Unlisted Procedure and Not Otherwise Classified Codes: Noridian

Processing Changes: Effective 9/16/13, items requiring an invoice must follow the below criteria. Faxes will only be reviewed for PWK processing.
When billing for a service or procedure, select the CPT, HCPCS, or drug code that accurately identifies the service or procedure performed. If no such code exists, then report the service or procedure using the appropriate "unlisted procedure code or Not Otherwise Classified (NOC) code (which often end in 99). Noridian will not correctly code unlisted codes when a valid code is available.

Correct Coding Guidelines

• It is the responsibility of the provider to ensure all information required to process unlisted procedure codes or (NOC) codes is included on the CMS-1500 form or the electronic media claim (EMC) when the claim is submitted.
• If required information is missing, the code will be denied or deemed unprocessable.
• Descriptions of the unlisted procedure codes include, but are not limited to, narratives, trip notes for ambulance claims, etc.
• Enter a concise description of the services rendered in Item 19 on the CMS-1500 claim form. If the description does not fit in Item 19, an attachment describing the services must be submitted for providers who submit paper claims.
• When submitting attachments (e.g., operative report, office notes, invoices) to support the unlisted code billed, unless it is immediately evident, identify the unlisted procedure with a written description, or by underlining or marking the billed service on the attachments. Highlighters should not be used as this obliterates the text and is not visible after the document is photocopied or scanned.
• The electronic equivalent for Item 19 on EMC submissions will hold up to 80 characters for the concise statement and should be enough space to describe the unlisted procedure code.

Unclassified Drug Billing

The following unclassified drug codes should be used only when a more specific code is unavailable:

• J3490 Unclassified drugs
• J3590 UNCLASSIFIED BIOLOGICS
• J9999 Not otherwise classified, anti-neoplastic drug

When submitting a claim using one of the codes listed above, enter the drug name and dosage in Item 19 on the CMS 1500-claim form or the electronic equivalent. Pricing will be based on the information entered in these fields. The quantity-billed field must be entered as one (1).

Compound Drug Billing Exception

An exception to the unclassified drug code instruction above is the billing of compound drugs (often prepared by special pharmacies), which should be billed as outlined in the companion articles published simultaneously with this article:

• Compounded Drugs Reimbursement Billing Revised – November 2011
• Infusion Drugs Reimbursement Billing Revised – November 2011

If there is a valid J-code for the drug billed, the unlisted code will not be correctly coded by Noridian. The unlisted code will be denied as a billing error. Medicare payment will be based on the information submitted. If the required information is not submitted, any unlisted procedure or service will be denied as unprocessable.
Source: Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 26, Section

Courtesy of Noridian https://www.noridianmedicare.com/je/docs/unlisted_procedure_and_not_otherwise_classified_codes.html

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Medicare: Noridian Telephone Reopening Request Guidelines

Beginning September 16, 2013, Part B providers can contact Noridian Telephone Reopening through a single toll free service phone number, 855-609-9960, which includes the Part A and B Provider Contact Centers (PCC), Electronic Data Interchange Support Services (EDISS), Provider Enrollment and User Security.
Telephone Reopenings will be staffed to respond to Part B inquiries Monday – Friday from 6 a.m. – 5 p.m. PT. We will continue to accept telephone reopening requests for items and services Palmetto previously allowed; however, we would also like to inform you of additional telephone reopening services we provide.

Additional Telephone Reopening Services
5 Reopenings per call
Diagnosis additions or changes due to medical necessity (including Local Coverage Determination (LCD) and National Coverage Determination (NCD) denials)
Add modifier AS, 80, 82, 52, 24
Add GV and GW modifier to Hospice claims
Change the MSP type Who Can Request a Telephone Reopening? Physician or supplier Third party authorized by physician or supplier. (Clearinghouse, biller, coder) Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations Complete Claim(s) Research before Calling Reopenings Claim status inquiries call Interactive Voice Recognition (IVR) at the single toll free customer service number. All other inquiries contact Provider Contact Center (PCC) at the single toll free customer service number. If your facility has received an Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR) indicating that a claim has denied as unprocessable (e.g. MA130 and CO16), it does not have rights to a reopening or an appeal and must be corrected and submitted as a new claim. NOTE: To ensure that the claim in question is truly finalized, wait 4–5 days following your ERA receipt to call Reopenings. Be Prepared When calling Telephone Reopenings the following information must be available when you call. If the following information is not available, you will be referred back to the IVR to obtain the information prior to completing any telephone reopenings. Please remember there’s a limit 5 reopening requests per call. Caller’s name and phone number Provider name and Medicare billing number, National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) (individual or group) * Beneficiary’s Medicare Health Insurance Claim (HIC) number * Beneficiary’s last name and first initial* Beneficiary’s date of birth * Date of Service (DOS) Internal Claim Number (ICN) of the claim Billed amount Procedure code (CPT or HCPCS) in question Corrective action to be taken on the claim *The elements with an asterisk must be verified for compliance with the Privacy Act. Corrections (changes/additions/deletions) can be made for the following clerical errors or omissions: Diagnosis additions, changes and deletions Place of service changes Clinical Laboratory Improvement Act (CLIA) Numbers changes or additions Mammography Certification Numbers changes or additions Month/Day of service changes Procedure code changes – up and down code Modifiers additions, changes and deletions Add or change post operative dates Assignment changes (Participating to Non-Participating) Changes that may cause an overpayment (ex. down coding) Change the MSP Type – must match the type and primary insurer on file Add 25 modifier to paid Critical Care (99291-99292, 99298) Prolonged Services (99354-99359) All Psychology codes Initial Preventive Physical Examination (IPPE) Codes (G0402-G0405) Change rendering NPI & PTAN of provider – must be within the same group Ground Ambulance miles changes – up to 50 miles Ground Ambulance (A0428) when billed modifiers HH, RH, NH, EH, SH, PH, HI, and IH Ambulance claims denied duplicate when there were two trips at different times Corrections (changes/additions/deletions) cannot be made for the following clerical errors or omissions: Unprocessable claims Claims that require documentation to make a change (too complex) Year of service Claim line additions and deletions MSP Type changes Recoupment issues Claim(s) with initial determination dates over one year old Erythropoietin (EPO) (J0881-J0886, Q4081) Vertebroplasty (22520-22525) Paravertebral Facet Joint (64493-64495, 64635-64636) Claims paid by another contractor (denial message 610) Modifier additions – GA, GY, GX, GZ, QA, QU, QV, Q1, QJ, 21, 22, 23, 66, and 74 must be requested in writing Air Ambulance Transitional codes 99495-99496 Corrections (changes/additions/deletions) may be made for the following clerical errors or omissions, depending on situation. Units /number(s) of service Modifiers Unlisted procedure codes (if code is on adjudication list, we can adjust) Hospice modifiers May add date span and fractions only (77427, 77336, 77417) Note: Lists included above are not all-inclusive. Reopening Filing Limits Requests must be received by Noridian within one (1) year from the original claim processing date determined by the original Medicare Summary Notice (MSN), ERA, or SPR date. Requests received after the one (1) year time limit will be dismissed as untimely. Good cause for late filing will not be considered over the phone and is not applicable for Telephone Reopenings as described in the Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 29, Section 240. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf   Reopening Timeline Calculator available on the Noridian “Appeals” webpage Type remittance advice date in box Click “Check” button Displays date the request must be received at Noridian CMS mandates that Reopening requests be completed by the Medicare Contractor (Noridian) within 60 days from the date the request was received at the Noridian office. Reopening Determination Notification Approved Determination – An ERA or SPR will contain the payment determination. A separate determination letter for fully favorable reopenings is not sent. Per CMS, IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 34, Section 10.2, "If a contractor receives a reopening request and does not believe they can change the determination, they should not process the request." Disclaimer: If any of the above requested changes, upon research, are determined to be too complex, the requestor will be notified that the request needs to be sent in writing, with the appropriate documentation, as a Redetermination. Courtesy of: Noridian https://www.noridianmedicare.com/je/docs/telephone_reopening_request_guidelines.html

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What is a superbill?

What is a superbill? Also known as a charge slip or patient encounter. A superbill is an itemized form consisting of CPT, HCPC and ICD-9-CM/ICD-10-CM codes. This form is completed by a provider to communicate services rendered to his biller.

 

The patient name, date of birth, medical record number, demographic information and insurance information is commonly found at the top of a superbill.
When the patient arrives at their physician's office the receptionist prints a superbill. The physician will complete the superbill during and/or after seeing the patient and completing the chart notes. The superbill then goes to the medical biller to enter into the billing software and send a claim electronically or by paper to the patients insurance company.
Electronic Medical Records (EMR) programs will have a superbill template on the screen the physician uses, often on a tablet. The physician simply chooses the diagnosis/diagnoses and service(s) rendered by touching his screen. The information is then sent electronically to the medical biller. Then it is reviewed and converted onto a claim form for electronic or paper claim billing to the insurance company.
By: Gina Thatcher of Smart Billing Solutions www.smartbillingsolutions.net

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CMS 1500 claim form instructions

The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies. Please contact your Medicaid State Agency for more details.
The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form. CMS does not supply the form to providers for claim submission. In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).
The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form. The majority of paper claims sent to carriers and DMERCs are scanned using Optical Character Recognition (OCR) technology. This scanning technology allows for the data contents contained on the form to be read while the actual form fields, headings, and lines remain invisible to the scanner. Photocopies cannot be scanned and therefore are not accepted by all carriers and DMERCs.
You can find Medicare CMS-1500 completion and coding instructions, as well as the print specifications in Chapter 26 of the Medicare Claims Processing Manual (Pub.100-04).

The NUCC has developed a 1500 Reference Instruction Manual detailing how to complete the claim form. The purpose of this manual is to help standardize nationally the manner in which the form is being completed.

The current version of the instructions (v 9.0) was released in July 2013.
• Version 9.0 7/13

Courtesy of: http://www.nucc.org/index.php?option=com_content&view=article&id=33&Itemid=114

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HCPCS Background Information

Each year, in the United States, health care insurers process over 5 billion claims for payment. For Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II Code Set is one of the standard code sets used for this purpose. The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. These health care professionals use the CPT to identify services and procedures for which they bill public or private health insurance programs. Decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are republished and updated annually by the AMA. Level I of the HCPCS, the CPT codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.
Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established for submitting claims for these items. The development and use of level II of the HCPCS began in the 1980's. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits.
In October of 2003, the Secretary of HHS delegated authority under the HIPAA legislation to CMS to maintain and distribute HCPCS Level II Codes. As stated in 42 CFR Sec. 414.40 (a) CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. Within CMS there is a CMS HCPCS Workgroup which is an internal workgroup comprised of representatives of the major components of CMS, as well as other consultants from pertinent Federal agencies. Prior to December 31, 2003, Level III HCPCS were developed and used by Medicaid State agencies, Medicare contractors, and private insurers in their specific programs or local areas of jurisdiction. For purposes of Medicare, level III codes were also referred to as local codes. Local codes were established when an insurer preferred that suppliers use a local code to identify a service, for which there is no level I or level II code, rather than use a "miscellaneous or not otherwise classified code." The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required CMS to adopt standards for coding systems that are used for reporting health care transactions. We published, in the Federal Register on August 17, 2000 (65 FR 50312), regulations to implement this part of the HIPAA legislation. These regulations provided for the elimination of level III local codes by October 2002, at which time, the level I and level II code sets could be used. The elimination of local codes was postponed, as a result of section 532(a) of BIPA, which continued the use of local codes through December 31, 2003.
Courtesy of: http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/medhcpcsgeninfo/

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What is a Modifer?

A modifier is a two-digit numeric or alpha numeric character reported with a CPT/HCPCS code,

when appropriate. Modifiers are designed to give Medicare and commercial payers additional
information needed to process a claim.
A modifier provides the means by which a physician can report or indicate that a service or
procedure that has been performed has been altered by some special circumstances(s), but has
not changed in its definition or code. Modifiers also enable health care professionals to effectively
respond to payment policy requirements established by other entities. These codes should be
entered in item 24D on the Form CMS-1500 or electronic equivalent.

Some examples of when a modifier may be appropriate include:
A service or procedure has both a professional and technical component, but both
components are not applicable

A service or procedure was performed by more than one physician and/or in more than

one location

A service or procedure has been increased or decreased in complexity or performance

 

An adjunctive service was performed

 

A bilateral procedure was performed

Unusual events occurred during a procedure or service

Placement of a modifier after a CPT or HCPCS code does not insure reimbursement. A special

report may be necessary if the service is rarely provided, unusual, variable or new. The special
report should contain pertinent information and adequate definition of the procedure or service
performed that supports the use of the assigned modifier. If the service is not documented, or the
special circumstance is not indicated, it is not considered appropriate to report the modifier. A
report should not be submitted unless requested.

Some modifiers are informational only (e.g., -24 and -25) and do not affect reimbursement. They

can however, determine if the service will be covered or denied.
Other modifiers such as modifier -22 (increased procedural services) will increase the
reimbursement and protocol for many third-party payers if documentation supports the use of
this modifier. Modifier -52 (reduced services) will usually equate to a reduction in payment.

There will be times when the coding and modifier information issued by CMS differs from the
AMA’s coding advice in the CPT manual regarding the use of modifiers. A clear understanding
of Medicare’s rules is necessary in order to assign the modifier correctly. It is the responsibility of
each provider or practitioner submitting claims to keep abreast of the Medicare program
requirements.

The use of modifiers is an important part of coding and billing for health care services. Modifier

use has increased as various commercial payers, who in the past did not incorporate modifiers
into their reimbursement protocol, recognize and accept CPT/ HCPCS codes appended with
these specialized billing flags.

Correct modifier use is also an important part of avoiding fraud and abuse or noncompliance

issues, especially in coding and billing processes involving the federal and state governments.
Several of the top billing errors involve the incorrect use of modifiers.

This article courtesy of: http://www.medicarenhic.com/providers/pubs/ModifierBillingGuide0611.pdf
 

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