Lab Resources August 06, 2007
  August 06, 2007

In This Issue:
CMS:

California Medi-Cal:


Updated CARCs and RARCs

  CMS

Transmittal 1267: CR5634 (PDF).
Effective Date: July 1, 2007

Change Request 5634 which instructs Medicare contractors that a Remittance Advice Remark Code (RARC) must be used with Claim Adjustment Reason Codes (CARCs) 16, 17, 96, 125, and A1. The code committee that maintains the CARC code set recently modified five CARCs (16, 17, 96, 125, and A1). These CARCs were selected for modification because they were very generic, and they were used most frequently. Of these 5 CARCs, the following 4 now require the use of at least one appropriate RARC, and they are effective April 1, 2007:

CARC Definition
16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
96 Non-covered charge(s). This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)


The following CARC also requires at least one RARC, but it is effective June 1, 2007:
CARC Definition
A1 Claim denied charges


In addition, the committee that maintains reason codes approved the following CARC effective February 28, 2007:
CARC Definition
204 This service/equipment/drug is not covered under the patient’s current benefit plan

 

Top 10 Duplicate Claim Submitters

  CMS

CMS continues to focus identification of provider compliance errors on duplicate claim denials through the CERT review process, which indicates the following specialties as high volume duplicate submitters:

Specialty % of claim denials for California

  1. Otolaryngology 12.67%
  2. General Practice 7.62%
  3. Family Practice 7.18%
  4. Physical Therapist in Private Practice 7.10%
  5. Diagnostic Radiology 6.34%
  6. Internal Medicine 6.29%
  7. Cardiology 5.60%
  8. Multiple Specialty Group 4.41%
  9. Ophthalmology 4.38%
  10. Clinical Laboratory 2.07%

Duplicate billing is not cost effective for the Medicare program. Duplicate submissions are also the number one reason for poor provider compliance in the CERT review. Remember, duplicate billing is considered abusive by CMS and can result in additional auditing of providers. Carriers suggest that providers post payments and denials promptly and review denials in order to take the appropriate action.

 

New CLIA Waived Tests

  CMS

Transmittal 1244: CR5600 (PDF).
Implementation Date: July 2, 2007

Laboratory claims are currently edited at the CLIA certificate level in order to ensure that CMS only pays for laboratory tests categorized as waived complexity under CLIA (for facilities with a CLIA certificate of waiver).

Listed below are the latest tests approved by the Food and Drug Administration as waived tests under the CLIA. CPT codes for the following new tests must have the modifier QW to be recognized as a waived test.

Description   Effective Date   CPT Code / Modifier
Wolfe Drug Testing RealityCheck Integrated Specimen Cup December 28, 2006 80101QW
Drug Detection Devices Ltd. Multi-Drug Multi-Line Screeners Dip Drug Test With the Integrated Screeners AutoSplit KO Test Cup December 28, 2006 80101QW
Insure Quik Fecal Immunochemical Test (F.I.T.) January 26, 2007 82274QW, G0328QW
Polymer Technology Systems CardioChek PA Analyzer (PTS Panels Metabolic Chemistry Panel Test Strips) February 7, 2007 82947QW, 82950QW, 82951QW, 82952QW, 83718QW and 84478QW
Inverness Medical Clearview H. pylori Test {whole blood} February 7, 2007 86318QW
Innovacon Integrated E-Z Split Key Cup II {Professional Use} February 22, 2007 80101QW
Redwood Toxicology Laboratory Reditest 6 Cassette substance abuse screening device {Professional Use} March 14, 2007 80101QW
Roche Diagnostics CoaguChek XS March 23, 2007 85610QW

 

NPPES Errors, Using the NPI on Medicare Claims

  CMS

Medicare Learning Network:  SE0725 (PDF).

Important Information for Providers/Suppliers Regarding National Plan and Provider Enumeration System (NPPES) Errors, Using the NPI on Medicare Claims and 835 Remittance Advice Changes

Common Enumeration Errors in NPPES
The following are some of the more frequent errors providers have been making when applying for NPIs:

  • Errors in Employer Identification Number (EIN): As a reminder, providers that are organizations are required to report the EIN when they apply for an NPI. When the EIN error is on the Medicare provider enrollment record, the provider should submit a CMS-855 to the Medicare contractor to correct it.
  • Invalid or incomplete data within the “Other Provider Identifiers” section of the NPPES online application, such as:
    • The absence of the Medicare legacy number,
    • Not having the “Type” listed as Medicare for a Medicare provider number, and/or
    • Reporting Medicare provider numbers that do not belong to the provider applying for the NPI and, therefore, should not be linked to the assigned NPI.
  • Reporting an Incomplete Identifier: When reporting the Medicare legacy identifiers to NPPES, report the full identifier. This means that suffixes to the OSCAR/Certification Numbers are to be reported.
  • Having More than the Allowable Number of Legacy Numbers: At the present time, the NPPES can capture a grand total of 20 “Other Provider Identification Numbers.” NPPES will be expanded to capture more than 20 “Other Provider Identification Numbers” at a future date.
  • Listing Legacy Numbers that Do Not Belong to the Applicant: The provider/supplier should make sure that any Medicare legacy identifier(s) entered in that field in NPPES are those that will need to be linked directly to the NPI to be assigned.

Dos and Don’ts When Reporting “Other Provider Identification Numbers” in NPPES

  • For a Medicare physician or other practitioner applying for an NPI: DO include your UPIN and your PIN when applying for an NPI. DO NOT include the PIN of your group practice or clinic if you are affiliated with a group practice or clinic.
  • For a Medicare group practice or clinic applying for an NPI: DO include your PIN. DO NOT include the PINs or UPINs of any of the members of the group practice or clinic.

If Medicare providers/suppliers determine that they should make changes to their NPPES records, they may do so by going to NPPES at https://nppes.cms.hhs.gov/ at any time and updating their information.

 

Medi-Cal begins using 2007 CPT-4 codes August 1, 2007

  California Medi-Cal

Medi-Cal General Medicine: Bulletin 397 (PDF).

Effective August 1, 2007, Medi-Cal will adopt the 2007 CPT-4 and HCPCS Level II codes. Claims billed for dates of service on or after August 1, 2007 must use the appropriate 2007 codes.

 

Diagnosis code restrictions for 83001 and 83002 effective August 1, 2007

  California Medi-Cal

Medi-Cal General Medicine: Bulletin 397 (PDF).

Effective for dates of service on or after August 1, 2007, CPT-4 codes 83001 (gonadotropin; follicle stimulating hormone [FSH]) and 83002 (…luteinizing hormone [LH]) are reimbursable only when billed in conjunction with one of the following ICD-9-CM diagnosis codes:

072.0 192.8 236.0 – 236.6 626.0 – 626.9
147.0 194.0 – 194.9 237.0 – 239.7 627.0 – 627.9
170.0 213.0 240.0 – 279.9 628.0 – 628.1
174.0 – 175.9 215.0 303.9 752.0 – 752.9
183.0 – 183.9 220 307.1 758.0 – 759.9
185 222.0 359.0 – 359.9  
186.0 – 186.6 225.0 – 225.9 456.4  
191.0 227.0 – 227.9 606.0 – 606.9  

Codes 83001 and 83002 should only be ordered when medically indicated, based on patient evaluation. Gonadotropin level tests for screening or non-indicated disease processes are not medically justified, and therefore, not reimbursable. ICD-9-CM codes 403.0 – 403.9, 404.0 – 404.9 and 571.0 – 571.9, that were previously supported in connection with codes 83001 and 83002, have been deleted.

 


Family PACT To Release New Provider Manual in October 2007

  California Medi-Cal

Medi-Cal General Medicine: Bulletin 397 (PDF).

The Family PACT (Planning, Access, Care and Treatment) Program will release its new provider manual in October 2007. This new manual will replace the current Policies, Procedures and Billing Instructions (PPBI) manual. All enrolled Family PACT Program providers will automatically receive an initial copy of the new Family PACT Program provider manual at no charge.

 

Providers Must Begin Using the New 1500 Claim Form June 25, 2007

  California Medi-Cal

Medi-Cal General Medicine: Bulletin 397 (PDF).

Medi-Cal implemented the use of the CMS-1500 claim form on June 25, 2007. Providers who previously submitted claims on the HCFA 1500 must bill on the new CMS-1500 claim form immediately. Providers not using the new CMS-1500 should be in the process of transitioning. Failure to use the new form for claims submitted after June 25, 2007 may result in rejection of the provider’s claim

 

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