Medicare Compliance & Reimbursement

Tip: Ensure the primary EOB is correct for MSP claims.

Many Part B providers find the Medicare claims process complicated and confusing. If your practice is struggling to keep on top of the ever-changing rules and regulations impacting your payments, you’re not alone.

In fact, Part B Medicare Administrative Contractors (MACs) field questions every day from practices grappling with claims innuendo and confusion, so you can benefit from understanding the common queries the MACs see. By reviewing the answers to the most frequently-asked questions MACs receive, you may find solutions to resolve your own practice coding and billing issues.

Noridian Healthcare Solutions’ Carynne Godfrey shared expert insight on providers’ top claims woes during the Part B MAC’s webinar, “Top Provider Inquiries and Solutions.”

Read on to get a handle on some of the highlights, which could benefit your Part B practice.

Make Sure the CPT^® Code Is Valid

“One of the top coding errors that we see is an invalid CPT® code,” Godfrey said. “These can include services that are non-covered, invalid for Medicare, or bundled.” To halt these types of denials, you can go to the Medicare Physician Fee Schedule (MPFS), where you can review the indicators and descriptors for a specific code. “If you see that it has a ‘B’ for the claim indicator, then you’ll see that it’s a bundled code and it’s not going to be paid separately for Medicare,” she advised.

Important: In the Fee Schedule, you’ll also find the bilateral indicators, whether physician assistants can be employed during surgery, whether a multiple procedure reduction exists, and more.

Review the Proper Usage of E/M Modifiers

Another frequently seen issue is the incorrect use of an E/M modifier. “The most common issue we see is with modifiers 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), and 57 (Decision for surgery) being billed on the surgical code itself and not on the E/M code,” explained Godfrey. “Always make sure you’re appending E/M modifiers to the actual E/M code,” she added.

In addition, Noridian also sees incorrect use of the E/M modifiers, such as modifier 57 used on an E/M code when it’s reported with a procedure code that has a zero-day global period, for example. In reality, modifier 57 applies only to E/M services billed on the same date as procedures with 90-day global periods.

Don’t Drop the Modifiers — Append Accordingly

Another area that prompts claim denials involves missing modifiers, Godfrey said. “Unbundling modifiers represents a big area here,” she indicated. The claim could deny because a modifier wasn’t appended to a code pair that is bundled, but which can be billed together in certain circumstances.

Tip: To find the Correct Coding Initiative (CCI) information, you can use the Centers for Medicare & Medicaid Services (CMS) website, she suggested. Once you identify the edits that bundle certain codes together, you can investigate whether a modifier can separate the codes, which will help guide you when submitting claims that include these codes.

Godfrey advises practices to investigate the global surgical periods of every procedure they’re planning to report. “This is good to know so you can find out if there’s a modifier you need to append before billing so you don’t get a denial,” she added.

Revisit Medicare Secondary Payer Rules and Requirements

Noridian also sees a lot of issues with Medicare Secondary Payer (MSP) claims. “If you see the error that’s an Invalid MSP Type, that means the MSP code you’re billing is different from what we have on file for that beneficiary,” mentioned Godfrey. Depending on what type of insurance that the patient has, the MSP Type will be different, she said. If you report the incorrect MSP Type, you can request a reopening and change the MSP Type, she noted.

In other cases, MSP information is missing from a claim. “When you’re billing a paper claim, if the patient does not have another insurance, you need to enter the word ‘none’ in box 11 of the paper claim,” she said. “This error happens very often, and it will deny. This doesn’t apply to electronic claims.”

In other cases, the practice will put the word “none” in box 11, but the patient actually does have other insurance. “It’s your responsibility as a provider to verify that information,” Godfrey noted.

Tip: If you do file an MSP claim, you’ll need to attach a copy of the primary EOB to your claim. “We can’t pay as a secondary payer without knowing what the primary insurance paid,” she said. “It needs to be a clear, legible copy, and must have the same date of service as the claim date of service. We often see an EOB for the wrong patient or with a different date of service, so you need to make sure that information is there.”

Peruse These FAQs

In addition to its most frequent denial reasons, the MAC also shared the questions that providers frequently ask.

Payments: “The most common payment question we get asked has to do with the applied deductible,” Godfrey relayed. “Sometimes you’ll receive a Remittance Advice (RA) showing the claim is being paid but at a $0 amount. This is usually due to those monies being applied to that patient’s deductible. You can see this on the RA itself, and it most often happens at the beginning of the year,” she said.

Another common question arises when a claim is processed and doesn’t pay anything because the money instead goes to the patient. “If you don’t accept assignment in item 27 of the claim form, or if there’s any dollar amount in item 29, the claim will pay to the patient,” Godfrey cautioned. “Item 29 is only for the amount the patient has paid. If this is a secondary claim, do not put the primary insurance information into box 29. If either of those boxes has information in it, the money is going to be paid to the patient.”

Post-op: Providers also call the MAC to ask about postoperative care claims, which occur when one surgeon performs the actual surgery, but another physician takes over the postoperative care. An example of this would be if a thoracic surgeon performs a lung volume reduction surgery in another town where a large hospital is located, and then the patient returns to her hometown for the rest of the postoperative period, where the pulmonologist handles the postoperative care.

“Often these claims will involve missing modifiers 54 (Surgical care only) or 55 (Postoperative management only); sometimes the post-op physician will report a different code than the surgeon, or the wrong modifier. The codes and modifiers for the post-op care provider must match the same codes and modifiers the surgeon reports,” she said. In addition, the date of service should be the date of surgery — not the date you took over care. The post-op and surgery claims must have matching dates of service.

In item 19, however, the post-op provider should include the date span of care. “If you don’t include a date span, we don’t know how many days of post-op care you performed, so we can’t pay you for it,” Godfrey noted. “Those are all manually calculated — how many days you’re billing leads to how much each physician gets paid. So the date span is very important.”

Double trouble: Duplicate claims can also present problems. “Billing multiple claims for the same date of service is very common,” Godfrey said. “It could be that you rebilled instead of reopening a claim, it could be that the claim is applied to the deductible and that didn’t get noticed on a remittance advice.” If you know that you submitted a claim and you’re just seeking claim status, don’t resubmit the claim, she advised. Instead, go to the MAC portal and check the status of the claim there.