I billed a Skilled Nursing Facility (SNF) inpatient claim, which is now editing with reason code 12206 stating that the number of days represented must equal the covered days plus the non-covered days billed. How can I correct this claim?
When from dates and through dates are not the same on the claim, the number of days represented must equal the sum of the covered days plus the non-covered days, unless the patient status is 30, then 1 additional day is added to the calculation. If the dates of service are the same, the bill must show only one day. Enter the amount of covered and non-covered days on page 1 and page 2. After corrects are made, PF9 to update.

I have an outpatient claim editing with reason code 19201 stating that claims received after 05/23/2008 must have the physicians National Provider Identifier (NPI). How do I correct my claim?
As of May 23, 2008, the NPI, which is a single, ten-digit identification number that replaced all other health care provider identifiers - including Medicare provider identification numbers and Unique Physician Identification Numbers (UPINs) used on Medicare claims and all other payers' standard health care transactions. All health care providers, including individual physicians and practitioners, and organizations such as group practices, hospitals, and nursing homes, are required to obtain and use NPIs in connection with all of their HIPAA standard health care transactions. The provider will need to update the claim to add the NPI number.

For more information on National Provider Identifier, visit the WPS Medicare NPI page.

I have a claim that returned back to me for reason code W7072 stating to remove or update the non-billable HCPCS code(s). How can I find out which HCPCS code on my claim is non-billable?
In order to find out which HCPCS on the claim are non-billable you will need to check the Federal Register Addendum B to see which HCPC code has a status indicator of a B or M. Please see CMS' Addendum A and Addendum B Updates to find the most current Addendum B .

I submitted a hardcopy adjustment on a claim that previously rejected due to other insurance coverage. The adjustment is now editing with reason code 77730 stating that the MSP record on Common Working File (CWF) is still showing Medicare as secondary payer. Who do I contact to update CWF?
If CWF has not been updated, you must call the Coordination of Benefits Contractor (COB) at 1-800-999-1118 to update the MSP screen. You may store your adjustment once the screen has been updated.

If we have a patient come into our Critical Access Hospital (CAH) for outpatient services and on the same day they are sent to us from the Rural Health Clinic (RHC) for laboratory services. Can we bill the laboratory services on an 85x type of bill?
Yes, in this scenario you should be billing with an 85x type of bill for the services provided.

Please see CMS' Medicare Claims Processing Manual, Chapter 4 , for more CAH billing information.

I have a claim that rejected with reason code 34471 stating that the A/B MAC records indicate that the beneficiary has coverage through a group health plan that is primary to Medicare. I have submitted the claim to the group health plan and received payment. Can I resubmit a new claim with the payment information or should I adjust the initial claim that rejected?
In order to provide better customer service, reduce phone calls, and have you provide appropriate documentation, we have developed a new process for requesting MSP adjustments. This will allow the MSP Department to more efficiently adjust your claims. Once your information is correct, you may proceed with adjusting the initial claim which was rejected.

For more information, please see the Adjustments page on the WPS Medicare Website.

I have several claims that had lines reject with reason code W7047 stating that service is not separately payable. Is there a way for us to identify which services are not separately reimbursed?
Yes, In order to find out which HCPCS on the claim are not separately payable you will need to check the Federal Register Addendum B to see which HCPCS code has a status indicator of a N.

Please see CMS' Addendum A and Addendum B Updates to find the most current Addendum B .

If a patient has received more than 2 hours of follow-up diabetes self management training for the year, will the provider be held responsible for these services if an Advance Beneficiary Notice (ABN) isn't given?
Yes, the beneficiary is liable for services denied over the limited number of hours with referrals for MNT. An ABN should be issued in these situations. In absence of evidence of a valid ABN, the provider will be held liable.

An ABN should not be issued for Medicare-covered services such as those provided by hospital dietitians or nutrition professions who are qualified to render the service in their state but who have not obtained Medicare provider numbers.

Please see Please see CMS' Medicare Claims Processing Manual, Chapter 4 , for more information on ABNs.

We have several claims editing for reason code 548HR stating that documentation for observation services greater than 48 hours needs to be submitted. These claims have less than 48 hours of observation time billed. Do we still have to submit our documentation for review?
No, if the claims have less than 48 hours of observation time you do not have to submit documentation for review. This was a Claims Processing/Payment Issue and has now been corrected.

We have several bariatric surgery claims suspended with reason code 75013. Is there anything we need to do to these claims?
Claims will suspend into status location SM501B, we then verify bariatric surgery conditions are met. If so, claims are released from that location. If not, claims will be rejected accordingly.

I work for a Critical Access Hospital (CAH). When we bill for a patient that comes to our facility from a Part A Skilled Nursing Facility (SNF) stay to receive laboratory work, emergency room, etc., on an outpatient basis, what discharge status do we use?
If the patient is going back to the Skilled Nursing Facility (SNF), the correct discharge status code would be 03. If the patient is not going back to the SNF and is going home, the correct discharge status code would be 01.

See CMS' Medicare Claims Processing Manual, Chapter 25 , for more information on discharge statuses.

Can emergency room services be billed on a 12x type of bill?
No, the FISS system will edit to prevent payment on Type of Bill 12x for claims containing revenue code 45x, Emergency Room (ER).

Please see CMS' Medicare Claims Processing Manual, Chapter 4 , for more information.

How many occult blood tests (HCPCS code 82270) are allowed at one time?
According to the Medically Unlikely Edits (MUEs), only one unit is allowed per visit.

For more information on MUEs please visit the CMS Website .

Is it acceptable to bill all hyperbaric oxygen therapy (HBO) services on one claim for the month?
Yes, even though hyperbaric oxygen therapy services are not considered a repetitive service, recurring services may be billed either with all services on one claim or billed separately by date.

Please see CMS' Medicare Claims Processing Manual, Chapter 1 , for more information on recurring services.

I understand that Critical Access Hospitals should be billing laboratory tests on an 85x type of bill if the patient is seen in our facility the same day non-patient laboratory tests are performed. Is an Advance Beneficiary Notice (ABN) required to be given in these instances?
No, an Advance Beneficiary Notice (ABN) is not a mandatory requirement. An ABN should only be given when there is a question of whether Medicare will pay for the service provided.

Please see CMS' Medicare Claims Processing Manual, Chapter 30 , for more information on ABNs.

I have a Skilled Nursing Facility (SNF) patient for whom there are several claims that processed out of sequential order. Are there any circumstances to which the A/B MAC would have claims cancelled and processed in order?
If a SNF, any beneficiary, or secondary insurer is disadvantaged by the Common Working Files' (CWFs) first-in/first-out processing, the SNF must notify the A/B MAC to arrange reprocessing of all affected claims.

Please see CMS' Medicare Claims Processing Manual, Chapter 6 , for more information on Reprocessing Inpatient Bills in Sequence.

It is our policy to do 3 creatine kinase (CPK) (HCPCS 82550) tests on a cardiac patient per day. Is this allowable based on the Medicare Unlikely Edit (MUE) table?
According to the latest Medically Unlikely Edits (MUE) table updated on 10/01/2009, 3 units would be allowed for HCPCS 82550.

Can we bill for medications that were ordered by a physician but that the patient refused to take?
The hospital may bill only for services provided. If the provider billing system initiates billing based on services ordered, the provider must confirm that the service has been provided before billing the A/B MAC, Carrier, or fiscal intermediary (FI).

I bill for a Critical Access Hospital (CAH). When one of our employees collects a specimen from a patient in a nearby facility that is not in a skilled care status, can we bill this with type of bill 14x?
Yes, you can bill with type of bill 14x as long as the patient has not received services directly from your facility the same day the specimen was collected. If services were received, you should bill with an 85x type of bill.

For more information, please refer to section 250.6 of the Part B Processing Manual .

Can we, as a Critical Access Hospital (CAH) Swing Bed unit, file a separate claim for an MRI that is done at our facility?
Services provided by the CAH, while the beneficiary is inpatient in the CAH Swing bed that are considered exclusions from SNF Consolidated Billing shall be billed on a 85X type of bill. All related outpatient charges shall be included on the 85X type of bill that would typically be billed for outpatient services.

Page Last Updated: Friday, 06-Nov-2009 14:05:02 CST

Frequently Asked Questions