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Neurology & Pain Management Coding Alert

Have You Gone Electronic?

Published on Tue Jan 20, 2004

CMS final rule mandates e-claims

Have you begun submitting your Medicare claims electronically? If you haven't, you won't be compliant with HIPAA's transaction rule - and in virtually every circumstance, you won't get paid.
 
CMS made that clear in an interim final rule published in the Federal Register Aug. 15. The rule formally requires that Medicare claims be submitted electronically starting Oct. 16, with only a handful of exceptions.
 
CMS makes the biggest exception for small providers and suppliers. CMS defines "small" entities as either a.) a provider of services with fewer than 25 full-time equivalent employees, or b.) a physician, practitioner, facility or supplier with fewer than 10 full-time employees. The remaining exceptions include:
 

  • Circumstances in which there is no method available for the submission of an electronic claim - claims submitted directly by beneficiaries, for example, would fall into this category, as would roster billing of vaccinations, claims submitted under Medicare demonstration projects, and claims in which more than one plan is responsible for payment prior to Medicare.
     
  • Claims submitted during a service interruption that's beyond the control of the organization submitting the claim.

    CMS states that practices can appeal to their carriers for special waivers that will excuse them from electronic billing. But carriers will likely grant these waivers only in "extraordinary circumstances," states an alert from attorneys William Sarraille, Laura Cole and Susie Squier with Sidley Austin Brown & Wood in Washington. The agency also says in the rule that it applies to initial Medicare claims - not changes, adjustments or appeals.
     
    Failing to bill electronically could saddle you with severe consequences. "The Secretary may audit entities that continue to bill Medicare nonelectronically, and those in violation may be subject to claim denials, overpayment recoveries, and applicable interest on overpayments," the Sidley Austin attorneys say.

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