Duplicate Claims_2014 .pptx

Duplicate Claims Alert

Avoiding Denials

Presented by: Tammy Ewers, CPC

DISCLAIMER

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous

improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at

http://www.noridianmedicare.com and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

ACRONYM _DESCRIPTION

ABN

Advance Beneficiary Notice of Non Coverage

CCI

Correct Coding Initiative

CERT

Comprehensive Error Rate Testing

CR

Change Request

EDISS

Electronic Data Interchange Support Services

IOM

Internet Only Manual

MLN

Medicare Learning Network

Agenda

• How to Avoid Duplicate Submissions

• Proper Use of Repeat Modifiers

• Medical Necessity Denials

• Reopening vs. Redetermination

• Resources

• Noteworthy information

– Endeavor updates

Duplicate Claim/Service Denials

• Duplicate denials continue to be one of the

top billing errors.

• Unnecessary duplicate filing of Medicare

claims cost the provider's office valuable

time and resources as well as Medicare's

time and money to process them.

Duplicate Claim is…

• HIC Number

• Provider Number

• From Date of Service

• Through Date of

Service

• Type of Service

• Procedure Code

• Place of Service

• Billed Amount

A claim or claim line that exactly matches

another claim or claim line with respect to the

following elements:

Submitting Duplicate Claims

• May lead to or may result in :

– Delay in payment

– Identification as an abusive biller

– A fraud investigation if a pattern of duplicate

billing is established

Tip to Avoiding Denials

• Check your Remittance Advice (RA) for

previously posted claim

• Verify reason initial claim was denied

• Don’t just resubmit to correct a denial

• Use the IVR to check on current claim status

• Allow 30 days from the receipt date

• Make sure your billing service/clearing

Correct Process for Unpaid Claims

• Payment that have not been received after 30

days and there is concern follow the below steps:

– Verify claim status. Call the Interactive Voice Response (IVR) System.

– If IVR cannot find the claim, call the Provider Contact Center (PCC).

– Electronic Submitters (EMC) should check the

Electronic Data Interchange (EDI) reports to verify which claims were received and accepted or rejected or Contact EDI at 800-967-7902.

Duplicate Error Messages

Most Common Error messages

CO18: Duplicate claim/service

N20 Service not payable with other service rendered on the same date N347 Your claim for a referred or purchased service cannot be paid because

payment has already been made for this same service to another provider by a payment contractor representing the payer

M86 Service denied because payment already made for same/similar procedure within set time frame

Repeat Modifiers

• Modifier 76 is defined as “Repeat Procedure by

Same Physician”

•

Appropriate Use of Modifier 76

• Used to report a service or procedure that was

repeated by the same practitioner subsequent to

the original service or procedure

• Used if there is no anatomical modifier to indicate

the procedure was performed more than once on

the same day or when the same “procedure” is

performed in multiple locations

Example Modifier 76

• A radiological examination of the chest was

performed, 2 views, frontal and lateral. CPT

71020 is billed on the first line with no modifier.

The second line is billed with modifier 76.

Example of Duplicate Billing

• Example 1: A provider received duplicate denial on 7/24/13 and on 8/10/13 for CPT 71020 (Chest x-ray) with billed date of service of 7/10/13. Both claims were billed for same patient, same provider, and same date of service, same charge, same CPT code, and same units, without a modifier.

• Resolution: Billing of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or 77 (repeat procedure or service by another physician or other

Repeat Modifier 77

• Modifier 77 is to be used when another

physician repeats a procedure or service(s)

on the same day.

• Modifier guidelines are the same rules as

76 except it is performed by another

physician.

• Documentation may be necessary for

repeating a procedure on the same day or

during a global period.

Repeat Modifiers

(2)

• Modifier 91 is defined as “Repeat Clinical Diagnostic Laboratory Test to Obtain Multiple Results”.

Appropriate Use of Modifier 91

• Used to report repeat laboratory tests or studies performed on the same day on the same patient

• If billing a procedure code two or more times for the same date of service, the claim should be submitted with the

procedure code listed on the first line without the 91 modifier and each subsequent procedure listed on a separate line using modifier 91

Example Modifier 91

• Example Modifier 91

CPT 81001 is performed twice on the same day. Bill CPT 81001 with no modifier on the first line and add modifier 91 to CPT 81001 on the second claim line.

Modifier 59

• Modifier 59 is defined as a “Distinct Procedural Service” which identifies procedures or services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

• Appropriate Use

• Documentation indicates two separate procedures performed on the same day by the same physician or same group

• Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)

• Used when Correct Coding Initiative (CCI) edit indicates a “code pair” can be unbundled due to procedures being performed in different anatomical sites or different times of day

Example Modifier 59

• A biopsy was performed on the right arm (CPT

17000) and a lesion was removed from the left

hand (CPT 11000). The NCCI edit table lists the

modifier indicator of 1 for CPT 11000. Modifier

59 can be appended to CPT 11000 to unbundle

the services

Inappropriate Use of Modifier 59

• Using as a repeated procedure modifier. Claims billed with the same procedure code two or more times on the same date of service should be submitted with the appropriate modifier (76, 91 or anatomical)

• Code combination does not appear in CCI edits

• Evaluation & Management (E/M) codes (99201 – 99499) • Weekly radiation therapy management codes (CPT 77427) • Procedure code has a modifier indicator of "0" on NCCI

listing

• Documentation does not support separate and distinct status

Other Modifiers

• An anatomical modifier is available ex LT,

RT, E1,T3

• Modifiers RT or LT may also be used in

the case of a unilateral service

• For bilateral services a Modifier 50 may be

appropriate.

Medical Necessity

Denials

Medical Necessity Denials

• An increase of resubmission of denied claims on

a targeted medical review.

• This practice may be considered fraud.

• NCD/LCD policies clarify coverage and related

medical necessity coding

– Diagnosis is most common reason for denial – Know your policies

– Review LCDs/CMS guidelines

• Code lists subject to quarterly/annual updates

Medical Review (MR) Reminders

• Inappropriate to resubmit claims

– If no payment/denial received

• MR has up to 60 days to review pending claims

– Medical necessity denial

• Must appeal – do NOT resubmit claim

– Duplicate denial

• Find original denial message and correct billing

• Resubmission overwhelms payment systems

– If office software set up to auto rebill frequently,

Medical Review Tips

• When Automated Development System

(ADS) letters received

– Documentation return time – 45 days

– Review time for MR staff – up to 60 days

– https://www.noridianmedicare.com/partb/cover

age/mr/ads_submission.html

• Email

ONLY

for Service Specific Review

inquiries

:

Recovery Auditors – Automated

Reviews

• Continue to review duplicate submissions for

overpayments

• Some claims that appear to be duplicates are

actually claims or claim lines that contain an item or

service, or multiple instances of an item or service,

for which Medicare payment may be made.

• Correct coding rules applicable to all billers of health

care claims encourage the appropriate use of

modifiers to identify claims that may appear to be

duplicates

Example of Duplicate Billing

• Example 2: A provider received duplicate payment on

2/22/13 and again on 4/20/13 for CPT 77080 Dual-energy X-ray absorptiometry (DXA), Bone Density axial) with

billed date of service of 1/31/13. Both claims were billed for the same patient, same provider, and same date of service, same charge, same CPT code, and same units, without a modifier. Recovery initiated

• Resolution: Billing of modifier 76 or 77 should be used to report the performance of multiple diagnostic services on the same day if these were not actually duplicate claims.

Reopenings vs.

Redeterminations

Reopening vs. Redetermination

• Reopening

–Think clerical errors/omissions

• Left off modifier, transposed date of service, place of service (POS) incorrect, Dx error etc.

–Can not call reopenings for the following:

• RA requests, recoupment issues, Medicare Secondary Payer (MSP) or timely denials

• Redetermination

–Need documentation to support the appeal –Check correct box (CERT, RA, etc.)

Redetermination Reminders

• Complete appropriate request form

• Submit all pertinent medical records to

support services provided

– Include documentation of physician’s intent

and/or order

– Records include physician’s legible signature

• Check for correct DOS on records

Resources

•

_{Change Request 8121-}

_{Clarification of}

Detection of Duplicate Claims Section of

the CMS Internet Only Manual

• 100-04, chapter 1, section 120:

"

Detection of Duplicate Claims"

of the

Medicare Internet-Only Manual (IOM).

• Special Edition SE1314 –Duplicate Claims

Outpatient ( Recovery Auditor)

Noteworthy

Information

ENDEAVOR

Endeavor JF Subscribers

State Part A Part B Total

AK 29 220 249

AZ 366 3526 3892

ID 146 587 733

MT 205 444 649

ND 120 277 397

OR 364 1737 2101

SD 95 316 411

UT 149 944 1093

WA 617 2442 3059

WY 52 282 334

Registration

2

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Registration

3

• Required Fields (

*

)

– First and last name

– Organization name

– User Type:

• Provider

• Billing Provider

• Clearing house

• Third Party

Registration

4

• SSO designated

authority responsible for Endeavor use

– Keep records up-to-date and first ones contacted if there is suspicious activity – All organizations are

required to have SSO – SSO can be provider,

office manager, executive officer or selected

employee

•Icon System Security Official (SSO) describes SSO responsibilities

ENDEAVOR

New Functionality:

Financial Information

Most Recent 50 Checks

Endeavor Assistance

• JF: 877-908-8431

• Account access: passwords, locked

accounts, functionality access

– User Security

• Results: specific claim information,

eligibility

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own account

• If contacted by anyone other than

Noridian, user account is deleted

Endeavor Resources

• User Manual

–Step-by-step instruction on

registration and usage

• JFB:

https://www.noridianmedicare.com/pa

rtb/claims/endeavor/endeavor_user_m

anual.html

Go Green

– Sign up for ERAs!

• Electronic Remittance Advice (ERA)

– Paper remit version

• Benefits of ERAs:

– Paper reduction helps save money and time

– Capability of automatically posting

– Expedite filing to secondary payers

• Contact EDISS at

www.edissweb.com

– JF: 877-908-8431

– JE: 855-609-9960

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