Frequently Asked Questions - Top 10 Phone Inquiries

Home Provider Part B FAQs

WPS is please to publish FAQ's 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 June 2008.

Top 10 Reason Codes for Wisconsin, Illinois, Michigan, and Minnesota:
June 2008
(Excluding Claim Status and Eligibility Issues)

Description	Occurrences
National Provider Identifier (NPI)	1,447
Coding Errors/Modifiers	1,345
CMS 1500 Claim Form Item	1,247
Duplicate Claim Denials	1,195
Provider Information	1,036
Address/Phone/Fax/Web Address	985
Payment Explanation/Calculation	894
Contractual Obligation not Met - Claim Denials	830
Medicare Secondary Payer (MSP)	783
Contractual Obligation not Met	740

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

June

National Provider Identifier (NPI)

1. I tried to use the Interactive Voice Response (IVR) and was unable to obtain any information, because my National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) numbers did not match. I am using the group PTAN and the individual NPI and they are linked. Why would I receive this message? (08/04/08)
2. Why are my claims denying for the billing provider? We only have one doctor. (08/04/08)

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? (08/04/08)

Submitted to Incorrect Program

1. Why are my claims denying for another contractor? (08/04/08)

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)

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

Obligation Not Met - RTP/Unprocessable Claim

1. Why would a claim deny with a message "missing/incomplete/invalid patient or authorized representative signature"? (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)

Submitted to Incorrect Program*

1. What does remarks message C0 072 mean when it states "claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor"? (05/19/08)

National Provider Identifier*

1. What is my correct National Provider Identifier? I have more than one. How are they used? (05/19/08)

*Please note: Although not represented in the Top 10 Inquiry Topics for March, FAQ numbers 3, and 4 (above) generated a considerable number of calls from providers throughout the WPS Medicare jurisdiction, and ranked numbers 11 and 14, respectively, in frequency. We feel that addressing them in this month's update is important, and have therefore provided you with this information. We hope you find this helpful.

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)

January

Contractual Obligation Not Met - Claim Denials

1. My claims are being denied stating "missing/incomplete/invalid information on where the services were furnished." Box 32 has the name and address listed, so why is Medicare denying my claims? (03/24/08)

ATP Amount / Check Information

1. I have three different providers for whom I need to obtain approved-to-pay and pending claims information, as well as check amounts and issue dates. What is my best way of getting this information? (03/24/08)

December

Coding Errors/Modifiers

1. How do I bill for a procedure that is performed bilaterally? (03/03/08)

Address/Phone/Fax/Web Address

1. Is there a telephone number where I can reach the EDI Department? (03/03/08)

November

Medicare Secondary Payer (MSP)

1. Why is my claim denying, stating that the beneficiary has another payee contractor? He states he only has Medicare. (03/03/08)

National Provider Identifier (NPI)

1. Why is my claim denying for invalid primary identifier? All the correct information is on claim. (03/03/08)

October

CMS-1500 Claim Form Item

1. What information is required in item 11 on the CMS-1500 claim form when Medicare is the primary insurance? (12/26/07)

September

Address/Phone/Fax/Web Address

1. I have a patient who is enrolled in the Medicare Advantage program through United Healthcare. Do you know how I can get their phone number? (09/04/07)



2. I have received notification that Medicare is monitoring my paper claims filing under the Administrative Simplification Compliance Act (ASCA). This states that I should be trying to file my claims electronically. Do you offer any type of guidance or software that can help me get started with electronic filing? We do not have a large volume of Medicare claims, but maybe we should file them electronically anyway. (09/04/07)

Coding Errors/Modifiers

1. Why did the chest x-ray (CPT 71010), on my claim deny? The doctor performed and interpreted it in the office, but my denial says the procedure is inconsistent with the place of service. (09/04/07)
2. Why are my therapy codes denying? I always bill therapy procedure codes and are paid for them; so, why are they denying now? (12/26/07)

Duplicate Claim Denial

1. I called the Interactive Voice Response (IVR) system to see if I could find out why I had not received payment on a claim I submitted. The IVR stated that the claim denied as a duplicate. What is going on? (09/04/07)
2. We continually receive duplicate denials on radiology services performed multiple times per day to a patient. Why? (12/26/07)

Payment Explanation/Calculation

1. Why was my claim paid at a lower allowed amount for surgery than what is shown on the Medicare fee schedule? (09/04/07)

August

Duplicate Claim Denials

1. My claims are being denied as duplicates when I do not have record that payment has been received. How long should I wait before I re-file the claims when I have not heard anything from Medicare? (10/08/07)

CMS-1500 Claim Form Item

1. In what field on the CMS-1500 claim form do I place the provider's National Provider Identifier (NPI) number(s)? (10/08/07)

Medicare Secondary Payer (MSP)

1. I received denials for a patient stating that Medicare cannot make payment for the date of service without an Explanation of Benefits (EOB) from the primary insurer. However, the patient states that Medicare is primary. Why are you denying? (10/08/07)

July

Address/Phone/Fax/Web Address

1. Our office began filing claims for services covered under the Physician Quality Reporting Initiative last month. We are not certain that the quality measures we reported are accurate. Is there a location where we may find additional information about this program? (09/04/07)

Appeals Process/Rights

1. What is the time limit for filing a written appeal of a denied service? (09/04/07)

Coding Errors/Modifiers

1. Our office is providing a service to a patient that Medicare lists as Non-covered. Do we need to supply the patient with an Advance Beneficiary Notice in order to collect from them? (09/04/07)

Medical Necessity

1. Medicare denied a procedure we billed as not medically necessary. When I went to your Website and looked at the policy for the procedure, the diagnosis on the claim is payable. Why is it being denied? (09/04/07)

June

National Provider Identifier (NPI)

1.	I tried to use the Interactive Voice Response (IVR) and was unable to obtain any information, because my National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) numbers did not match. I am 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 Websites: http://www.wpsmedicare.com/part_b/selfservice/ivr.pdf http://www.cms.hhs.gov/NationalProvIdentStand/ 01_Overview.asp#TopOfPage Posted (08/04/08)
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/ 01_Overview.asp#TopOfPage Posted (08/04/08)

Modifiers

3.	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?
	You should use the 78 modifier 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/part_b/education/modifier_78.pdf Posted (08/04/08)

Submitted to Incorrect Program

4.	Why are my claims denying for another contractor?
	You are submitting claims that have a Medicare number, which begins with an Alpha character, meaning the claims 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 (08/04/08)

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)

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/part_b/business/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)

Payment Explanation/Calculation

3.	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. This information is explained in detail in National Coverage Provision (NCP) PSYCH-012. You may find the entire policy and additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/policy/psych012.pdf Posted (06/23/08)

March

Contractual Obligation Not Met - RTP/Unprocessable Claim

1.	Why would a claim deny with a message "missing/incomplete/invalid patient or authorized representative signature"?
	This occurs when item 12 on the CMS 1500 claim form or equivalent field on the electronic claim is submitted without the patient's signature or a statement "Signature on File". 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)

Payment Explanation/Calculation

2.	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. Please refer to the policy GSURG-001 on the Medicare Website at: http://www.wpsmedicare.com/part_b/policy/gsurg001.pdf Posted (05/19/08)

Submitted to Incorrect Program

3.	What does remarks message C0 072 mean when it states "claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor"?
	This denial occurs when Medicare has received notification that a patient is in a skilled nursing facility (SNF) stay for the specific date(s) of service. This provision of Medicare law is known as SNF Consolidated Billing. The SNF Consolidated Billing provision requires a SNF to include on its Part A bill almost all of the services that its residents receive during the course of a Part A covered stay. However, there are several categories of services that the law (§1888(e)(2)(A)(ii) of the Social Security Act) specifically excludes from this provision. These "excluded" services remain separately billable under Part B by the outside provider or supplier that furnishes them. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/SNFConsolidatedBilling/ Posted (05/19/08)

National Provider Identifier

4.	What is my correct National Provider Identifier? I have more than one. How are they used?
	You should have been assigned one NPI, to be used to identify you as a rendering provider of services. If you belong to a group or clinic, a separate NPI would have been assigned to identify them, to be used in billing. When submitting claims to Medicare, Box 24-J of the CMS 1500 claim form is to be utilized to report the rendering provider's NPI, whereas Box 33-A should contain the group, or clinic NPI. Some providers who are solo practitioners have only one NPI, to be used to identify both their status as both rendering and billing provider. Other providers, who may also be solo practitioners, who are also incorporated, will need two NPIs, one to identify them as the performing provider, and another to identify the corporation. You may find additional information on this topic at the following Website: http://nppes.cms.hhs.gov/NPPES/Welcome.do Posted (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?
	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/part_b/ education/modifier_global_surg.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 Websites: http://www.wpsmedicare.com/part_b/ business/appeal_howto.pdf and at 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)

January

Contractual Obligation Not Met - Claim Denials

1.	My claims are being denied stating "missing/incomplete/invalid information on where the services were furnished." Box 32 has the name and address listed, so why is Medicare denying my claims?
	The Centers for Medicare & Medicaid Services (CMS) has determined that some ZIP codes fall into more than one payment locality. Therefore, beginning October 1, 2007, Medicare requires the submission of a 9-digit ZIP code for services paid under the Medicare Physician Fee Schedule and anesthesia services when the services are provided in those ZIP codes which cross the lines of more than one payment locality. The requirement does not apply to services provided with the place of service Home. Change request (CR) 5208 issued on March 9, 2007 contains the list of ZIP codes that require the use of the full 9-digit ZIP code for claims with dates of service on or after October 1, 2007. This ZIP code list was updated by CR 5730. You may find additional information on this topic at the following Websites: CR5208 - http://www.cms.hhs.gov/mlnmattersarticles/ downloads/mm5208.pdf CR5730 - http://www.cms.hhs.gov/mlnmattersarticles/ downloads/mm5730.pdf Posted (03/24/08)

ATP Amount / Check Information

2.	I have three different providers for whom I need to obtain approved-to-pay and pending claims information, as well as check amounts and issue dates. What is my best way of getting this information?
	The WPS Medicare Website offers a number of self-service tools to assist providers and their agents in obtaining needed information. Among these tools, providers may access instructions for utilizing the Interactive Voice Response (IVR) unit. Providers can obtain approved-to-pay and pending claims information, as well as check amounts and paid dates via the Provider Summary option of the IVR. You may find additional information on this topic at the following Web address http://www.wpsmedicare.com/part_b/selfservice /contact_info.shtml Posted (03/24/08)

December

Coding Errors/Modifiers

1.	How do I bill for a procedure that is performed bilaterally?
	When a procedure is done bilaterally AND the Medicare Physician Fee Schedule Database (MPFSDB) indicator for the procedure is "1," report the procedure code once, append modifier 50 to it, and report it with one unit of service. Some procedures, even though they can be performed bilaterally, are not shown on the on the MPFSDB as having indicator "1" in the bilateral column. This means that they cannot be billed with modifier 50. Medicare carriers are not able to override such restrictions found on the MPFSDB. For procedures performed bilaterally which do not allow modifier 50, bill the service on two separate lines, and append modifier LT (for left) on the first line of service, and modifier RT (for right) on the second line of service. You may find additional information on this topic at the following Web address: http://www.wpsmedicare.com/part_b/education/modifiers.shtml Posted (03/03/08)

Address/Phone/Fax/Web Address

1.	Is there a telephone number where I can reach the EDI Department?
	The telephone number for Electronic Data Interchange (EDI) for all providers in Wisconsin, Illinois, and Michigan is 877-567-7261. Minnesota providers should call 866-380-4742. If you need to leave a message, please leave your name, telephone number, and submitter ID. A member of the EDI staff will return your call as soon as possible. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/selfservice/contact_info.shtml Posted (03/03/08)

November

Medicare Secondary Payer (MSP)

1.	Why is my claim denying, stating that the beneficiary has another payee contractor? He states he only has Medicare.
	The patient may have another insurance, primary over his Medicare, indicated on his master file. If so, he should contact the Coordination of Benefits Contractor, (COBC) at 800-999-1118 to have his files updated with the correct information. Once he has done so, you can resubmit your claims. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/COBGeneralInformation Posted (03/03/08)

National Provider Identifier (NPI)

1.	Why is my claim denying for invalid primary identifier? All the correct information is on claim.
	When a claim denies for invalid primary identifier, Medicare has identified that you have billed something incorrect in item 33-A. The incorrect data is most likely an incorrect NPI. Item 33-A should have the NPI of the billing provider, or that of the practice. If you are having problems with an incorrect NPI, you can go to the Website for the National Plan and Provider Enumeration System (NPPES) and contact the NPI Enumerator. They can direct you on how to obtain the correct provider or group numbers you need. You may also want to contact Provider Enrollment to see how your clinic and doctors are listed in Medicare's provider files. You may find additional information on this topic at the following Website: http://nppes.cms.hhs.gov/NPPES/Welcome.do Posted (03/03/08)

October

CMS-1500 Claim Form Item

1.	What information is required in item 11 on the CMS-1500 claim form when Medicare is the primary insurance?
	If Medicare is primary, enter the word "NONE" in this field and proceed to item 12 on the claim form. You may find additional information on this topic at the following Website: http://www.cms.hhs.gov/manuals/ downloads/clm104c26.pdf Posted (12/26/07)

September

Address/Phone/Fax/Web Address

1.	I have a patient who is enrolled in the Medicare Advantage program through United Healthcare. Do you know how I can get their phone number?
	Please refer to the CMS website. This Website has the most current listing of contact information, including phone numbers, for all Medicare Advantage plans. It is important to remember that Medicare Advantage plans work like a Health Maintenance Organization (HMO) program and replace traditional Medicare. Posted (09/04/07)
2.	I have received notification that Medicare is monitoring my paper claims filing under the Administrative Simplification Compliance Act (ASCA). This states that I should be trying to file my claims electronically. Do you offer any type of guidance or software that can help me get started with electronic filing? We do not have a large volume of Medicare claims, but maybe we should file them electronically anyway.
	It is important that all providers file their claims electronically, unless they meet one of the ASCA exceptions. Medicare offers free HIPAA-compliant billing software, named PC-Ace Pro 32. This is a "stand alone" software package that creates a patient database and allows your office to electronically submit Medicare Part B claims electronically. Please call our EDI Hotline at (877) 567-7261 for additional information. Minnesota providers should call (952) 885-2881, (952) 885-2882, or (952) 885-2811. Posted (09/04/07)
Coding Errors/Modifiers
1.	Why did the chest x-ray (CPT 71010), on my claim deny? The doctor performed and interpreted it in the office, but my denial says the procedure is inconsistent with the place of service.
	The claim Medicare received indicated a facility place of service code. Medicare cannot pay globally (professional and technical components combined) in a facility. If the correct place of service is office, the correct place of service code is "11." Either you can re-bill the claim with the correct place of service, or you can call the reopening hotline line, at the Provider Customer Service telephone number for the state in which you practice. Posted (09/04/07)
1.	Why are my therapy codes denying? I always bill therapy procedure codes and are paid for them; so, why are they denying now?
	In order to pay correctly, you must bill therapy procedure codes with a modifier. Wisconsin Physicians Service (WPS) Medicare outlines this instruction in medical policy PhysMed-001, page 34. By category, the appropriate therapy modifiers and their corresponding usage, are: GN, for Speech-Language Therapy GO, for Occupational Therapy GP, for Physical Therapy KX, for Specific, Required Therapy services You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b/ policy/physmed-001.pdf Posted (12/26/07)
Duplicate Claim Denial
1.	I called the Interactive Voice Response (IVR) system to see if I could find out why I had not received payment on a claim I submitted. The IVR stated that the claim denied as a duplicate. What is going on?
	Claims deny as duplicate when they "hit" against another claim that was received but which has not finalized, or for which the approved amount was applied to deductible. Of course, claims will also deny as duplicate when we have paid the service previously. You should always wait until you receive your Remittance Notice before submitting another claim. Remember: it takes paper claims 30- 45 days to complete processing, and electronic claims take 14 days to complete processing. Posted (09/04/07)
We continually receive duplicate denials on radiology services performed multiple times per day to a patient. Why?
	A provider may perform multiple procedures, or "repeat procedures" to a patient on a single day. These are more common with radiology and clinical laboratory services. If Wisconsin Physicians Service (WPS) Medicare cannot accept multiple numbers of services (quantity billing), then the provider of service must bill separate line items for each service. Providers can apply modifier 76 (radiology or diagnostic services) or modifier 91(clinical laboratory services only) to the second and subsequent lines of service to avoid duplicate denials. You may find additional information on this topic at the following Website: http://www.wpsmedicare.com/part_b /business/avoid_dup.shtml Posted (12/26/07)
Payment Explanation/Calculation
1.	Why was my claim paid at a lower allowed amount for surgery than what is shown on the Medicare fee schedule?
	With the procedures you are billing, Medicare bases reimbursement for the paid amount upon multiple surgery guidelines. To find out more specifics about multiple surgeries, please refer to National Coverage Provision (NCP) GSURG-001 on the Medicare Website. In addition, we frequently publish articles in our monthly newsletter, the Communiqué, which address this topic. Finally, the Medicare Physician Fee Schedule Database (MPFSDB) contains indicators which point to whether or not a given procedure code is subject to multiple surgery guidelines. When this applies, Medicare reduces reimbursement for second (and additional) procedures. You may find the MPFSDB on the CMS website. Posted (09/04/07)

August

Duplicate Claim Denials

1.	My claims are being denied as duplicates when I do not have record that payment has been received. How long should I wait before I re-file the claims when I have not heard anything from Medicare?
	Before re-filing a claim, allow sufficient time for the claim to reach Medicare, for the claim to process, and for the Provider Remittance Notice (PRN) to reach you. Claim processing time cannot be shorter than the "payment floor," which is 13 days for electronic claims, and 29 days for paper claims. This is the minimum amount of time that must elapse from the date Medicare receives the claim until the date Medicare issues a payment. Actual processing time may be longer. Also, before re-filing, carefully review your records, and access the Interactive Voice Response (IVR) system for claim status. When submitting a claim, send it in either a paper or electronic format, but not both. Please note that restrictions associated with both the Health Insurance Portability and Accountability Act (HIPAA) and the Administrative Simplification Compliance Act (ASCA) allow only certain providers to continue to submit paper claims. You may find additional information on duplicate claim denials on the WPS Website. Posted (10/08/07)
CMS-1500 Claim Form Item
1.	In what field on the CMS-1500 claim form do I place the provider's National Provider Identifier (NPI) number(s)?
	The CMS-1500 claim form utilizes multiple fields for different purposes when reporting provider's National Provider Identifiers (NPIs) to Medicare. Use field 17B for the ordering/referring providers' NPI. This replaces the Unique Physician Identification Number (UPIN), previously reported in this field. Field 24J (non-shaded area) is reserved for the rendering/performing providers' NPI. Field 32A is the service facility NPI; and 33A is the billing provider or group NPI. The reporting scenarios listed above are only a few of the many instances where billers need to report a provider's National Provider Identifier (NPI) on the CMS-1500 claim form. For a complete listing of all fields, and the information required, please refer to CMS's Internet Only Manual (IOM) 100-04, Chapter 26, Sections 10.2-10.4. Information specific to NPI is contained in Section 10.4. You can find these instructions on the CMS Website at http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf Posted (10/08/07)
Medicare Secondary Payer
1.	I received denials for a patient stating that Medicare cannot make payment for the date of service without an Explanation of Benefits (EOB) from the primary insurer. However, the patient states that Medicare is primary. Why are you denying?
	If Medicare files indicate that a patient has primary coverage through another insurer, and the patient indicates this is incorrect, the patient (or an authorized representative of the patient) can contact the Coordination of Benefits (COB) contractor and have their files updated. This process will take approximately 72 hours, after which time you may re-file claims. For additional information regarding the role of the COB, please refer to: http://www.cms.hhs.gov/COBGeneralInformation/ Posted (10/08/07)

July

Address/Phone/Fax/Web Address

1.	Our office began filing claims for services covered under the Physician Quality Reporting Initiative last month. We are not certain that the quality measures we reported are accurate. Is there a location where we may find additional information about this program?
	There is a tremendous amount of information available regarding the Physicians Quality Reporting Initiative (PQRI) on the CMS Website at http://www.cms.hhs.gov/PQRI. At this location, you will find the following: 2007 PQRI quality measures and the associated measure specifications the complete list of eligible professionals who may choose to participate new and revised Frequently Asked Questions Posted (09/04/07)
Appeals Process/Rights
1.	What is the time limit for filing a written appeal of a denied service?
	Part B providers and beneficiary's 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 that Medicare contractor's conduct. You can find this information in the Internet Only Manual (IOM) 100-4, Chapter 29, Section 30.7 at the following Web address: http://www.cms.hhs.gov/manuals/downloads/clm104c29.pdf Posted (09/04/07)
Coding Errors/Modifiers
1.	Our office is providing a service to a patient that Medicare lists as Non-covered. Do we need to supply the patient with an Advance Beneficiary Notice in order to collect from them?
	No. CMS designed the Advance Beneficiary Notice (ABN) as a tool of communication between providers and their patients to be used when it is expected that Medicare will deny a service that may otherwise be paid. The two primary categories for which such denials occur are 1) diagnosis, and 2) frequency of service. If a service is statutorily Non-covered, the provider (or supplier) may always bill the patient. No written notification is required. Posted (09/04/07)
Medical Necessity
1.	Medicare denied a procedure we billed as not medically necessary. When I went to your Website and looked at the policy for the procedure, the diagnosis on the claim is payable. Why is it being denied?
	If a procedure is being denied as not medically necessary for a diagnosis that is found on a policy, go to the end of the policy to the Revision History Number/Explanation for your state to locate the revision date and the explanation of what was added or removed from the policy. Unless otherwise noted, the revision date is the effective date. If the date of service being denied is prior to the revision/effective date, the service will be denied. Medical necessity denials may also occur for services which are provided more frequently than is allowed. Posted (09/04/07)

Page Last Updated: Monday, 04-Aug-2008 14:24:31 CDT