

Address/Phone/Fax/Web Address

1. I have an old phone number for the former Medicare B contractor in my state. However, my state was transitioned to a Medicare Administrative Contractor (MAC) earlier this year. When I call, a message at the old number tells me the number is disconnected. How can I get the correct phone numbers and addresses for WPS, the new Medicare Administrative Contractor for my jurisdiction? (06/23/08)

Payment Explanation/Calculation

1. Why does Medicare pay less than the fee schedule amount when a patient is being treated for a mental health illness? (06/23/08)

March

Coding Errors/Modifiers

1. Why is my claim for an Evaluation and Management (E/M) visit denied as bundled into another procedure, when I have billed the 25 modifier on the claim, which is needed since a surgery was performed on the same day as the E/M visit? (05/19/08)

CMS 1500 Claim Form Item

1. How do I report an NPI on a CMS-1500 claim form when the provider is a sole practitioner? (05/19/08)

Appeals Process/Rights

1. If Medicare denies a service, do I have any appeal rights and, if so, what is the process to file an appeal? (05/19/08)

Payment Explanation/Calculation

1. Why was my claim paid at a lower amount for surgery than what the fee schedule indicates is appropriate? (05/19/08)

February

Coding Errors/Modifiers

1. Why is my claim for an Evaluation and Management (E/M) visit denied as bundled into another procedure, when I have billed the 25 modifier on the claim, which is needed since a surgery was performed on the same day as the E/M visit? (05/09/08)

CMS 1500 Claim Form Item

1. How do I report an NPI on a CMS-1500 claim form when the provider is a sole practitioner? (05/09/08)

Appeals Process/Rights

1. If Medicare denies a service, do I have any appeal rights and, if so, what is the process to file an appeal? (05/09/08)

Provider Information

1. Why was my claim returned indicating an incorrect primary identifier? (05/09/08)

Medicare Secondary Payer (MSP)

1. My claim denied stating that the patient has other primary insurance; however, when I checked eligibility on the IVR it stated that Medicare is primary. Why is my claim being denied? (05/09/08)

Payment Explanation/Calculation

1. Why was the reimbursement for the claim I submitted reduced? (05/09/08)

February

Coding Errors/Modifiers

1.	Why is my claim for an Evaluation and Management (E/M) visit denied as bundled into another procedure, when I have billed the 25 modifier on the claim, which is needed since a surgery was performed on the same day as the E/M visit?
	The E/M service may be in the global period of another procedure. If the E/M service is unrelated to the previous procedure and significant, separately identifiable from the procedure performed on the same day both Modifier 24 and 25 may be necessary. The 24 modifier is appropriate if the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is also needed to identify that the E/M services is significant, separately identifiable from the minor surgery/procedure performed on the same day. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/mac/ education/global_surgery.pdf Posted (05/09/08)

CMS 1500 Claim Form Item

2.	How do I report an NPI on a CMS-1500 claim form when the provider is a sole practitioner?
	A sole practitioner should enter their NPI in box 33-a. This is different from a provider who is a member of a group. Providers who are members of a group must enter their individual NPI in box 24-j, and the group NPI in box 33-a You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/manuals/ downloads/clm104c26.pdf Posted (05/09/08)

Appeals Process/Rights

3.	If Medicare denies a service, do I have any appeal rights and, if so, what is the process to file an appeal?
	Part B providers and beneficiaries have 120 days to file a request for a redetermination from the date of receipt of the remittance notice or Medicare Summary Notice (MSN). This is the first level of appeal conducted by Medicare contractors, and it must be done in writing. If a claim was returned as unprocessable, a new claim should be submitted with additional or corrected information. A redetermination cannot be performed on unprocessable claims. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/OrgMedFFSAppeals/ Posted (05/09/08)

Provider Information

4.	Why was my claim returned indicating an incorrect primary identifier?
	Reference to the primary identifier usually means that you are billing something incorrectly regarding the billing/individual provider (number), in CMS 1500 claim form box 33-a, or box 24-j. This would indicate the Provider Transaction Access Number (PTAN) or NPI of the group or the individual performing provider. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/manuals/ downloads/clm104c26.pdf Posted (05/09/08)

Medicare Secondary Payer (MSP)

5.	My claim denied stating that the patient has other primary insurance; however, when I checked eligibility on the IVR it stated that Medicare is primary. Why is my claim being denied?
	Often times an MSP record is updated by the Coordination of Benefits Contractor (COBC) after a claim has been submitted and denied by Medicare. If you have verified that the records are updated to reflect Medicare as primary on the date of the denied service, then a new claim can be resubmitted. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/Provider Services/01_overview.asp Posted (05/09/08)

Payment Explanation/Calculation

6.	Why was the reimbursement for the claim I submitted reduced?
	There are several reasons whereby reimbursement levels can be reduced. For example, payments can be reduced based upon multiple surgery guidelines, when a secondary surgical procedure is billed with a "51" modifier. For surgical procedures which are appropriately billed as secondary, the reimbursement level is reduced to 50 percent of what that procedure would approve were it to be performed by itself. Similarly, an Evaluation and Management Code (E/M) billed the day of or the day before surgery is usually considered part of the surgical package, and reimbursement for it may be included in the reimbursement for the surgery itself. The Medicare Physician Fee Schedule Database (MPFSDB) offers additional information regarding this process. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/Transmittals/ Downloads/R28CP.pdf Posted (05/09/08)

March

Coding Errors/Modifiers

1.	Why is my claim for an Evaluation and Management (E/M) visit denied as bundled into another procedure, when I have billed the 25 modifier on the claim, which is needed since a surgery was performed on the same day as the E/M visit?
	The E/M service may be in the global period of another procedure. If the E/M service is unrelated to the previous procedure and significant, separately identifiable from the procedure performed on the same day both Modifier 24 and 25 may be necessary. The 24 modifier is appropriate if the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is also needed to identify that the E/M services is significant, separately identifiable from the minor surgery/procedure performed on the same day. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/mac/ education/global_surgery.pdf Posted (05/19/08)

CMS 1500 Claim Form Item

2.	How do I report an NPI on a CMS-1500 claim form when the provider is a sole practitioner?
	A sole practitioner should enter their NPI in item 33A. This is different from a provider who is a member of a group. Providers who are members of a group must enter their individual NPI in item 24J and the group NPI in item 33A. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf Posted (05/19/08)

Appeals Process/Rights

3.	If Medicare denies a service, do I have any appeal rights and, if so, what is the process to file an appeal?
	Part B providers and beneficiaries have 120 days to file a request for a redetermination from the date of receipt of the remittance notice or Medicare Summary Notice (MSN). This is the first level of appeal conducted by Medicare contractors, and it must be done in writing. If a claim was returned as unprocessable, a new claim should be submitted with additional or corrected information. A redetermination cannot be performed on unprocessable claims. You may find additional information on this topic at the following Websites: http://www.wpsmedicare.com/mac/business/b_appeal.pdf and at http://www.cms.hhs.gov/OrgMedFFSAppeals/ Posted (05/19/08)

Payment Explanation/Calculation

4.	Why was my claim paid at a lower amount for surgery than what the fee schedule indicates is appropriate?
	Based on the combination of codes you are billing, the reduction was most likely based upon multiple surgery guidelines. These guidelines reduce Medicare's reimbursement for secondary and additional procedures in most instances where multiple surgical procedures are performed during the same operative session. Posted (05/19/08)

April

CMS 1500 Claim Form

1.	Can you direct me on how to fill out my CMS 1500 claim form? I am receiving denials related to where I enter my provider information.
	Please go to the WPS Website, and click on the link entitled Medicare Areas, at http://www.wpsmedicare.com/mac/business/b_claims.shtml The second item from the top will take you to the CMS Manual instructions for completing the CMS 1500 Claim Form. You may access this information directly in a pdf format at the CMS Website: http://www.cms.hhs.gov/manuals/downloads /clm104c26.pdf Posted (06/23/08)

Appeals: Status/Explanation/Resolution

2.	I submitted a written redetermination request to Medicare several weeks ago. The Interactive Voice Response (IVR) system is not providing me with a status of this request. How can I verify the status of my appeal, and how long should I wait for a response?
	The IVR will not provide status of a written redetermination. You can contact the Provider Call Center (PCC) for your state to obtain status of your appeal; however; the carrier will generally issue a decision (either in a letter or a revised remittance advice) within 60 days of receipt of the redetermination request. Therefore, please allow 60 days before contacting the PCC for status. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/OrgMedFFSAppeals/ Posted (06/23/08)

Address/Phone/Fax/Web Address

3.	I have an old phone number for the former Medicare B contractor in my state. However, my state was transitioned to a Medicare Administrative Contractor (MAC) earlier this year. When I call, a message at the old number tells me the number is disconnected. How can I get the correct phone numbers and addresses for WPS, the new Medicare Administrative Contractor for my jurisdiction?
	You can go to the WPS website. It has all the phone numbers, billing addresses and fax numbers. The address is http://www.wpsmedicare.com/mac/selfservice/ contact_info.shtml Once there, you should find all the contact information you will need. Posted (06/23/08)

Payment Explanation/Calculation

4.	Why does Medicare pay less than the fee schedule amount when a patient is being treated for a mental health illness?
	Mental health services that are furnished by a physician or any other health care practitioner (i.e., CP, CSW, PA, etc.) to an individual who is not a hospital inpatient are limited to 62.5 percent of the Medicare-allowed amount. This limitation applies to mental health services furnished to a person in a physician's office, in the patient's home, in a skilled nursing facility, outpatient facility and so forth. Posted (06/23/08)

May

Medicare Secondary Payer (MSP)

1.	My electronic claim denied stating that other insurance was primary over Medicare; however, I included the primary insurance allowed and paid amounts on the claim. Why would it deny?
	This denial occurs on electronic Medicare Secondary Payer (MSP) claims if the paid amounts and the adjusted amounts by the primary payer do not equal the billed amounts, or if the claim lacks standard claim adjustment reason codes to identify adjustments. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/publications/msp_balance_faq.shtml Posted (06/30/08)

Modifiers

2.	Why has my claim rejected? The remittance advice states that the reimbursement for this service is included in another payment.
	Your service rejected as being part of another service your provider rendered. It may be included in the post-operative period of a surgical procedure, or it may be subject to the National Correct Coding Initiative. Depending upon the situation, it may need a modifier to pay correctly. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/education/modifiers.shtml Posted (06/30/08)

Appeals Process/Rights

3.	If Medicare denies a redetermination request, what is the next step to further appeal the decision?
	The next level or second level of appeal is a reconsideration by a Qualified Independent Contractor (QIC). You may find additional information on this topic at the following Websites: http://www.cms.hhs.gov/OrgMedFFSAppeals/ http://www.wpsmedicare.com/part_b/business/appeals.shtml Posted (06/30/08)

Submitted to Incorrect Program

4.	Why are my claims being denied by another contractor? How could I have known this would happen?
	The code you are billing does not identify a service or supply for a Medicare claim processed in our office, as it does not fall within our jurisdiction. In order to obtain additional information about the processing of this supply, you should contact your Durable Medical Equipment (DME) contractor. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/center/dme.asp Posted (06/30/08)

June

National Provider Identifier (NPI)

1.	I tried to use the Interactive Voice Response (IVR) and was unable to obtain any information, because my NPI and PTAN numbers did not match. I'm using the group PTAN and the individual NPI and they are linked. Why would I receive this message?
	When accessing the IVR system, you will need to use either the group or corporation PTAN and group or corporation NPI, or the Individual providers PTAN and Individual providers' NPI. You cannot use a combination of group and individual NPI and PTAN numbers. You may find additional information on this topic at the following Web addresses: http://www.wpsmedicare.com/mac/transition/ivr.pdf http://www.cms.hhs.gov/nationalprovidentstand/ Posted (08/11/08)
2.	Why are my claims denying for the billing provider? We only have one doctor.
	Although, according to your provider files, you have only one doctor; he has changed his billing status by incorporating his office. He is currently filing under a Federal Tax ID number and, as such, has two NPI numbers, one for him and one for his office. This change from individual status requires that both his provider NPI and his corporation NPI be used when billing Medicare. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/nationalprovidentstand/ Posted (08/11/08)

Modifiers

1.	I am receiving a denial of "invalid procedure code/modifier combination" on my claim. I billed an Evaluation and Management (E/M) code with a 78 modifier. Why would this deny?
	A 78 modifier is used with surgery procedure codes only. It is not appropriate to use on the E/M code. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/mac/education/78.pdf Posted (08/11/08)

Submitted to Incorrect Program

1.	Why are my claims denying for another contractor?
	You are submitting claims that have a Medicare number which begins with an Alpha character, which means they do not fall within traditional Medicare jurisdiction. You should be submitting your claims to the Railroad Medicare contractor. Claims for Railroad Retirement beneficiaries should be filed to: Palmetto GBA, Railroad Medicare, P.O. Box 10066, Augusta, GA 30999 You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/Transmittals/Downloads/R72CP.pdf Posted (08/11/08)

July

CLIA Waived Tests, QW Modifier

1.	Do all lab codes require a QW modifier?
	No. Not all codes require a QW modifier. You can view which codes require a modifier on the CMS Website. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/CLIA/downloads/waivetbl.pdf Posted (10/13/08)

Physician Quality Reporting Initiative (PQRI) Bonus, Bonus Check

1.	What if a provider doesn't agree with the amount of the bonus payment shown on the 2007 PQRI CMS report?
	The PQRI bonus payment is 1.5% of the allowed charges for professional services. CMS based the amount on charges for dates of services 7/1/07 through 12/31/07 processed prior to 2/29/08, and paid under the Physician Fee Schedule. Amounts paid based on other types of payment methods are not part of the calculation (lab fee schedule, anesthesia, etc.). Providers cannot appeal the bonus payment. CMS worked with an outside contractor to determine the amounts. CMS published specific information on the calculation of the bonus amounts on the following Web page: http://www.cms.hhs.gov/pqri/downloads/ PQRIIncentivePayment.pdf Posted (10/13/08)

Co-surgery/Co-surgeons

1.	Does Medicare pay for co-surgeons? Why would a co-surgery claim deny?
	The data found in the Medicare Physicians Fee Schedule Database (MPFSDB) addresses billing guidelines such as co-surgery. Providers append modifier "62" to these services, when appropriate and allowed. Additional documentation is needed for Medicare to make a payment determination, when a surgical procedure code listed on the MPFSDB has a co-surgeon indicator of "1." You may find more on the Medicare Physician Fee Schedule Database (MPFSDB) at the following Website: http://www.cms.hhs.gov/PhysicianFeeSched/01_overview.asp Posted (10/13/08)

August

Medically Unlikely Edits (MUEs)

1.	What resources are available to providers related to Medically Unlikely Edits (MUEs)?
	Anyone with questions concerning MUEs may go to the following link on the CMS Website: http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp Any MUE values that are releasable to the provider community are contained at this site, as well as links to helpful FAQs pertaining to MUEs. Posted (10/13/08)

National Disasters: Hurricanes

1.	Where can I find questions and answers regarding hurricanes, and other national disasters that may affect the delivery of healthcare and Medicare?
	During the recent hurricane season, CMS posted a Question and Answer (Q&A) document to their Website, which they updated frequently. The most recently updated Q&As are available at the following link: http://www.cms.hhs.gov/Emergency/Downloads/ GustavMasterQsAs_100308.pdf You may find additional information on the main page for hurricane-related information at the following Website: http://www.cms.hhs.gov/Emergency/02_Hurricanes.asp Posted (10/13/08)

Physician Quality Reporting Initiative (PQRI)

1.	How do I get my report for the PQRI bonus payment?
	Providers can call 1-866-484-8049. At this number, they can get help to get set up to pull their report and for technical support as well. There are also two MLN Matters Articles, SE0747 and SE0753, that address PQRI. The report shows the number of paid claims submitted through the National Claims History File. You can access your Remittance Advices for the reporting period to determine if you believe you submitted codes we did not receive. The following link to the PQRI Feedback Reports Job Aid is meant to be a helpful guide to respond to and refer inquiries regarding PQRI feedback reports, when appropriate: http://www.cms.hhs.gov/ContractorLearningResources /downloads/JA080608.pdf Posted (10/13/08)

September

Global Surgery Period

1.	What is the definition of the global surgery period? When does the global period begin for major and minor surgery?
	The global surgery period includes preoperative visits after the decision is made to operate. To determine the global period for major surgeries, carriers count one day immediately before the day of surgery, the day of surgery and the 90 days immediately following the day of surgery. For minor surgery, carriers do not allow separate payment for preoperative visits on the day of surgery and do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to the recovery of the procedure. Carriers do not allow separate payment for preoperative visits on the day of surgery ("0 days") and do not allow separate payment for postoperative visits on the day of the procedure. You may find additional information regarding this topic and the application of modifiers to address various global surgery scenarios at the following address: http://www.wpsmedicare.com/mac/education/global_surgery.pdf Posted (11/24/08)

Hospital Discharge

1.	If a provider is covering for another physician, and the other physician's patient is discharged, can a claim be submitted for a Hospital Discharge Day Management Service for the final visit?
	Yes, if the provider is acting on behalf of the attending physician of record this code can be billed for the final visit and have met the code requirements. You may find information on this topic at the following Website: http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm5794.pdf Posted (11/24/08)

Routine Foot Care

1.	Are routine foot care services ever covered by Medicare? Please elaborate.
	Yes, foot care services that are normally considered routine may be covered under two circumstances: When the beneficiary has a systemic condition, which results in severe circulatory problems, where foot or nail care procedures performed by a non-professional may be detrimental to the health of the beneficiary. When there is clinical evidence of mycosis of the nails and the beneficiary’s symptoms include ambulation limitations, pain or secondary infection resulting from the mycotic infection. You may find additional information regarding this topic at the following address: http://www.wpsmedicare.com/mac/education/b_type_footcare.pdf Posted (11/24/08)

Emergency Room Services for Critical Care Patients

1.	Can a provider bill an emergency room visit on the same date that they provide critical care to the same patient?
	No. Hospital emergency department services are not payable for the same date as critical care services when provided by the same physician to the same patient. You may find additional information regarding billing emergency room visits, critical care visits, and other evaluation and management (E/M) services at the following address: http://www.wpsmedicare.com/mac/education/b_type_em_qa.pdf Posted (11/24/08)

Page Last Updated: Wednesday, 31-Dec-2008 10:48:41 CST