Jurisdiction 11 (J11) Part A
Medicare Updates and Reminders
HFMA West Virginia Chapter
Meeting
January 18, 2012
Disclaimer
This presentation was current at the time it was published or uploaded onto the
Palmetto GBA Web site. Medicare policy changes frequently so links to the source
documents have been provided within the document for your reference.
This presentation was prepared as a tool to assist providers and is not intended to grant
rights or impose obligations. Although every reasonable effort has been made to assure
the accuracy of the information within these pages, the ultimate responsibility for the
correct submission of claims and response to any remittance advice lies with the
provider of services.
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff
make no representation, warranty, or guarantee that this compilation of Medicare
information is error-free and will bear no responsibility or liability for the results or
consequences of the use of this guide.
This publication is a general summary that explains certain aspects of the Medicare
Program, but is not a legal document. The official Medicare Program provisions are
contained in the relevant laws, regulations, and rulings.
Agenda
• J11 Part A Medicare Updates
• J11 Part A Medicare Reminders
J11 Part A Medicare Updates
Additional Way to Submit Medical
Record Documentation: Update
MLN Matters® Number: MM7254
Related Change Request (CR) #: 7254
MLN Matters® Number: SE1110 Revised Medicare Pilot Project for
Electronic Submission of Medical Documentation (esMD).
Effective: January 15, 2012
• Palmetto GBA providers will be able to submit medical records via esMD.
• In order to send medical documentation electronically to review
contractors, Medicare providers, including physicians, hospitals, and
suppliers, must obtain access to a CONNECT-compatible gateway.
• Certain larger providers, such as hospital chains, may choose to build their
own gateway.
• Many providers may choose to obtain gateway services by entering into a
contract or other arrangement with a Health Information Handler (HIH)
that offers esMD gateway services.
• For more information about esmd, see www.cms.gov/esmd
Medicare Fee-For-Service (FFS) Policy Regarding
90 Day Discretionary Enforcement Period for Non-
Compliant HIPAA Covered Entities
• The Centers for Medicare and Medicaid Services (CMS) announced it would not
initiate enforcement action with respect to any HIPAA covered entity that is non
compliant with Version 5010, NCPDP, NCPDP D.0 and 3.0 standards until 90 days
after the upcoming January 1, 2012 compliance date.
• Although compliance will not be enforced for Version 5010 until April 1, 2012, it is
important to continue to take the necessary steps to complete your transition to Version
5010 as soon as possible.
• Medicare FFS is planning to take the following steps for submitters and receivers of
Medicare Part B and Durable Medical Equipment (DME) transactions:
– In December 2011, submitters and receivers that have tested and been approved for
5010/D.0 will be notified that they have 30 days to cutover to the 5010/D.0 versions.
– Submitters and receivers that have not yet tested will be notified in December 2011 that
they must submit their transition plans and timelines to their MAC within 30 days.
– MACs will notify the submitters and receivers, but submitters/receivers have the
responsibility to notify the providers they service.
•
Note: Submitters and receivers of Medicare Part A transactions will follow the
same action plan starting 30 days after Part B and DME.
New ASC X12 Version 5010 FAQs Posted
to the CMS Web site
• CMS has published six FAQ items related to 90 Day
Discretionary Enforcement Period for Non-Compliant
HIPAA Covered Entities
• These new FAQs can be found at:
http://www.cms.gov/Versions5010andD0/Downloads
/QandA_for_90_day_announcement.pdf
• For more information on ASC X12 Version 5010,
NCPDP D.0, and NCPDP 3.0; please visit
www.CMS.gov/Versions5010andD0
Update to Medicare Deductible,
Coinsurance and Premium Rates for 2012
MLN Matters® Number: MM7567 Revised
Related Change Request (CR) #: CR 7567
Effective Date: January 1, 2012
Implementation Date: January 3, 2012
• The 2012 inpatient deductible is $1,156.00.
• The coinsurance amounts are shown below in the following table:
Hospital Coinsurance
Hospital Coinsurance
SNF Coinsurance
Days 61-90
Days 91-150 (Lifetime
Reserve Days)
Days 21-100
$289.00
$578.00
$144.00
Update to Medicare Deductible,
Coinsurance and Premium Rates for 2012
• 2012 Part B - Supplementary Medical Insurance
(SMI)
Standard Premium:
$99.90 a month
Deductible:
$140.00 a year
Coinsurance:
20%
Screening and Behavioral Counseling
Interventions in Primary Care to Reduce
Alcohol Misuse
MLN Matters® Number: MM7633
Related Change Request (CR) #: 7633
Effective Date: October 14, 2011
Implementation Date: December 27, 2011, for local contractor
system edits; April 2, 2012-for Medicare’s shared system edits,
July 2, 2012 for provider inquiry screens & HICR changes
• CMS will cover annual alcohol screening, and for those that
screen positive, up to 4, brief, face-to-face behavioral
counseling interventions annually for Medicare beneficiaries,
including pregnant women.
Intensive Behavioral Therapy (IBT) for
Cardiovascular Disease (CVD)
MLN Matters® Number: MM7636
Related Change Request (CR) #: 7636
Effective Date: November 8, 2011
Implementation Dates: December 27 for local Medicare Contractor system
edits; April 2, 2012, for Medicare shared system edits; and July 2, 2012, CWF
provider screens and HICR changes
• CMS covers IBT for CVD, inclusive of one face-to-face CVD risk
reduction visit annually.
• The Medicare patient receiving this care must be competent and alert at the
time the service is rendered and the service must be furnished by a
qualified primary care physician or other primary care practitioner in a
primary care setting.
Therapy Cap Values for
Calendar Year (CY) 2012
MLN Matters® Number: MM7529 Revised
Related Change Request (CR) #: 7529
Effective Date: January 1, 2012
Implementation Date: January 3, 2012
• Therapy caps for 2012:
PT and SLP Combined:
$1880.00
OT:
$1880.00
• If Congress extends the therapy cap exceptions process, CMS will
provide an update to inform providers of the details of such
extension.
Screening for Depression in Adults
MLN Matters® Number: MM7637
Related Change Request (CR) #: 7637
Effective Date: October 14, 2011
Implementation Date: April 2, 2012
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Medicare covers annual screening for adults for depression in the primary care setting that has
staff-assisted depression care supports in place to assure accurate diagnosis, effective
treatment, and follow-up.
Medicare contractors will recognize new Healthcare Common Procedure Coding System
(HCPCS) code, G0444, annual depression screening, 15 minutes, as a covered service.
NOTE: This code will appear on the January 2012 Medicare Physicians Fee Schedule update. The
Type of Service (TOS) for HCPCS code G0444 is 1. Effective October 14, 2011, beneficiary
coinsurance and deductibles do not apply to claim lines with annual depression screening, G0444.
For Dates of Service on or after October 14, 2011, through December 31, 2011, Medicare
contractors will use their pricing for paying HCPCS code G0444 and update their HCPCS files
accordingly
President Obama Signs the Temporary
Payroll Tax Cut Continuation Act of 2011
(TPTCCA)
• On Friday, December 23, 2011, President Obama signed into
law the TPTCCA.
• This new law prevents a scheduled payment cut for physicians
and other practitioners who treat Medicare patients from
taking effect immediately.
• The negative update for the 2012 Medicare Physician Fee
Schedule is now scheduled to take effect on March 1, 2012.
• CMS Web site for the updated 2012 MPFS Public
Use Files at:
http://www.cms.gov/PhysicianFeeSched/PFSNPAF/li
st.asp#TopOfPage.
Correct Provider Billing of Admission
Date and Statement Covers Period
MLN Matters® Number: SE1117
Related Change Request (CR) #: N/A
Effective Date: N/A
Implementation Date: N/A
• In collaboration with the National Uniform Billing Committee’s (NUBC)
definition for reporting of the Admission Date and Statement Covers Period
elements on claims, the CMS would like to remind you to review the NUBC
definitions for claims submitted on or after October 1, 2011 with a discharge
date of July 1, 2011 forward.
• This edit logic change does not apply for claims with a discharge date prior to
July 1, 2011.
• The Admission Date (Form Locator 12) is the date the patient was admitted
as an inpatient to the facility. It is reported on all inpatient claims regardless
of whether it is an initial, interim, or final bill.
• The Statement Covers Period (“From” and “Through” dates in Form
Locator 6) identifies the span of service dates included in a particular bill.
The “From” Date is the earliest date of service on the bill.
Correct Provider Billing of Admission
Date and Statement Covers Period
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Previously, Medicare’s Fiscal Intermediary Shared System (FISS) edits required
that the Admission Date not be later than the “From” date on initial provider claims
as required to match NUBC UB-92 definitions. In order to pass FISS edits and
avoid getting a claim rejected, providers may have engineered workarounds that
force the two dates to match.
CMS has issued instructions to FISS for modifying FISS edits regarding these data
elements to match NUBC UB-04 definitions:
Based on UB-04 definitions of these two data elements, CMS has modified FISS
edits so Admission Date and “From” Dates are not required to match.
Based on UB-04 definitions of these two data elements, CMS has modified FISS
edits so as not to compare the number of days in the Statement Covers Period to
any other data element (e.g., total accommodation days reported in the revenue
code section).
As a reminder, you should verify your systems edit logic for correct application of
these data elements. If you implemented workaround routines, you need to
deactivate them. You should contact your trading partners to ensure they are aware
of the changes and that they are taking the appropriate steps to correct any edit
logic. Please ensure that your staffs are aware of these upcoming changes.
2011 Version of Advance Beneficiary Notice
of Noncoverage Must Be Used Beginning
January 1, 2012
– In May 2011, CMS released an updated version of the ABN
(form CMS-R-131), which will replace the 2008 version of this
form.
– The 2011 version contains no substantive changes from the
2008 version of the notice.
– The 2008 and 2011 ABN notices are identical except that the
release date of '3/11' is printed in the lower left hand corner of
the new version.
– The ABN is used by all providers, practitioners and suppliers
paid under Medicare Part B, as well as hospice providers and
religious non-medical health care institutions (RNHCIs) paid
exclusively under Part A.
2011 Version of Advance Beneficiary
Notice of Noncoverage Must Be Used
Beginning January 1, 2012
– Providers and suppliers are allowed to use either the 2008 or
2011 version of the ABN through the end of this year.
– Beginning January 1, 2012, they must begin using the 2011
version.
– ABNs issued after January 1 that are prepared using the
2008 version of the notice will be considered invalid by
Medicare contractors.
– 2008 versions of the ABN that were issued prior to January
1 as long-term notification for repetitive services delivered
for up to one year will remain effective for the length of
time specified on the notice.
– Reference: www.CMS.gov/BNI, under the 'FFS Revised
ABN' link.
Hospital Routine Services under
Arrangement Requirement
– Per the FY 2012 IPPS final rule:
– Only therapeutic and diagnostic services may be furnished
outside of the hospital ‘under arrangement’.
– ‘Routine Services' (for example, bed, board, and nursing
services) must be provided by the hospital.
• ‘Routine Services’ that are furnished in the hospital to its inpatients are
considered as being provided by the hospital.
• If ‘Routine Services’ are provided outside of the hospital, the services
are considered as being provided under arrangement.
– Beginning with the FY 2013, all hospitals will need to be in
full compliance with the modified under arrangement
provisions.
J11 Part A Medicare Reminders
Provider Contact Center (PCC) Training
and Holiday Closure Schedule
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The PCC will continue to close up to eight hours per month for customer service representative (CSR)
training and staff development.
The Interactive Voice Response (IVR) unit will be available during these scheduled training sessions
for automated customer service transactions.
Listed below are training closure dates and times:
January 2, 2012
Office closed/New Year's Day
January 5, 2012
PCC closed 2:30 p.m. - 4:30 p.m
January 12, 2012
PCC closed 2:30 p.m. - 4:30 p.m.
January 16, 2012
Office closed/MLK Day
January 19, 2012
PCC closed 2:30 p.m. - 4:30 p.m.
January 26, 2012
PCC closed 2:30 p.m. - 4:30 p.m.
Reminder - Quarterly
Release Temporary Hold
• Each quarter, the Fiscal Intermediary Shared
System (FISS) is updated to include new logic
for claims processing, pricing, etc.
• Palmetto GBA places a temporary 'hold' to
ensure the release is installed properly.
• Claims with dates of service January 1, 2012,
or later will be held
• Claims will be released on or about January
13, 2012, to continue processing.
Reminder - Quarterly Release
Temporary Hold
Reason Code
Status Location
Description
36231
SM6231
ESRD Claims (72X TOB)
37147
SM7147
IRF Claims
37148
SM7148
Swing-Bed PPS SNF Claims
37150
SM7150
PPS Claims
37167
SM7167
LTCH PPS Claims
37181
SMPRIC
IPF Claims
IPPS1
SMOPPS
OPPS Claims
WW999
SMFISS
Holds All Claims
7OUTP
SMOUTP
TOB 13X, 14X, 12X, 22X,
23X, 34X, 71X, 74X, 75X,
76X, or 85X
J11 Part A Claims
Processing Issues Log
– www.palmettogba.com/J11A
– Select Claims Processing Issues Log
• System Issues Reported to CMS and /or FISS
• Affecting multiple providers and/or large numbers of
claims
• Updated at least weekly
Current Claims Issues
Provider Types
Affected
Situation
Impact to Providers
Status
J11 Part A
A system release incorrectly
affected the Release of
Information (RI) field for
the payer ID. Claims are
auto populating a value of
'N' instead of 'Y' for the RI
field for the payer ID.
This is causing claims to
deny incorrectly with
reason code 31313.
12/22/2011
The scheduled system fix is
ongoing. For providers with
claims that are still being
affected, you are able to
correct the RI field of the
claim.
J11 Part A
Medicare Secondary Payer
(MSP) claims are returning
to the provider (RTP)
incorrectly with reason code
33981.
MSP claims
with contractual obligation
value code 44 are being
affected. The contractual
obligation amount and the
OTAF amount are not
balancing out.
12/22/2011
Additional claims have
been identified as being
affected by this issue. The
issue is still being
researched by the FISS
maintainer.
Current Claims Issues
Provider Types
Affected
Situation
Impact to Providers
Status
J11 Rural Health Clinics
(RHCs)
The Centers for Medicare
& Medicaid Services
(CMS) has instructed
Palmetto GBA to hold all
rural health clinic claims
(type of bill 71x)
containing preventative
services noted in Change
Request 7208.
Claims impacted by this
issue will be held in a
suspense location until a
correction is
implemented.
12/22/2011
A fix is scheduled for
January 2012.
J11 Part A
The July 2011 system
release incorrectly affected
Medically Unlikely Edits
(MUEs) for several
HCPCS/CPT codes.
Claims submitted with
HCPCS/CPT codes
affected by this issue are
denying incorrectly with
reason code 51MUE or
52MUE.
12/22/2011
CMS will begin to adjust
claims mid-January 2012.
Current Claims Issues
Provider
Types
Affected
J11 Skilled
Nursing
Facilities
(SNFs) and
Swing Bed
(SB)
Situation
Impact to Providers
Status
J11 Skilled Nursing Facilities
(SNFs) and Swing Bed
(SB)Change Request (CR)
7019, effective January 1,
2011, instructs providers to
report the ARD date with
occurrence code 50. However,
the Health Insurance
Prospective Payment System
(HIPPS) code AAA00 does not
need an accompanying
occurrence code 50.
SNF and swing bed claims billed
with the default HIPPS code AAA00
(no-pay bills) are editing incorrectly
with reason code 31742 and cannot
continue to process.
12/22/2011
The implemented fix did not
address all issues. Therefore,
a new fix is in research
status. This revised fix is
being scheduled.
Current Claims Issues
Provider
Types
Affected
J11 Part A
Situation
Impact to Providers
Status
Effective for claims with dates of
service on or after May 9, 2011,
Medicare will begin paying for CPT
code 90654, influenza virus vaccine,
split virus, preservative-free, for
intradermal use.
Providers have the option to
hold their claims containing
CPT code 90654 until Monday,
April 2, 2012.
12/22/2011
CMS will issue a Change
Request when system
update occurs no later
than April 2, 2012, and
claims may be released.
Providers may refrain
from submitting claims
containing CPT code
90654 until April 2,
2012.
CMS has instructed Medicare
contractors to hold all institutional
claims containing CPT code 90654
with dates of service on or after May
9, 2011 until their systems are able to
accept them for processing no later
than April 2, 2012.
Current Claims Issues
Provider
Types
Affected
J11 Part A
Situation
Impact to Providers
Under the Inpatient Prospective
Payment System (PPS), hospitals
receive a special add-on payment for
the costs of furnishing blood clotting
factors to Medicare beneficiaries with
hemophilia, admitted as inpatients of
PPS hospitals. The clotting factor
add-on payment is automatically
calculated by FISS.
FISS is not applying the blood
clotting factor add-on payment
when billed on inpatient PPS
claims. These claims are only
receiving the DRG payment.
Status
12/22/2011
The issue is currently
being researched by the
FISS maintainer.
FISS System IssuePhysical Therapy Denials
• We are having issues with ICD 9 and CPT
codes related to physical therapy and therefore
some PT claims are denying incorrectly.
• The problem is that FISS has not been updated
with the new codes. This is a FISS system
issue and FISS is currently working on a
resolution.
• We are having to manually work these claims
in the mean-time.
Probe Medical Review of Inpatient Medical
Severity Diagnostic Related Group (MSDRG)
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The J11 A/B MAC Medical Review department will perform a service-specific prepay probe
review on inpatient hospital claims in Virginia and West Virginia.
Data analysis identified inpatient hospital services and the circulatory Medical MS-DRGs as
number one in these states.
Further analysis indicated the Medical MS-DRGs listed below as the top three for Virginia
and West Virginia.
Claims review will be performed on approximately 100 claims per state for each of the
Medical MS-DRGs selected.
The DRGs identified are:
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DRG 291 (Heart Failure & Shock w/MCC)
DRG 247 (Percutaneous cardiovascular proc w/drug-eluding stent w/o MCC)
DRG 292 (Heart Failure & Shock w/CC)
Providers who receive an Additional Documentation Request (ADR) must submit the
requested medical record information within 30 days to:
Palmetto GBA
J11 Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238
Or fax to (803) 699-2432
Probe Medical Review of Inpatient Medical
Severity Diagnostic Related Group (MSDRG)
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Hospitals should ensure the accuracy of their billing and send the following documentation
when responding to the ADRs:
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Hospital history and physical
Physician’s orders for the admission to inpatient and all services billed
Plan of care
Diagnostic test results/reports, including imaging reports
Itemized list of all charges
Clinical/therapy notes
Hospital admission assessment
Consultation reports
Physician progress notes
Hospital discharge summary
Please submit all documentation to support the medical necessity of services/DRG code billed
If you question the legibility of your signature, you may submit a signature log or an
attestation statement in your ADR response. Medicare requires that medical record entries for
services provided/ordered be authenticated by the author. The method used shall be a
handwritten or an electronic signature. Stamp signatures are not acceptable. Patient
identification, date of service and provider of the service should be clearly identified on the
submitted documentation.
Completed review results will be posted to the Palmetto GBA Web Site. Individual providers
with significant denials will be contacted for one-on-one education.
Questions regarding this review may be directed to the Medical Review department at (803)
763-7491.
Responding to a Skilled Nursing
Facility (SNF) Additional
Documentation Request (ADR)
The following list is a recommendation for what to include when responding to a Skilled
Nursing Facility (SNF) Additional Document Request (ADR):
• The hospital transfer/discharge summary
• Physician’s certification that the beneficiary has a need for daily skilled care in the SNF
• Physician’s recertification(s) that the beneficiary has a need for continuing daily skilled
care in the SNF
• Physician’s orders for the look back period(s) and the dates of service under review
• Nurses' notes for the look back period(s) and the dates of service under review.
Documentation should support the look back periods related to the assessment reference
dates of the submitted MDS(s). It may include documentation 30 through 45 days prior
to the dates of service under review.
• Therapy documentation (including the look back period) - Documentation to support
therapy services must include the following:
a) Physician’s orders for therapy services
b) Initial therapy evaluation and any subsequent evaluations
c) Plans of treatment
d) Signed therapy daily treatment notes and progress notes
e) Documentation of the actual minutes of therapy rendered for each therapy session.
Therapy minutes may be recorded on a grid or in the therapy documentation.
f) Documentation of the number of group participants per therapist
Responding to a Skilled Nursing
Facility (SNF) Additional
Documentation Request (ADR)
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Physician’s orders for therapy services and therapy plans of treatment must be signed
and dated by the physician. Medical necessity of services must be apparent in the
therapists’ documentation.
Any additional documentation necessary to support the medical necessity of services
(e.g., social worker notes, pertinent lab and X-ray reports, consultations, aide notes,
etc.).
When responding to an ADR for a condition code 20 claim, a copy of the signed and
dated notice of non-coverage issued to the beneficiary/representative must be
submitted for review
Please send a manifest with medical records submitted and send the medical records
in secure packaging to ensure the security of medical records
If responding to multiple requests in a single envelope, ensure each response is clearly
separated. If responding to more than one date of service on the same beneficiary,
send a response for each request separately. Include a manifest or list identifying each
ADR response sent.
Attach a copy of the ADR request to each individual claim
Use one staple or elastic band per record to attach the documentation and ADR
together. Do not use paper clips as they can become dislodged.
Do not punch holes in medical records, as this may obscure valuable information
Return the medical records to the appropriate address listed below or on the ADR
Responding to a Skilled Nursing
Facility (SNF) Additional
Documentation Request (ADR)
For Postal Delivery Please Use:
J11 Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238
For FedEx/UPS/Certified Mail:
J11 Part A Medical Review
Mail Code: AG-230
2300 Springdale Drive, Building One
Camden, SC, 29020-1728
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•
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Do not include any correspondence other than ADR responses to the Medical Review
department in your envelope
If billing corrections are needed, submit a hardcopy UB-uniform billing (latest version from
CMS), with a XX7 bill type along with your medical records
We are not able to accept packages on a C.O.D. basis. Please make sure that you have sent
packages with the shipping prepaid.
The Palmetto GBA Medical Review Department developed a Responding to a Skilled
Nursing Facility (SNF) ADR checklist. Please complete this checklist and include it
when responding to an ADR. This checklist is available on the Palmetto GBA Web
site: Responding_to_a_SNF_ADR_checklist_rev08162011.pdf (PDF, 27 KB)
The J11 Part A Outlier Billing
Webinar handout is available
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www.PalmettoGBA.com/J11A
Select Learning and Education
Select Workshop Handouts
Select the PDF file to download or print:
J11A_Outlier_Billing_Webinar_102011.pdf
(PDF, 157 KB)
FAQs: Additional Medical Review
Projects and CERT
•
To help reduce the Comprehensive Error Rate Testing (CERT) program error rates, Palmetto
GBA was recently funded by CMS to undertake additional medical review projects that
involve medical review of and education for certain E/M coded claims, advanced imaging
claims, major procedure claims, inpatient hospital claims and home health claims that
contributed to the majority of the J11 MAC CERT payment errors.
•
Providers selected for education and/or medical review are selected based on the frequency of
their billings for the services/codes mentioned above. Palmetto GBA’s educational and review
efforts will primarily focused on reducing payment errors from insufficient documentation
and improper coding. Providers will receive written results of the project’s findings if
being selected for medical review.
•
FAQs were developed to help clarify what the additional medical reviews involved and how
providers can help in the process.
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www.PalmettoGBA.com/J11A
Select CERT
Select General
Select FAQs: Additional Medical Review Projects and CERT
For more information, please refer to the article 'The ABCs of the Comprehensive Error Rate
Testing (CERT) Program and How to Respond to CERT Requests.
What to do if you have a claim that needs
to have timely filing overridden to process
and pay back an overpayment
• If the claim is still online:
– Adjust the claim
– Put in remarks you need timeliness overridden to repay a Medicare
overpayment
• If it is offline:
– Call the PCC to request it be placed back online
– Once the claim is back online, make the adjustment
– Put in remarks you need timeliness overridden to repay a Medicare
overpayment
• This will assure the claim is correct in case it is reviewd in the
future and it assures you know the correct amount to pay back
to Medicare.
• The only time you report it on the credit balance report is if the
claim did not get adjusted to repay that quarter.
• Note: Timeliness will NOT be overridden to pay an
underpayment to the provider.
Determining to Appeal
Providers can appeal a claim or claim line that receives a full or
partial medical denial. If a claim or line item is medically denied
(status location = D B9997) and the provider has medical
evidence that the service should be covered by Medicare, an
appeal may be submitted by using the First Request:
• Redetermination Request Form
• To access this form, go to www.PalmettoGBA.com/J11A
• Select Forms from the Top Links box on the left navigation
Determining to Adjust
Claims that are processed, paid, or rejected (status location code = P B9997 or R B9997) and are 'posted' to Medicare
history in the Common Working File (CWF) can be adjusted. If a historical record of a claim exists in CWF, an
adjustment transaction must be processed to update the historical record. These adjustments may be made through
Direct Data Entry (DDE) or through a vendor’s software. It is important to note if the claim was partially denied, (i.e.,
the claim contains a medically denied line), the adjustment cannot be done through DDE. Please refer to the
instructions below for submitting a Clerical Error Reopening Request Form.
When to Submit an Online Adjustment
Providers can submit an online adjustment using bill type XX7 to correct:
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Number of inpatient days
•
Claims coding
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Adding additional charges
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Blood deductible
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Servicing hospital
•
Inpatient cash deductible of more than $1
•
Diagnosis Related Group (DRG) code *
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Discharge status in a Prospective Payment System (PPS) hospital
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Outlier payment amount
*If an adjustment the hospital initiates results in a change to a higher weighted DRG, the Medicare contractor edits the
adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted.
If it is, the Medicare Contractor processes the claim for payment. If the remittance date is more than 60 days prior to
the receipt date of the adjustment request and results in a change to a lower weighted DRG, the Medicare Contractor
processes the claim for payment and forwards it to CWF.
The proper way to submit an adjustment
claim (bill type XX7) that had previously
denied lines
• The proper way to submit an adjustment claim (bill type XX7) that had
previously denied lines is to delete all non-covered lines and re-enter the lines
with the corrections. This will prevent the claim from processing as non-covered
a second time.
• Providers should remember to use the following instructions when correcting
revenue code lines in Direct Data Entry (DDE):
To delete an entire revenue code line:
– TAB to the line and type zeros over the top of the revenue code to be deleted or type 'D' in the
first position
– Press HOME to go to the Page Number field. Press ENTER. The line will be deleted.
– Next, add up the individual line items and correct the total charge amount on Revenue Code
line (0001)
To add a Revenue Code line:
– TAB to the line below the total line (0001 revenue code)
– Type the new revenue code information
– Press HOME to go to the Page Number field. Press ENTER. The system will resort the
revenue codes into numerical order.
– Correct the total charge amount of revenue code line (0001)
The proper way to submit an adjustment
claim (bill type XX7) that had previously
denied lines
To change total and non-covered charge amounts:
– TAB to get to the beginning of the total charge field on a line item
– Press END to delete the old dollar amount. It is very important not to use the spacebar to
delete field information. Always use END when clearing a field.
– Type the new dollar amount without a decimal point (e.g., for $23.50 type '2350')
– Press ENTER. The system will align the numbers and insert the decimal point.
– Correct the totals line if necessary
– Press F9 to update/enter the claim into DDE for reprocessing and payment
consideration. If the claim still has errors, reason codes will appear at the
bottom of the screen. Continue the correction process until the system takes
you back to the claim correction summary. When the corrected claim has been
successfully updated, the claim will disappear from the screen. The following
message will appear at the bottom of the screen: ‘PROCESS COMPLETED –
ENTER NEXT DATA.’
• Reference: Direct Data Entry (DDE) Manual (PDF, 4.75 MB)
Reminder About Adjustments On Claims
With Medically Denied Lines:
•
•
•
If a line item on a claim is medically denied (status location = D B9997) and the
provider has medical evidence that he or she thinks should allow the denied service
to be covered by Medicare, an appeal must be filed using the Redetermination
Request Form.
If there is a medically denied line item on the claim, but the provider needs to adjust
the claim to make a change to something OTHER THAN the denied line item, the
provider may key the adjustment in the system with the appropriate condition
code(s) that describes the change(s) on the claim. Once adjusted, the claim will go
to an S “suspense” status and location to be reviewed by the claims department
before processing.
If there is a medically denied line item on the claim, and the Fiscal Intermediary
Shared System (FISS) does not allow the provider to make an online adjustment:
– In this instance, the provider should submit a hard copy adjustment using the:
– Clerical Error Reopening Request Form
– www.PalmettoGBA.com/J11A
– Select Forms from the Top Links box on the left navigation
When to Submit a Clerical
Error Reopening Form
The Centers for Medicare & Medicaid Services (CMS) defines clerical errors (including minor errors or
omissions) as human or mechanical errors on the part of the party or the contractor, such as:
•
•
•
•
•
•
Mathematical or computational mistakes
Transposed procedure or diagnostic codes
Inaccurate data entry
Misapplication of a fee schedule Computer errors Denial of claims as duplicates which the party believes were
incorrectly identified as a duplicate
Incorrect data items, such as provider number, use of a modifier or date of service
If there is a medically denied line item on the claim, the Fiscal Intermediary Shared System (FISS) may not allow
the provider to make an online adjustment.
– In this instance, the provider should submit a hard copy adjustment using the:
–
–
–
Clerical Error Reopening Request Form
www.PalmettoGBA.com/J11A
Select Forms from the Top Links box on the left navigation
Note: Clerical errors or minor errors are limited to errors in form and content, and that omissions
do not include failure to bill for certain items or services. A contractor shall not grant a reopening
to add items or services that were not previously billed, with the exception of a few limited items
that cannot be filed on a claim alone (e.g., G0369, G0370, G0371 and G0374). Third party payer
errors do not constitute clerical errors.
The following chart provides information
on claim change reason condition codes:
Code
Description
Code
Description
D0
Changes to Service Date
D6
Cancel only to repay a duplicate
IOG payment
D1
Changes to Charges
D7**
Change to Make Medicare
Secondary Payer
D2
Changes in Revenue
Codes/HCPCS/HIPPS
D8
Chang eto Make Medicare
Primary Payer
D3
Second or Subsequent Interim
PPS Bill
D4
Changes in Grouper Codes
D5
Cancel to correct HICN or
Provider Number
D9***
Any Other Change
E0
Change in Patient Status
**Use D9 when adjusting
primary payer to bill for
conditional payment.
***This code is used if adding a
modifier to change liability and
there is no change to the
covered charge amount.
Understanding When to Use the D9
Claim Change Reason (Condition) Code
• Use the D9 claim change reason code on an adjustment claim to reflect any other
changes to be made to a claim that was already processed.
• It is used to report an adjustment to a claim when an original claim was rejected
for Medicare Secondary Payer (MSP) but Medicare is primary.
• Additionally, it can be used when the original claim was processed as an MSP or
conditional claim and a change needs to be made to the claim such as a change
in the MSP value code amount.
• If an adjusted claim is in a Return to Provider (RTP) status (T B9997), it is
important to verify that the D9 code is being used correctly.
• If the D9 is the best code to use, the claim will need to include remarks
indicating the reason for the adjustment. If remarks are not submitted on the
claim, then the Medicare contractor will return the claim back to the provider
using reason code 37541.
Note: The Medicare contractor must suspend for investigation all adjustment
requests with claim change reason codes D4, D8 and D9. Providers that
consistently use D9 will be investigated. If a pattern of abuse is evident, they
may be reported to the Office of Inspector General (OIG).
Questions?
• Call the J11 Part A PCC at:
– (866) 830-3455
• Refer to the Palmetto GBA Web site J11 Part
A Home page:
– www.PalmettoGBA.com/J11A
• Refer to the CMS Internet-Only Manuals
– www.cms.gov/manuals