Change Request SUBJECT: Common Working File (CWF) Editing for Influenza Virus Vaccine and Pneumococcal Vaccine Codes

Transcription

1 anual ystem Pub edicare laims Processing Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 2267 Date: ugust 1, 2011 hange equest 7461 NOTE: This Transmittal is no longer sensitive and is being re-communicated ugust 5, The Transmittal Number, date of Transmittal and all other information remain the same. This instruction may now be posted to the nternet. UBJET: ommon Working ile (W) Editing for nfluenza Virus Vaccine and Pneumococcal Vaccine odes. UY O NGE: This provides instructions for contractors to update the W edits to include influenza virus vaccine procedure code and pneumococcal vaccine (PPV) procedure code to prevent payment duplication. EETVE DTE: January 1, 2012 PLEENTTON DTE: January 3, 2012 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED /N/D PTE / ETON / UBETON / TTLE 18/10.4.1/W Edits on /B laims 18/10.4.2/W Edits on arrier/b laims 18/10.4.3/W /B rossover Edits for /B and arrier/b laims

2 . UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the contracting officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTENT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

3 ttachment Business equirements Pub Transmittal: 2267 Date: ugust 1, 2011 hange equest: 7461 NOTE: This Transmittal is no longer sensitive and is being re-communicated ugust 5, The Transmittal Number, date of Transmittal and all other information remain the same. This instruction may now be posted to the nternet. UBJET: ommon Working ile (W) Editing for nfluenza Virus Vaccine and Pneumococcal Vaccine odes Effective Date: January 1, 2012 mplementation Date: January 3, GENEL NOTON. Background: This provides instructions for W edits to be updated to include influenza virus vaccine procedure code and pneumococcal vaccine procedure code, for claims processed on or after January 3, B. Policy: Effective for claims processed on or after January 3, 2012, influenza virus code and pneumococcal vaccine (PPV) code are being added to existing W edits to prevent payment duplication.. BUNE EQUEENT TBLE Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OT E B E aintainers ontractors shall add influenza virus vaccine code to the existing influenza virus vaccine edits ontractors shall add PPV code to the existing pneumococcal vaccine edits and W PPV logic ontractors shall update the Provider nquiry creens, PVN screen, and UQ to add the PPV vaccine code ontractors shall not search their files to either retract payment for claims already paid or retroactively pay claims. owever, contractors shall adjust claims brought to their attention. X E X X X X V W X X ET X BD NGD

4 . POVDE EDUTON TBLE Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OT E B E aintainers None V. UPPOTNG NOTON ection : ecommendations and supporting information associated with listed requirements: hould" denotes a recommendation. E V W X-ef equirement Number ecommendations or other supporting information: N/ ection B: ll other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): Bridgitté Davis (410) Joscelyn Lissone (410) Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), arriers, and egional ome ealth ntermediaries (s): No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the contracting officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by , and request formal directions regarding continued performance requirements.

5 W Edits on /B laims (ev.2267, ssued: , Effective: , mplementation: ) n order to prevent duplicate payment by the same /B, W edits by line item on the /B number, the beneficiary ealth nsurance laim () number, and the date of service, the influenza virus procedure codes 90655, 90656, 90657, 90658, 90660, or and the pneumococcal procedure codes 90669, 90670, or 90732, and the administration codes G0008 or G0009. f W receives a claim with either P codes 90655, 90656, 90657, 90658, 90660, or and it already has on record a claim with the same number, same /B number, same date of service, and any one of those P codes, the second claim submitted to W rejects. f W receives a claim with P codes 90669, 90670, or and it already has on record a claim with the same number, same /B number, same date of service, and the same P code, the second claim submitted to W rejects when all four items match. f W receives a claim with P administration codes G0008 or G0009 and it already has on record a claim with the same number, same /B number, same date of service, and same procedure code, W rejects the second claim submitted when all four items match. W returns to the /B a reject code 7262 for this edit. s/b s must deny the second claim and use the same messages they currently use for the denial of duplicate claims W Edits on arrier/b laims (ev. 2267, ssued: , Effective: , mplementation: ) n order to prevent duplicate payment by the same carrier/b, W will edit by line item on the carrier/b number, the number, the date of service, the influenza virus procedure codes 90655, 90656, 90657, 90658, 90660, or 90662; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009. f W receives a claim with either P codes 90655, 90656, 90657, 90658, 90660, or and it already has on record a claim with the same number, same carrier/b number, same date of service, and any one of those P codes, the second claim submitted to W will reject. f W receives a claim with P codes 90669, 90670, or and it already has on record a claim with the same number, same carrier/b number, same date of service, and the same P code, the second claim submitted to W will reject when all four items match. f W receives a claim with P administration codes G0008 or G0009 and it already has on record a claim with the same number, same carrier/b number, same date of service, and same procedure code, W will reject the second claim submitted.

6 W will return to the carrier/b a specific reject code for this edit. arriers/b s must deny the second claim and use the same messages they currently use for the denial of duplicate claims. n order to prevent duplicate payment by the centralized billing contractor and local carrier/b, W will edit by line item for carrier number, same number, same date of service, the influenza virus procedure codes 90655, 90656, 90657, 90658, 90660, or 90662; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009. f W receives a claim with either P codes 90655, 90656, 90657, 90658, 90660, or and it already has on record a claim with a different carrier/b number, but same number, same date of service, and any one of those same P codes, the second claim submitted to W will reject. f W receives a claim with P codes 90669, 90670, or and it already has on record a claim with the same number, different carrier/b number, same date of service, and the same P code, the second claim submitted to W will reject. f W receives a claim with P administration codes G0008 or G0009 and it already has on record a claim with a different carrier/b number, but the same number, same date of service, and same procedure code, W will reject the second claim submitted. W will return a specific reject code for this edit. arriers/b s must deny the second claim. or the second edit, the reject code should automatically trigger the following edicare ummary Notice (N) and emittance dvice () messages. N: 7.2 This is a duplicate of a claim processed by another contractor. You should receive a edicare ummary Notice from them. laim adjustment reason code 18 duplicate claim or service W /B rossover Edits for /B and arrier/b laims (ev. 2267, ssued: , Effective: , mplementation: ) When W receives a claim from the carrier/b, it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted. W will edit on the beneficiary number; the date of service; the influenza virus procedure codes 90655, 90656, 90657, 90658, 90660, or 90662; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009. W will return a specific reject code for this edit. ontractors must deny the second claim and use the same messages they currently use for the denial of duplicate claims.