Claim Submission Error FAQs - JE Part A

Q1. How do I use the JW modifier?
A1. Effective January 1, 2017 (CR9603), providers are required to:

• Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals) and
• Document the discarded drug or biological in the patient's medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded

Example: Provider is billing a 10 mg vial and the charge amount for the vial is $100. 5 mgs are administered; 5 mgs are wasted. 5 mgs would be billed for $50 for administration, and 5 mgs billed for $50 with the JW modifier for wastage.

See CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 17 for more information.

Q2. How should a provider submit a Reopening request for a claim that is beyond the claim filing timeframe?
A2. Providers should submit a Reopening request on type of bill (TOB) XXQ to identify them as a Reopening. This TOB should only be used when the submission falls outside the period to submit an adjustment bill. Also, submit the appropriate R1-R9 reopening condition code and adjustment condition code, adjustment reason code (Direct Data Entry (DDE) users only) and good cause remarks in the proper format. Claims determined to not have good cause will be Returned to Provider (RTP'd). See CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 34 for further guidance.

Q3. How should providers submit claims for partial hospitalization services?
A3. Community Mental Health Centers (CMHC) that submit claims on TOBs 76X must bill correct TOB in sequential order. Prospective Payment System (PPS) hospitals that submit claims on 13X TOBs and Critical Access Hospitals (CAH) that submit claims on 85X TOBs must report condition code 41 on claim and bill correct TOB and in sequential order

• Example: November 2015 TOB 132 should be finalized before submitting TOB 133

Q4. How can providers find information on reason codes?
A4. View Noridian Reason Code Guidance webpage.

Q5. Where can I find a list of Multi-Channel Lab HCPCS Codes?
A5. There is a chart of lab panel's codes that role up into the multi-channel lab panels in the CMS IOM, Medicare Claims Processing Manual, Publication 100-04, Chapter 16, Section 90.2.

Q6. How do I resolve an overlap with another provider's claim?
A6. First, try to resolve the overlap by working directly with the other provider. If a provider is unable to resolve the overlap, call the Provider Contact Center. Providers must provide documentation supporting their claim, as well as proof that attempts were made to resolve the overlap with the overlapping facility. From there, Noridian will work with the other contractor to find a resolution. View Overlapping Claim Resolution Tips webpage.

Q7. Do rejected and denied claims appear on a Remittance Advice (RA)?
A7. Yes. Rejected and denied claims appear on a RA; however, "Return To Provider (RTP)" claims do not appear on it as they have not completed processing.

Q8. How does a provider obtain a Z code identifier for submission of molecular tests?
A8. Go to the DEX^TM Diagnostics Exchange (DEX) website to register. Within 30 days of a complete and valid registration, the DEX Z-Code^TM identifier will be assigned for tests.

Q9. How does a provider submit a registered DEX Z-Code™ on a claim?
A9. Providers who submit claims on the UB04 claim form must use block 80 to submit the DEX Z-Code™. For electronic claim submission, the DEX Z-Code™ must be reported on DDE page 02 (MAP171E) for each applicable line. Effective April 1, 2019, failure to submit the DEX Z-Code™ in the new MolDX ID field will result in the claim being Returned to Provider (RTP). MolDX IDs submitted in the remarks field will no longer be accepted.

Q10. How should "information only" claims be billed?
A10. Information only claims should be billed as a covered TOB, with condition code 04, and days/charges in covered.

Q11. I have contacted the overlapping facility numerous times and have asked them to correct their claim, but the claim has not been corrected. What steps can be taken to get the other facility's claim updated?
A11. While providers/facilities are required and expected to work together to resolve the billing issue, providers may occasionally require assistance from the Medicare Administrator Contractor (MAC). In that case, Noridian will work with both providers/facilities for a resolution and will work with other MACs when the overlapping claim is processed by another MAC. Contact the Provider Contact Center.

Q12. I contacted the SNF and asked them to update the patient status on their claim, but they stated that the patient's benefits are exhausted, and that they are not responsible for paying the services. What can be done?
A12. Determine if the services were provided during the covered period of the SNF Part A stay or after the benefits exhausted, since consolidated billing rules may or may not apply. The SNF is required to bill "benefits exhaust" and/or "no pay" claims until the patient is discharged from the facility. To bypass Medicare edits, refile a corrected claim after the SNF has submitted or corrected their claims. In addition, it is recommended that you work with the SNF to help determine if the patient's services were provided during the covered or non-covered portion of the stay and for claims resolution since timely filing rules apply.

Scenarios:

• Services were provided during SNF covered Part A Stay
  • SNF consolidated billing rules apply
• Services were provided after benefits exhausted
  • SNF is only responsible for billing physical, occupational, and speech therapy services
  • All other services may be billed directly to the Medicare administrative contractor (MAC)
• Services were provided after patient was discharged
  • All services may be billed directly to the MAC

Q13. When are uncorrected return to provider (RTP) claims purged from the Fiscal Intermediary Standard System (FISS)?
A13. Return to provider (RTP) claims purge after 180 days. Suppress view claims are removed from FISS Claim Correction but are not removed from the Claim Count Summary in FISS. NOTE: The 180-day count begins on the last date of access to the claim in RTP under Claims Correction in FISS Direct Data Entry (DDE).

Q14. On many of our outpatient hospital claims we are receiving reason code W7062, which means 'code not recognized by OPPS; alternative code for same service may be available'. Is there any coding guidance for this?
A14. Outpatient Prospective Payment System (OPPS) guidance concerning alternate codes is available on the CMS Hospital Outpatient PPS webpage. Coding guidance and resources are available on the HCPCS Coding Questions page on the CMS HCPCS Coding Questions webpage.

Q15. When should Condition Code D0 be used?
A15. Use Condition Code D0 when both the from and to dates of the claim are changed.

Q16. I am unsure of what Condition Code to use; can I just use D9?
A16. Use Condition Code D9 if no other Condition Codes are more appropriate. If D9 is used, be sure to include comments on the claim indicating what changes are made.

Q17. Should 77 Occurrence span code provider liable days be put in the non-covered day field and non-covered charges?
A17. Charges should always be in non-covered but days should only be shown in the non-covered day field if there are comments for the following reasons: does not meet inpatient criteria, not medically necessary, waiting for psych bed to open or bed hold.

Q18. Why does the CERT contractor correct code CPT 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) to CPT 85027 (CBC, automated [Hgb, Hct, RBC, WBC and platelet count])?
A18. Quite often, the documentation submitted included a physician's order for a "CBC" and no differential was ordered. The CERT contractor will review the specific language in the order and correct code the claim to the most appropriate CPT code, if/as necessary.

Q19. How do I adjust a claim that has medically denied lines?
A19: All lines that were medically denied must be left in non-covered. These lines cannot be removed from the claim or moved to covered. An appeal must be submitted to adjust these lines. It is not sufficient to just enter comments "Not adjusting medically denied lines." The lines must be submitting in non-covered exactly as they were on the original claim. If there is a GZ Modifier on any line on the original claim, it must be present with charges in non-covered on new claim also.

Q20. Is your claim RTPd with reason code 30995?
A20: Any claim submitted after January 1, 2020, regardless of date of service, must be submitted with the MBI. Refer to our MBI webpage for more information.

Q21. How do I add a KX modifier to a claim that has rejected for reason code 7THER?
A21: Fully delete and rekey the lines hitting out for 7THER and add the KX modifier to each line.

Q22. My claim was submitted with condition code DR but it rejected for benefits exhaust? What is the next step?
A22: Due to the COVID-19 pandemic, CMS utilized its authority under section 1812(f) of the Social Security Act to waive certain Medicare requirements under the SNF PPS. Specifically, for patients who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period. This waiver applies only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances.

In cases where a patient qualifies for renewed SNF benefits under this waiver, the following impacts on typical billing and assessment processes would occur:

1. For patients that have exhausted their 100 day SNF benefit period and have begun, but not yet completed, the process of ending the current benefit period, the patient's renewed benefit period would be treated as a new SNF stay. This means that providers would be required to complete a 5-day assessment and the variable per diem schedule would begin on Day 1.
2. For patients that exhaust their 100 day SNF benefit period during a SNF stay and continue the SNF stay under renewed SNF benefits, the patient must be discharged from the SNF stay on the day the patient's benefits exhaust. This includes completing a PPS Discharge Assessment. The patient would then be admitted to a new SNF stay beginning on the first day of the renewed benefits. This means that providers would be required to complete a 5-day assessment and the variable per diem schedule would begin on Day 1.

For further details on the SNF waiver billing, please refer to the CMS MLN Special Edition SE20011.

Q23. My claim was submitted for the SNF waiver and it is being Returned to Provider, why?
A23: Please check to ensure that all full and co days are exhausted before you submit your claim for the waiver and review the previous SNF claim to make sure the patient status is a 01 if it is your claim. Claims should be billed in sequential order.

For further details on the SNF waiver billing, please refer to the CMS MLN Special Edition SE20011

Q24. My claim was submitted for the Qualifying Hospital Stay (QHS) waiver and it is being Returned to Provider, why?
A24: Please check to ensure that you are submitting claims for the QHS waiver with a DR condition code and comments stating ‘declared emergency’ in Form Locator (FL) 80.

Q25: I am receiving ADRs for NPI reason code 32105, what do I do?
A25: Please ensure the zip code (including the +4) is submitted on the claim and it matches the zip code on file in PECOS for the NPI submitted on your claim.

If you have more than one PTAN to one NPI, each PTAN needs to have its own zip code +4 to ensure claim accuracy, please have one NPI per location.

If you are sending responses via fax, ESMD or mail please enclose a cover letter with each ADR with the PTAN you would like used or hand write the PTAN you would like used on each letter.

Q26: I am a Military Treatment Facility (MTF) provider, where can I find the information that is needed on the UB04 form?
A26: Completing the 1450 data set is outlined in Medicare Claims Processing Manual Crosswalk (cms.gov).

Noridian also has a quick reference billing guide outlining value codes.

Q27: I am submitting an unlisted code, where can I find the information on what to include on my claim?
A27: Noridian has an article on what to include when submitting an unlisted code located at: Unlisted Code Billing

Q28: What is a SNF Readmission and how do I bill for it?
A28: A SNF readmission is when a beneficiary discharges from a SNF and then admits to another SNF (either the same SNF or a different one) within 30 days of that discharge and both stays are for the same reason. The original Qualifying Hospital Stay from the first stay can be used on the new stay if the patient doesn’t have a new 3+ day QHS in between. The readmission coding allows the claim to bypass issues with the Admit Date being more than 30 days from the qualifying stay date. Quick Reference Billing Guide

Certain coding is required when billing for a readmission:

• Occurrence Span Code 70 - Qualifying Hospital Stay
• Occurrence Span Code 80 - Dates of the previous SNF stay showing discharge is within 30 days of the new admission
• Condition Code 57 - Signals to FISS that the claim is a readmission within 30 days
  • Claim will be returned to the provider if missing

Q29: How does a SNF readmission affect my claims if I am on a Denial of Payment for new admissions?
A29: If there is a valid prior SNF stay with a discharge date within 30 days of the new admission AND the admit date of that previous stay is prior to the effective date of the DPNA the patient is not considered a new admission. Even if the admit date of the second stay is during the effective and termination dates of the DPNA, it would not apply. Use the coding from Q28/A28.

Always verify that there is a valid prior stay that discharges within 30 days of your admission. If claims are found to be billed as a readmission so that the DPNA does not apply but there is no valid prior stay, your claims will be cancelled. As SNFs are required to bill sequentially, this error may cause multiple claims to be cancelled that are outside of the DPNA dates.