Avoiding Denials on Priced Per Invoice Claims - JF Part B

Procedure codes that require pricing per invoice, must contain the below elements in Item 19 of the CMS-1500 claim form or its electronic equivalent for each line item submitted.

• Total invoice price plus shipping cost (do not include handling or other fees)
• If billing an unlisted code (codes ending in ***99) supply a description of the code
• 'Invoice' or 'Inv' followed by the price in a currency format using a decimal
  • Examples:
    • Invoice $130 - claim priced at $1.30
    • Invoice $130.00 - claim priced at $130.00
    • Invoice 13000 - claim priced at $130.00
    • Invoice $13000 - claim priced at $130.00
    • Invoice $1,300 - claim priced at $1,300.00

If this required information is not submitted, the item will be denied as unprocessable.

Note: Total invoice price is the net amount a provider pays for an item/service, taking into account ALL discounts, rebates, refunds, or other adjustments*. In addition, Medicare will reimburse for shipping but no other additional fees (tax, handling fees, delivery fees, administrative fees).

L8600-L8679, L8681-L8699: If no amount is available within the DMEPOS fee schedule, submit an invoice price.

P9005-P9099: Submit an invoice price unless pricing is provided within a fee schedule

Skin substitute codes that are not priced off the ASP file.

*References include but not limited to:

• CMS Paper-Based Manual, Publication 15-1, The Provider Reimbursement Manual - Part 1, Chapter 8, Section 804
• Medicare Fraud & Abuse: Prevent, Detect, Report (ICN MLN4649244)
• 42 U.S.C. § 1320a-7b(b)(3)
• 42 CFR § 1001.952
• SSA Section 1128J(d)