WPS Medicare Provider Part A - Medicare Areas - Claims

All items and nonphysician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of whether they are subject to PPS. Therefore, your services will need to be billed directly to the hospital where the patient was an inpatient.

As a way of reducing the amount of cancels being done by CWF, WPS Medicare suggests that providers create a discharge checklist that will specifically require the physician to indicate if the patient was discharged to a SNF. This will allow you to bill claims with the correct patient status of 03.

You will have to call the correction line and verify our beneficiary header matches CWF records. If records match the provider will need to contact the beneficiary to verify their information. If records do not match, have the correction line update our records to match CWF. You will have to re-submit your claim after the corrections are made.

If the dates of incarceration (INCR) on the Common Working File (CWF) are incorrect, you will have to contact the State Department of Corrections to verify the actual dates.

If the information is not updated on CWF, then you will need to contact the CMS Regional Office (RO) in their region (CR 3872, Transmittal 648 issued 8/12/05).

Please use the following link to determine the appropriate region and phone number:
http://www.cms.hhs.gov/about/
regions/professionals.asp

Once CWF has been updated to show the correct incarceration dates the RO will notify our office. At that time we will initiate the reprocessing of all claims that were impacted as a result of the incorrect incarceration dates.

The POA indicator is required only on inpatient Acute Care claims. There was an issue with outpatient claims editing incorrectly at one point in time, but this was corrected on 03/03/08. Claims that returned to providers incorrectly can now be stored (PF9) in the Fiscal Intermediary Standard System (FISS). Outpatient claims should not edit for a POA indicator.

No, there is no provider action needed. Status location WW404 is a temporary quarterly release hold. WPS Medicare will release these claims once the release is implemented.

The POA indicator is required only on inpatient acute care claims. There was an issue with outpatient claims editing incorrectly at one point in time, but this was corrected on 03/03/08. Claims that returned to providers incorrectly can now be stored (PF9) the Fiscal Intermediary Standard System (FISS). Outpatient claims should not edit for a POA indicator.

This claim is lacking a valid procedure code. Please submit a valid procedure code that corresponds with the device code.

Providers should check the National Correct Coding Initiative (NCCI) documentation on CMS' Website to see if the procedures can be billed together utilizing modifier 59. If the 59 modifier is appropriate, you may submit the claim with modifier 59. For more information, go to http://www.cms.hhs.gov/NationalCorrectCodInitEd/
NCCIEHOPPS/list.asp .

When a patient's condition prevents them from being admitted to the Skilled Nursing Facility (SNF) within 30 days, providers should bill the claim with Condition Code "56." This indicates that the admission was delayed more than 30 days because the patient's condition made it inappropriate to begin active care within that period. The original 3-day qualifying hospital stay must be included on the claim in the occurrence span code section.

For more information, please refer to the Internet Online Manual (IOM) 100-4, Chapter 6, Section 40.3.2 http://www.cms.hhs.gov/manuals/
downloads/clm104c06.pdf

The 2008 Therapy Physician Fee Schedule is located on the WPS Website under "Fees."

Go to http://www.wpsmedicare.com/part_a/index.shtml
Click on "Fees"
Choose "Therapy"
Search for your state
Select the year 2008

Yes, providers are required to submit claims to traditional Medicare to utilize the Benefit Days on Common Working File (CWF). Please see Change Request 5653 for instructions on how to submit claims to your Fiscal Intermediary (FI). For more information, go to
http://www.cms.hhs.gov/Transmittals/
Downloads/R1290CP.pdf .

The current regulations for outpatient therapy services, as listed in the Internet-Only Manual (IOM) Publication 100-2, Chapter 15, Section 220.1.3, state that certification/recertification needs to be performed every 30 days. We are aware however that the Federal Regulations changed this effective January 1, 2008 to every 90 days with amendments listed in sections 409.17 and 409.23, which are effective July 1, 2008. We encourage providers to continue to follow the current CMS regulations until the time that regulatory changes take effect. For more information, refer to the CMS online manual at http://www.cms.hhs.gov/manuals/
Downloads/bp102c15.pdf .

No, an appeal would not be necessary. Providers should submit a hardcopy adjustment request with the updated diagnosis codes. Hardcopy requests should be sent to:
WPS Medicare
P.O. Box 1601
Omaha, NE 68101

You will need to contact the SNF to have them adjust their claim to change the patient status to 02. Once this has been done, your claim should process.

I have a claim that is editing with reason code 31715 stating that it is in excess of the medically reasonable daily allowable frequency. How do I get this claim to process?
CMS established units of service edits referred to as Medically Unlikely Edits (MUEs). An MUE is defined as an edit that tests claim lines for the same beneficiary, HCPCS code, date of service, and billing provider against a criteria number of units of service. Providers should determine why the claim was returned, correct the error, and resubmit the corrected claim if appropriate.

Go to http://www.cms.hhs.gov/
Click on "Outreach and Education"
Under "MLN" click on "MLN Matters Articles"
Click on "2007 MLN Matters Articles"
Go to "MLN 5603" http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5603.pdf

I billed a claim with HCPCS code 62290. The claim denied with reason code W7027 stating that only incidental services were reported. Why won't this claim reimburse?
HCPCS code 62290 has a status indicator of an "N" in the Federal Register. There is no separate payment for incidental services; the payment is packaged into the payment for other services.

Does Medicare allow providers to discount or waive the deductible or coinsurance charged to the beneficiary?
Yes, but providers should never automatically waive the coinsurance/deductible amounts without attempting to collect from the beneficiary first. The provider must be making reasonable attempts to receive the payment from the beneficiary before automatically waiving the amount due from the patient. To be considered a reasonable collection effort, the effort to collect Medicare coinsurance/deductible amounts must be similar to the effort made to collect comparable amounts from non-Medicare patients.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 23
Scroll down or search for Section 80.8.1

http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf

Several of our inpatient SNF claims denied for Ban on Admissions. We have received a letter from the Department of Health and Human Services stating that we are no longer on a Ban. What do we do to obtain reimbursement on these claims?
In order to obtain reimbursement on claims, the provider file will have to be updated. Please mail or fax in the letter from Health and Human Services stating the provider is no longer on a Ban. Send the request attention to the Medicare Claims Supervisor(s). If the documentation is valid, the Claims department will have the claims adjusted for payment.

We have several claims that denied for exceeding the therapy cap limit. These claims were billed appropriately with the KX modifier. Why did these claims reject?
WPS Medicare is aware of an issue where some revenue lines that contain a "KX" modifier received a line level rejection of V8022 and/or V8024 and/or a claim rejection of 10417. Our System Maintainer has been advised of this issue and is actively working on a fix. Until we receive this fix, we have an internal resolution in place. You do not need to notify our office of claims that have been affected by this issue. We are able to identify the impacted claims on an ongoing basis and they will be adjusted internally to ensure proper processing.

More information is available within the News article entitled "Some Charges Billed with the "KX" Modifier Have Been Rejected in Error"

Is there any information on wound care billing for skilled nursing facilities (SNF)?
Information regarding wound care billing for skilled nursing facilities can be found in a Local Coverage Determination (LCD) on WPS Medicare's Website http://www.wpsmedicare.com/

Choose "Policy/Coverage" from the top navigation bar
Select Local Coverage
Select the policy entitled "Wound Care"

On the UB-92 we had to report the number of covered days under Form Locator 7. Do we have to report this on the UB-04?
No, Form Locator 7 on the UB-92 has been deleted and is not reported on the UB-04 claim form. You should be using Value Code 80 to represent the number of covered days.

For additional information, please review the Medicare Claims Processing Manual Publication 100-4, Chapter 25 http://www.cms.hhs.gov/manuals/downloads/clm104c25.pdf

I have an outpatient claim that denied because it was overlapping a Home Health Episode (U5390). What can we do to receive reimbursement for this claim?
Direct Data Entry (DDE) providers can go to HIQA and check to see if the claim dates of service falls within the Home Health Episode. If you do not have DDE, you may contact customer service for this information. If the dates of service are within the Home Health Episode then you will need to bill the appropriate Home Health Agency. If the dates of service are not within the Home Health Episode, an adjustment may be submitted for Medicare processing.

Can you tell me where I can find information on observation services?
Information regarding observation services can be found in the Local Coverage Determination (LCD) area on WPS Medicare's Website.http://www.wpsmedicare.com/

Click on "Policy/Coverage" within the top navigation bar
Select the Local Coverage option
Select "Outpatient Observation Services"

We have a patient that terminated his Medicare Part B coverage in June of 2006. Can we get a termination letter?
No, WPS Medicare does not issue termination letters. Termination letters will have to be obtained from the Social Security Administration (SSA).

I have several outpatient therapy claims editing for reason code W7040 which states that a component of comprehensive procedure would be allowed if an appropriate modifier were present. What do I need to do to get them to process?
Providers should check the National Correct Coding Initiative (NCCI) documentation on CMS' Website to see if the procedures can be billed together utilizing modifier 59. If the 59 modifier is appropriate, you may submit the claim with modifier 59.

Go to http://www.cms.hhs.gov/
Click on "Medicare"
Under "Coding" click on "National Correct Coding Initiative"
Click on "NCCI Edits-Hospital Outpatient PPS"
Scroll Down and select a category
http://www.cms.hhs.gov/NationalCorrectCodInitEd/ NCCIEHOPPS/list.asp

I have a patient that came in to have preoperative diagnostic services two days before their inpatient surgery stay. Can these services be billed separately?
Diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or operated by the hospital (or by another entity under arrangements with the hospital), within 3 days prior to the date of the beneficiary's admission are deemed to be inpatient services and should be billed on the inpatient claim.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under Manuals Overview on the Left side, click on "Internet-Only Manuals"
Under Publications click on 100-04
Under Downloads click on Chapter 3
Scroll down or search for Section 40.3
http://www.cms.hhs.gov/manuals/downloads/ clm104c03.pdf

I have a lot of physical and occupational therapy claims hitting reason code 7CAPS which states for Fiscal Intermediary use only, no provider action needed. Is there anything that I need to do to get these claims to process?
No, this reason code is handled internally, therefore, no provider action is needed.

I am confused and would like to know the proper use of modifier 59. Can you explain it to me?
Under certain circumstances, a physician may need to indicate that a procedure or service was distinct or independent from other services and modifier "59" may be appropriate depending on the circumstances. Modifier "59" is used to identify procedures/services that are not normally reported together, and this includes the following procedures/services that are not ordinarily encountered or performed on the same day by the same physician:

A different

Session or patient encounter,
Procedure or surgery,
Site or organ system, or

A separate

Incision/excision,
Lesion, or
Injury (or area of injury in extensive injuries)

I have an outpatient claim editing with reason code W7077 stating that the claim lacks an allowed procedure code. How can I get this claim to process?
This claim is lacking a procedure code. Please submit a valid procedure code that corresponds with the device code.

I have an outpatient claim editing with reason code W7006 stating that an invalid procedure code was used. How can I get this claim to process?
The claim was billed with an invalid procedure code (HCPCS), please update with a correct procedure code.

I have a SNF claim editing with reason code E51#U stating that the covered days are not matching the leave of absence days and accommodation days. How do I correct my claim?
You will need to correct the units for revenue code 0022 on page 2 to make sure they match the accommodation days shown with revenue codes 21X.

To correct your claim in DDE Claims Correction, change the accommodation days (Page 2) to equal the units billed under revenue code 0022 (page 2). Providers that don't have DDE can contact our Corrections line.

I submitted a MSP adjustment claim to make Medicare primary. The claim returned to me for reason code 77730 stating that Common Working File (CWF) still shows Medicare as the secondary payer. How can I correct this?
You need to contact the Coordination of Benefits Contractor to have the beneficiary's MSP record updated. They can be reached at 1-800-999-1118. Once the MSP Record has been updated and closed please resubmit the claim.

I have a Skilled Nursing Facility (SNF) claim that is editing with reason code 7RUGG. The claim was billed with the correct number of days for the assessment period. Is there anything that I need to do to get this claim to process?
No, as long as your claims are billed correctly according to the following assessment schedule your claim will be worked internally:

The 5 day assessment will pay for up to 14 days of service.
The 14 day assessment will pay for up to 16 days of service.
The 30 day and 60 day assessments will pay for up to 30 days of service; and
The 90 day assessment will pay for up to 10 days of service.

To correct your claim in DDE Claims Correction, change the sum of the covered units associated with the accommodation days (Page 2) to equal the covered days (Page 1). Providers that don't have DDE can contact our Corrections line.

I have a claim that rejected for reason code U5235, stating that it was overlapping the service dates for a Hospice claim and the claims contain the same diagnosis. How can I get reimbursed for the services given?
If the diagnosis is hospice related and the beneficiary is enrolled in hospice, then Hospice would be responsible to reimburse the claim.

Several claims that previously processed through the system were cancelled by the Common Working File (CWF) because of an incorrect discharge status. We realize now that the patient went to a Home Health Agency within three days of discharge and should have appended a discharge status of 06. Can we resubmit a new claim with the correct discharge status?
Yes, providers can resubmit a new claim with the correct discharge status.

We submitted a claim that rejected for reason code U538H, stating that these charges were overlapping an incarceration period. We contacted the beneficiary and verified that the beneficiary was not incarcerated at the time of service. How do we get this corrected?
If the dates of incarceration (INCR) on the CWF are incorrect, you will have to contact the State Department of Corrections to verify the actual dates. If the information is not updated on the CWF, then you will need to contact the CMS Regional Office (RO) in their region.

I billed an inpatient claim, which is now editing with reason code 15202 stating that the accommodation days are greater than the covered days. How can I correct this claim?
Your covered days must match the accommodation days shown with revenue codes 10X-21X. To correct your claim in Direct Data Entry (DDE) Claims Correction, change the sum of the covered units associated with the accommodation days (Page 2) to equal the covered days (Page 1). Providers that do not have DDE can contact our Corrections line.

All of my claims are hitting reason code WW404, stating that this is a temporary edit to suspend all claims. Is there anything that I need to do to get these claims to process?
No, there is no provider action needed. Status location WW404 is a temporary quarterly release hold. WPS Medicare will release these claims once the release is implemented.

I submitted a Medicare Secondary Payer (MSP) claim. The claim was returned to me for reason code 77745, stating that Medicare is primary. How can I correct my claim?
If Medicare is the primary payer and a primary payment was received from another insurance, refund the payment and then resubmit the claim as Medicare Primary. If a primary payment was not received from another insurance but a denial was received, please remove all other insurance information from the claim and resubmit the claim as Medicare Primary. If Medicare is not the primary payer, please contact the Coordination of Benefits Contractor (COBC) at 1-800-999-1118 to have the primary insurance information added to the patient's MSP record. When the CWF is updated, resubmit the patient's Medicare Secondary claim.

We have several claims that denied (DB9997) for reason code 32153, stating that the claims overlaps a period of time that the operating physician was sanctioned by the Office of the Inspector General (OIG). The physician was not sanctioned at this time. How do I get these claims to pay?
At this time, we are aware of the issue and no provider action is needed. The Fiscal Intermediary will correct the claims.

Several claims that I submitted are editing with reason code 30022, stating that it is for intermediary use only, no provider action needed. Is there anything I need to do to get these claims to process?
No, providers do not need to take any action on these claims when they are editing for reason code 30022.

I submitted an MSP claim without an appropriate value code. The claim is now editing for reason code 31102 stating that the primary payer code on the claim is "C" and is missing or has an incorrect occurrence code or value code. How do I correct my claim?
Providers must add the MSP value code with no amount listed and ensure that Occurrence code 01, 02, 03, 04, or 24 is present and F9 (store) the claim.

We have had several claims error out for reason code W7062 because procedure code 90780 is not recognized by the Outpatient Prospective Payment System (OPPS). What steps should I take to determine the correct code?
Procedure code 90780 is no longer recognized by OPPS; an alternate code for the same service may be available. You will need to correct the code and re-submit the claim to Medicare.

Who do we contact to obtain our Electronic Remittance Advice (ERA) if it was not received?
Providers that receive ERAs have up to 30 days from the original ERA date to contact the Medicare Systems Area and request a duplicate electronic copy of their ERA. You must fax all requests to 402-351-6188 on your company letterhead to our Electronic Data Interchange (EDI) Department.

If the ERA is over 30 days old, we will not be able to provide an electronic copy. Instead, providers on ERA will have to mail or fax a request for a paper copy of their ERA to the following address or fax number:

WPS Insurance Company
Medicare Administration
PO Box 1602
Omaha, NE 68101
FAX (402) 351-8047

For more information, visit our Website at the following address: http://www.wpsmedicare.com/part_a/selfservice/dup_advice.shtml

If a patient in our Skilled Nursing Facility (SNF) drops to a non-skilled level of care, we are required submit a No-Pay claim. Do we have to continue to bill a No-Pay claim when the patient discharges to the hospital?
Yes, this claim can be billed either monthly if a denial is needed or when the patient discharges, whether that would be to home or to a non-certified bed.

We have a claim that denied for timely filing. What documentation is accepted as proof of timely filing?
Medicare will consider claims as received for timely processing based on the date of receipt. Improperly completed claims that are returned are considered received for timely processing purposes when received again, properly completed. Documentation showing that the claim was previously submitted and in our system is needed (i.e., screen print of system, 201 report). Exception rules on when an extension is allowed to the time limit can be found in the CMS Internet-Only Manual (IOM) Pub. 100-4, Medicare Claims Processing Manual, Chapter 1, Sections 70.7 - 70.7.1. The following instructions detail how to access Pub. 100-4 on the CMS Website:

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under "Manuals" on the left side, click on "Internet Online Manuals"
Click on 100-4 Medicare Claims Processing Manual
Click on Chapter 1
Click on section 70.7 & 70.7.1

I billed a SNF claim with the wrong patient assessment indicator. Would I need to appeal the claim to have the indicator changed?
You do not need to file an appeal. Providers should send in an adjustment bill with the correct assessment indicator.

Does an outpatient hospital department need certification to provide digital mammographies?
Effective October 1, 1994, all facilities providing screening and diagnostic mammography services (except VA facilities) must have a certificate issued by the Food and Drug Administration (FDA) to continue to operate.

For more information, please refer to the CMS Internet-Only Manual (IOM) Pub. 100-4, Medicare Claims Processing Manual, Chapter 18, Section 20.1. The following information details how to access Pub. 100-4 on the CMS Website:

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Manuals"
Under "Manuals" on the left side, click on "Internet Online Manuals"
Click on 100-4 Medicare Claims Processing Manual
Click on Chapter 18
Click on section 20.1

The Common Working File (CWF) is showing a Date of Death for patient that is still living. How can we get this corrected?
The representative for the beneficiary must contact the Social Security Administration (SSA) to have this corrected, as the Fiscal Intermediary cannot correct these cases.

I submitted a claim with the wrong admission type. The claim is now inactivated (IB9997) with reason code 11701 stating that correct type of admission is required. How can I correct this claim?
Claims that have been inactivated cannot be corrected. Providers would need to send in a new claim with the correct admission type.

I submitted an outpatient claim with procedure code 97039. It is now editing with reason code 36602, stating that this procedure code is either not a billable code and/or is being held until a price is obtained from the carrier. Is there anything I need to do to correct this claim?
If claims are returned to providers for reason code 36602, providers will need to verify that procedure code 97039 is valid and seek documentation. Once the provider has located the documentation and it is determined that the code is valid, please contact Medicare Customer Service for assistance to get this corrected.

What is the difference between the GZ and GY modifiers?
Modifier GZ is used when you think a service will be denied because it does not meet Medicare program standards for medically necessary care and you did not obtain a signed Advance Beneficiary Notice (ABN) from the beneficiary. Claims will deny provider liable.

Modifier GY is used when an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. The provider should show non-covered charges on a payable claim. Claims will deny Beneficiary liable.

For more information, please see Change Request (CR) 3416. Please follow the directions below to access CR 3416 on the CMS Website.

Go to http://www.cms.hhs.gov/
Click on "Regulations and Guidance"
Under "Guidance" click on "Transmittals"
Under Transmittals Overview on the Left side, click on "2004 Transmittals"
Select CR 3416

Where can I find information on billing a non-covered observation claim?
The hospital should submit a claim with the GY modifier on the line item next to the procedure codes for non-covered services.

For more information, visit our Computer-Based Training (CBT) Web page at http://www.wpsmedicare.com/part_a/education/cbt.shtml for a tutorial on "Observation Services."

Page Last Updated: Wednesday, 20-Aug-2008 08:19:40 CDT