Billing Guide TDD/TYY CeltiCareHealthPlan.com

Transcription

1 Billing Guide TDD/TYY Plan.com

2 P OVIDE BILLING G UIDE For Mass: areplus onnector: onnector: Direct 2014 Plan of Massachusetts, Inc.

3 POVIDE BILLING GUIDE TABLE OF ONTENTS Procedures for laim Submission... 4 Phone and Fax numbers... 4 Accurate Billing Information... 5 laims Filing Deadlines... 7 laim equests for econsideration, laim Disputes and... 8 orrected laims... 8 laim Payment Procedures for ELETONI Submission Electronic laim Submission Electronic laim Flow Description & Important General Information Invalid Electronic laim ecord ejections/denials Specific Electronic Edit equirements Information Adjusted EDI laims Exclusions Electronic Billing Inquiries Important Steps to a Successful Submission of EDI laims: Procedures for ONLINE LAIM Submission EFT and EA Paper laim Submissions oding of laims/billing odes Important Steps to a Successful Submission of Paper laims: ode Auditing and Editing PT ategory II odes

4 POVIDE BILLING GUIDE TABLE OF ONTENTS ode Editing Assistant ejections vs. Denials EJETION DENIAL Appendix APPENDIX I: OMMON AUSES OF UPFONT EJETIONS APPENDIX II: OMMON AUSES OF LAIMS POESSING DELAYS AND DENIALS APPENDIX III: OMMON EOP DENIAL ODES AND DESIPTIONS Appendix IV: Instructions For Supplemental Information MS-1500 FOM, Shaded Field 24A-G Appendix V: OMMON HIPAA ompliant EDI ejection odes Appendix VI: laims form instructions ompleting a MS 1500 laim Form UB-04 laim Form UB-04 Hospital Outpatient laims/ambulatory Surgery ompleting a MS 1450 (UB-04) Form Appendix VII: Billing Tips and eminders

5 POEDUES FO LAIM SUBMISSION Welcome to Plan of Massachusetts ( ). We are pleased to provide a comprehensive set of instructions for submitting and processing claims with us. You will find detailed information in this guide for initiating transactions, addressing rejections and denials, and processing of payments. For questions regarding billing requirements not addressed in this guide, or for any other questions, please feel free to contact a Service epresentative at the appropriate benefit plan numbers listed below. ELTIAE HEALTH POVIDE SEVIES PHONE AND FAX NUMBES Phone and Fax numbers Benefit Plan Phone Fax AEPLUS OMMONWEALTH AE OMMONWEALTH HOIE ELTIAE DIET In general, follows the enters for Medicare and Medicaid (MS) billing requirements for paper, electronic data interchange (EDI), and secure web-submitted claims. is required by state and federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements in order to ensure timely processing of claims and to avoid unnecessary rejections and/or denials. laims will be rejected or denied if not submitted correctly. 4

6 AUATE BILLING INFOMATION It is important that providers ensure has accurate billing information on file. Please confirm with our elations Department that the following information is current in our files: name (as noted on current W-9 form) National Identifier (NPI) Tax Identification Number (TIN) Taxonomy code Physical location address (as noted on current W-9 form) Billing name and address We recommend that providers notify 30 days in advance of changes pertaining to billing information. Please submit this information on a W-9 form. hanges to a provider s TIN and/or address are NOT acceptable when conveyed via a claim form. When required data elements are missing or are invalid, claims will be rejected or denied by for correction and re- submission. For EDI claims, rejections happen through one of our EDI clearinghouses if the appropriate information is not contained on the claim. For paper claims, rejections happen prior to the claims being received in the claims adjudication system and will be sent to the provider with a letter detailing the reason(s) for the rejection. Denials happen once the claim has been received into the claims adjudication system and will be sent to the provider via an Explanation of Payment (EOP) or Electronic emittance Advice (EA). laims for billable services provided to members must be submitted by the provider who performed the services or by the provider s authorized billing vendor. 5

7 VEIFIATION POEDUES All claims filed with are subject to verification procedures. These include, but are not limited to, verification of the following: All required fields are completed on an original MS 1500 laim Form (HFA), MS 1450 (UB-04) laim Form, EDI electronic claim format, or claims submitted on our Secure Portal, individually or batch. All claim submissions will be subject to 5010 validation procedures based on MS Industry Standards. All Diagnosis, Procedure, Modifier, Location (Place of Service), evenue, Type of Admission, and Source of Admission odes are valid for: Date of service type and/or provider specialty billing Age and/or sex for the date of service billed Bill type All Diagnosis odes are to their highest number of digits available (4 th or 5 th digit). National Drug ode (ND) is billed in the appropriate field on all claim forms when applicable. Principal diagnosis billed reflects an allowed principal diagnosis as defined in the volume of ID-9-M for the date of service billed. For a MS 1500 laim Form, this criteria looks at all procedure codes billed and the diagnosis they are pointing to. If a procedure points to the diagnosis as primary, and that code is not valid as a primary diagnosis code, that service line will deny. All inpatient facilities are required to submit a Present on Admission (POA) indicator on all claims. laims will be denied (or rejected) if the POA indicator is missing. Please reference the MS Billing Guidelines regarding POA for more information and for excluded facility types. Member is eligible for services under during the time period in which services were provided. were provided by a participating provider, or if provided by an "out of plan" provider authorization has been received to provide services to the eligible member. (Excludes services by an out of plan provider for an emergency medical condition; however, authorization requirements apply for post-stabilization services.) An authorization has been given for services that require prior authorization by. 6

8 Third party coverage has been clearly identified and appropriate OB information has been included with the claim submission. laims eligible for payment must meet the following requirements: The member is effective on the date of service The service provided is a covered benefit under the member s contract on date of service eferral and prior authorization processes were followed Payment for services is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in this guide. LAIMS FILING DEADLINES Original claims (first time claim submissions) and encounters must be submitted to within 90 days from the date services were rendered or reimbursable items were provided by contracted providers (in-network). Non-contracted providers (out-ofnetwork) must submit all original claims (first time claims) and encounters within 180 calendar days from the date of service. The filing limit may be extended where the eligibility has been retroactively received by up to a maximum of 365 calendar days. When is the secondary payer, claims must be received within 90 calendar days of the final determination of the primary payer. laims received outside of this timeframe will be denied for untimely submission. All corrected claims, requests for reconsideration, or claim disputes must be received within 90 calendar days from the date of notification of payment or denial. Prior processing will be upheld for corrected claims or provider claim requests for reconsideration or disputes received outside of the 90 day time frame, unless a qualifying circumstance is offered and appropriate documentation is provided to support the qualifying circumstance. Qualifying circumstances include: atastrophic event that substantially interferes with normal business operations of the provider, or damage or destruction of the provider s business office or records by a natural disaster. Mechanical, administrative delays, or errors by or the Authority. 7

9 The member was eligible; however the provider was unaware that the member was eligible for services at the time services were rendered. onsideration is granted in this situation only if all of the following conditions are met: The provider s records document that the member refused or was physically unable to provide his or her ID card or information. The provider can substantiate that he or she continually pursued reimbursement from the patient until eligibility was discovered or Safety Net, if applicable. The provider can substantiate that a claim was filed within 90 days of discovering Plan eligibility. The provider has not filed a claim for this member prior to the filing of the claim under review. LAIM EQUESTS FO EONSIDEATION, LAIM DISPUTES AND OETED LAIMS All claim requests for reconsideration, corrected claims, or claim disputes must be received within 90 calendar days from the date of notification of payment or denial is issued. If a provider has a question, or is not satisfied with the information they have received related to a claim, there are five (5) effective ways in which the provider can contact. 1. eview the claim in question on the Secure Portal: Participating providers, who have registered for access to the Secure Portal, can access claims to obtain claim status, submit claims, or submit a corrected claim. 2. Submit an Adjusted or orrected laim to : orrected claims must clearly indicate they are corrected in one of the following ways: Submit corrected claim via the Secure Portal. Follow the instructions on the portal for submitting a correction Submit corrected claim electronically via clearinghouse Institutional laims (UB): Field LM05-3 = 7 and EF*F8 = Original laim Number Professional laims (HFA): Field LM05-3 = 6 and EF*F8 = Original laim Number 8

10 Mail corrected claims to: Plan of Massachusetts Attn: orrected laim P.O. Box 3080 Farmington, MO Paper claims must clearly be marked as E-SUBMISSION or OETED LAIM and must include the original claim number; or the original EOP must be included with the resubmission. Failure to mark the claim as a resubmission and include the original claim number (or include the EOP) may result in the claim being denied as a duplicate, a delay in the reprocessing, or denial for exceeding the timely filing limit. 3. Submit a equest for econsideration to : A request for reconsideration is a written communication (i.e., a letter) from the provider about a disagreement with the manner in which a claim was processed, but does not require a claim to be corrected and does not require medical records. The request must include sufficient identifying information which includes, at a minimum, the patient name and patient ID number, date of service, total charges, and provider name. The documentation must also include a detailed description of the reason for the request. Mail equests for econsideration to: Plan of Massachusetts Attn: econsideration P.O. Box 3080 Farmington, MO Submit a laim Dispute Form to : A claim dispute should be used only when a provider has received an unsatisfactory response to a request for reconsideration. The laim Dispute Form is located on the Website at To expedite processing of your dispute, please include the original equest for econsideration letter and the response. 9

11 Mail your laim Dispute Form and all other attachments to: Plan of Massachusetts Attn: laim Dispute P.O. Box 3000 Farmington, MO ontact a Service epresentative at the appropriate benefit plan numbers listed below. s may inquire about claim status, payment amounts, or denial reasons. A provider may also make a simple request for reconsideration by clearly explaining the reason the claim is not adjudicated correctly. For information about how to submit Medical Necessity Appeals, refer to the Grievances and Appeals section of the Manual located on our website under esources. If any of the five steps above results in an adjusted claim, the provider will receive a revised Explanation of Payment (EOP). If the original decision is upheld, the provider will receive a phone call, revised EOP, or letter detailing the decision and steps for escalated reconsideration. will process and finalize all corrected claims, requests for reconsideration, and disputed claims to a paid or denied status within 45 business days from the point of contact. LAIM PAYMENT lean claims will be adjudicated (finalized as paid or denied) at the following levels: 90% within 30 days of the receipt of the electronically or paper filed claim. 99% within 90 days of the receipt of the electronically or paper filed claim. LEAN LAIM DEFINITION A clean claim is defined as a claim received by for adjudication, in a nationally accepted format, in compliance with standard coding guidelines, and which requires no further information, adjustment, or alteration by the provider of services in order to be processed by. The following exceptions apply to this definition: (a) a claim for which fraud is suspected; and (b) a claim for which a third party resource should be responsible. 10

12 NON-LEAN LAIM DEFINITION A non-clean claim is defined as a submitted claim that requires further investigation or development beyond the information contained in the claim. The errors or omissions in the claim may result in: (a) a request for additional information from the provider or other external sources to resolve or correct data omitted from the claim; (b) the need for review of additional medical records; or (c) the need for other information necessary to resolve discrepancies. In addition, non-clean claims may involve issues regarding medical necessity and include claims not submitted within the filing deadlines. POEDUES FO ELETONI SUBMISSION Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claim submissions for providers. EDI, performed in accordance with nationally recognized standards, supports the healthcare industry s efforts to reduce administrative costs. The benefits of billing electronically include: eduction of overhead and administrative costs: Eliminates the need for paper claim submission educes claim re-work (adjustments) eceipt of clearinghouse reports as proof of claim receipt Faster transaction time for claims submitted electronically Validation of data elements on the claim format All the same requirements for paper claim filing apply to electronic claim filing. laims not submitted correctly, or not containing the required field data, will be rejected and/or denied. ELETONI LAIM SUBMISSION s are encouraged to participate in s Electronic laims/encounter Filing Program through entene. (entene) has the capability to receive an ANSI X12N 837 professional, institution, or encounter transaction. In addition, (entene) has the capability to generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). For more information on electronic filing, contact: 11

13 Plan of Massachusetts c/o entene EDI Department , extension Or by at: s who bill electronically are responsible for filing claims within the same filing deadlines as providers filing paper claims. s who bill electronically must monitor their error reports and evidence of payments to ensure all submitted claims and encounters appear on the reports. s are responsible for correcting any errors and resubmitting the affiliated claims and encounters. ELETONI SEONDAY LAIMS (TPL) has the ability to receive coordination of benefit (OB or secondary) claims electronically. The field requirements for successful electronic OB submission are described below (5010 format): OB FIELD NAME THE BELOW SHOULD OME FOM THE PIMAY PAYE'S EXPLANATION OF PAYMENT OB Paid Amount OB Total Non-overed Amount OB emaining Patient Liability OB Patient Paid Amount OB Patient Paid Amount Estimated Total laim Before Taxes Amount 837I - INSTITUTIONAL EDI SEGMENT AND LOOP If 2320/AMT01=D, MAP AMT02 or 2430/SVD02 If 2320/AMT01=A8, map AMT02 If 2300/AS01 = P, map AS03 Note: Segment can have 6 occurrences. Loop2320/AMT01=EAF, map AMT02 which is the sum of all of AS03 with AS01 segments presented with a P If 2300/AMT01=F3, map AMT02 If 2400/AMT01=N8, map AMT02 837P - POFESSIONAL EDI SEGMENT AND LOOP If 2320/AMT01=D, MAP AMT02 or 2430/SVD02 If 2320/AMT01=A8, map AMT02 If 2320/AMT01=EAF, map AMT02 If 2320/AMT01=F5, map AMT02 If 2320/AMT01=T, map AMT02 12

14 OB laim Adjudication Date OB laim Adjustment Indicator IF 2330B/DTP01=573, map DTP03 IF 2330B/EF01=T4, map EF02 IF 2330B/DTP01=573, map DTP03 IF 2330B/EF01=T4, map EF02 with a Y SPEIFI DATA EOD EQUIEMENTS laims transmitted electronically must contain all the same data elements identified within the laim Filing section of this guide. Please contact the clearinghouse you intend to use and ask if they require additional data record requirements. The ompanion Guide is located on s website at ELETONI LAIM FLOW DESIPTION & IMPOTANT GENEAL INFOMATION In order to send claims electronically to, all EDI claims must first be forwarded to one of s clearinghouses. This can be completed via a direct submission to a clearinghouse, or through another EDI clearinghouse. Once the clearinghouse receives the transmitted claims, they are validated against their proprietary specifications and plan specific requirements. laims not meeting the requirements are immediately rejected and sent back to the sender via a clearinghouse error report. It is very important to review this error report daily to identify any claims that were not transmitted to. The name of this report can vary based upon the provider s contract with their intermediate EDI clearinghouse. Accepted claims are passed to and the clearinghouse returns an acceptance report to the sender immediately. laims forwarded to by a clearinghouse are validated against provider and member eligibility records. laims that do not meet provider and/or member eligibility requirements are rejected and sent back on a daily basis to the clearinghouse. The clearinghouse in turn forwards the rejection back to its trading partner (the intermediate EDI clearinghouse or provider). It is very important to review this report daily. The report shows rejected claims; these claims must be reviewed and corrected timely. laims passing eligibility requirements are then passed to the claim processing queues. s are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from the clearinghouse must be reviewed and validated against transmittal records daily. 13

15 Since the clearinghouse returns acceptance reports directly to the sender, submitted claims not accepted by the clearinghouse are not transmitted to. If you would like assistance in resolving submission issues reflected on either the acceptance or claim status reports, please contact your clearinghouse or vendor ustomer Service Department. ejected electronic claims may be resubmitted electronically once the error has been corrected. Be sure to clearly mark your claim as a corrected claim per the instructions above. INVALID ELETONI LAIM EOD EJETIONS/DENIALS All claim records sent to must first pass the clearinghouse proprietary edits and plan-specific edits prior to acceptance. laim records that do not pass these edits are invalid and will be rejected without being recognized as received by. In these cases, the claim must be corrected and re-submitted within the required filing deadline of 90 calendar days from the date of service. It is important that you review the acceptance or claim status reports received from the clearinghouse in order to identify and re-submit these claims accurately. Questions regarding electronically submitted claims should be directed to our EDI BA Support at Ext , or via at [email protected]. If you are prompted to leave a voice mail, you will receive a return call within 24 business hours. The full ompanion Guides can be located on the Executive Office of and Human (EOHHS) website: SPEIFI ELTIAE HEALTH ELETONI EDIT EQUIEMENTS INFOMATION Institutional laims - 837I v5010 Edits Professional laims - 837P v5010 Edits Please refer to the EDI HIPAA Version 5010 Implementation section on our website for detailed information: 14

16 ADJUSTED EDI LAIMS LM05-3 equired 6 or 7. IN 2300 Loop/EF segment is F8; ef 02 must input original claim number assigned. Failure to include the original claim number will result in rejection of the adjustment (error code 76). EXLUSIONS EXLUDED LAIM ATEGOIES - Excluded from EDI Submission Options - Must be Filed Paper - Applies to Inpatient and Outpatient laim Types laim records requiring supportive documentation or attachments (i.e., consent forms) Note: OB claims can be filed electronically, but if they are not, the primary payer EOB must be submitted with the paper claim. Medical records to support billing miscellaneous codes laim for services that are reimbursed based on purchase price (e.g., custom DME, prosthetics) is required to submit the invoice with the claim. laim for services requiring clinical review (e.g., complicated or unusual procedure). is required to submit medical records with the claim. laim for services requiring documentation and a ertificate of Medical Necessity (e.g., oxygen, motorized wheelchairs) Please direct inquiries as follows: ELETONI BILLING INQUIIES Action Submitting laims through clearinghouses (with Payer ID numbers): ontact Availity: apario (formerly MedAvant): Emdeon:

17 Action ontact NEHEN: ISA (Medical) elay : Prof- 2128, Inst Smart Data Solutions: (Medical), (enpatico) Action General EDI Questions: laims Transmission eport Questions: laim Transmission Questions (Has my claim been received or rejected?): emittance Advice Questions: Payee, UPIN, Tax ID, Payment Address hanges: ontact ontact EDI Support at Ext or (314) or via at [email protected]. ontact your clearin ghouse technical support area. ontact EDI Support at Ext or via at [email protected]. ontact at the appropriate benefit plan phone numbers below, or the Secure Portal at Notify in writing at: Plan of Massachusetts Attn: elations 250 West Street, Suite 250 Waltham, MA IMPOTANT STEPS TO A SUESSFUL SUBMISSION OF EDI LAIMS: 1. Select clearinghouse to utilize. 2. ontact the clearinghouse to inform them you wish to submit electronic claims to. 3. Inquire with the clearinghouse what data records are required. 4. Verify with elations at that the provider is set up in the system before submitting EDI claims. 16

18 5. You will receive two (2) reports from the clearinghouse. ALWAYS review these reports daily. The first report will be a report showing the claims that were accepted by the clearinghouse and are being transmitted to, and those claims not meeting the clearinghouse requirements. The second report will be a claim status report showing claims accepted and rejected by. ALWAYS review the acceptance and claim status reports for rejected claims. If rejections are noted, correct and resubmit. 6. MOST importantly, all claims must be submitted with providers identifying numbers. See the MS 1500 and MS 1450 (UB-04) laim Forms instructions and claim forms for details. POEDUES FO ONLINE LAIM SUBMISSION For providers who have internet access and choose not to submit claims via EDI or paper, has made it easy and convenient to submit claims directly to us on our Secure Portal at You must request access to our secure site by registering for a user name and password, and you must select the laims ole Access module. To register, please go directly to If you have technical support questions, please contact at the appropriate benefit plan contact numbers listed below. Once you have access to the secure portal, you may file first time claims individually or submit first time batch claims. You will also have the capability to find, view, and correct any previously processed claims. Detailed instructions for submitting via Secure Web Portal are also stored on our website; you must login to the secure site for access to this manual. EFT AND EA partners with PaySpan to provide electronic funds transfer (EFT) and electronic remittance advice (EA) to its participating providers. EFT and EA services help providers reduce costs, speed secondary billings, and improve cash flow by enabling online access of remittance information, and straightforward reconciliation of payments. As a provider, you can gain the following benefits from using EFT and EA: educe accounting expenses Electronic remittance advices can be imported directly into practice management or patient accounting systems, eliminating the need for manual re-keying 17

19 Improve cash flow Electronic payments mean faster payments, leading to improvements in cash flow Maintain control over bank accounts You keep TOTAL control over the destination of claim payment funds and multiple practices and accounts are supported Match payments to advices quickly You can associate electronic payments with electronic remittance advices quickly and easily For more information on our EFT and EA services, please visit our website at contact at the appropriate benefit plan phone numbers below, or contact PaySpan directly at or PAPE LAIM SUBMISSIONS Submit claims to at the following address: FIST TIME LAIMS, OETED LAIMS, AND EQUESTS FO EONSIDEATIONS: Plan of Massachusetts laim Processing Department P. O. Box 3080 Farmington, MO LAIM DISPUTE FOMS: Plan of Massachusetts Attn: laim Disputes P. O. Box 3000 Farmington, MO encourages all providers to submit claims electronically. Our ompanion Guides for electronic billing are available on our website at Paper submissions are subject to the same edits as electronic and web submissions. only accepts the MS 1500 and MS 1450 (UB-04) paper laim Forms. Other claim form types will be rejected and returned to the provider. Professional providers and medical suppliers complete the MS 1500 (8/05) laim Form and institutional providers complete the MS 1450 (UB-04) laim Form. does not supply claim forms to providers. s should purchase these from a supplier of their choice. It is preferred that all paper claim forms be typed or printed, and in the original 18

20 red and white version to ensure clean acceptance and processing. If the form is handwritten, the information must be: clear, written in black or blue ink, and all data must be within the pre-determined lines/boxes on the form. If you have questions regarding what type of form to complete, contact a epresentative at the appropriate benefit plan phone numbers listed below. ODING OF LAIMS/BILLING ODES requires claims to be submitted using codes from the current version of ID-9-M, ID-10-M, ASA, DG, PT 1, and HPS Level II for the date the service was rendered. These requirements may be amended to comply with federal and state regulations as necessary. Below are some code related reasons a claim may reject or deny: ode billed is missing, invalid, or deleted at the time of service ode inappropriate for the age or sex of the member Diagnosis code missing the 4 th or 5 th digit as appropriate Procedure code is pointing to a diagnosis that is not appropriate to be billed as primary ode billed is inappropriate for the location or specialty billed ode billed is a part of a more comprehensive code billed on same date of service Written descriptions, itemized statements, and invoices may be required for non-specific types of claims or at the request of. For more information regarding billing codes, coding, and code auditing/editing, please contact a Plan epresentative at the appropriate benefit plan phone numbers listed below. IMPOTANT STEPS TO A SUESSFUL SUBMISSION OF PAPE LAIMS: 1. omplete all required fields on an original, red MS 1500 or MS 1450 (UB- 04) laim Form. 1 PT opyright 2012 American Medical Association. All rights reserved. PT is a registered trademark of the American Medical Association. 19

21 2. Ensure all Diagnosis, Procedure, Modifier, Location (Place of Service), Type of Admission, and Source of Admission odes are valid for the date of service. 3. Ensure all Diagnosis and Procedure odes are appropriate for the age and sex of the member. 4. Ensure all Diagnosis odes are coded to their highest number of digits available (4 th and 5 th digit). 5. Ensure member is eligible for services under during the time period in which services were provided. 6. Ensure that services were provided by a participating provider or that the out-of-plan provider has received authorization to provide services to the eligible member. 7. Ensure an authorization has been given for services that require prior authorization by. 8. laim forms submitted without red dropout O forms may cause unnecessary delays to processing. ODE AUDITING AND EDITING uses HIPAA compliant code auditing software to assist in improving accuracy and efficiency in claims processing, payment, and reporting. The software will detect, correct, and document coding errors on provider claim submissions prior to payment by analyzing PT, HPS, modifier, and place of service codes. laims billed in a manner that do not adhere to the standards of code auditing software will be denied. The code auditing software contains a comprehensive set of rules addressing coding inaccuracies such as: unbundling, fragmentation, up-coding, duplication, invalid codes, and mutually exclusive procedures. The software offers a wide variety of edits that are based on: American Medical Association (AMA) The software utilizes the PT Manuals, PT Assistant, PT Insider s View, the AMA website, and other sources. enters for Medicare & Medicaid (MS) National orrect oding Initiative (NI) which includes column 1/column 2, mutually exclusive and 20

22 outpatient code editor (OE0 edits). In addition to using the AMA s PT Manual, the NI coding policies are based on national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. Public-domain specialty society guidance (i.e., American ollege of Surgeons, American ollege of adiology, American Academy of Orthopedic Surgeons). linical consultants who research, document, and provide edit recommendations based on the most common clinical scenario. In addition to nationally-recognized coding guidelines, the software has added flexibility to its rule engine to allow business rules that are unique to the needs of individual product lines. The following provides conditions where the software will make a change on submitted codes: Unbundling of Identifies That Have Been Unbundled Example: Unbundling lab panels. If component lab codes are billed on a claim along with a more comprehensive lab panel code that more accurately represents the service performed, the software will bundle the component codes into the more comprehensive panel code. The software will also deny multiple claim lines and replace those lines with a single, more comprehensive panel code when the panel code is not already present on the claim. ode Description Status omprehensive Metabolic Panel Disallow omplete B, automated and automated differential WB count Disallow Thyroid Stimulating Hormone Disallow General Panel Allow Explanation: 80053, 85025, and are included in the lab panel code 80050; therefore, they are not separately reimbursable. Those claim lines containing the component codes are denied and only the comprehensive lab panel code is reimbursed. 21

23 ode Description Status omprehensive Metabolic Panel Disallow omplete B, automated and automated & automated differential WB count Disallow Thyroid Stimulating Hormone Disallow General Panel Add Explanation: 80053, 85025, and are included in the lab panel code 80050; therefore, they are not separately reimbursable. Those claim lines containing the component codes are denied, and PT code is added to a new service line and recommended for reimbursement. Bilateral Surgery Identical procedures performed on bilateral anatomical sites during same operative session. Example: ode Description Status DOS=01/01/ DOS=01/01/10 Tympanostomy Tympanostomy billed with modifier 50 (bilateral procedure) Disallow Allow Explanation: Identifies the same code being billed twice, when reimbursement guidelines require the procedure to be billed once with a bilateral modifier. These should be billed on one line along with modifier 50 (bilateral procedure). Note: Modifiers T (right) or LT (left) should not be billed for bilateral procedures. Duplicate Submission of same procedure more than once on same date of service that cannot be, or are normally not, performed more than once on same day. Example: Excluding a Duplicate PT 22

24 ode Description Status adiologic exam, spine, entire, survey study, anteroposterior & lateral adiologic exam, spine, entire, survey study, anteroposterior & lateral Allow Disallow Explanation: Procedure includes radiologic examination of the lateral and anteroposterior views of the entire spine that allow views of the upper cervical vertebrae, the lower cervical vertebrae, the thoracic vertebrae, the lumbar vertebrae, the sacrum, and the coccyx. It is clinically unlikely that this procedure would be performed twice on the same date of service. Evaluation and Management (E/M) Submission of E/M service either within a global surgery period or on the same date of service as another E/M service: Global Surgery: Procedures that are assigned a 90 day global surgery period are designated as major surgical procedures; those assigned a 10 day or 0 day global surgery period are designated as minor surgical procedures. Evaluation and management services, submitted with major surgical procedures (90 day) and minor surgical procedures (10 day), are not recommended for separate reporting because they are part of the global service. Evaluation and management services, submitted with minor surgical procedures (0 day), are not recommended for separate reporting or reimbursement because these services are part of the global service, unless the service is a service listed on the Massachusetts Fee Schedule with an asterisk. Example: Global Surgery Period ode Description Status DOS=05/20/09 Arthroplasty, knee, condoyle and plateau; medial and lateral compartments with or Allow 23

25 99213 DOS=06/02/09 without patella resurfacing (total knee arthroplasty). Office or other outpatient visit for the evaluation and management of an EST patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. ounseling & coordination of care w/other providers or agencies are provided consistent w/nature of problem(s) & patient's &/or family's needs. Problem(s) are low/moderate severity. Typically 15 minutes are spent face-to-face w/patient &/or family. Disallow Explanation: Procedure ode has a global surgery period of 90 days. Procedure ode is submitted with a date of service that is within the 90 day global period. When a substantial diagnostic or therapeutic procedure is performed, the evaluation and management service is included in the global surgical period. Example: E/M with Minor Surgical Procedures ode Description Status DOS=01/23/ DOS=01/23/10 Debridement of extensive eczematous or infected skin; up to 10% of body surface. Office or other outpatient visit for the evaluation and management of an EST patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. ounseling and coordination of care with other providers or agencies are provided consistent w/ nature of problem(s) and patient's and/or family's needs. Problem(s) are low/moderate severity. Typically 15 minutes are spent face-to-face Allow Disallow 24

26 with patient and/or family. Explanation: Procedure (0 day global surgery period) is identified as a minor procedure. Procedure is submitted with the same date of service. When a minor procedure is performed, the evaluation and management service is considered part of the global service. Same Date of Service One evaluation and management service is recommended for reporting on a single date of service. Example: Same Date of Service ode Description Status Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. ounseling and/or coordination of care with other providers or agencies are provided consistent w/ nature of problem(s) and patient's and/or family's needs. Usually, problem(s) are moderate/high severity. Typically 40 minutes are spent face-to-face with patient and/or family Office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. ounseling/coordination of care with other providers or agencies are provided consistent with nature of problem(s) and patient's/family's needs. Presenting problem(s) are low severity. Typically 30 minutes are spent face-to-face with patient/family. Allow Disallow 25

27 Explanation: Procedure is used to report an evaluation and management service provided to an established patient during a visit. Procedure is used to report an office consultation for a new or established patient. Separate reporting of an evaluation and management service with an office consultation by a single provider indicates a duplicate submission of services. Interventions, provided during an evaluation and management service, typically include the components of an office consultation NOTE: Modifier -24 is used to report an unrelated evaluation and management service by the same physician during a post-operative period. Modifier -25 is used to report a significant, separately identifiable Evaluation and Management service by the same physician or other qualified health care professional on the same day of a procedure. Modifier -50 is used to indicate a procedure performed on bilateral anatomical sites and applied to a surgical, radiological or diagnostic procedure. Modifier -79 is used to report an unrelated procedure or service by the same physician or other qualified health care professional during the post-operative period. When modifiers -24 and -25 are submitted with an evaluation and management service on the same date of service or during the post-operative period by the same physician, the evaluation and management service is questioned and a review of additional information is recommended. When modifier -79 is submitted with an evaluation and management service on the same date of service or during the post-operative period by the same physician, separate reporting of the evaluation and management service is recommended. Modifiers odes added to the main procedure code to indicate the service has been altered by a specific circumstance: 26

28 Modifier -26 (professional component) Definition: Modifier -26 identifies the professional component of a test or study. If modifier -26 is not valid for the submitted procedure code, the procedure code is not recommended for separate reporting. When a claim line is submitted without the modifier -26 in a facility setting (for example: POS 21, 22, 23, 24), the rule will replace the service line with a new line with the same Procedure ode and the modifier -26 appended. Example: ode Description Status POS=Inpatient POS=Inpatient Acute gastrointestinal blood loss imaging Acute gastrointestinal blood loss imaging Disallow Allow Explanation: Procedure code is valid with modifier -26. Modifier -26 will be added to procedure code when submitted without modifier -26. Modifier -80 and -82 (assistant surgeon) Definition: This edit identifies claim lines containing Procedure odes billed with an assistant surgeon modifier that typically do not require an assistant surgeon. Many surgical procedures require aid in prepping and draping the patient, monitoring visualization, keeping the wound clear of blood, holding and positioning the patient, and assisting with wound closure and/or casting (if required). This assistance does not require the expertise of a surgeon. A qualified nurse, orthopedic technician, or resident physician can provide the necessary assistance. Example: ode Description Status Tonsillectomy and adenoidectomy; under age Disallow 27

29 12 Explanation: Procedure ode is not recommended for assistant surgeon reporting because a skilled nurse or surgical technician can function as the assistant in the performance of this procedure. PT ATEGOY II ODES PT ategory II odes are supplemental tracking codes developed to assist in the collection and reporting of information regarding performance measurement, including HEDIS. Submission of PT ategory II odes allows data to be captured at the time of service and may reduce the need for retrospective medical record review. Uses of these codes are optional and are not required for correct coding. They may not be used as a substitute for ategory I codes. However, as noted above, submission of these codes can minimize the administrative burden on providers and health plans by greatly decreasing the need for medical record review. ODE EDITING ASSISTANT A web-based code auditing reference tool designed to mirror how code auditing product(s) evaluate code combinations during the auditing of claims is available for participating providers via the Secure Portal. This allows to share with our contracted providers the claim auditing rules and clinical rationale we use to pay claims. You can access the tool in the laims Module by clicking laim Auditing Tool in our Secure Portal. This tool offers many benefits: POSPETIVELY access the appropriate coding and supporting clinical edit clarifications for services BEFOE claims are submitted POATIVELY determine the appropriate code/code combination representing the service for accurate billing purposes 28

30 The tool will review what was entered, and will determine if the code or code combinations are correct based on the age, sex, location, modifier (if applicable), or other code(s) entered. The ode Editing Assistant is intended for use as a what if or hypothetical reference tool. It is meant to apply coding logic only. The tool does not take into consideration historical claims information which may have been used to determine an edit. The tool assumes all PT codes are billed on a single claim. The tool will not take into consideration individual fee schedule reimbursement, authorization requirements, or other coverage considerations. EJETIONS VS. DENIALS All paper claims sent to the claims office must first pass specific edits prior to acceptance. laim records that do not pass these edits are invalid and will be rejected or denied. EJETION A EJETION is defined as an unclean claim that contains invalid or missing data elements required for acceptance of the claim into the claim processing system. These data elements are identified in the ompanion Guide located on the website at A list of common upfront rejections can be located in Appendix 1. ejections will not enter our claims adjudication system, so there will be no Explanation of Payment (EOP) for these claims. The provider will receive a letter or a rejection report if the claim was submitted electronically. DENIAL If all edits pass and the claim is accepted, it will then be entered into the system for processing. A DENIAL is defined as a claim that has passed edits and is entered into the system, however has been billed with invalid or inappropriate information causing the claim to deny. An EOP will be sent that includes the denial reason. A list of common delays and denials can be found listed below with explanations in Appendix II. 29

31 APPENDIX I. ommon auses for Upfront ejections II. ommon auses of laim Processing Delays and Denials III. ommon EOP Denial odes IV. Instructions for Supplemental Information MS-1500 (8/05) Form, Shaded Field 24a-G V. ommon HIPAA ompliant EDI ejection odes VI. laims Form Instructions VII. Billing Tips and eminders 30

32 APPENDIX I: OMMON AUSES OF UPFONT EJETIONS Unreadable Information - The ink is faded, too light, or too bold (bleeding into other characters or beyond the box), the font is too small, or hand written information is not legible. Member Date of Birth is missing. Member Name or Identification Number is missing. Name, Taxpayer Identification Number (TIN), or National Practitioner Identification (NPI) Number is missing. Attending information missing from Loop 2310A on Institutional claims when LM05-1 (Bill Type) is 11, 12, 21, 22, or 72 or missing from box 48 on the paper UB claim form. Date of Service is not prior to the received date of the claim (future date of service). Date of Service or Date Span is missing from required fields. o Example: "Statement From" or Service From" dates. Type of Bill is invalid. Diagnosis ode is missing, invalid, or incomplete. Service Line Detail is missing. Date of Service is prior to member s effective date. Admission Type is missing (Inpatient Facility laims UB-04, field 14). Patient Status is missing (Inpatient Facility laims UB-04, field 17). Occurrence ode/date is missing or invalid. evenue ode is missing or invalid. PT/Procedure ode is missing or invalid. Incorrect Form Type used. 31

33 APPENDIX II: OMMON AUSES OF LAIMS POESSING DELAYS AND DENIALS Diagnosis ode is missing the 4th or 5th digit. Procedure or Modifier odes entered are invalid or missing. o This includes GN, GO, or GP modifier for therapy services. DG code is missing or invalid. Explanation of Benefits (EOB) from the primary insurer is missing or incomplete. Third Party Liability (TPL) information is missing or incomplete. Member ID is invalid. Place of Service ode is invalid. TIN and NPI do not match. evenue ode is invalid. Dates of Service span do not match the listed days/units. Tax Identification Number (TIN) is invalid. 32

34 APPENDIX III: OMMON EOP DENIAL ODES AND DESIPTIONS See the bottom of your paper EOP for the updated and complete description of all explanation codes associated with your claims. Electronic Explanations of Payment will use standard HIPAA denial codes. 33

35 APPENDIX IV: INSTUTIONS FO SUPPLEMENTAL INFOMATION MS-1500 FOM, SHADED FIELD 24A-G The following types of supplemental information are accepted in a shaded claim line of the MS 1500 laim Form field 24A-G: Anesthesia duration Narrative description of unspecified/miscellaneous/unlisted codes Vendor Product Number Industry Business ommunications ouncil (HIB) Product Number are Uniform ode ouncil Global Trade Item Number (GTIN), formerly Universal Product ode (UP) for products The following qualifiers are to be used when reporting these services. 7 Anesthesia information ZZ Narrative description of unspecified/miscellaneous/unlisted codes OZ Product Number are Uniform ode ouncil Global Trade Item Number (GTIN) VP Vendor Product Number- Industry Business ommunications ouncil (HIB) Labeling Standard To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not enter a space between the qualifier and the supplemental information. When reporting a service that does not have a qualifier, enter two blank spaces before entering the information. More than one supplemental item can be reported in a single shaded claim line IF the information is related to the un-shaded claim line item it is entered on. When entering 34

36 more than one supplemental item, enter the first qualifier at the start of 24A followed by the number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the HIB or GTIN number/code. After the entry of the first supplemental item, enter three blank spaces and then the next qualifier and number, code, or other information. Do not enter a space between the qualifier and the supplemental information. Do not enter hyphens or spaces within the HIB, or GTIN number/code. Examples: Anesthesia Unlisted, Non-specific, or Miscellaneous PT or HP ode ND Vendor Product Number - HIB Product Number are Uniform ode ouncil GTIN No Qualifier - More Than One Supplemental Item 35

37 APPENDIX V: OMMON HIPAA OMPLIANT EDI EJETION ODES These codes are the Standard National ejection odes for EDI submissions. All errors indicated for the code must be corrected before the claim is resubmitted. Please see s list of common EDI rejections to determine specific actions you may need to take to correct your claims submission. ode Description 01 Invalid Mbr DOB 2 Invalid Mbr 6 Invalid Prv 7 Invalid Mbr DOB & Prv 8 Invalid Mbr & Prv 9 Mbr not valid at DOS 10 Invalid Mbr DOB; Mbr not valid at DOS 17 Invalid Diag 18 Invalid Mbr DOB; Invalid Diag 19 Invalid Mbr; Invalid Diag 23 Invalid Prv; Invalid Diag 34 Invalid Proc 35 Invalid Mbr DOB; Invalid Proc 36 Invalid Mbr; Invalid Proc 38 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 39 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 40 Invalid Prv; Invalid Proc 41 Invalid Mbr DOB, Invalid Prv; Invalid Proc 42 Invalid Mbr; Invalid Prv; Invalid Proc 43 Mbr not valid at DOS; Invalid Proc 36

38 44 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Proc 46 Prv not valid at DOS; Invalid Proc 48 Invalid Mbr; Prv not valid at DOS; Invalid Proc 49 Mbr not valid at DOS; Invalid Prv; Invalid Proc 51 Invalid Diag; Invalid Proc 74 performed prior to ontract Effective Date 75 Invalid units of service 37

39 APPENDIX VI: LAIMS FOM INSTUTIONS Billing Guide for a MS 1500 and MS 1450 (UB-04) laim Forms. equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. Note: laims with missing or invalid equired () field information will be rejected or denied OMPLETING A MS 1500 LAIM FOM FIELD# Field Description Instruction or omments equired or onditional 1 INSUANE POGAM IDENTIFIATION heck only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. Enter X in the box noted Medicaid (Medicaid #). 1a INSUED S I.D. NUMBE The 8-digit Medicaid identification number on the member s I.D. card. 2 PATIENT S NAME (Last Name, First Name, Middle Initial) Enter the patient's name as it appears on the member's I.D. card. Do not use nicknames. 3 PATIENT S BITH DATE / SEX Enter the patient s 8-digit date of (MMDDYYYY) and mark the appropriate box to indicate the patient s sex/gender. M = male F = female 38

40 FIELD# Field Description Instruction or omments equired or onditional 4 INSUED S NAME Enter the patient's name as it appears on the member's I.D. card. Enter the patient's complete address and telephone number including area code on the appropriate line. 5 PATIENT'S ADDESS (Number, Street, ity, State, Zip code) Telephone (include area code) First line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Second line In the designated block, enter the city and state. Third line Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803) ). Note: Patient s Telephone does not exist in the electronic 837 Professional 4010A1. 6 PATIENT S ELATION TO INSUED Always mark to indicate self. Enter the patient's complete address and telephone number including area code on the appropriate line. 7 INSUED'S ADDESS (Number, Street, ity, State, Zip code) Telephone (include area code) First line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Second line In the designated block, enter the city and state. Third line Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803) ). Not equired Note: Patient s Telephone does not exist in the electronic 837 Professional 4010A1. 8 PATIENT STATUS Not equired 39

41 FIELD# Field Description Instruction or omments equired or onditional 9 OTHE INSUED'S NAME (Last Name, First Name, Middle Initial) efers to someone other than the patient. EQUIED if patient is covered by another insurance plan. Enter the complete name of the insured. 9a *OTHE INSUED S POLIY O GOUP NUMBE EQUIED if field 9 is completed. Enter the policy of group number of the other insurance plan. 9b OTHE INSUED S BITH DATE / SEX EQUIED if field 9 is completed. Enter the 8-digit date of birth (MMDDYYYY) and mark the appropriate box to indicate sex/gender for the person listed in field 9. M = male F = female 9c EMPLOYE'S NAME O SHOOL NAME Enter the name of employer or school for the person listed in field 9. Note: Employer s Name or School Name does not exist in the electronic 837 Professional 4010A1. 9d INSUANE PLAN NAME O POGAM NAME EQUIED if field 9 is completed. Enter the other insured s (name of person listed in field 9) insurance plan or program name. 10a, b, c IS PATIENT'S ONDITION ELATED TO Enter a Yes or No for each category/line (a, b, and c). Do not enter a Yes and No in the same category/line. 10d ESEVED FO LOAL USE Not equired 11 INSUED S POLIY O FEA NUMBE EQUIED when other insurance is available. Enter the policy, group, or FEA number of the other insurance. 11a INSUED S DATE OF BITH / SEX Same as field 3. 11b EMPLOYE S NAME O SHOOL NAME EQUIED if Employment is marked Yes in field 10a. 11c INSUANE PLAN NAME O POGAM NUMBE Enter name of the insurance health plan or program. 11d IS THEE ANOTHE HEALTH BENEFIT PLAN Mark Yes or No. If Yes, complete fields 9a-d and 11c. 12 PATIENT S O AUTHOIZED PESON S SIGNATUE Enter Signature on File, SOF, or the actual legal signature. The provider must have the member s or legal guardian s signature on file or obtain their legal signature in this box for the release of information necessary to process and/or adjudicate the claim. 13 PATIENT S O AUTHOIZED PESONS SIGNATUE Obtain signature if appropriate. Not equired 40

42 FIELD# Field Description Instruction or omments equired or onditional 14 DATE OF UENT: ILLNESS (First symptom) O INJUY (Accident) O Pregnancy (LMP) Enter the 6-digit (MMDDYY) or 8-digit (MMDDYYYY) date reflecting the first date of onset for the: Present illness Injury LMP (last menstrual period) if pregnant 15 IF PATIENT HAS SAME O SIMILA ILLNESS. GIVE FIST DATE Not equired 16 DATES PATIENT UNABLE TO WOK IN UENT OUPATION Not equired 17 NAME OF EFEING PHYSIIAN O OTHE SOUE Enter the name of the referring physician or professional (first name, middle initial, last name, and credentials). Not equired 17a ID NUMBE OF EFEING PHYSIIAN equired if field 17 is completed. Use ZZ qualifier for Taxonomy code. 17b NPI NUMBE OF EFEING PHYSIIAN equired if field 17 is completed. If unable to obtain referring NPI, servicing NPI may be used. 18 HOSPITALIZATION DATES ELATED TO UENT SEVIES Not equired 19 ESEVED FO LOAL USE Not equired 20 OUTSIDE LAB / HAGES Not equired 41

43 FIELD# Field Description Instruction or omments equired or onditional 21 DIAGNOSIS O NATUE OF ILLNESS O INJUY. (ELATE ITEMS 1,2,3, O 4 TO ITEM 24E BY LINE) Enter the diagnosis or condition of the patient using the appropriate release/update of ID- 9/ID-10 M Volume 1 for the date of service. Diagnosis codes submitted must be valid ID-9/ID-10 codes for the date of service and carried out to its highest digit 4th or 5th. "E" codes are NOT acceptable as a primary diagnosis. Note: laims missing or with invalid diagnosis codes will be denied for payment. 22 MEDIAID ESUBMISSION ODE / OIGINAL EF.NO. For re-submissions or adjustments, enter the DN (Document ontrol Number) of the original claim. A resubmitted claim MUST be marked using large bold print within the body of the claim form with ESUBMISSION to avoid denials for duplicate submission. 23 PIO AUTHOIZATION NUMBE Enter the authorization or referral number. efer to the Manual for information on services requiring referral and/or prior authorization. Not equired 24a-j General Information Box 24 contains six claim lines. Each claim line is split horizontally into shaded and un-shaded areas. Within each un-shaded area of a claim line there are 10 individual fields labeled A-J. Within each shaded area of a claim line there are four individual fields labeled 24A-24G, 24H, 24J, and 24Jb. Fields 24A through 24G are a continuous field for the entry of supplemental information. Instructions are provided for shaded and un-shaded fields. The shaded area for a claim line is to accommodate the submission of supplemental information, EPSDT qualifier, and Medicaid Number. Shaded boxes a-g are for line item supplemental information and provide a continuous line that accepts up to 61 characters. efer to the instructions listed below for information on how to complete. The un-shaded area of a claim line is for the entry of claim line item detail. 42

44 FIELD# Field Description Instruction or omments equired or onditional The shaded top portion of each service claim line is used to report supplemental information for: ND 24a-g Shaded SUPPLEMENTAL INFOMATION Anesthesia start/stop time & duration Unspecified, miscellaneous, or unlisted PT and HP code descriptions. HIB or GTIN number/code. For detailed instructions and qualifiers refer to Appendix IV of this guide. 24a Unshaded DATE(S) OF SEVIE Enter the date the service listed in field 24D was performed (MMDDYYYY). If there is only one date, enter that date in the From field. The To field may be left blank or populated with the From date. If identical services (identical PT/HP code(s)) were performed each date must be entered on a separate line. 24b Unshaded PLAE OF SEVIE Enter the appropriate 2-digit MS Standard Place of Service (POS) ode. A list of current POS odes may be found on the MS website. 24c Unshaded EMG Enter Y (Yes) or N (No) to indicate if the service was an emergency. Not equired 24d Unshaded POEDUES, SEVIES O SUPPLIES PT/HPS MODIFIE Enter the 5-digit PT or HP code and 2-character modifier, if applicable. Only one PT or HP and up to four modifiers may be entered per claim line. odes entered must be valid for date of service. Missing or invalid codes will be denied for payment. Only the first modifier entered is used for pricing the claim. Failure to use modifiers in the correct position or combination with the Procedure ode, or invalid use of modifiers, will result in a rejected, denied, or incorrectly paid claim. 24e Unshaded DIAGNOSIS ODE Enter the numeric single digit diagnosis pointer (1,2,3,4) from field 21. List the primary diagnosis for the service provided or performed first followed by any additional or related diagnosis listed in field 21 (using the single digit diagnosis pointer, not the diagnosis code.) Do not use commas between the diagnosis pointer numbers. Diagnosis odes must be valid ID-9/10 odes for the date of service or the claim will be rejected/denied. 24f Unshaded HAGES Enter the charge amount for the claim line item service billed. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. 24g Unshaded DAYS O UNITS Enter quantity (days, visits, units). If only one service provided, enter a numeric value of one. 43

45 FIELD# Field Description Instruction or omments equired or onditional 24h Shaded EPSDT (Family Planning) Leave blank or enter Y if the services were performed as a result of an EPSDT referral. 24h Unshaded EPSDT (Family Planning) Enter the appropriate qualifier for EPSDT visit. 24i Shaded ID QUALIFIE Use ZZ qualifier for Taxonomy. Use 1D qualifier for Medicaid ID, if an Atypical. Enter as designated below the Medicaid ID number or taxonomy code. Typical s: 24j Shaded NON-NPI POVIDE ID# Enter the taxonomy code that corresponds to the qualifier entered in field 24I shaded. Use ZZ qualifier for Taxonomy ode. Atypical s: Enter the Medicaid ID number. 24j Unshaded NPI POVIDE ID Typical s ONLY: Enter the 10-character NPI ID of the provider who rendered services. If the provider is billing as a member of a group, the rendering individual provider s 10-character NPI ID may be entered. Enter the billing NPI if services are not provided by an individual (e.g., DME, Independent Lab, Home, H/FQH General Medical Exam, etc.). 25 FEDEAL TAX I.D. NUMBE SSN/EIN Enter the provider or supplier 9-digit Federal Tax ID number and mark the box labeled EIN. 26 PATIENT S AOUNT NO. Enter the provider's billing account number. Not equired 27 AEPT ASSIGNMENT? 28 TOTAL HAGES Enter an X in the YES box. Submission of a claim for reimbursement of services provided to a Medicaid recipient using Medicaid funds indicates the provider accepts Medicaid assignment. efer to the back of the MS 1500 (12-90) laim Form for the section pertaining to Medicaid Payments. Enter the total charges for all claim line items billed claim lines 24F. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. 44

46 29 AMOUNT PAID EQUIED when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing. programs are always the payers of last resort. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. EQUIED when field 29 is completed. 30 BALANE DUE Enter the balance due (total charges minus the amount of payment received from the primary payer). Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line SIGNATUE OF PHYSIIAN O SUPPLIE INLUDING DEGEES O EDENTIALS SEVIE FAILITY LOATION INFOMATION If there is a signature waiver on file, you may stamp, print, or computer-generate the signature; otherwise, the practitioner or practitioner s authorized representative MUST sign the form. If signature is missing or invalid the claim will be returned unprocessed. Note: Does not exist in the electronic 837P. EQUIED if the location where services were rendered is different from the billing address listed in field 33. Enter the name and physical location. (P.O. Box numbers are not acceptable here.) First line Enter the business/facility/practice name. Second line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Third line In the designated block, enter the city and state. Fourth line Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. 32a NPI SEVIES ENDEED Typical s ONLY: EQUIED if the location where services were rendered is different from the billing address listed in field 33. Enter the 10-character NPI ID of the facility where services were rendered. EQUIED if the location where services were rendered is different from the billing address listed in field b OTHE POVIDE ID Typical s Enter the 2-character qualifier ZZ followed by the Taxonomy ode (no spaces). Atypical s Enter the 2-character qualifier 1D (no spaces). 45

47 33 BILLING POVIDE INFO & PH # Enter the billing provider s complete name, address (include the zip + 4 code), and phone number. First line Enter the business/facility/practice name. Second line Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Third line In the designated block, enter the city and state. Fourth line Enter the zip code and phone number. When entering a 9-digit zip code (zip+ 4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803)551414). NOTE: The 9 digit zip code (zip + 4 code) is a requirement for paper and EDI claim submission 33a GOUP BILLING NPI Typical s ONLY: EQUIED if the location where services were rendered is different from the billing address listed in field 33. Enter the 10-character NPI ID. Enter as designated below the Billing Group taxonomy code. Typical s: 33b GOUP BILLING OTHE ID Enter the Taxonomy ode. Use ZZ qualifier. Atypical s: Enter the Medicaid ID number. UB-04 LAIM FOM A UB-04 is the only acceptable claim form for submitting inpatient or outpatient Hospital claims charges for reimbursement by. In addition, a UB-04 is required for omprehensive Outpatient ehabilitation facilities (OF), Home Agencies, nursing home admissions, inpatient hospice services, and dialysis services. Incomplete or inaccurate information will result in the claim/encounter being rejected for corrections. 1 (UNLABELED FIELD) Line 1: Enter the complete provider name. Line 2: Enter the complete mailing address. 46

48 Line 3: Enter the ity, State, and zip+4 code (include hyphen). NOTE: The 9-digit zip (zip + 4 code) is a requirement for paper and EDI claims. Line 4: Enter the area code and phone number. 2 (UNLABELED FIELD) Enter the Pay-To Name and Address. Not equired 3a PATIENT ONTOL NO. Enter the facility patient account/control number. Not equired 3b MEDIAL EOD NUMBE Enter the facility patient medical or health record number. Enter the appropriate 3-digit Type of Bill (TOB) ode as specified by the NUB UB-04 Uniform Billing Manual minus the leading 0 (zero). A leading 0 is not needed. Digits should be reflected as follows: 4 TYPE OF BILL 5 FED. TAX NO. 1 st digit - Indicating the type of facility. 2nd digit - Indicating the type of care. 3rd digit - Indicating the billing sequence. Enter the 9-digit number assigned by the federal government for tax reporting purposes. 6 STATEMENT OVES PEIOD FOM/THOUGH Enter begin and end, or admission and discharge dates, for the services billed. Inpatient and outpatient observation stays must be billed using the admission date and discharge date. Outpatient therapy, chemotherapy, laboratory, pathology, radiology, and dialysis may be billed using a date span. All other outpatient services must be billed using the actual date of service (MMDDYY). 7 (UNLABELED FIELD) Not Used Not equired UB-04 HOSPITAL OUTPATIENT LAIMS/AMBULATOY SUGEY The following information applies to outpatient and ambulatory surgery claims: Professional fees must be billed on a MS 1500 claim form. Include the appropriate PT code next to each revenue code. EXEPTIONS Please refer to your provider contract with or research the Uniform Billing Editor for evenue odes that do not require a PT ode. 47

49 OMPLETING A MS 1450 (UB-04) FOM 8a Enter the patient s identification number on the member s I.D. card. Not equired 8 a-b PATIENT NAME 8b Enter the patient s last name, first name, and middle initial as it appears on the ID card. Use a comma or space to separate the last and first names. Titles: (Mr., Mrs., etc.) should not be reported in this field. Prefix: No space should be left after the prefix of a name (e.g., McKendrick. H). Hyphenated names: Both names should be capitalized and separated by a hyphen (no space). Suffix: A space should separate a last name and suffix. Enter the patient s complete mailing address of the patient. 9 a-e PATIENT ADDESS Line a: Street address Line b: ity Line c: State Line d: ZIP code (except line 9e) Line e: ountry ode (NOT EQUIED) 10 BITHDATE Enter the patient s date of birth (MMDDYYYY). 11 SEX Enter the patient's sex. Only M or F is accepted. 12 ADMISSION DATE Enter the date of admission for inpatient claims and date of service for outpatient claims. 13 ADMISSION HOU Enter the time using 2-digit military time (00-23) for the time of inpatient admission or time of treatment for outpatient services :00 midnight to 12: :00 noon to 12: :00 to 01: :00 to 01: :00 to 02: :00 to 02: :00 to 03: :00 to 03: :00 to 04: :00 to 04: :00 to 05: :00 to 05: :00 to 06: :00 to 06: :00 to 07: :00 to 07: :00 to 08: :00 to 08: :00 to 09: :00 to 09: :00 to 10: :00 to 10:59 48

50 11-11:00 to 11: :00 to 11:59 14 ADMISSION TYPE equired for inpatient admissions (TOB 11X, 118X, 21X, 41X). Enter the 1-digit code indicating the priority of the admission using one of the following codes: 1 Emergency 2 Urgent 3 Elective 4 Newborn 5 Trauma Enter the 1-digit code indicating the source of the admission or outpatient service using one of the following codes. 15 ADMISSION SOUE For Type of admission 1,2,3, or 5: 1 Physician eferral 2 linic eferral 3 Maintenance eferral (HMO) 4 Transfer from a hospital 5 Transfer from Skilled Nursing Facility (SNF) 6 Transfer from another health care facility 7 Emergency oom 8 ourt/law enforcement 9 Information not available For type of admission 4 (newborn): 1 Normal Delivery 2 Premature Delivery 3 Sick Baby 4 Extramural Birth 5 Information not available 16 DISHAGE HOU Enter the time using 2-digit military time (00-23) for the time of inpatient or outpatient discharge :00 midnight to 12: :00 noon to 12: :00 to 01: :00 to 01: :00 to 02: :00 to 02: :00 to 03: :00 to 03: :00 to 04: :00 to 04: :00 to 05: :00 to 05: :00 to 06: :00 to 06: :00 to 07: :00 to 07:59 49

51 08-08:00 to 08: :00 to 08: :00 to 09: :00 to 09: :00 to 10: :00 to 10: :00 to 11: :00 to 11:59 17 PATIENT STATUS EQUIED for inpatient claims. Enter the 2-digit disposition of the patient as of the through date for the billing period listed in field 6 using one of the following codes: 01 outine Discharge 02 Discharged to another short-term general hospital 03 Discharged to SNF 04 Discharged to IF 05 Discharged to another type of institution 06 Discharged to care of home health service organization 07 Left against medical advice 08 Discharged/transferred to home under care of a Home IV provider 09 Admitted as an inpatient to this hospital (only for use on Medicare outpatient hospital claims) 20 Expired or did not recover 30 Still patient (To be used only when the client has been in the facility for 30 consecutive days if payment is based on DG) 40 Expired at home (hospice use only) 41 Expired in a medical facility (hospice use only) 42 Expired place unknown (hospice use only) 43 Discharged/Transferred to a federal hospital (such as a Veteran s Administration [VA] hospital) 50 Hospice Home 51 Hospice Medical Facility 61 Discharged/ Transferred within this institution to a hospital-based Medicare approved swing bed 62 Discharged/ Transferred to an Inpatient rehabilitation facility (IF), including rehabilitation distinct part units of a hospital 63 Discharged/ Transferred to a Medicare certified long-term care hospital (LTH) 64 Discharged/ Transferred to a nursing facility certified under Medicaid but not certified under Medicare 65 Discharged/ Transferred to a Psychiatric hospital or psychiatric distinct part unit of a hospital 66 Discharged/transferred to a critical access hospital (AH) 50

52 18-28 ONDITION ODES EQUIED when applicable. ondition codes are used to identify conditions relating to the bill that may affect payer processing. Each field (18-24) allows entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. 29 AIDENT STATE Not equired 30 (UNLABELED FIELD) Not Used Not equired a-b OUENE ODE and OUENE DATE Occurrence ode: EQUIED when applicable. Occurrence odes are used to identify events relating to the bill that may affect payer processing. Each field (31-34a) allows for entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. Occurrence Date: EQUIED when applicable or when a corresponding Occurrence ode is present on the same line (31a-34a). Enter the date for the associated Occurrence ode in MMDDYYYY format a-b OUENE SPAN ODE and OUENE DATE Occurrence Span ode: EQUIED when applicable. Occurrence odes are used to identify events relating to the bill that may affect payer processing. Each field (31-34a) allows for entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. Occurrence Span Date: EQUIED when applicable or when a corresponding Occurrence Span code is present on the same line (35a-36a). Enter the date for the associated Occurrence ode in MMDDYYYY format. 51

53 37 (UNLABELED FIELD) EQUIED for re-submissions or adjustments. Enter the DN (Document ontrol Number) of the original claim. A resubmitted claim MUST be marked using large bold print within the body of the claim form with ESUBMISSION to avoid denials for duplicate submission. 38 ESPONSIBLE PATY NAME AND ADDESS Not equired ode: EQUIED when applicable. Value codes are used to identify events relating to the bill that may affect payer processing. Each field (39-41) allows for entry of a 2-character code. odes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes) a-d VALUE ODES ODES and AMOUNTS Up to 12 codes can be entered. All a fields must be completed before using b fields, all b fields before using c fields, and all c fields before using d fields. For a list of codes and additional instructions refer to the NUB UB-04 Uniform Billing Manual. Amount: EQUIED when applicable or when a Value ode is entered. Enter the dollar amount for the associated value code. Dollar amounts to the left of the vertical line should be right justified. Up to eight characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($) or a decimal. A decimal is implied. If the dollar amount is a whole number (i.e ), enter 00 in the area to the right of the vertical line. General Information Fields SEVIE LINE DETAIL The following UB-04 fields 42-47: Have a total of 22 service lines for claim detail information. Fields 42, 43, 45, 47, 48 include separate instructions for the completion of lines 1-22 and line Line 1-22 EV D Enter the appropriate revenue codes itemizing accommodations, services, and items furnished to the patient. efer to the NUB UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions. Enter accommodation revenue codes first followed by ancillary revenue codes. Enter codes in ascending numerical value. 42 Line 23 ev D Enter 0001 for total charges. 52

54 43 Line 1-22 DESIPTION Enter a brief description that corresponds to the revenue code entered in the service line of field Line 23 PAGE OF Enter the number of pages. Indicate the page sequence in the PAGE field and the total number of pages in the OF field. If only one claim form is submitted, enter a 1 in both fields (i.e. PAGE 1 OF 1 ). 44 HPS/ATES EQUIED for outpatient claims when an appropriate PT/HPS ode exists for the service line revenue code billed. The field allows up to 9 characters. Only one PT/HP and up to two modifiers are accepted. When entering a PT/HPS with a modifier(s) do not use spaces, commas, dashes, or the like between the PT/HP and modifier(s). efer to the NUB UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions. Please refer to your current provider contract with HSHP or to the Department of and Hospitals Medicaid Procedures Manual. 45 Line 1-22 SEVIE DATE EQUIED on all outpatient claims. Enter the date of service for each service line billed. (MMDDYY) Multiple dates of service may not be combined for outpatient claims 45 Line 23 EATION DATE Enter the date the bill was created or prepared for submission on all pages submitted (MMDDYY). 46 SEVIE UNITS Enter the number of units, days, or visits for the service. A value of at least 1 must be entered. For inpatient room charges, enter the number of days for each accommodation listed. 47 Line 1-22 TOTAL HAGES Enter the total charge for each service line. 47 Line 23 TOTALS Enter the total charges for all service lines. 48 Line 1-22 NON-OVEED HAGES Enter the non-covered charges included in field 47 for the evenue ode listed in field 42 of the service line. Do not list negative amounts. 48 Line 23 TOTALS Enter the total non-covered charges for all service lines. 49 (UNLABELED FIELD) Not Used Not equired 53

55 50 A- PAYE Enter the name for each Payer from which reimbursement is being sought in the order of the Payer liability. Line A refers to the primary payer; B, secondary; and, tertiary. 51 A- HEALTH PLAN IDENTIFIATION NUMBE Not equired 52 A- EL. INFO EQUIED for each line (A, B, ) completed in field 50. elease of Information ertification Indicator. Enter Y (yes) or N (no). s are expected to have necessary release information on file. It is expected that all released invoices contain "Y. 53 ASG. BEN. 54 PIO PAYMENTS Enter Y" (yes) or "N" (no) to indicate a signed form is on file authorizing payment by the payer directly to the provider for services. Enter the amount received from the primary payer on the appropriate line when is listed as secondary or tertiary. 55 EST. AMOUNT DUE Not equired 56 NATIONAL POVIDE IDENTIFIE or POVIDE ID equired: Enter provider s 10-character NPI ID. 57 OTHE POVIDE ID 58 INSUED'S NAME a. Enter the numeric provider Medicaid identification number assigned by the Medicaid program. b. Enter the TPI number (non -NPI number) of the billing provider. For each line (A, B, ) completed in field 50, enter the name of the person who carries the insurance for the patient. In most cases this will be the patient s name. Enter the name as last name, first name, middle initial. 59 PATIENT ELATIONSHIP Not equired 60 INSUED S UNIQUE ID EQUIED: Enter the patient's Insurance ID exactly as it appears on the patient's ID card. Enter the Insurance ID in the order of liability listed in field GOUP NAME Not equired 54

56 62 INSUANE GOUP NO. Not equired 63 TEATMENT AUTHOIZATION ODES Enter the Prior Authorization or referral when services require pre-certification. 64 DOUMENT ONTOL NUMBE Enter the 12-character Document ontrol Number (DN) of the paid claim when submitting a replacement or void on the corresponding A, B, line reflecting Plan from field 50. Applies to claim submitted with a Type of Bill (field 4) Frequency of 7 (eplacement of Prior laim) or Type of Bill Frequency of 8 (Void/ancel of Prior laim). * Please refer to reconsider/corrected claims section. 65 EMPLOYE NAME Not equired 66 DX VESION QUALIFIE Not equired 67 PINIPAL DIAGNOSIS ODE Enter the principal/primary diagnosis or condition using the appropriate release/update of ID-9/10-M Volume 1& 3 for the date of service. Diagnosis code submitted must be a valid ID-9/10 ode for the date of service and carried out to its highest level of specificity 4 th or 5 digit. "E" and most V odes are NOT acceptable as a primary diagnosis. Note: laims with missing or invalid diagnosis codes will be denied. 67 A-Q OTHE DIAGNOSIS ODE Enter additional diagnosis or conditions that coexist at the time of admission or that develop subsequent to the admission and have an effect on the treatment or care received using the appropriate release/update of ID-9/10-M Volume 1& 3 for the date of service. Diagnosis codes submitted must be valid ID-9/10 odes for the date of service and carried out to its highest level of specificity 4 th or 5 digit. "E" and most V codes are NOT acceptable as a primary diagnosis. Note: laims with incomplete or invalid diagnosis codes will be denied. 68 (UNLABELED) Not Used Not equired 55

57 69 ADMITTING DIAGNOSIS ODE Enter the diagnosis or condition provided at the time of admission as stated by the physician using the appropriate release/update of ID-9/10-M Volume 1& 3 for the date of service. Diagnosis odes submitted must be valid ID-9/10 odes for the date of service and carried out to its highest level of specificity 4 th or 5 digit. "E" codes and most V are NOT acceptable as a primary diagnosis. Note: laims with missing or invalid diagnosis codes will be denied. 70 a,b,c PATIENT EASON ODE Enter the ID-9/10-M ode that reflects the patient s reason for visit at the time of outpatient registration. Field 70a requires entry, fields 70b-70c are conditional. Diagnosis odes submitted must be valid ID-9/10 odes for the date of service and carried out to its highest digit 4 th or 5. "E" codes and most V are NOT acceptable as a primary diagnosis. Note: laims with missing or invalid diagnosis codes will be denied. 71 PPS / DG ODE Not equired 72 a,b,c EXTENAL AUSE ODE Not equired 73 (UNLABELED) Not equired 74 PINIPAL POEDUE ODE / DATE EQUIED on inpatient claims when a procedure is performed during the date span of the bill. ODE: Enter the ID-9/10 Procedure ode that identifies the principal/primary procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code, it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). EQUIED for EDI Submissions. EQUIED on inpatient claims when a procedure is performed during the date span of the bill. 74 a-e OTHE POEDUE ODE DATE ODE: Enter the ID-9 procedure code(s) that identify significant a procedure(s) performed other than the principal/primary procedure. Up to five ID-9 Procedure odes may be entered. Do not enter the decimal between the 2nd or 3rd digits of code, it is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). 75 (UNLABELED) Not equired Enter the NPI and name of the physician in charge of the patient care. NPI: Enter the attending physician 10-character NPI ID. Taxonomy ode: Enter valid taxonomy code. QUAL: Enter one of the following qualifier and ID number: 76 ATTENDING PHYSIIAN 0B State License #. 1G UPIN. G2 ommercial #. ZZ Taxonomy ode. LAST: Enter the attending physician s last name. FIST: Enter the attending physician s first name. 77 OPEATING PHYSIIAN EQUIED when a surgical procedure is performed. 56

58 NPI: Enter the operating physician 10-character NPI ID. Taxonomy ode: Enter valid taxonomy code QUAL: Enter one of the following qualifier and ID number: 0B State License #. 1G UPIN. G2 ommercial #. ZZ Taxonomy ode. LAST: Enter the operating physician s last name. FIST: Enter the operating physician s first name. 78 & 79 OTHE PHYSIIAN Enter the Type qualifier, NPI, and name of the physician in charge of the patient care. (Blank Field): Enter one of the following Type Qualifiers: DN eferring. ZZ Other Operating MD. 82 endering. NPI: Enter the other physician 10-character NPI ID. QUAL: Enter one of the following qualifier and ID number: 0B State License #. 1G UPIN. G2 ommercial #. LAST: Enter the other physician s last name. FIST: Enter the other physician s first name. 80 EMAKS Not equired 81 A: Taxonomy of billing provider. Use ZZ qualifier. 57

59 APPENDIX VII: BILLING TIPS AND EMINDES Adult Day are Must be billed on a MS 1500 laim Form Must be billed in location 99 Ambulance Must be billed on a MS 1500 laim Form. Appropriate modifiers must be billed with the Transportation odes Ambulatory Surgery enter (AS) Ambulatory surgery centers must submit charges using the MS 1500 laim Form Must be billed in place of service 24 Invoice must be billed with orneal Transplants Most surgical extractions are billable only under the AS Anesthesia bill total number of minutes in field 24G of the MS 1500 laim Form Failure to bill total number of minutes may result in incorrect reimbursement or claim denial Anesthesiologist must bill modifiers listed below for all ASA codes: AA - Anesthesia service performed personally by anesthesiologist; or QX - NA/AA service with medical direction by a physician QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals NA s must bill with modifiers listed below for all ASA odes QZ - NA service without medical direction by a physician Qualifying circumstances are billed in addition to ASA services Only billable with a count of 1 There are no acceptable modifiers billable for these services Injections of anesthetic substance must be billed using the appropriate PT Procedure ode. Only billable with a count of 1 58

60 Spinal anesthesia is not covered with modifiers AA, QK, QX, and QZ. omprehensive Day ehab Must be billed on a MS 1500 laim Form Must be billed in location 99 Acceptable modifiers DME/Supplies/Prosthetics and Orthotics Must be billed with modifier Purchase only services must be billed with modifier NU EPSDT Must be billed with modifier EP Populate field 24h with appropriate indicator: E if the service is an EPSDT screening; F if the service is family planning related; or B if the service is both EPSDT and Family Planning related Hearing Aids Must be billed with the modifier LT or T Home Must be billed on a UB 04 Bill type must be 3XX Must be billed in location 12 Modifiers Appropriate Use of 25, 26, T, 50, GN, GO, GP 25 Modifier should be used when a significant and separately identifiable E&M service is performed by the same physician on the same day of another procedure (e.g., and Well-hild and sick visit performed on the same day by the same physician). *NOTE: 25 modifier is not appended to non E&M procedure codes, e.g. lab. 26 Modifier should never be appended to an office visit PT code. Use 26 modifier to indicate that the professional component of a test or study is performed using the (radiology) or (pathology) series of PT codes Inappropriate use may results in a claim denial/rejection 59

61 T Modifier used to indicate the technical component of a test or study is performed 50 Modifier indicates a procedure performed on a bilateral anatomical site Procedure must be billed on a single claim line with the 50 modifier and quantity of one. T and LT modifiers or quantities greater than one should not be billed when using modifier 50 GN, GO, GP Modifiers therapy modifiers required for speech, occupational, and physical therapy Multi page claims The page leading up to the last page of a multi-page claim should contain the word continued or cont. Totaling each page will result in separate claims that may incorrectly reimburse Nurse Midwife Must be billed on a MS 1500 laim Form. Must be billed in location 11, 12, 21, 22, or 25 Office Supplies Physicians may bill for supplies and materials in addition to an office visit if these supplies are over and above those usually included with the office visit. Supplies such as gowns, drapes, gloves, specula, pelvic supplies, urine cups, swabs, jelly, etc., are included in the office visit and may not be billed separately. s may not bill for any reusable supplies. POA Indicator Present on Admission (POA) Indicator is required on all inpatient facility claims Failure to include the PAO may result in a claim denial/rejection Telemedicine Physicians at the distant site may bill for telemedicine services and MUST utilize the appropriate modifier to identify the service was provided via telemedicine. Use appropriate value codes as well as birth weight when billing for delivery services. 60

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