(Medicare Claims Processing Manual)

a. If present, for ICD -9-CM must be four or five positions, left justified, with no decimal points.  For ICD -10-CM must be three to seven positions, left justified, with no decimal points.  b. POA is a one position field.  FL 74. Principal Procedure Code and Date   a. If present, must be valid procedure code for service date.  For ICD -9-CM must be 3 - 5 characters; first character may be numeric or alpha, characters 2 - 5 must be numeric.  For ICD -10-PCS must be 3 -  7 characters; first character must be alpha, second character must be numeric, characters 3  7 may be alpha or numeric.  b. If code is present, date must be present and valid.  c. Date must fall before the Through date in FL 6.  (In some cases it may be before the admission date, i.e., where complications and admission ensue from outpatient surgery.)   FL 74 a -e. Other Procedure Codes and Dates.   a. If present, apply edits for FL 74   FL 76. Attending Provider Name and Identifiers.   a. The UPIN must be present on inpatient Part A bills with a Through date of January 1, 1992, or later.  For outpatient and other Part B services, the UPIN must be present if the From date is January 1, 1992, or later.  This requirement applies to all provider types and all Part B bill types.  Effective May 23, 2007, providers are required to submit NPI.  b. An institutional provider may not submit their own NPI, except for Institutional billing of COVID -19, influenza, and pneumococcal vaccinations and their administration as the only billed service on a claim, roster billing of COVID -19, influenza, and pne umococcal vaccinations and their administrations, self -referred screening mammography as the only billed service on a claim, HCPCS K1034 as the only billed service on a claim, or where the provider only has a type -1 NPI as a physician/practitioner owned sole -proprietor (i.e., RHC).   c. An institutional provider may not submit an organizational type -2 NPI in the attending NPI field except as noted above in b.   FL 77. Operating Physician Name and Identifiers   a. Effective May 23, 2007, providers are required to submit NPI.  NPI must be present if:    Bill type is 11X and a procedure code is shown in FL 74;    Bill type is 83X or 13X and a HCPCS code is reported that is subject to the ASC payment limitation or is on the list of codes the QIO furnishes that require approval; or    Bill type is 85X and HCPCS code is in the range of 10000 through 69979.  b. If required:    NPI, last name and first initial must be present; and    Left justified.   80.3.3 - Timeliness Standards for Processing Other -Than -Clean Claims  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The Social Security Act, at 1869(a)(2), mandates that Medicare process all other -than-clean claims and notify the individual filing such claims of the determination within 45 days of receiving such claims.  Claims that do not meet the definition of clean claims are other -than-clean claims.  Other -than-clean claims require investigation or development external to the contractors Medicare operation on a prepayment basis.  The contractor shall process all other -than-clean claims and notify the provider and provider of the determination within 45 calendar days of receipt.  (See Pub100- 4, Chapter 1, 80.2.1 for the definition of receipt date and for timeliness standards for clean claims.)  However, when the contractor develops to the provider/supplier or beneficiary for additional information, the contractor shall cease counting the 45 calendar days on the day that the contractor sends the development letter.  Upon receiving the materials requested in the development letter from the provider/supplier and/or beneficiary, the contractor shall resume counting the 45 calendar days.  EXAMPLE:   The contractor receives a claim on June 1st, but does not send a development letter to the provider/supplier/ and/or beneficiary until June 5th.  In this situation, 5 of the 45 allotted calendar days will have already passed before the contractor requested  the additional information.  Upon receiving the information back from the provider/supplier and/or beneficiary, the contractor has 40 calendar days left to process the claim and notify the individual that filed the claim of the payment determination for that claim.   Contractors shall follow existing procedures relative to both the length of time the provider/supplier and/or beneficiary is afforded to return information requested in the development letters and situations where the provider/supplier and or beneficiary does not respond.  Contractors shall report the number of other -than-clean claims processed in 45 days or less on Form Y of the Contractor Reporting of Operational and Workload Data (CROWD) report.  Use identifier code 0005 in column 1 to report this information.  Report t he number of other -than-clean claims processed in 46 days or longer on Form Y of the CROWD system, under column 1 on a line using code 0006 as the identifier.   The following types of claims do not apply to this instruction:    Claims where the Social Security Administration blocks a beneficiarys Medicare beneficiary identifier,    Claims the contractors are required to hold due to CMS instructions,    Translator rejects,    Claims where CWF is unable to process due to technical issues with the CWF beneficiary record or beneficiary identification issues,    Claims submitted by a hospice, and    Claims in development due to processing requirements (e.g. medical review), in Publication 100- 8, the Medicare Program Integrity Manual.   80.4 - Enforcement of Provider Billing Timelines and Accuracy Standard to Continue PIP (Periodic Interim Payment)  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   A.  General  To remain on PIP, providers, (with the exception of HHAs that do not receive PIP with the advent of PPS mandated by law on October 1, 2000), must submit 85 percent of their bills timely and accurately.  Timely and accurately means that 85 percent of its bi lls (excluding those listed below) are submitted within 30 days of discharge and pass front -end edits for consistency and completeness.  A bill is not considered received unless it can pass FI edits.  FIs must accumulate statistics on inpatient and SNF billing performance for each PIP provider to monitor whether it meets this requirement. These instructions do not effect bi -weekly payments for pass -throughs (Medicare Provider Reimbursement Manual, (PRM) 2405.2) and for adjustments to indirect cost for medi cal education (PRM 2405.3). The evaluation for timeliness of billing should be consistent with the frequency for monitoring the payment amounts under the PIP program.  Thus, for non- PPS hospitals and SNFs the evaluation process is scheduled at 3- month intervals and PPS providers are evaluated every 4 months.  The evaluation includes data from the entire 3-  or 4-month period.  In determining whether a provider submitted its bills within 30 days of discharge or through date on interim bills, count the date from Form CMS -1450 FL6 (through date) to the date received by the FI.  If the provider does not meet the criteria, discontinue PIP immediately.  The periodic performance report that is provided in accordance with subsection B will constitute advance notice before discontinuing PIP. Exclude the following:   MSP cases (value codes 12 -16);  Any special situation identified by the provider or FI that is documented as beyond provider control.  Exclusions must be approved by the RO; and   Bills that have not passed FI front -end edits for acceptance.  (Such bills are counted only when acceptable to the shared system edit processes.)  The FIs must accumulate statistics monthly and summarize them for the entire evaluation period. B.  Procedure for Measuring and Reporting to Hospitals and SNFs  The FIs accumulate a record for each bill that passes front -end edits. Bills must be counted in the month received regardless of the discharge month.  No later than 10 work-days after the end of the month, FIs furnish a report to each hospital/SNF. For the  month indicating the following:   The total number of bills received;   The number not excluded as described in section A;   The number not excluded received in 30 days or less;   The percentage not excluded received in 30 days or less. Also, for providers that fail to meet the standard, furnish individual case identification of claims that were not billed within 30 days of discharge.  List only claims that are not excluded and are identified in subsection A.  The report must be furnished in electronic media, unless the FI determines a paper listing would be cheaper to process.  If electronic media is used, use the following record format.  Determine the physical characteristics of the file.  Fld Description  Psn. Picture  Just From  Thru  1 Provider Number  6 X(6)  L 001 006 2 Blank  3 X(3)   007 009 3 Blank  1 X  010  4 Medicare beneficiary identifier  12 X(12)  L 011 022 5 Blank  1 X  023  6 Beneficiary Surname  6 X(6)  L 024 029 7 Blank  1 X  030  8 Patient Control Number  17 X(17)  L 031 047 9 Blank  1 X  048  10 From Date  6 9(6)  049 054 11 Blank  1 X  055  12 Discharge or Thru Date  6 9(6)  056 061 13 Blank  1 X  062  14 Date Bill Received  6 9(6)  063 068 15 Blank  1 X  069  16 Days Elapsed  4 9(4) R 070 073 If sub -provider identification is used, positions 7, 8, and 9 may be utilized.  C.  Reinstatement of PIP  Do not reinstate PIP for a provider until it meets all criteria in PRM 2405.1.B  and 2407 and has met the requirements in subsection A for timeliness and accuracy for six consecutive months.  D.  New Request for PIP  Evaluate new requests for PIP as in subsections A and B.  At least three months experience is required for new requests, (except for new providers with less experience).  E.  Hospitals on 100 Percent PRO Prepayment Review  The 30- day requirements for submitting bills to FIs are not applicable.  The RO makes determinations of timely and accurate bill submission by hospitals for which the PRO reviews 100 percent of the discharges before payment.  However, other standards remai n applicable for retaining PIP in such cases.  See PRM 2405.1.B and 2407 for the requirements.   80.5 - Do Not Forward Initiative (DNF)  (Rev. 1, 10- 01-03)