Medicare Compliance & Reimbursement

Watch those dates of service, MAC addresses, and more.

Your provider documented a claim thoroughly, and you think you’ve selected the right codes — but your claim could still end up denied if you don’t properly bill it.

When it comes to billing issues, Medicare payers have been issuing warnings for years about the most common errors, but many practices haven’t updated their processes to account for the most recent updates. This can lead to claim rejections and denials — which mean lengthy and time-consuming appeals for your practice to create, submit, and process.

Your best bet is to avoid some of the most common Medicare billing errors, so you can submit clean claims and bring in accurate pay every time. Check out eight common errors, along with tips to avoid making these mistakes in your practice.

1. Only Confirming Patient Eligibility Once a Year

Although denials due to patient eligibility most commonly happen in January, they can strike any time of year. For instance, if a patient moves across the state line, you may need to submit their claim to a different Medicare Administrative Contractor (MAC). Or patients who are new to Medicare midyear may tell you they have original Medicare, but you later find out that they’re actually part of an Advantage plan.

Solution: The best way to verify this data and avoid errors is to confirm every patient’s eligibility at every visit, and not just once a year. You should make a copy of their insurance card or scan it into your system and then confirm their eligibility in the plan before rendering services. Don’t wait until you get a denied claim before you start investigating whether a patient actually has the plan they claim to have.

2. Leaving Details Off a Claim

Sure, you can show the payer what you did and demonstrate medical necessity with CPT^® and ICD-10-CM codes, but there’s a lot more to a complete and accurate Medicare claim than adding these details. And when you leave important information off a claim, you’re opening your practice up to denials.

Solution: Make sure you check to see if the service you’re performing has a Local Coverage Determination (LCD) or National Coverage Determination (NCD) in place that guides claim-submission protocol. In some cases, a modifier such as TC (Technical component …) or 26 (Professional component) must be added to a particular code or you can’t collect for it. By researching the coverage guidelines and submission requirements of every service before you bill, you can prevent denials.

3. Missing Filing Deadlines

Every practice thinks they’re on top of filing deadlines, but the MACs say they return tens of thousands of denials every month due to practices missing the claim deadline. This is probably among the easiest mistakes to avoid — you just need to keep your eye on the calendar. And always remember that if your claim is denied due to missing the filing deadline, you have no appeal rights. That claim is reduced to zero, and you have no option to collect.

Solution: You have one year to submit claims to Medicare, so never take longer than that. Some practices may set a claim aside because they’re awaiting additional information — and then forget to follow up later, letting the claim fall through the cracks. By the time they realize the claim remains unpaid, they submit it too late. The best way to avoid this error is to always monitor your billing process and follow up on any unsubmitted claims right away.

4. Failure to Confirm Provider Eligibility

After you go through the credentialing and enrollment process for your anesthesiologists, you may still need to take additional steps in the future to ensure they stay credentialed and enrolled. And if their National Provider Identifiers (NPIs) expire, or you miss a reenrollment or credentialing deadline, your claims could be dead in the water.

Solution: Always put provider credentialing and enrollment deadlines on your calendar and start the revalidation process several months before the deadline approaches. This can be helpful since you may find errors or issues that need to be resolved during the application process. Plus, you won’t always get an approval overnight — there’s sometimes a delay. By starting early, you’ll have better odds of ensuring that your provider revalidation process is complete before it’s due.

5. Mismatching Your Modifiers and Procedure Codes

If your procedure code is inconsistent with the modifier used or the modifier is missing from the claim, your payer will send you a denial.

Solution: Always check your LCD and NCD, as well as the National Correct Coding Initiative (NCCI) table, to see if you’re even able to use a specific modifier. If not, check whether an alternate is required or available.

6. Using Incorrect or Deleted Codes

You must ensure that you’re reporting accurate, up-to-date, and complete ICD-10-CM diagnosis and CPT^® procedure codes. If your claim includes codes that have been deleted, revised, or expanded upon and you don’t report them accurately, you’ll face denials.

Solution: Verify that you’re using the most timely and updated codes and stay on top of the quarterly updates to the NCCI changes. In addition, when you report an ICD-10-CM code, it must be documented in the patient’s record that the patient has that condition. You can’t just put an ICD-10-CM code on a claim because it’s payable.

7. Including an Inaccurate Date of Service

Although it may seem implausible, MACs say they see thousands of claims each year in which the date of service listed was actually after the patient’s date of death. Outside of certain unusual circumstances (such as the radiologist interpreting X-rays after the time of death), this is not acceptable.

Solution: Verify the patient’s eligibility information is correct, and you’ve submitted the correct date of service. If any Social Security files were updated incorrectly with the wrong date of death, the patient’s family will have to get involved to rectify the situation on the Social Security records by submitting the death certificate.

8. Reporting Work-Related Injuries When They Should Go to Workers’ Comp

Work-related injuries or illnesses should be submitted to a workers’ compensation payer before they go to Medicare whenever applicable, but many practices submit them to the MAC as primary, which leads to denials.

Solution: You must verify the patient’s eligibility information to ensure that you know whether a workers’ compensation payer is involved in the claim. If you’re processing a claim for a work-related injury or illness, always double-check who is listed as the primary payer on the claim before submitting it.

Torrey Kim, Contributing Writer, Raleigh, N.C.