JE Medicare Part B Processing Changes Using CPT Modifier 52-Reduced Services - Effective September 16, 2013

Noridian has identified a claim processing difference between contractors .This notification is to make all Part B providers served by Jurisdiction E (JE) aware of this difference. 
Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. A concise statement that explains the nature of the reduced service along with any other supporting documentation the provider deems relevant. The concise statement may appear on the operative report but, it must be clearly identified. This statement may be entered in the electronic documentation field or submitted via the fax attachment process. For paper claims, this documentation must be submitted as an attachment to the CMS-1500 claim form. Services that are submitted with CPT modifier 52 that do not include a concise statement will be rejected as 'unprocessable' and must be resubmitted as new claims
Noridian requires the provider to determine the charge amount, reduce normal fee by percentage of service not provided e.g., if 75% of normal service provided, reduce amount billed by 25% Medicare reimburses lower of actual charge or fee schedule allowance.

Example: Provider performs 75% of service and appends modifier 52
Medicare Physician Fee Schedule (MPFS) allowed amount	$300
Reduced Billed Amount ($300 x 75%)	$225

• Reflect statement “reduced services” in Item 19 (narrative or electronic equivalent)
• Documentation reflecting “reduction” reason retained in patient’s medical record
• Do not confuse with “terminated procedure” modifier 53
• Never use with evaluation and management or anesthesia codes

Appeals

• When submitting the Redetermination request include:
•  A separate, concise statement explaining the necessity for allowable reduction
•  An operative report or chart notes

Example

• Performed on one eye; unilateral
• Do not use RT or LT

Treatment Description	CPT/Modifier
Fundus photography with interpretation/report; bilateral	92250 52

READ MORE - JE Medicare Part B Processing Changes Using CPT Modifier 52-Reduced Services - Effective September 16, 2013

"New" CMS-1500: WCMS-1500CS-12 Date of Implimentation Unknown (as of August 2013)

1500 Health Insurance Claim Form Change Log 6/17/2013 
The following is the list of changes between the 1500 Claim Form 08/05 version and the 02/12 version.

 

Header: The barcode was removed.

Header: The language “PLEASE DO NOT STAPLE IN THIS AREA” was removed from the left-hand side.

Header: The rectangle with “1500” was added in black ink to the left-hand side.

Header: The title “HEALTH INSURANCE CLAIM FORM” was moved from the lower, right-hand side to the left-hand side.

Header: The language “APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05” was added to the left-hand side.

Header: The language “TEST VERSION – NOT FOR OFFICIAL USE” was added to the right-hand side. This language will be removed when the form is approved by OMB.

Box 1: “TRICARE” was added above “CHAMPUS”.

Box 1: Under CHAMPVA, “VA File #” was changed to “Member ID#”.

Box 17a: The box was split in half length-wise.

Box 17a: This area was shaded. This box will accommodate other ID numbers.

Box 17a: Two vertical lines were added. This field will accommodate a two byte qualifier for other ID numbers.

Box 17b: This field was added.

Box 17b: Two vertical lines were added with the “NPI” label. This field will accommodate the NPI number.

Box 21: The lines after the decimal point in items 1, 2, 3, and 4 were extended to accommodate four bytes.

Box 24: The line with the alpha indicators was removed. The alpha indicators were moved next to the respective titles in the title fields.

Box 24: The line numbers to the left of Box 24 were increased in size and centered with each line.

Box 24: Each of the six lines were split length-wise and shading was added to the top portion of each line. This area is to be used for the reporting of supplemental information.

Box 24: Vertical line separators on each of the six lines have been removed from the shaded area,               except for the lines before Boxes 24I and 24J.

Box 24C: “Type of Service” was removed. This field is now titled “EMG”.

Box 24D: The field became wider by three bytes.

Box 24D: Shading was added vertically between “CPT/HCPCS” and “MODIFIER”.

Box 24D: Vertical lines were added in the unshaded “MODIFIER” section to accommodate four                  sets of two bytes.

Box 24E: The title was changed from “DIAGNOSIS CODE” to “DIAGNOSIS POINTER”.

Box 24E: The field was decreased by three bytes.

Box 24G: This field was increased by one byte.

Box 24H: This field was decreased by one byte.

Box 24I: The title was changed from “EMG” to “ID. QUAL.”.

Box 24I: A horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field.

Box 24I: The label “NPI” was added in the unshaded portion of the field.

Box 24J: The title was changed from “COB” to “RENDERING PROVIDER ID. #”. 1500 Claim                            Form Change Log – 11/29/05

Box 24J: A dotted horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field. The NPI number is to be reported in the unshaded field. An other ID number can be reported in the shaded field.

Box 24K: This field, “RESERVED FOR LOCAL USE”, was removed.

Box 32: Boxes 32a and 32b were added at the bottom.

Box 32a: This field was added to accommodate reporting of the NPI number and is indicated by the shaded label of “NPI”.

Box 32b: This shaded field was added to accommodate the reporting of other ID numbers.

Box 33: Parentheses were added after the title to indicate the location for reporting the telephone number.

Box 33: Boxes 33a and 33b were added at the bottom.

Box 33a: The title of this field was changed from “PIN#” to “a.”.

Box 33a: A shaded label of NPI was added to the box to indicate the reporting of the NPI number.

Box 33b: The title was changed from “GRP#” to “b.” to accommodate the reporting of other ID numbers.

Box 33b: The field was shaded.

Footer: The language “NUCC Instruction Manual available at: www.nucc.org” was added to the left-hand side.

Footer: The OMB approval numbers were removed and the language “OMB APPROVAL                 PENDING” was added. The numbers will be added after approval has been received by OMB.

Back: The following language was added in the last line at the bottom of the form: “This address     is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM  FORMS TO THIS ADDRESS.”

 

Courtesy of HMBA

READ MORE - "New" CMS-1500: WCMS-1500CS-12 Date of Implimentation Unknown (as of August 2013)

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

READ MORE - What is a superbill?

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

READ MORE - CMS 1500 claim form instructions