Claim Submission Errors - JF Part B

Q1. How can I ensure correct payment on procedure codes that require an invoice price?
A1. The current listing of codes requiring an invoice cost are located on the Avoiding Denials on Priced Per Invoice Claims list and is updated as needed. To ensure correct payment, submit the total invoice cost (invoice + shipping), in a currency format using a decimal, preceded by the word Invoice or Inv. If not submitted in decimal format, it will be adjudicated as if there were a decimal. This must be submitted for each line requiring an invoice in Item 19 of the CMS-1500 claim form or its electronic equivalent. Do not include handling or other fees. Example: invoice 13000 - This will be priced at $130.00

Q2. How do I submit documentation for Non-Medical ADR letters?
A2. Documentation can be submitted multiple ways. It can be mailed or faxed to the address/number provided at the bottom of the ADR letter, or submitted electronically through esMD.

Q3. Where is a comment placed on an electronic media claim (EMC)?
A3. Comments can be entered in multiple places, Loop 2300 NTE, Loop 2400 NTE or loop 2400/SV101-7. For faster claims processing, enter comments in loop 2400/SV101-7.

Q4. When is it appropriate to append the AQ modifier?
A4. The AQ modifier is used when the address of the location the services were rendered has a HPSA geographic designation, but the zip code is not allowed for automatic payment. Eligibility is determined by designation as of Dec 31 of the prior year. If your address became designated within 2024, you would append the AQ modifier on claims with DOS in 2025. Additional information is located on the Health Professional Shortage Area (HPSA) and HPSA Surgical Incentive Payment (HPIP) webpage.

Q5. Why would my postoperative claims deny?
A5. To avoid denials on claims for Postoperative Management, submit claims with original surgical date of service with number of service = 1. Only comment the date span of assumed care. Be sure it is after the surgery and that the correct year(s) is included. View the Modifier 55 webpage for more detailed information on submitting postoperative claims. Note: 2022 and 2023 are not leap years so February only has 28 days.

Q6. What is the correct format for Postoperative dates in comments?
A6. To avoid incorrect payments or denials use the following format MM/DD/YY or MM/DD/YYYY.

Q7. When billing an ambulance claim with the QL modifier, are origin and destination modifier(s) required?
A7. No. Origin and destination modifier(s) are not required with the QL modifier but billing them may result in a claim denial.

Q8. When submitting an ambulance claim, do the base and mileage codes need to have the same zip code for the same trip?
A8. Yes. To avoid the claim being denied, base and mileage codes for the same trip must have the same zip code, including any four-digit extension on the zip code.

Q9. When is modifier 50 used?
A9. Use modifier 50 when bilateral surgeries performed on both sides of the body during the same operative session or on the same day. Correct bilateral surgery billing will ensure timely and accurate processing of these claims. See Modifier 50 webpage for more.

Q10. What is the proper way to bill Anatomic Modifiers?
A10. When billing services with anatomic modifiers, it is unnecessary to also append a 'side of body' modifier. Modifier T1, for example, is for "left foot, second digit". An additional modifier of LT would not be appropriate and may cause a delay in claims processing. Additional information can be found on the modifiers page.

Q11. Should modifier 51 be submitted?
A11. It is recommended that modifier 51 not be included on Medicare claims. Noridian's claims processing system has hard-coded logic to add the modifier 51 to the correct procedure code if necessary.

Q12. When do I need to append the 99 modifier?
A12. Only submit the 99 modifier when more than four modifiers are needed to describe a service on the same procedure code. Submitting the 99 modifier along with other modifiers will cause the claim to suspend for review and is an incorrect use of the modifier. Additional information can be found on the Modifier 99 page.

Q13. I am receiving inconsistent payments on claims billed for the same drug. How can I prevent this?
A13. Submit the drug name and total dosage given in Loop 2400/SV101-7 for the applicable line only. Adding comments in multiple places can lead to incorrect processing. For more information, see instructions regarding Unclassified Drug Billing When Submitting EMC.

Q14. What is the correct way to bill an unclassified Drug?
A14. When billing unclassified drugs, enter the drug name and dosage in Item 19 on the CMS 1500-claim form or Loop 2400/SV101-7. For faster claims processing and to avoid denials, verify the dosage is entered correctly, using the most appropriate unit of measurement. Examples: Micrograms = MCG; Milligrams = MG; Grams = G or GM; Milliliters = ML; Cubic Centimeters = CC

Q15. When billing Testopel, is it correct to comment the number of pellets?
A15. No. Only comment the drug name and the dosage administered in MG. See the Testopel Coverage article for more information.

Q16. How do I properly bill hemophilia clotting factor codes?
A16. First, determine the correct units to bill per line by dividing the number of units by the Medically Unlikely Edit (MUE) value. If more than one line needs to be billed, append the repeat modifier to the subsequent lines. Example: HCPCS J7185 has a MUE Value of 4000 units per line. This is the maximum number of units which can be billed per line (as per MUE adjudication indicator (MAI)). See the Hemophilia Clotting Factor Billing webpage for instructions and more.

Q17. What is the correct way to submit a beneficiary name on the CMS-1500 form?
A17. Clearly submit the beneficiary name with a comma between last, first, and middle initial. Making sure the name is exactly how it appears on their Medicare card. For additional information see Item 2 of the CMS-1500 Form Instructions.

Q18. What happens to a claim when an invalid character is submitted in the name field?
A18. Submitting an invalid character in the name field will cause the claim to deny. To avoid denials and delays in claims processing, submit the name exactly as it appears on the beneficiary's Medicare card. For additional information see Item 2 of the CMS-1500 Form Instructions

Q19. I am receiving denials on claims billed for unlisted procedures. What can be done to ensure correct payment?
A19. When billing unlisted procedure codes, submit a concise description of the services rendered. This description must give enough information to adjudicate the exact service rendered. Do not comment "unlisted procedure, stomach," as this does not describe what was performed. Instead, Indicate more details such as the approach (open/laparoscopy), gastro upper/lower, revision/removal of neurostimulator electrodes, etc.

Q20. Where do I mail CMS-1500 paper claim forms?
A20. Each state has their own PO Box. To prevent any issues with claims processing, be sure all claims for the same state are sent to the correct PO Box. See the Mailing Addresses webpage for state specific mailing addresses.

Q21. When should the QW modifier be appended?
A21. Use modifier QW with lab codes whose test has been granted waived status under Clinical Laboratory Improvement Amendment (CLIA) requirements. If the modifier is appended to a lab code whose test is not waived, the claim will deny unprocessable. See the CMS Categorization of Tests webpage for additional information and a listing of waived tests.

Q22. What is the proper way to submit a claim with the Q0 or Q1 modifier?
A22. Noridian encourages providers submit separate claims to split services billed with the Q0 and/or Q1 modifier from other services not billed with these modifiers. This helps reduce delays in claims processing.

Q23. I need to submit a claim that contains lines with and without a KX modifier, how should I submit this?
A23. Noridian encourages providers submit separate claims to split services billed with the KX modifier from other services not billed with this modifier. This helps reduce delays in claims processing.

Q24. Can I submit multiple CLIA numbers on one claim?
A24. Submitting multiple CLIA numbers on one claim will result in unprocessable denials. Only one CLIA number should be submitted per CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 70.10.

Q25. How do I prevent monthly End Stage Renal Disease (ESRD) claims from denying?
A25. To prevent Monthly ESRD CPT codes 90951-90966 from denying, submit only one code per month with a QB of 1.

Q26. On a screening pap smear test claim, which pointer does my diagnosis code need to be in?
A26. Any of the ICD-10 diagnosis codes listed under Screening Pap Tests must point to the claim detail line.

Q27. How do I know if a HCPCS/CPT code is subject to MUE (medically unlikely edit)?
A27. Not all HCPCS/CPT codes have a MUE. Submitting the total number of services on one line may result in faster claims processing. View the Medical Unlikely Edit webpage for more information along with a handy MUE lookup tool.

Q28. Medicare is the beneficiary's secondary payer and I am receiving denials when submitting using the 1500 form. How can I resolve this?
A28. Claims submitted via paper for beneficiaries with Medicare as a secondary payer need to include a clear copy of the Primary payers Explanation of Benefits (EOB) for each claim submitted. More information is found under Billing MSP via CMS-1500 Paper Form.

Q29. How do I submit my diagnosis pointers?
A29. Enter diagnosis code reference letter as shown in item 21 or reference number in loop 2400 SV107 for the line. Enter only one letter/number per line item.

Q30. How do I know if I am billing the JZ modifier correctly?
A30. If none of the single-use container drug was discarded, append the JZ modifier. If some of the single-use container drug was discarded, continue with the current process of reporting the JW for all wastage. Additional information is found on CMS Discarded Drugs and Biologicals - JW Modifier and JZ Modifier Policy Frequently Asked Questions (FAQs).

Q31. Why is my subsequent hospital care code denying?
A31. If your primary specialty is 50 or 97 you need to comment your secondary specialty in numerical form. Example SPC 06. For faster claims processing, enter comments in loop 2400/SV101-7.