Otolaryngology Coding Alert

Record the beneficiary's exact card data, or face nonpayment

If Medicare denies 99213-25 in addition to 31575 on the same claim, your beneficiary information could 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, states the Medlearn Matters article SE0516 issued on Feb. 14, 2005. Here's what you need to do to avoid rejections.

Match These 3 Elements

Old rule: To get a match on a Medicare patient, CMS previously required only three of five elements on the common working file (CWF). 

New guideline: Medicare now requires three of three elements. When you submit a Medicare claim, the data must match the Medicare beneficiary record on these elements:

1. beneficiary's first name.

2. beneficiary's last name (surname)

3. health insurance claim number.

Example: An otolaryngologist treats a current Medicare beneficiary for follow-up of pansinusitis and controlled asthma. Due to the patient's new complaint of hoarseness, the physician also performs a laryngoscopy that reveals no problems. Documentation supports a level-three established patient office visit separate from the procedure.

You assign 99213-25 (Office visit for the evaluation and management of an established patient ...; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) in addition to 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) and enter the patient's name "John Stevens" on the claim form. Because you use separate diagnoses for the service and procedure - 493.01 (Extrinsic asthma, with status asthmaticus) and 473.8 (Chronic sinusitis; other chronic sinusitis) linked to 99213-25, and 784.49 (Voice disturbance, other [including hoarseness]) with 31575 - you expect payment on both codes.

Problem: The patient's Medicare card reads, "Michael J. Stevens." But he uses his middle name, John, which you reported instead of his given first name, Michael.

Result: Medicare denies the entire claim, including the laryngoscopy and the office visit. The rejection delays payment of about $169.78. The 2005 National Physician Fee Schedule pays 99213 at a national rate of $52.68 (1.39 relative value units) and 31575 at a nonadjusted rate of $117.10 (3.09 RVUs).

Verify Your Records

To avoid across-the-board denials, you should check patients' Medicare cards. Otherwise, you could be setting the claim up for failure.

Verify that the name on record matches the name shown on the beneficiary's Medicare card. If you haven't updated a patient's Medicare information or received the demographics from the hospital, you could be submitting outdated, incomplete or incorrect data.
 
Strategy: If the patient indicates that the name on the card is incorrect, you should still report the "card" information. Advise the individual to contact his local Social Security Field Office to obtain a new Medicare card.

Method: In the laryngoscopy and office visit claim, the coder should have checked the long-time patient's information. If she had noticed the discrepancy between the patient's nickname and card data, she could have avoided the denial for 99213-25, 31575.

Editor's note: To download the Medlearn Matters article SE0516 "Modified Edits for Matching Claims Data to Beneficiary Records," go to www.cms.hhs.gov/medlearn/matters/.