To assist electronic billing customers with error messages received on the electronic reports, an interactive 1450 (UB-04) form has been developed as a crosswalk. This crosswalk is an interactive feature that displays the appropriate loops, segments, and qualifier detail when clicking on each block of the 1450 (UB-04) sample claim form. A crosswalk chart is also available to provide a...
During the first quarter of 2010, 158 CERT errors were assessed for all Part B contracts within Highmark Medicare Services (HMS). Of those 158 errors, 77 errors were due to insufficient documentation (error code 21), 40 were due to incorrect coding (error code 31), 38 were due to medical necessity (error code 25), and 3 was due to improper documentation submitted to the CERT contractor (...
OVA1™ is an FDA-cleared qualitative serum test that combines the biomarker values of five immunoassays, using a proprietary algorithm, to further assess the likelihood that an ovarian mass is malignant, in women whose pre-surgical assessment did not indicate malignancy. Highmark Medicare Services will cover OVA1™ in keeping with the FDA-cleared indication until such time that a Local Coverage...
During the fourth quarter, 148 CERT errors were assessed for all Part B contracts within J12. Of those 148 errors, 66 errors were due to insufficient documentation (error code 21), 47 were due to medical necessity (error code 25), 33 were due to incorrect coding (error code 31) and 2 were due to service billed were not rendered (error code 41). The majority of the errors for insufficient...
Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in the Provider Enrollment, Chain and Ownership System (PECOS). A current enrollment record is one that is in the PECOS and also contains the National...
Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary! An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed...
As you should know, the CERT program consists of a random sample of Medicare claims selected each month which undergo an independent medical review process whereby the claims data are adjudicated against the medical records of the physician/provider. The results are analyzed and used to produce annualized estimates of the dollars paid incorrectly for each of the 15 Medicare Jurisdictions as well...