Uniform Claim Editor for Professional Services. A Guide to Accurate CMS-1500 and 837P Professional Claim Submission

Transcription

1 Uniform Claim Editor for Professional Services A Guide to Accurate CMS-1500 and 837P Professional Claim Submission

2 Contents Summary of Changes... Summary of Changes-1 How to Use the Uniform Claim Editor for Professional Services... How to Use-1 Introduction... How to Use-1 837P... How to Use-3 Trading Partner Agreements and Requirements... How to Use-4 Differences Between the 837P and 1500 Formats... How to Use-4 Time Limit for Filing Medicare Claims... How to Use-5 Guide to Icons... How to Use-5 Item Number Unlabeled Carrier Block... How to Use-9 Unlabeled Item Carrier Block... How to Use-9 Item Numbers 1 13: Patient and Insured Information... Patient & Insured-1 Item Number 1. Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other... Patient & Insured-1 Item Number 1a. Insured s ID Number... Patient & Insured-2 Item Number 2. Patient s Name... Patient & Insured-4 Item Number 3. Patient s Birth Date, Sex... Patient & Insured-6 Item Number 4. Insured s Name... Patient & Insured-7 Item Number 5. Patient s Address... Patient & Insured-9 Item Number 6. Patient Relationship to Insured...Patient & Insured-11 Item Number 7. Insured s Address...Patient & Insured-12 Item Number 8. Reserved for NUCC Use...Patient & Insured-13 Item Number 9. Other Insured s Name...Patient & Insured-14 Item Number 9a. Other Insured s Policy or Group Number...Patient & Insured-16 Item Numbers 9b and 9c. Reserved for NUCC Use...Patient & Insured-16 Item Number 9d. Insurance Plan Name or Program...Patient & Insured-17 Item Numbers 10a-10c. Is Patient s Condition Related To: Employment, Auto Accident, or Other Accident...Patient & Insured-19 Item Number 10d. Claim Codes...Patient & Insured-22 Item Number 11. Insured s Policy, Group, or FECA Number...Patient & Insured-24 Item Number 11a. Insured s Date of Birth, Sex...Patient & Insured-30 Item Number 11b. Other Claim ID...Patient & Insured-31 Item Number 11c. Insurance Plan Name or Program Name...Patient & Insured-32 Item Number 11d. Is There Another Health Benefit Plan?...Patient & Insured-33 Item Number 12. Patient s or Authorized Person s Signature Release of Information...Patient & Insured-33 Item Number 13. Insured s or Authorized Person s Signature Payment Authorization...Patient & Insured-35 Item Numbers 14 33: Physician or Supplier Information... Physician or Supplier-1 Item Number 14. Date of Current Illness, Injury, Pregnancy (LMP)... Physician or Supplier-1 Item Number 15. Other Date... Physician or Supplier-2 Item Number 16. Dates Patient Unable to Work in Current Occupation... Physician or Supplier-4 Item Number 17. Name of Referring Provider or Other Source... Physician or Supplier-5 Item Number 17a and 17b. Other ID Number and National Provider Identifier... Physician or Supplier Optum360, LLC i

3 Contents Uniform Claim Editor for Professional Services Item Number 18. Hospitalization Dates Related to Current Services... Physician or Supplier-10 Item Number 19. Additional Claim Information... Physician or Supplier-11 Item Number 20. Outside Lab? $Charges... Physician or Supplier-17 Item Number 21. Diagnosis or Nature of Illness or Injury... Physician or Supplier-18 Item Number 22. Resubmission and/or Original Reference Number... Physician or Supplier-20 Item Number 23. Prior Authorization Number... Physician or Supplier-21 Item Number 24. Supplemental Information... Physician or Supplier-23 Item Number 24A. Date(s) of Service [lines 1 6]... Physician or Supplier-28 Item Number 24B. Place of Service [lines 1 6]... Physician or Supplier-29 Item Number 24C. EMC (Emergency) [lines 1 6]... Physician or Supplier-33 Item Number 24D. Procedures, Services, or Supplies [lines 1 6]... Physician or Supplier-34 Item Number 24E. Diagnosis Pointer [lines 1 6]... Physician or Supplier-41 Item Number 24F. $Charges [lines 1 6]... Physician or Supplier-42 Item Number 24G. Days or Units [lines 1 6]... Physician or Supplier-43 Item Number 24H. EPSDT/Family Plan [lines 1 6]... Physician or Supplier-48 Item Number 24I. ID Qualifier [lines 1 6]... Physician or Supplier-50 Item Number 24J. Rendering Provider ID # [lines 1 6]... Physician or Supplier-52 Item Number 25. Federal Tax ID Number... Physician or Supplier-53 Item Number 26. Patient s Account No.... Physician or Supplier-54 Item Number 27. Accept Assignment?... Physician or Supplier-55 Item Number 28. Total Charge... Physician or Supplier-57 Item Number 29. Amount Paid... Physician or Supplier-58 Item Number 30. Reserved for NUCC Use... Physician or Supplier-59 Item Number 31. Signature of Physician or Supplier Including Degrees or Credentials... Physician or Supplier-60 Item Numbers 32, 32A, and 32B. Service Facility Location Information... Physician or Supplier-61 Item Numbers 33, 33A, and 33B. Billing Provider Information... Physician or Supplier-67 Additional 837P Fields...Additional Fields-1 Claim ID Number for Clearinghouses or Other Transmission Intermediaries... Additional Fields-1 Pay-to Name and Address... Additional Fields-1 Special Program Indicator... Additional Fields-2 Delay Reason Code... Additional Fields-3 Appendix A: Modifiers for Other Than Facility Use... Appendixes-1 Appendix B: Place of Service Codes... Appendixes-7 Appendix C. Type of Service Codes... Appendixes-15 Appendix D. Specialty Codes... Appendixes-17 Appendix E. State Abbreviations and Country Abbreviations... Appendixes-23 Appendix F. Medically Unlikely Edits for Practitioner Services... Appendixes-27 Appendix G. Taxonomy Codes for Selected Providers... Appendixes-31 Appendix H. CMS Not Otherwise Classified Codes for Medicare Editing, Jurisdictions, and Their MPFS Status Code... Appendixes-37 Appendix I. Claim Adjustment Reason Codes... Appendixes-47 Appendix J. Remittance Advice Remarks Codes... Appendixes-59 ii 2015 Optum360, LLC

4 Uniform Claim Editor for Professional Services Contents Appendix K. Medicare Coverage for Selected Services... Appendixes-95 Glossary...Glossary-1 Index... Index Optum360, LLC iii

5 Uniform Claim Editor for Professional Services Item Numbers 14 33: Physician or Supplier Information Item Number 24G. Days or Units [lines 1 6] This field is the number of days corresponding to the dates entered in Item 24A or the number units as defined in CPT or HCPCS Level II coding manual(s) P Loop (837P only) 2400 Item or data element number and name Unit or basis for measure Unit amount Item 24G Days or units Unit or basis for measurement code and quantity SV103 SV104 Status Required Required Length units or basis for measure 2 AN Length unit amount 3 N 8 N Repeatable Once per line Once per service line A=alphabetic character N=numeric character AN=alphanumeric character Both formats: Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Both formats: This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. 1500: Enter numbers left-justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point. Both formats: Anesthesia services must be reported as minutes. Units may be reported for anesthesia services only when the code description includes a time period (such as daily management ). 1500: Enter numbers right-justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point. 837P, version 5010: SV103 identifies the type of units being reported in SV104 with one of the following: Coding Structure MJ Minutes UN Units 837P, version 5010: Field allows a decimal point in SV104. The field length of eight digits does not include the decimal point. If a decimal is used, the maximum number of digits allowed to the right of the decimal is three. 837P, version 5010: Anesthesia services must be reported as minutes. Units may be reported for anesthesia services only when the code description includes a time period (such as daily management ). 837P, version 5010: According to the implementation guide, anesthesia time is counted from the moment the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the 2015 Optum360, LLC 5010 refers to version X222A1 Physician or Supplier-43 New or Changed Information

6 Item Numbers 14 33: Physician or Supplier Information Uniform Claim Editor for Professional Services A A A D D patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. Both formats: Report the number of units based on the CPT or HCPCS code description reported in Item 24d of that service line. Both formats: Ambulance mileage is reported for loaded mileage only. Report all medically necessary mileage, including the mileage subject to a rural adjustment, in a single line item. Air mileage must be reported in whole numbers of loaded statute miles flown. (Medicare Claims Processing Manual, Pub , chapter 15, section ) Both formats: Report ambulance ground mileage as fractional units for trips totaling up to 100 covered miles. When reporting fractional mileage, suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage. The decimal must be used in the appropriate place (e.g., 99.9). For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., miles should be reported as 999). For trips totaling less than one mile, enter a 0 before the decimal (e.g., 0.9). (Medicare Claims Processing Manual, Pub , chapter 15, section ) Both formats: For mileage HCPCS code billed on a Form CMS-1500 or ANSI X12N 837P only, contractors shall automatically default to 0.1 units when the total mileage units are missing in Item 24G. (Medicare Claims Processing Manual, Pub , chapter 15, section ) Both formats: When reporting drugs, biologicals, or radiopharmaceuticals that require HCPCS Level II codes, units are entered in multiples of the units shown in the HCPCS narrative description. When the NDC is required, units are entered in multiples of the units shown in the NDC label description. If the units provided exceed the size of the units field or require more characters to report than there are spaces available in the format, repeat the HCPCS or NDC code on multiple lines until all units can be reported. (Medicare Claims Processing Manual, Pub , chapter 17, section 70) Both formats: For rental DME items, including oxygen equipment, report a separate line for each month. One month of service equals a unit of 1. (Medicare Claims Processing Manual, Pub , chapter 20, section 130.6) Both formats: For oxygen contents (HCPCS codes E0441, E0442, E0443, and E0444), report the number of feet or pounds as described by the HCPCS Level II code. (Medicare Claims Processing Manual, Pub , chapter 20, section 150) Both formats: CMS has added a category of edits to the CCI edit file, the medically unlikely edits (MUE), which establish maximum daily allowable units of service. The edits are applied to the services provided to the same patient, for the same CPT or HCPCS code, on the same date of service, when billed by the same provider. Edits are based on both medically reasonable expectations and anatomical considerations. (For more information about MUEs, go to the CMS website at An automatic denial will occur for any units of any line item billed with units greater than the allowable, for claims billed to the carrier. There are separate MUE files for practitioner services and DME supplier services, as well as hospital outpatient department services. An appeals process will be allowed for those claim line items that are denied. Services denied due to these edits cannot be billed to the patient, nor can an ABN be used to assign financial responsibility to the patient. 44-Physician or Supplier 5010 refers to version X222A Optum360, LLC New or Changed Information

7 Uniform Claim Editor for Professional Services Item Numbers 14 33: Physician or Supplier Information Both formats: A carrier claim will be returned as unprocessable if it does not indicate at least one day or unit in Item 24G. The carrier may program the system to automatically default to one unit when the information in this item is missing. (Medicare Claims Processing Manual, Pub , chapter 1, section ) Both formats: The units reported for rehabilitation services must be based on the procedure code or service reported in Item 24d. Units are reported based on the number of times the procedure, as described by the HCPCS code definition, is performed. For HCPCS codes that do not define a specific time frame for the procedure, use 1 in the units field. Both formats: CMS is imposing edits based on the units of service for therapy services. The following codes may be billed, when covered, only at or below the number of units indicated in the table per treatment day. When units over the stated limit are billed, the units that exceed the limit shall be denied as medically unnecessary. Denied claims may be appealed, and an ABN may be appropriate to notify the patient of liability (Medicare Claims Processing Manual, Pub , chap. 5, sec and 30). The following edits are to be applied: CPT/ HCPCS Level II Description Timed or Untimed PT Allowed units OT Allowed units SLP Allowed units Speech/hearing Untimed NA evaluation Oral speech device eval Untimed NA Ex for speech device rx, Timed NA 1hr Motion Untimed fluoroscopy/swallow Endoscope swallow test Untimed (fees) Laryngoscopic sensory Untimed test Fees w/laryngeal sense Untimed test Limb muscle testing, Untimed manual Limb muscle testing, Untimed manual Developmental test, Untimed limb Developmental test, Untimed extend PT evaluation Untimed NA PT re-evaluation Untimed NA OT evaluation Untimed NA OT re-evaluation Untimed NA *Physician or nonphysician practitioner (NPP) Physician/NPP * NOT under Therapy POC 2015 Optum360, LLC 5010 refers to version X222A1 Physician or Supplier-45 New or Changed Information

8 Item Numbers 14 33: Physician or Supplier Information Uniform Claim Editor for Professional Services D D D D The allowed units may be billed no more than once per provider, per discipline, per date of service, per patient. A zero (0) in the units column indicates that the code may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP). When physicians or NPP bill always therapy codes, they must follow the policies of the type of therapy they are providing, among them using a plan of care and billing with the appropriate therapy modifier (GP, GO, GN). The allowed units in the table that apply for PT, OT, or SLP depend on the plan of care. A physician or NPP cannot bill an always therapy code unless the service is provided under a therapy plan of care. Both formats: Therapy providers report the code for the time actually spent delivering the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted in determining treatment time. The time counted is the time the patient is treated. Do not bill for services performed for less than eight minutes. The expectation is that the provider s time for each unit will average 15 minutes. It does not imply that any minute until the eighth should be excluded from the total count. The beginning and ending times of the treatment should be recorded in the patient s medical record along with a note describing the treatment. If more than one CPT code is billed during the calendar day, the total number of units reported is limited to the total treatment time. For example, if treatment for CPT code lasts 24 minutes and treatment for CPT code lasts 23 minutes, the total time reported is 47 minutes. Only three units of service can be reported. Two units are allocated to CPT code and one unit to code (Medicare Claims Processing Manual, Pub , chap. 5, sec and 30) Both formats: Review LCDs for limitations on size, amounts, and/or frequency of usage, all of which can affect units reported. Both formats: For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products supplied as refills to the original order, suppliers must contact the patient no sooner than 14 calendar days before the delivery date to confirm that the refilled item remains reasonable and necessary and that existing supplies are approaching exhaustion, and to ascertain whether there are any changes or modifications to the order. (Medicare Program Integrity Manual, Pub , chap. 5, sec ) Both formats: Units reported for DMEPOS should correspond to the physician orders for usage and frequency and to actual supplies delivered, and must be justified by medical record documentation. No more than a one month's supply of dressings may be provided at one time, unless documentation substantiates the necessity of greater quantities. For example, if the order is for a composite dressing to be changed every other day, 10 units are reported for one month. Both formats: Before submitting a claim to the DME MAC, the supplier must have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. Documentation must be maintained in the supplier's files for seven years from date of service.(medicare Program Integrity Manual, Pub , chapter 5, section 5.8 [Trans. 528, July 3, 2014]) Both formats: DME suppliers are required to maintain proof-of-delivery documentation in their files. The proof-of-delivery requirements are based on the method of delivery. The three methods of delivery are: Delivery directly from the supplier to the beneficiary or authorized representative 46-Physician or Supplier 5010 refers to version X222A Optum360, LLC New or Changed Information

9 Uniform Claim Editor for Professional Services Item Numbers 14 33: Physician or Supplier Information D Use of a delivery/shipping service to deliver items Delivery of items to a nursing facility on behalf of the beneficiary Proof-of-delivery documentation must be available to the DME MAC, recovery auditor, and ZPIC on request. All items without appropriate proof of delivery from the supplier will be denied, and overpayments will be requested. Suppliers who consistently do not provide documentation to support their services may be referred to the OIG for imposition of civil monetary penalties or administrative sanctions. (Medicare Program Integrity Manual, Pub , chapter 5, section 5.8 [Trans. 528, July 3, 2014]) Both formats: Medicare does not automatically assume payment for a DMEPOS item that was covered before a patient became eligible for the Medicare fee-for-service program. When a patient receiving a DMEPOS item from another payer becomes eligible for the program, the patient may continue to receive such items only if Medicare requirements are met for those DMEPOS items. The supplier must submit an initial or new claim for the item and the necessary documentation to support Medicare payment upon request to the DME MAC even if there is no change in the beneficiary s medical condition. The proof of delivery, which requires the patient s signature, is evidence that the patient is already in possession of the item. A date of delivery must be noted by the supplier, patient, or designee. The first day of the first rental month in which Medicare payments are made for the item is the start date of the reasonable useful lifetime and period of continuous use. The DME MAC considers the proof-of-delivery requirements met for this type of patient when the supplier obtains a statement, signed and dated by the patient (or patient s designee), that the supplier has examined the item. The supplier must also attest to the fact that the item meets Medicare requirements.(medicare Program Integrity Manual, Pub , chapter 5, section 5.8 [Trans. 528, July 3, 2014]) 2 Fraud Alert In early 2014, recovery audit contractors (RACs) for region A and B began reviewing units billed for hospital visits. Both initial hospital care codes (CPT codes ) and subsequent hospital care codes (CPT codes ) are per diem services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice. Also in early 2014, RACs for region A and B began reviewing observation claims. Region A is looking at physician reporting of observation care of less than eight hours. Region B is looking at discharge services incorrectly reported with observation services on the same date of service Optum360, LLC 5010 refers to version X222A1 Physician or Supplier-47 New or Changed Information