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CWF Update

The Centers for Medicare & Medicaid Services (CMS) issued CR 3551, Transmittal 124, on October 29, 2004, to implement a new edit in Medicare’s systems, effective April 01, 2005, to check for duplicate claims for referred clinical diagnostic laboratory services and purchased diagnostic services submitted by physicians/supplier to more than one carrier. This edit for clinical diagnostic laboratory services and purchased diagnostic claims, which was implemented on April 04, 2005, did not edit line items that contained the “90” modifier.

When performing the data matching, the Medicare duplicate claim edit for referred clinical diagnostic laboratory performed the matching on the claim fields: (a) Beneficiary Name; (b) Beneficiary Health Insurance Claim Number (HICN); (c) Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code; (d) Date of Service; and (e) CPT/HCPCS Code Modifier. That edit was not applied to claims with a “90” modifier. Medicare will modify the duplicate claim edit to reject all clinical laboratory services submitted to carriers when it has been determined that another carrier has already paid for the same service on the same date of service, with the exception of those claims containing the “91” modifier. This modified edit will apply to all laboratory claims with dates of service on or after January 01, 2006. When claims are denied as a result of this edit, Medicare carriers will use remark code N347 on the remittance advice to show “Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.”

Note: Repeat clinical laboratory services for the same beneficiary on the same date of service are identified by the “91” modifier. When performing the data matching, the CWF duplicate claim edit for referred clinical diagnostic laboratory service will not include the “91” modifier on referred laboratory claims in the matching criteria, but will perform matching on all others as specified above.


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INDUSTRY NEWS TAGS: CMS


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