Internal Medicine Coding Alert

Question: We've been receiving numerous Medicare claim denials recently, and there doesn't seem to be any correlation between the rejections and certain types of billed services. Any idea what's going on?


South Dakota Subscriber


Answer: The Medicare beneficiary information you're submitting for each patient may be to blame. Since Medicare implemented an October 2004 edit requiring an exact match between claim data and a beneficiary's card information, denials have tripled, according to the Medlearn Matters article SE0516 issued on Feb. 14. Here's how you can avoid rejections:

Match all three elements. To get a match on a Medicare patient, CMS previously required only three of five elements on the common working file (CWF). The new guideline now requires three of three elements. When you submit a Medicare claim, the data must match the Medicare beneficiary record on these three elements:

1. beneficiary's first name,  2. beneficiary's last name (surname), and  3. health insurance claim number.

Verify your records: If you haven't updated a patient's Medicare information in a while, or if you received the demographics from the hospital, you could be submitting outdated, incomplete or incorrect data. And a faulty match will trigger a denial.

Solution: Check patients' Medicare cards - or you're setting your claims up for failure. Verify that the name on the record matches the name on the beneficiary's Medicare card. Sometimes the denial-causing mismatch can be as simple as a different spelling of the patient's name or a missing middle initial.

If the patient indicates that the name is incorrect, you should still report the "card" information, then advise the individual to contact his local Social Security Field Office to obtain a new Medicare card.