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Claims Submission Tips

"Do's and Don'ts" for Claims Submission

 

Do

 

Do make sure the beneficiary's name matches their ID card exactly.

Do use the right modifiers. Make sure you have used the appropriate modifier (-51 is the most problematic, carriers say).

Do list the Medicare identification number (UPIN) for the provider.

Do check your codes against the CCI list to determine which CPT® codes can be billed together for Medicare. Some insurance carriers will follow Medicare's determination of which CPT® codes can be billed together.

Do use the correct diagnosis code for the service. This is a common problem and frequent reason for denials. Check that you haven't submitted a three-digit code when a fourth- or fifth-digit code exists (remember, you must code to the highest degree of specificity), or made any typographical errors.

Do list your Clinical Laboratory Improvement Amendments (CLIA) identification number for claims containing laboratory tests performed in your office.

Do properly list purchased diagnostic tests. Those diagnostic services with a professional and technical component are subject to the "purchased diagnostic" provision of the Medicare program. Carriers may decide whether or not the physician performed both components (i.e., did not purchase one of the components from an outside source). To signify whether the test was both performed and interpreted in the physician's office, some carriers require the use of locally assigned codes. Check with your carrier for local guidelines.

 

Don't

 

Don't submit an operative report and a cover letter for claims filed with unlisted CPT codes or CPT codes with modifier 22, Unusual procedural service. Wait until the carrier sends a request for documentation. When the request comes in send your documentation to include the operative report and cover letter. Remember, the operative report is the documentation that describes the procedure performed for which there is no appropriate CPT code or explains what was unusual about the service to warrant additional payment to support modifier 22. The cover letter should detail the procedure performed, explain in layman's terms why the procedure was different, took a longer amount of time or why a higher skill level was required, as the clerk who reviews your claim may not have extensive medical knowledge. This is a change due to the mandatory electronic claim submission implemented by Medicare in July 2005.

Don't bill for a visit that is included in the global period for a surgery or procedure. This rule only applies to those codes with a global period. Remember, you cannot bill for a visit that is used to perform a surgical procedure. Only if the decision to perform the surgery was made during the visit (and modifier -57, Decision for Surgery, is used) can you bill for both the visit and the procedure.

Don't re-submit returned or rejected claim forms. If your claim is returned or rejected for any reason, re-submit a completely new claim. Do not resend the old one and mark it "corrected." This will only result in a second rejection.

Don't bill for an unrelated visit during the postoperative period without modifier -24, Unrelated E&M Service by the Same Physician During a Postoperative Period. A visit during the postoperative period must be unrelated to the surgery to be billed and must include modifier -24. The diagnosis code for this visit should be for something completely unrelated.

Don't automatically resubmit a claim. Remember, it takes roughly 13 days to process an electronic claim and 27 days to process a paper claim. Check the filing date on your original claim before resubmitting.

Don't bill Medicare for routine physical exams and related services. Medicare does not pay for these services. These charges should be collected from the patient. A signed waiver is not required.

Don't write "signature on file" for Item 31 (Signature of Physician or Supplier) of the CMS form 1500 for paper claims. It is appropriate to use "signature on file" and/or a computer-generated signature for electronic claims.

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