Which type of claim includes those that were rejected due to an error or omission and need to be processed?

Comprehensive Coding Initiative Edit Denial Information

The Remittance Advice will contain the following codes when this denial is appropriate.

• M80: Not covered when performed during the same session/date as a previously processed service for the patient
• CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

Correct Coding Initiative (CCI): The Centers for Medicare and Medicaid Services (CMS) wanted to develop, promote, and encourage correct coding practices in order to prevent payment that could be given in error.

The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual.

Resolution/Resources

Check CCI edits

For specific information on modifiers that may be used to denote exceptions to CCI (including CPT modifiers 24, 25, 59, 76 and 91), refer to the Modifer Tool on the CGS website.

Evaluation and Management Services, with Direct Reference to Global Surgery Denials

The Remittance Advice will contain the following code when this denial is appropriate.

Resolutions/Resources

The global days of a surgery are determined by CMS. As part of the Medicare Physician Fee Schedule database (MPFSDB), the codes all include their global information.  Please check the website

• Evaluation and Management Services can be payable according to certain guidelines within a global period.  However, verification of the post-operative global days for the services provided and the appropriate diagnosis information will help make sure that any action taken to correct the claim will be approved.
• The modifiers 24 and 25 are the common modifiers that are used in these situations.  However, they do have guidelines.  Please check the CGS Modifier Tool for further information about the 24 and 25 modifier.

Please Note: When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.

Reference

Non-Global Denials Involving Modifiers

Hospice: Non-Attending Physician Denials

The Remittance Advice will contain the following code when this denial is appropriate.

Resources/Resolution

Determine whether the patient has elected hospice benefits prior to submitting claims to Medicare.  That information can be verified through the Provider Customer Service customer service line. 

Hospice Benefits and Medicare Part B

• Claims from the attending physicianfor services provided to hospice-enrolled patients with HCPCS modifier GV. This is true regardless of whether the care is related to the patient's terminal illness. HCPCS modifier GV signifies that the attending physician for the patient's hospice care is not employed or under any sort of payment arrangement with the particular hospice provider who is providing services.
• If the physician in question was rendering services that were unrelated to the patient's terminal hospice condition, the GW modifier should be reported in order to indicate payment should be allowed for those services.

Reference

Access CMS guidelines related to hospice through the following links:

CPT Modifier 26

The Remittance Advice will contain the following code when this denial is appropriate.

Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier "26" to the usual procedure code.

This modifier denotes that the provider performed the "interpretation only". Modifier "26" is most commonly used with diagnostic tests, including labs and x-rays.  Refer to the Medicare Physician Fee Schedule Database (MPFSDB)

Reference

Complete definitions of supervision indicators are available in CMS Pub. 100-04, Chapter 23

What is a dirty claim?

What is a clean claim?

What is the proper term for a claim that has been successfully submitted without errors?

What is the process of accepting or denying a submitted claim called?