In order to send claims to Medicare , the proper software , electronic IDs and registration with Common Electronic Data Interchange ( CEDI ) needs to be established . In the near future , claims will have to be sent via a service bureau . The service bureau will bundle the claims and send them to the DME MAC , and , in turn , will send all reports back to you . There is an annual fee for this service , and charges do vary widely . Please do your research on each company , as there are significant differences in fees .
Medicare claims are based on the address where the beneficiary applied for Medicare . A person residing in Indiana may have turned Medicare age while snow birding in Florida , in which case the claims have to be sent to Jurisdiction C . Claims with an address that does not match that on their Common Working File ( CWF ) will be rejected . Another problem is with birthdays . The date in the CWF may be different from the one the patient gives to you . This is a more common problem than one would imagine .
It is a good idea to verify the data with either the IVR or CONNEX whenever a new patient is added . The birthday issue will quickly be identified because you need the date to get into their system .
Next , the webinar covered coding . The Healthcare Common Procedure Coding System ( HCPCS ) level 2 coding is an alphanumeric code . CPT codes are numeric only . Pedorthists use HCPCS codes in their billing . Modifiers are used in conjunction with the codes to indicate more specifics on the code used . Modifiers are used in paying claims according to the payment policy and need to be present for accurate processing of the claim . The type of modifier depends on the payment category . It is important that you review the codes and modifiers for your claims . You often don ’ t get a chance to correct a mistake , and that can cost you revenue .
There are several places to look online to find information for claims , including your DME MAC ’ s website . DME PDAC is the branch that reviews codes , payment structures and even items such as therapeutic shoes for conformity with CMS regulations .
If you need more than four modifiers on a claim line , the code “ 99 ” is placed in the fourth placeholder with the additional modifiers in the NTE box ( narrative ).
Medicare pricing is established via the fee schedule . This is published at the end of the calendar year and becomes effective Jan . 1 . The schedule is updated annually , and it is important to review it because HCPCS codes , modifiers and pricing frequently change . Some codes are added , some are deleted , etc . ( More information is available in Chapter 16 of the Supplier Manual .)
Chapter 17 covers benefit and denial categories . The most common are CO-50 ( medical necessity denials ), PR-96 ( statutory exclusions ), B15 ( fragmented coding ), CO-18 ( duplicate claim denial ) and CO-16 ( incomplete claims ).
Chapter 18 covers remittance notices and how to read them . The homepage of the MAC website has a link to an interactive guide to the codes used and what they mean .
Reopening and appeals can be a technical nightmare if you do not understand how to use them .
Reopening is used for claim corrections for minor appeals . The claim will be denied first , and if it is found that some minor error was made — for instance , not enough detail in the diagnosis — the error can be corrected by contacting the appropriate office either by phone or fax . Please check the date on the remittance advice . The call can be placed only after the payment date shown on the document . There is a 12-month window from the date on the remittance form to do this .
There are multiple levels to appeals , and they are completely explained in the supplier manual . Here are some highlights :
Redeterminations are sent to the DME MAC that originally processed the claim . Redeterminations are used when more information is needed to support the claim or a major clerical error occurs .
Reconsiderations are sent to an outside contractor who reviews the case with a new set of eyes .
The third common level is to ask for a hearing from the local administrative law judge .
Overpayments are of two types : supplier initiated and CMS initiated . A supplier who was paid in error has a responsibility to return the funds to the MAC . There is a specific form available on the website for this purpose . Most overpayments come from the MAC once they determine that a claim was paid in error . There are times when the MAC is in error and you will have to go through the appeals process . If you get the notice from CMS about an overpayment , you have 30 days to respond to it ( repay or file an appeal ). CMS recommends that you send the funds back at the first request , then go through the appeal process . If you are successful , you will be repaid with interest . Should the funds not be repaid , interest accrues from the 30-day period if your appeal is unsuccessful .
Lost checks : Most suppliers are paid via electronic remittances . If a paper check is lost , you must wait 90 days from issue date to make a written request for replacement . Mutilated checks are to be sent back to the overpayment unit , which will issue a new document . ■
Dean Mason , C . Ped ., OST , BOCO , CO , BOC Pedorthist , owns North Shore Pedorthics , LLC , in Lorain , Ohio , and is a member of PFA ’ s Board of Directors as well as co-chair of PFA ’ s Government Affairs Committee and a member of the Marketing , Communications and Editorial Committee .
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