Keys to Successful Claims Filing

August 30th, 2018 - Noridian Medicare
Categories:   Claims   HCPCS Coding   Medicare  
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There are many factors that can contribute to your success in filing claims and getting reimbursed.  The information below is from the CMS website.

Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim

A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on assigned and/or non-assigned claims; future claims for those services can be filed without obtaining an additional signature. The exception is DME rentals. The one-time authorization for DME rental claims is limited to assigned claims. If you bill non-assigned for DME rentals, you will need to obtain the beneficiary's authorization every month.

Home Blood Glucose Monitor testing supply claims require the spanning of dates

Item 24a - Dates of service must be spanned for the following covered supplies: blood glucose test reagent strips (A4253), platforms (A4255), glucose control solutions (A4256) and lancets (A4259). If the dates of service are not spanned, the claim line will be denied with reason code 16 and remark code N64.

Verify the correct modifiers are appended to the HCPCS code (when applicable) on the claim

Modifiers can be alphabetic, numeric or a combination of both, but will always be two digits for Medicare purposes. Some modifiers cause automated pricing changes, while others are used to only convey information. All applicable modifiers must be appended to the HCPCS code. (Refer to the CMS-1500 claim form instructions for how to report modifiers when more than four modifiers are required.)

Use all resources available, including the following, to determine the appropriate modifier(s).

  • Chapter 5, DME MAC Jurisdiction D Supplier Manual - lists the DMEPOS payment categories and modifier requirements per category.

Beware of duplicate claim denials

Allow 29 days for paper claims and 14 days for electronic claims to process through the system. Use the Interactive Voice Response (IVR) system to inquire on the claim status.

Claims that are denied for medical necessity must be appealed and should not be resubmitted.

Verify the place of service

Coverage for any DMEPOS items will be considered if the place of service is:

01 - Pharmacy
04 - Homeless Shelter
12 - Home
13 - Assisted Living Facility
14 - Group Home
33 - Custodial Care Facility
54 - Intermediate Care Facility/Mentally Retarded
55 - Residential Substance Abuse Treatment Facility
56 - Psychiatric Residential Treatment Center
65 - Dialysis Treatment Center (for IDPN - intradialytic parenteral nutrition)

Coverage consideration for DMEPOS items in a Skilled Nursing Facility (31) or Nursing Facility (32) is limited to the following unless covered under a Part A stay:

  • Prosthetics, orthotics and related supplies
  • Urinary incontinence supplies
  • Ostomy supplies
  • Surgical Dressings
  • Oral anticancer drugs
  • Oral antiemetic drugs
  • Therapeutic shoes for diabetics
  • Parenteral/enteral nutrition (including E0776XA, the pole used to administer parenteral/enteral nutrition)
  • ESRD - dialysis supplies only
  • Immunosuppressive drugs

Make sure you are using a valid procedure code

  • Verify the procedure code in Chapter 16 of the DME MAC Jurisdiction D Supplier Manual.
  • Verify the modifiers to be used with the procedure code.
  • Verify effective date of procedure code or modifiers.

Verify the HCPCS code before using a Not Otherwise Classified (NOC) code

If you are uncertain which procedure code to use, you should contact the Pricing, Data Analysis and Coding (PDAC) for coding verification. When you call make sure to have the product information available. Remember, the appearance of a code does not necessarily indicate coverage.

Submit all the required information when submitting a claim with a Not Otherwise Classified (NOC) code

Required information when submitting a NOC code is manufacturer's name or product name, model number, suggested retail price or manufacturer's invoice price and full description of the item and document the medical necessity for that particular beneficiary (not what the item is used for but why this particular beneficiary needs the item).

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