Pathology/Lab Coding Alert

You know it’s wise to learn from your mistakes, and now you can do that by mining Medicare billing error intel to avoid future denials. Whether your job includes billing or you work with billers to analyze denials, this information will add to your knowledge and improve the success of your claims.

Here’s how: Study the following advice from National Government Services (NGS) provider outreach and education consultants Jennifer DeStefano and Jennifer Lee, in their recent webinar “Medicare Part B Common Billing Errors.” The NGS guidance will give you a good starting point, but always be sure to check each payer’s specific rules.

Effectively Resolve Denials

Before we peek into common error codes and what they mean, here are two bits of advice for how to maximize clean claims and minimize the time and effort you’ll have to invest:

• Monitor claims: Using the tool your Medicare Adminis­trative Contractor (MAC) provides, you can verify whether a claim is pending or approved to pay or has been denied or rejected. If a claim is denied, don’t just resubmit — that will cause a duplicate denial. Instead, you should appeal or request a reopening of the original denial.
• Reopen or redetermination: To fix a minor clerical error, such as a transposed number, reopening the claim is all you need to do. “A redetermination is used for more complex issues that require review of medical documen­tation,” said Lee.

Read on for a glossary of error codes you might see.

Halt Duplicate Billing to Save Time and Money

Submitting duplicate claims can lead to payment delays, getting flagged as an abusive biller, or at worst, fraud charges.

Error message: Medicare will reject duplicate electronic claims as a front-end edit with one of the following status codes on the 5010 277 CA:

• CSCC: A3 — Return as unprocessable
• CSC: 78 — Duplicate of an existing claim/line

Here are some items to keep in mind to avoid unintentional duplicate billing and delays:

• See if your system is set to rebill automatically after 30 days.
• Check electronic data interchange (EDI) software settings.
• See if a claim shows pending status because your MAC requested additional information by way of an EDI.
• Look for an Additional Development Request (ADR) that you may receive after submitting another claim.

Remember: Medicare may not identify and send an error message for duplicate claims received in the same batch. But that error could show up in an audit and still come back to bite you.

Dodge Reassignment of Benefits Errors

When you have a new pathologist in your practice, that individual shouldn’t submit Medicare claims until assigned a provider transaction access number (PTAN). Doing so will get this error code: N290 — Missing incomplete/invalid rendering provider primary identifier.

Cost: If a provider submits a claim before they’re officially linked to the practice, it’s not just the inconvenience of an error that’s at stake. In these instances, the provider is liable, not the patient.

“Once the provider’s application is approved and has an effective date with Medicare, under that group, any claims with dates of service on and after the provider’s effective date may be resubmitted for adjudication. Claims for dates of service outside of the provider’s effective date will not be reimbursed, and the provider is liable for these charges,” explained Lee.

Verify Patient Eligibility

Prior to claim submission, it’s important to verify the patient’s eligibility. Some of the most common eligibility code errors appear like this on the remittance advice (RA):

• OA-109 — Claim/service not covered by this payer/ contractor, you must send the claim/service to the correct payer/contractor.
• PR-31 — Patient cannot be identified as our insured.
• CO-22 — This care may be covered by another payer, or the patient has insurance that is primary to Medicare.

Solutions: Here are some tips to resolve the problem if you get one of those error codes:

• OA-109: You’ll often see this code if the patient is a Medicare Advantage enrollee. You’ll have to track down that information and submit the claim accordingly.
• PR-31: The cause of this error usually occurs during patient registration and is often the result of a transposed Medicare Beneficiary Identifier (MBI). Resubmitting the claim with the updated information should resolve the problem.
• CO-22: Check the eligibility file for information on the patient’s primary insurance (if still working) and after settling with the primary, submit a secondary claim to Medicare. On the other hand, if the insured is retired, submit a Medicare primary claim and report the retirement date in Item 11b of the CMS-1500 claim form or the electronic equivalent.

Distinguish Rejection From Denial

If you submit a claim with missing, incorrect, or incomplete data, you’ll likely see one of the following “rejection” codes:

• CO-16 — Claim/Service lacks information and cannot be adjudicated
• N822 — Missing procedure modifier(s)
• N382 — Missing/incomplete/invalid patient identifier
• MA27 — Missing/incomplete/invalid entitlement number or name shown on the claim
• MA112 — Missing/incomplete/invalid group practice information
• N105 — This is a misdirected claim/service for an RRB beneficiary

Rejection is not the same as a denial; you cannot appeal a rejected claim. “There is only one way to correct a rejected claim, and that’s to correct and resubmit as a new claim,” said Lee.