Cirius Newsletter Issue 10 January 2010

Proper Billing of the Statement Covers From and Admission/Start of Care Dates on Institutional Claims
Medicare modifies system edits to review the Statement FROM and Through dates of an initial inpatient claim to be reported prior to the 'Admission/Start of Care: date, for those claims which require "Admission/Start of Care" dates. Medicare systems shall note the applicable bill types are 011x, 012x, 018x, 021x, 022x, 034x, 041x, 081x, 082x, 032x, and 033x.
CMS Transmittal 581OTN CR6584

Billing for Services Related to Voluntary Uses of ABN for Non-coverage
Modifier - GA has been redefined to mean "waiver of Liability Statement Issued as Required by Payer Policy" and should be used to report when a required ABN was issued for a service.
NEW Modifier - GX has been created with the definition "notice of Liability Issued, Voluntary Under Payer Policy" and is to be used to report when a voluntary ABN was issued for a services. Note: GX modifier must be submitted with non-covered charges only, and you MAC will deny the claim as a beneficiary liability.
MLN6563

IP Claims and processing of non-covered ICD-9-CM procedure codes
Hospitals MUST submit ICD-9-CM codes for non-covered procedures performed in the same inpatient stay with covered procedures on a SEPARATE CLAIM. Note that the Statement Covers Period should match on both the covered and the non-covered claim.
CMS Transmittal R1838CP CR6547
MLN6547

ESRD 50/50 Modifier Rule
Medicare will validate claims for AMCC ESRD-related tests provided to a beneficiary who is ESRD eligible to ensure your compliance with billing instructions regarding the use of the ESRD 50/50 rule modifiers CD, CE, AND CF.
CMS Transmittal 586OTN CR 6683
MLN6683

POS for Walk-In Retail Health Clinics
Effective March 11, 2010
The current place of service has been updated to add a new code of 17 (Walk-in Retail Health Clinic). The codes description is as follow: "a walk-in health clinic, other than an office,urgent care facility, pharmacy or independent clinic and not described by any other POS code, that is listed within a retail operation and provides on an ambulatory basis, preventative and primary care services."
CMS Transmittal 1869 CR6752
MLN6752

Medically Unlikely Edits (MUEs)

The MUE program was designed to reduce errors due to clerical entries and incorrect coding. An MUE is a unit of service (UOS) edit for a HCPCS/CPT code for services that a single provider/supplier rendered to a single beneficiary on the same date of service. In order to report medically reasonable and necessary services example CPT modifiers such as 76, 77, RT, LT, F1, F2, 91 and 59 may be used. Finally, a denial of services due to an MUE is a coding denial, not a medical necessity denial. An ABN is not allowed to be issued,nor can the beneficiary be billed for denied units.
CMS Transmittal 617 CR6712

Gender/Procedure Conflict

Report Condition Code 45 for Part A claims processing, institutional providers on inpatient or outpatient services that can be subjected to gender specific editing. Part B claim professional claims may use KX modifier on the detailed line item in question.

CMS Transmittal R1877 CR6638
MLN6638

Modifiers PA, PB, PC

Some providers are using the PC modifier to represent the professional component of a service. This is incorrect. The PC modifier is defined as "Wrong Surgery on a Patient". The incorrect modifier is causing a significant number of denied claims.
CMS Transmittal R1867CP CR6718

MLN6718

RAC Medical Record Limits Defined
This week CMS announced limits on the number of medical records that may be requested contractors.
Read full guideline here