Inpatient SNF Denial and Error Codes: How to Avoid or Correct Them August 8, 2012 Agenda Part I: Part II: Part III: Top Claim Denials for Skilled Nursing Facilities (SNF) Common Claim Submission Errors Strategies for Billing Correctly PART I TOP CLAIM DENIALS FOR SNFs        7NC21 – Noncovered or excluded service (beneficiary liable) 38200 – Duplicate claims C7010 – Overlapping hospice dates of service 39508 – Benefits exhausted 19904 – No 3 day qualifying stay 11503 – SNF admission is longer than 30 days after a qualifying hospital stay 34528 – Medicare is secondary to another payer 7NC21 – Noncovered or Excluded Service (Beneficiary Liable) 7NC21 is the most common denial reason code for SNFs for the last six months. However, this error code is assigned to claims that are submitted as beneficiary liable because services are not at a covered level of care or are statutory exclusions. The submitting provider realizes the services on the claim are not covered, but is requesting a denial notice from Medicare. 38200 - Duplicate Claims Claim is an exact duplicate of a previously submitted claim where the following fields on a previously processed claim and the rejected claim are the same:  Health Insurance Claim (HIC) number  Type of bill  Provider number  Statement from and through date  Total charges (0001 revenue line item)  Revenue code(s)  HCPCS and modifiers Verify the information billed and resubmit a new claim if appropriate. Questions to ask:  Is the claim for the correct beneficiary, correct dates of service?  If the claim in question is in the system, does an error need to be worked? Created 04/20/12 1 http://www.wpsmedicare.com/    Does the claim need to be adjusted instead of resubmitted? http://www.wpsmedicare.com Has the claim rejected for a technical reason? Has it denied for a medical reason? C7010 – Overlapping Hospice Claim Claim has from and through dates that overlap a hospice election period and is not indicated as treatment of a non-terminal condition. If the claim is not related to a terminal condition, append a 07 condition code to bypass the edit. If the claim is related to a terminal illness, the charges should be billed to the hospice. 39508 – Benefits Exhausted The beneficiary’s benefits have been exhausted relative to this SNF claim which is subject to benefit period determinations. If benefits have been exhausted, SNF still needs to submit all Part A claims to keep Common Working File (CWF) billing periods up to date. 19904 – No 3 Day Qualifying Stay Medicare payment cannot be made for these services because the claim does not indicate that the beneficiary had a three day qualifying hospital stay. Code 19904 can be bypassed if condition code 04, 21, or DR is present on claim.    Condition Code 04 – Informational only Condition Code 21 - Demand Bill Condition Code DR – Item/service/claim affected by CMS deemed emergency/disaster 11503 – SNF Admission is More Than 30 Days After a Qualifying Hospital Stay The date of admission to a SNF is greater than 30 days after the through date of the qualifying stay. However, neither condition code 55, 56 or 57 is present. Code 11503 will also be assigned to all subsequent 213 and 214 SNF claims if condition codes 55, 56, or 57 are not present. This edit will be bypassed if condition code 55, 56, or 57 is on the claim:  Condition Code 55 – SNF bed not available  Condition Code 56 – Medical appropriateness  Condition Code 57 – SNF readmission 34528 – Medicare is Secondary to Another Payer Records indicate that this beneficiary has coverage through a group health plan that is primary over Medicare. 2 Verify MSP information. If Medicare is the secondary payer, bill the primary payer and then Medicare. If Medicare is the primary payer, bill Medicare after MSP information on http://www.wpsmedicare.com CWF has been updated. PART II COMMON SUBMISSION ERRORS         12206 – The number of days billed do not equal the date span 12302 – Covered plus noncovered days must equal days billed in statement covers period 38118 – Continuing stay SNF claim; prior claim is pending but not finalized 38119 – Continuing stay SNF claim, but no record of a prior claim 39011 – Claim was not filed timely 39012 – Justification for timeliness N5052 – Beneficiary’s name and HIC do not match U5233 – Claim overlaps one or more HMO periods 12206 – The Number of Days Billed Do Not Equal the Date Span The number of covered and noncovered days billed are not equal to the number of days between the from and through dates.     If the patient status is not a 30, the though date of the claim is not counted. If the patient status is a 30, the through date is counted. If the from and through dates match, the claim must show one day. If the claim is a same day transfer, the day must be counted as a non-covered day; however, the charges are listed as covered. 12302 – Covered Plus Noncovered Days Must Equal Days Billed in Statement Covers Period The number of covered and noncovered days that are billed are not equal to the number of days between the from and through dates of the claim. If the patient status is not a 30, the through date of the claim is not counted; if the patient status is a 30, the through date is counted. If the from and through dates match, the claim must show one day. If the claim is for a same day transfer, the day is counted as a noncovered day. 38118 – Continuing Stay SNF Claim. Prior Claim is Pending But Not Finalized This is a continuing stay SNF claim. SNF claims must process in chronological sequence. The prior claim is pending but has not yet finalized. Resubmit or store (PF9) this claim after you have received the remittance advice for the prior claim. 3 38119 – Continuing Stay SNF Claim, But No Record of a Prior Claim http://www.wpsmedicare.com Inpatient SNF claims must process in chronological sequence. There is no record of the prior claim. Submit the prior claim(s) and store (PF9) this claim after you have received the remittance advice for the prior claims(s). 39011 – Claim Was Not Filed Timely Claims with date of service (DOS) on or after 01/01/10 which are received more than 1 year beyond the DOS will be denied as being past the timely filing deadline. For inpatient SNF claims timely filing is counted from the through date on each monthly claim. 39012 – Justification For Timeliness The justification for timeliness reason code 39011 override message is not formatted correctly or is missing. On page 4 of the claim enter one of the following verbatim:  Justify: MSP Involvement  Justify: SSA Involvement  Justify: PRO review involvement  Justify: Other involvement N5052 – Beneficiary’s Name and HIC Do Not Match Beneficiary identification is incorrect. CWF records indicate that the beneficiary’s name and/or HIC do not match, or the HIC number is not on file. Verify the information with the beneficiary’s Medicare card. Make corrections as appropriate. U5233 – Claim Overlaps One or More HMO Periods If a SNF claim overlaps more than one Health Maintenance Organization period:  Split bill the claims using the effective and termination dates of the HMOs (recorded on CWF) to determine the from and through dates of the claims. For a claim that is submitted with condition codes 04 and 07:   If the claim falls within a hospice election period remove the 04 condition code. If the claim discharge date is equal to a hospice election date, remove the 07 condition code. 4 PART III STRATEGIES FOR BILLING CORRECTLY http://www.wpsmedicare.com Admission Procedures When admitting a beneficiary to an inpatient stay: Verify beneficiary identification.  Check name against Medicare card – does it match Check beneficiary eligibility.  Part A and/or Part B Verify if beneficiary has Traditional Medicare or HMO.  Check CWF; check start and termination dates of Medicare Advantage policies Collect MSP information.  Administer MSP Questionnaire  Check CWF for primary insurance information  Contact Coordination of Benefits Contractor (COBC) with any changes Communication between various staff members and departments.  Admission and billing  Billing and clinical  Management MSP and COBC To ensure correct claim submissions and timely payment:    Collect health insurance information upon each office visit, outpatient visit, and hospital admission. Identify primary payer and bill responsible payer. Use specific and correct diagnosis codes, especially for accident related claims. Report directly to the COBC any changes in MSP related information.    Update with beneficiary in the office. COBC will update information via a telephone call only on the first call. No update will be made on subsequent calls. Work with beneficiary or representative to contact COBC. Can fax or mail proof of information on the insurer or employer’s letterhead. Billing Procedures Bill covered inpatient SNF claims monthly and in chronological sequence. Bill No–Pay claims monthly if a denial is needed for another insurance, or at discharge if a denial is not needed. 5 Bill all Part A claims whether payment is expected or not to keep benefit period information up to date on CWF. http://www.wpsmedicare.com To avoid duplicate errors, verify the claim was entered into the FISS system before resubmitting a new claim. If a claim was assigned an error code, make the appropriate correction(s). If you are unsure about why the claim received an error, contact Customer Service. Providers without access to DDE can call the Correction Line to have the claim worked. When adjusting a claim, make sure to adjust the correct claim. Remember, each adjustment cancels the previous claim on Common Working File. If unsure of which claim to adjust, contact Customer Service. RESOURCES & REFERENCES The following resources and references were used to create this presentation and are given here for provider convenience. For more information on claim submission and processing we recommend providers visit the WPS Medicare and CMS websites frequently, and sign up for the WPS eNews. eNews is the fastest way for WPS to keep providers up to date with the latest Medicare regulation changes. CMS website: http://www.cms.gov/ WPS Medicare website: http://www.wpsmedicare.com/ To sign up for eNews: https://corpws.wpsic.com/apps/commercial/unauth/medicareListservUserWelcomeLoadAction.do Direct Data Entry (DDE) Direct online access to Medicare claims. Features claim entry, claim status, eligibility inquiries through Common Working File (CWF), as well as other functions. Legacy: http://www.wpsmedicare.com/part_a/resources/claims_elig_tools/direct_data_entry/inde x.shtml J5: http://www.wpsmedicare.com/j5macparta/resources/claims_elig_tools/direct_data_entry/ index.shtml 6 Interactive Voice Response Unit (IVR) http://www.wpsmedicare.com Quick and easy access to Medicare information 24 hours a day. Legacy: http://www.wpsmedicare.com/part_a/resources/claims_elig_tools/interactive_voice_resp onse/index.shtml J5: http://www.wpsmedicare.com/j5macparta/resources/claims_elig_tools/interactive_voice_ response/index.shtml CMS Secure Net Access Portal (C – SNAP) J5 MAC Providers Self-service source for patient eligibility, claim status and more. http://www.wpsmedicare.com/j5macparta/resources/claims_elig_tools/csnap/index.shtml Customer Service Available for complex claim inquiries regarding Medicare coverage, billing and claim processing. J5 MAC: http://www.wpsmedicare.com/j5macparta/departments/customer_service/index.shtml Legacy: http://www.wpsmedicare.com/part_a/departments/customer_service/index.shtml Covered, Noncovered, or Excluded Services CMS Internet – Only Manual (IOM) Publication 100 – 02, Medicare Benefit Policy Manual, Chapter 8  Section 20 – Prior Hospitalization and Transfer Requirements Publication 100 – 02, Medicare Benefit Policy Manual, Chapter 16  Section 10 – Excluded services Inpatient Skilled Nursing Facility Billing CMS Internet – Only Manual (IOM) Publication 100 – 04, Claims Processing Manual, Chapter 1  Section 70 – Time limitation for filing Part A and Part B claims Publication 100 – 04, Claims Processing Manual, Chapter 6  Section 30 – Billing procedures  Section 40.8 – Benefits exhaust billing 7 Skilled Nursing Facility and Hospice http://www.wpsmedicare.com CMS Internet – Only Manual (IOM) Publication 100 – 04, Claims Processing Manual, Chapter 6, Section 20.2.2 Medicare Secondary Payer Billing CMS Internet – Only Manual (IOM) Publication 100 – 05 Medicare Secondary Payer Manual, Chapter 3  Section 40 – Completing the Form CMS – 1450 in MSP Situations by Provider of Service  Section 50 – Summary of MSP Data Elements for Form CMS – 1450 MLN Matters Number SE1205 – Updating Beneficiary Information with the Coordination of Benefits Contractor MLN Matters Number SE1217 – Guidance for Correct Claims Submission When Secondary Payers are Involved This program is presented for informational purposes only. Current Medicare regulations will always prevail 8