WPS Medicare Provider Part B - Frequently Asked Questions

Frequently Asked Questions - Top 10 Phone Inquiries

WPS Medicare publishes FAQs based upon topics we identify as generating a high volume of telephone inquiries to Customer Service. The following table lists the top ten reasons (by topic) our Medicare providers and their agents telephoned our call centers during the months of July, August, and September 2009.

Top 10 Reason Codes for Wisconsin, Illinois, Michigan, and Minnesota:
July, August, and September
(Excluding Claim Status and Eligibility Issues)

Description	Occurrences
Coding Errors/Modifiers Claim Denials	5984
Issue Not Identified/Incomplete Information Provided	5455
Contractual Obligation Not Met	5372
Duplicate Claim Denials	5051
Medicare Secondary Payer (MSP) Claim Denials	4042
Address/Phone/Fax/Web Address	3600
Medical Necessity Claim Denial	3192
Claim Payment Calculation/Explanation	3157
Contractual Obligation Not Met - Claim Denials - Unprocessable	2939
Appeals Status/Explanation/Calculation	2532

WPS Medicare develops FAQs to specifically address telephone inquiries from the previous quarter's reporting period. We hope the answers to the questions listed below assist you in reducing the need to call our telephone centers and reduce claim errors associated with these topics.

FAQs developed to address Top 10 Inquiry Topics:

1. Topic: Issue Not Identified/Incomplete Information Provided

Q. What do you mean when you tell me I do not have the correct verification information in order for you to help me?

A. The most common reasons that our customer service representatives (CSRs) cannot address an issue when you call include:

The caller is providing a group provider transaction access number (PTAN) and an individual national provider identifier (NPI) or vice versa
The caller does not have the suffix of the patient's Medicare number
The call does not have the correct Medicare number for the person's name they are providing (sometime we are given the husband's Medicare number with the wife's name)

Medicare's Provider Enrollment Department issue providers a PTAN when they enroll in Medicare. The PTAN was previously referred to as the Provider Identification Number (PIN).

Providers are required to provide Medicare with certain verifying information before we can provide more than just general information to them. This includes the following elements:

PTAN,
NPI, and
the last 5 digits of their tax ID number

Callers are also required to verify certain patient information, including the complete name, Medicare number and date of birth.

If any of this information does not match Medicare's files, our CSR must instruct you to verify the information and call back.

For more information on the authentication process, see section 80.5.1 of the Medicare Contractor Beneficiary and Provider Communications Manual.

2. Topic: Coding Errors and Modifiers

Q. Why did my claim reject stating the reimbursement for this service is included in the payment for another service?
A. The service may be in the post-operative period of a surgical procedure or it may be subject to a National Correct Coding Initiative (NCCI) edit. Depending on the situation and if appropriate, you may need a modifier for the service to pay correctly.

Another reason could be that the code is a B Status Code on the Medicare Physician Fee Schedule Database, if so, it is never payable separately.

You will find information on global surgery and CCI modifiers and their use on the WPS Website and the CMS Website.

You will find the Medicare Physician Fee Schedule Database on the CMS Website.

3. Topic: Coding Errors and Modifiers

Q. What is the correct usage for modifier 59?
A. Modifier 59 is an important correct coding initiative (CCI) modifier that is often used incorrectly. This modifier is only used when medically appropriate and no other modifier exists to describe the situation. It identifies a service/procedure that is a distinct procedural service from another service/procedure performed on the same day. For CCI purposes, it identifies services that are not normally reported together but are appropriate given the clinical circumstances.

When the documentation supports its use, it is appropriate to use modifier 59 to indicate the procedures performed on the same day by the same physician for the same patient were:

provided in a different session or patient encounter
a different procedure or surgery
in a different body site or organ
a separate incision or excision
a separate lesion, or

It is not appropriate to use modifier 59:

if the code combination does not appear in the CCI edits,
on evaluation and management codes,
on weekly radiation therapy management codes,
on codes listed on the CCI edit table with a modifier indicator of "0",
when the documentation does not support the separate and distinct status, or
when another valid modifier exists to identify the services, such as an anatomical modifier (for example, RT, finger or toe digits, etc.)

For more information about modifier 59, see CMS' Modifier-59 Article.

The CCI edit tables are also available on CMS' site.

Page Last Updated: Friday, 06-Nov-2009 14:20:57 CST