Orthopedic Coding Alert

Take a few simple steps to ensure clean claims and proper payments

The Administrative Simplification Compliance Act requires that you electronically submit all initial Medicare claims for reimbursement as of Oct. 16, 2003 (except from small providers with limited exceptions). Of course what this means in our world is not always simple. Processing the changes and information that come our way on a daily basis is difficult, and claim resubmission can be a constant frustration.

But it doesn't have to be difficult if you know where to quickly find the information. CMS has come a long way in instructing our carriers regarding how to process claims and also, unfortunately, when to return them to us for errors.

The following is a list of the most common errors encountered by Medicare and some tips on how you can avoid them. You can discover more about these on the CMS Web site (www.cms.gov) in the Medlearn Matters article SE0712.

HICN Is a Must-Have

Always use the Health Insurance Claim Number (HICN) and name as it appears on the patient's Medicare card.

Tip: CMS carriers receive numerous claims that healthcare providers submit with invalid or incorrect HICNs requiring manual intervention, which could result in beneficiaries receiving incorrect Explanation of Medicare Benefits (EOMB) information. Always be certain you enter the HICNs correctly, and make sure the HICN belongs to the patient for whom you are billing.

HICN format: A correct HICN consists of nine digits immediately followed by an alphabetical suffix. Take particular care when entering the HICN for members of the same family who are Medicare beneficiaries. A husband and wife may have HICNs that share the same Social Security number, but every individual has his or her own alphabetical suffix at the end of the HICN. To ensure proper claim payment, you must append the correct alphabetical suffix to each HICN. And you should never use hyphens or dashes in the number.

Get the Full Address

2. Line item 32 requires that you indicate the place where the provider actually rendered the service to the patient, including the name and address -- and a valid ZIP code -- for all services unless it was in the patient's home.

Be aware that any missing, incomplete or invalid information recorded in this required field will result in the claim being returned or rejected in the system as unprocessable. In addition, using the term -same- in these blocks is not allowed.

Tip: A deliverable address may contain both a street name and number or a street name with a post office box number. Similarly, a PO box by itself is acceptable, and a rural route (RR) number must be with a box number.

On the other hand, a star route number is not a deliverable address, and RD numbers are no longer valid. If rural routes still exist in your area, the correct number should be preceded by RR, and then the box number.

Don't Omit UPIN/NPI

3. Include the referring or ordering physician's name and UPIN on the claim.

You must include this information in item 17 and 17a on all diagnostic services, including consultations. Don't forget the new requirements for using National Provider Identifiers (NPIs).

Tip: Make sure that you and your software vendor are ready to report the NPI numbers to meet the requirements, or your claims will be held up.

When you bill services for more than one provider within your group, you must put the individual provider number in item 24k because item 33 can only accept one individual provider number. Also, make sure the provider number on the claim is accurate and that it belongs to the group.

4. E/M procedure codes and the place of service (POS) do not match.

For example, when submitting 99283, which is an emergency department visit, using POS code 11 (office) is incorrect. Check out the POS code chart on page 118 for an easy reference when assigning these codes.

Make Sure You Have All the Digits

5. Diagnosis codes being used are either invalid or truncated.

If a carrier considers diagnosis codes invalid, this is usually because an extra digit is being added to make it five digits. All codes are not created equal. Make sure to code to the highest level of specificity.

Tip: You should update your encounter forms every year. The best time to do this is Oct. 1 of every year when the new diagnosis codes become effective.

6. Procedure code or modifier was invalid on the date of service.

Claims are being submitted with deleted procedure codes. AMA updates CPT every year in November to take effect Jan. 1, so make sure you-re using the most up-to-date codes and modifiers.

And Remember to Complete Everything

Did you find yourself in one of the above scenarios? It is not uncommon for any of us to be making one (or several) of the above-mentioned mistakes. Not having a global picture of where things are coming from or why we have to do things a certain way can be frustrating.

We must hold ourselves accountable to our providers and to our carriers by submitting clean and accurate claims the first time around. Most of our larger carriers have posted their versions of clean claim requirements on their Web sites for us to now follow, and finding exactly what we-re looking for is much easier for us.

Being proactive by doing your research and learning the requirements of your different carriers can enable your practice to enjoy a consistent cash flow that allows for a sense of satisfaction and stability.

-- Rhonda Buckholtz, CPC, is the practice administrator at Wolf Creek Medical Associates in Oil City, Pa