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Top Provider Questions – Claims

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  1. When do I adjust a claim versus appealing it?

    • Review the Claim Status and Corrections job aid and the Appeals, Adjustments and the D9 Claim Change Reason (Condition) Code article.

      • If the item you need to change is medically denied (e.g., remark code MA01: file an appeal using the CGS Redetermination FormPDF. Note: you must file an appeal within 120 days of the date of the initial claim determination (i.e., date on your Remittance Advice (RA).
      • If the item you need to change is not medically denied, adjust the claim through Direct Data Entry (DDE). "Note: Black Lung claims cannot be entered or adjusted through DDE".
      • If the adjustment cannot be completed in FISS (e.g., the claim is past timely filing and you need to correct the patient status so another provider can bill), submit a hard-copy adjustment using the Clerical Error Reopening Request Form, or XXQ Type of Bill in DDE.
      Reviewed 09/22/2021
  2. What is the correct way to submit a provider liability claim?

    • When an entire inpatient admission did not meet medically necessary inpatient criteria, that claim must be submitted as provider liable. The provider is liable because no notice was issued to the beneficiary. The beneficiary is not charged with utilization of benefit days, and the provider may not collect deductible and/or coinsurance. After the no-pay inpatient claim has been processed and a Remittance Advice (RA) issued, you may submit an ancillary (12X TOB) claim.

      The following information must be included on the claim:

      • Type of Bill (TOB) 110
      • Non-covered days
      • The services from admission through discharge
      • The appropriate patient status
      • Occurrence Span Code M1 and dates of service
      • Non-covered charges for all services rendered
      • All diagnosis codes
      • All procedures codes
      Reviewed 09/22/2021
  3. Under what circumstances should we submit Condition Code 44?

    • When a hospital utilization review committee determines inpatient admission does not meet criteria, the hospital may change the beneficiary's status from inpatient to outpatient. Submit an outpatient claim (TOBs 13X, 85X) for medically necessary Medicare Part B services. Use Condition Code 44, if ALL of the following conditions are met:

      • Change made in patient status PRIOR to discharge or release.
      • Hospital has NOT submitted an inpatient claim.
      • Physician concurs with the utilization review committee's decision.
      • Physician concurrence with utilization review committee is documented in the medical records.

      Reference:

      Reviewed 09/22/2021
  4. What is the appropriate use of Occurrence Code 42?

    • For dates of service prior to January 1, 2012, Occurrence Code (OC) 42 is required if the beneficiary was discharged or revoked the hospice benefit as of the 'TO' date on this claim. The date used with the OC 42 is the date of discharge or revocation.

      For dates of service January 1 through June 30, 2012, OC 42 is only required in the following situations:

      • Patient discharged as no longer terminally ill; or
      • Patient revokes his or her hospice election.

      For dates of service on and after July 1, 2012, OC 42 is only required when the patient revokes his or her hospice election.

      References:

      • CMS MLN Matters® article MM 7473External PDF, "Correction to Processing of Hospice Discharge Claims"
      • CMS MLN Matters® articleMM 7677External PDF, "New Hospice Condition Code for Out of Service Area Discharge"
      Reviewed 09/22/2021
  5. I am aware that source of admission code 7 is no longer valid. What code replaces it?

    • Source of admission code 7 was eliminated because if the beneficiary is in the hospital's emergency room (ER), they are already in the hospital. If they are already in the hospital, then the ER cannot be the source for the admission or visit to the hospital. In addition, the source of admission has been redefined as point of origin. Since the 7 is no longer valid, providers must enter one of the other point of origin codes. The code should reflect from where or by whom the beneficiary was referred to the hospital.

      Reference:

      Reviewed 09/22/2021
  6. I have a beneficiary who was part of a Medicare Advantage (MA) plan for part of his stay. How do I bill for services we provided to him?

    • Under the Medicare hospital benefit, if the provider is in inpatient acute care hospital, inpatient rehabilitation facility or a long term care hospital, and the patient changes MA status during an inpatient stay for an inpatient institution, the patient's status at admission or start of care determines liability.

      If the beneficiary was not an MA enrollee upon admission but enrolls before discharge, the MA organization is not responsible for payment.

      For hospitals exempt from the Prospective Payment System (PPS) (i.e., children's hospitals, cancer hospitals and psychiatric hospitals/units) and Maryland waiver hospitals, if the MA organization has processing jurisdiction for the MA involved portion of the bill, it will direct the provider to split the bill and send the appropriate portions to the appropriate Fiscal Intermediary (FI) or MA organization. When forwarding a bill to an MA organization, the provider must also submit the necessary supporting documents.

      If the provider is not a PPS provider, the MA organization is responsible for payment for services on and after the day of enrollment up through the day that disenrollment is effective.

      Reviewed 09/22/2021
  7. I have a claim where all lines are rejected due to reason code 10416. What does this code mean?

    • This is a claim level reject reason code for claims that have all line items rejected with C7251, C7252, C7253, C7254, C7255, C7256 or C7257 received from the Common Working File (CWF). These rejections usually appear on the claim when the line item dates of service (LIDOS) are within the admission and discharge dates of another facility's claim. For example, reason code C7251 will appear as the claim denial when the LIDOS of an outpatient claim (e.g., 12X, 13X, 14X, 22X, 23X, 34X, 74X, 75X, 83X and 85X) overlaps with a Part A skilled nursing facility (SNF) inpatient claim (21X) or when the outpatient claim LIDOS overlaps with an inpatient Part B (22X) claim.

      Reviewed 09/22/2021
  8. I recently started receiving edits for medical necessity on my clinical trial claims. I am using ICD-9 code V707. Was there a recent change to this diagnosis code for medical necessity?

    • You must ensure, based on the year of your claim, that the appropriate modifiers are present on the claim so that it may process correctly. For outpatient clinical trial claims:

      1. All services on the claim are related to the trial - Institutional providers billing clinical trial claims that contain only clinical trial line item services do not have to report the routine Healthcare Common Procedure Coding System (HCPCS) modifiers QV or Q1. The presence of condition code 30 along with the absence of HCPCS modifiers QV or Q1 is the provider's attestation that all line item services on the claim are routine clinical trial services, with the exception of any investigational item on the claim that would be identified with HCPCS modifier Q0.
      2. Claim contains both services related and unrelated to the trial - Institutional providers billing clinical trial claims that contain both clinical trial line item services and non-clinical trial line item services, must bill the following elements:
      3. Submit HCPCS modifier Q1 only on line items related to the clinical trial diagnosis code V70.7 (examination of participant in clinical trial) as the secondary diagnosis and condition code 30.

      Reference:

      Reviewed 09/22/2021
  9. Is there a limit to the number of claims that can be seen in the return to provider (RTP) status?

    • Yes currently, up to 5,000 RTP claims can be seen. Suppressed claims are excluded from this count.

      Reviewed 09/22/2021
  10. My claim contains HCPCS code C9399 (Unclassified drugs or biologicals), and received reason code 32512 indicating the associated units must be equal to one. Please explain this reason code.

    • Reason code 32512 states, 'type of bill is equal to outpatient, pricing indicator = Y, HCPC C9399 is present but associated units are greater than one. Units must be equal to one.'

      HCPCS code C9399 should be used to report drugs and biologicals that have been approved by the Food and Drug Administration (FDA), but that do not yet have a product-specific drug/biological HCPCS assigned. HCPCS code C9399 should be reported as follows:

      • For the ANSI ASC X12N 837 I, hospital outpatient departments will report on type of bill (TOB) = 13x, containing revenue code 0636, HCPCS code C9399, and NDC number present in Loop 2400 LIN 03 of the 837 I
      • The hospital may report in the 'Remarks' section of the CMS-1450 or its electronic equivalent the National Drug Code (NDC) for the drug, the quantity of the drug that was administered, the unit of measure applicable to the drug or biological, and the date the drug was furnished to the beneficiary

      When billing the applicable information for the unassigned drug on Page 2 in Direct Data Entry (DDE), providers should report one drug per revenue line. In addition, each occurrence of C9399 should be billed with a corresponding unit of one, regardless of the actual quantity of the drug that is administered.

      Examples:

      1. Drug 'X' is approved by the FDA, but does not yet have a HCPCS code assigned. During the outpatient encounter on January 1, 2013, five units of the drug are administered.

        Rev HCPC Unit Serv Date
        0636 C9399 1 0101

      2. Drug 'X' and Drug 'Y' are approved by the FDA, but do not yet have a HCPCS code assigned. During an outpatient encounter on March 1, 2013, five units of Drug 'X' are administered and three units of Drug 'Y' are administered.

        Rev HCPC Unit Serv Date
        0636 C9399 1 0101
        0636 C9399 1 0101

      Note that the unit of one will essentially act as a placeholder and will direct CGS to review the additional NDC information that will be present on the claim. In addition to the information included on Page 2, the provider should also include the NDC number, the quantity of the drug that was administered, the unit of measure applicable to the drug and the date the drug was furnished in both 'Remarks' and on the NDC page in DDE.

      This information will be reviewed and used in the pricing of the unassigned drug(s). CGS will manually calculate the payment for the drug or biological at 95 percent of the average wholesale price (AWP). The Fiscal Intermediary (FI) will pay 80 percent of that calculated payment to the hospital; beneficiaries will be responsible for the 20 percent co-insurance after the deductible is met.

      References:

      Reviewed 09/22/2021
  11. When are uncorrected returns to provider (RTP) claims purged from the Fiscal Intermediary Shared System (FISS)?

    • Return to provider (RTP) claims purge after 180 days from the FISS. Suppress view claims are removed from FISS Claim Correction but are not removed from the Claim Count Summary in FISS. Please note that the 180 day count begins on the last date of access to the claim in RTP under Claims Correction in FISS Direct Data Entry (DDE).

      Reviewed 09/22/2021
  12. Why are my adjusted claims receiving reason code 30902?

    • Reason code (RC) 30902 is applied to an adjusted claim when the cross-reference (x-ref) document control number (DCN) does not match with the original claim that is being adjusted. To ensure that the correct cross-reference DCN is applied to the adjusted claim,

      • Access the claim through DDE using the Claims Inquiries menu option 02 from the main menu.
      • Display the claim that needs to be adjusted, press the 'F8' key to move to Page 2 of the claim, then press the 'F2' key. The DCN will display at the top of the screen.
      • Some DCNs will be a series of numbers and three letters at the end of the DCN while other DCNs will include four spaces and a two-digit site indicator at the end. Ensure you are capturing the complete DCN. This means that if there is a two-digit site indicator code after the actual DCN, the site indicator code as well as all spaces between the DCN must be entered on the adjusted claim.

      DCN Examples:

      21007000000000NCR 03 (DCN with two-digit site indicator. The site indicator will vary.)
      21007000000000NCR (DCN without a site indicator.)
      Reviewed 09/22/2021
  13. I am a provider and my Remittance Advice (RA) indicates a 935 withholding. Please explain.
    • The 935 withholdings are due to Recovery Audit Contractor (RAC) adjustments. Providers are sent a letter from the finance department approximately the same day that the adjustments show on the Remittance Advice (RA); however, the money will not be withheld for 40 days. This will allow providers time to submit an appeal or send in a check to CGS. Should you have questions, please call the overpayment hotline at 803.763.5960. Representatives have copies of letters that were sent to the provider and should be able to explain the withholdings. The 935 withholdings can be for more than just RAC adjustments. Overpayments that are subject to 935 include the following:

      Determined post-pay denials of claims for benefits under Medicare Part A for which a written demand letter was issued:

      • Recovery Auditor (RA)
      • Program Safeguard Contractor (PSC) or Zone Program Integrity Contractor (ZPIC)
      • Comprehensive Error Rate Testing (CERT) contractor
      • Office of Inspector General (OIG)
      • Medicare Secondary Payer (MSP) recovery where the provider/supplier received a duplicate primary payment and for which a written demand letter was issued MSP recovery based on the provider's/supplier's failure to file a proper claim with the third party payer plan, program or insurer for payment
      • Final claims associated with a home health agency (HHA) Request for Anticipated Payment (RAP) under Home Health Prospective Payment System (HHPPS), but not the RAP itself

      Resource:

      Reviewed 09/22/2021
  14. Providers are currently beginning the recovery audit contractor (RAC) process. Where can providers find additional information regarding the RAC process?
  15. We had an outpatient therapy claim deny with reason code U5390 overlapping with a home health agency. How can we receive payment for therapy in this case?

    • It is the provider's responsibility to verify a patient's eligibility prior to rendering services. You may ask the Medicare patient if he/she is receiving home health care at the time of the services, or if you are a Direct Data Entry (DDE) provider, you may utilize HIQA and HIQH to verify if the services fall within the home health episode. If the dates of service are within the home health episode, you will need to contact the home health agency to set a contractual arrangement for reimbursement.

      Reviewed 09/22/2021
  16. We would like additional clarification on Condition Codes D9 versus D7 for MSP. We sent a claim as Medicare primary and later discovered that another payer is primary to Medicare. When we adjusted the claim to make Medicare secondary with a D7 condition code, the claim was rejected because no payment is reported from the primary. What should we do?

    • If the claim was initially processed as Medicare primary and is being adjusted to process as Medicare Secondary, and the primary payer made a payment, use the D7 condition code and verify that the correct MSP value code is reported with the amount paid by the primary payer. If no payment was made by the primary payer, or the claim was initially processed as a Medicare Secondary Payer code and being adjusted to reflect additional MSP information, use a D9 condition code. When using the D9 condition code, the adjustment reason must be entered in the Remarks field. One of these remarks must be included: BE, CD, DA, DP, FG, NB, PC, PE, or PP. Without remarks on the claim, the claim will be RTPd.

      Reviewed 09/22/2021
  17. Can there be a post of processing issues on the CGS website?

    • CGS maintains a Claims Processing Issues Log on our website. It is a list of current system-related claims processing issues that are reported to the Centers for Medicare & Medicaid Services (CMS) and/or the Fiscal Intermediary Standard System (FISS). Check this site often for updates before contacting the Provider Contact Center. This information is updated weekly.

      Reviewed 09/22/2021

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