(Medicare Claims Processing Manual)

NOTE:   For items 80.3.2.1.3 (g), (k), (l), (m),  and (n) above, e ffective for claims with dates of services (DOS) on or after the implementation date of the Phase 2 ordering and referring denial edits, the Part B clinical lab and imaging technical or global component claim, or Durable Medical Equipment, Prosthetics, and Orthotics Suppliers (DMEPOS) claim is denied due to the ordering/referring provider not allowed to order/refer.   For item N only: The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 183  RARC: N574  MSN: N/A  The claim is denied when the first four letters of the last name provided on the ordering/referring providers claim does not match what is listed in the providers record. RARC: N264   If the claim is submitted that lists an ordering/referring provider and the required matching NPI is not reported, then the claim shall be rejected.  This is the only instance when a rejection is allowed.  RARC: N256.  O.   For all laboratory work performed outside a physicians office, if the claim does not contain a name, address, and ZIP Code for where the laboratory services were performed in item 32 or if the NPI is not entered into item 32a of the Form CMS -1500 if the services were performed at a location other than the place of service home  12.  RARC: MA114   P.   For all physician office laboratory claims, if a 10- digit CLIA laboratory identification number is not present in item 23.  This requirement applies to claims for services performed on or after January 1, 1998.  RARC: MA120  Q.   For investigational devices billed in an FDA -approved clinical trial if an Investigational Device Exemption (IDE) number is not present in item 23, for dates of service through March 31, 2008.  RARC: MA50.  With the use of new modifier Q0, effective f or dates of service on and after April 1, 2008, contractors will no longer be able to distinguish an IDE claim from other investigational clinical services.  Therefore this edit will no longer apply.  R.   For physicians performing care plan oversight services if the 6 -digit Medicare provider number of the home health agency (HHA) or hospice is not present in item 23.   S.   For Competitive Acquisition Program drug and biological claims, in accordance with the instructions found in the Medicare Claims Processing Manual, chapter 17, section 100.2.1  section 100.9.  T.   For claims for artificial hearts covered by Medicare under an approved clinical trial, if procedure code 0051T is entered in Item 24D, and an 8- digit clinical trial number that matches an approved clinical trial listed at:  http://www.cms.hhs.gov/MedicareApprovedFacilitie/06_artificialhearts.asp#TopOfPage is not entered in Item 19; and the HCPCS modifier Q0 is not entered on the same line as the procedure code in Item 24D, and the diagnosis code V70.7 (if ICD -9-CM is applicab le) or Z00.6 (if ICD -10-CM is applicable) is not entered in Item 21 and linked to the same procedure code.   For item T only: The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 4  RARC: N/A  MSN: N/A  U.   For clinical trial claims processed after September 28, 2009, with dates of service on or after January 1, 2008, claims submitted with either the modifier QV or the modifier Q1, if the diagnosis code V70.7 (if ICD -9-CM is applicable) or Z00.6 (if ICD -10-CM is applicable) is not submitted with the claim.   V.   For ambulance claims, claims submitted without the ZIP Code of the loaded ambulance trips point -of-pickup in Item 23 of the CMS -1500 Form.  80.3.2.2 - Consistency Edits for Institutional Claims  (Rev. 12107; Issued:06- 29-23; Effective: 04 -01-23; Implementation: 01 -02-24)  In order to be processed correctly and promptly, a bill must be completed accurately. Medicare contractors processing institutional claims edit all Medicare required fields as shown below. If a bill fails these edits, contractors return it to the provider for correction.  If bill data is edited online, the edits are included in the software.  Depending upon special services billed, contractors may require additional edits.   The following instructions follow the format of Form CMS -1450.  For instructions about the location of these data elements on the ASC X12 837 institutional claim transaction format see the related implementation guide.   FL 4. Type of Bill   a. Must not be spaces.   b. Must be a valid code for billing.  Valid codes are:   First Digit -  Type of Facility:   1 - Hospital   NOTE : Hospital- based multi -unit complexes may also have use for the following first digits when billing non- hospital services:   2 - Skilled Nursing  3 - Home Health   4 - Religious Non- Medical (Hospital)   7 - Clinic or Renal Dialysis Facility (requires special information in second digit below)   8 - Special Facility or Hospital ASC Surgery (requires special information in second digit, see below)   Second Digit -  Classification (if first digit is 1 -5):  1 - Inpatient (Part A)   2 - Hospital -Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)   3 - Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)   4 - Other (Part B) (includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for nonpatients)   8 - Swing bed (used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement)   Second Digit -  Classification (first digit is 7):   1 - Rural Health Clinic (RHC)   2 - Hospital -Based or Independent Renal Dialysis Facility   4 - Other Rehabilitation Facility (ORF)   5 - Comprehensive Outpatient Rehabilitation Facility (CORF)   6 - Community Mental Health Center (CMHC)   7 - Free -Standing Provider -Based Federally Qualified Health Center (FQHC)   Second Digit -  Classification (first digit is 8):   1 - Hospice (Nonhospital -based)   2 - Hospice (Hospital -based)   5 - Critical Access Hospital (CAH)   Third Digit -  Frequency:   A - Admission/Election Notice   B - Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution -Termination/Revocation Notice   C - Hospice Change of Provider   D - Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution -Void/Cancel   E - Hospice Change of Ownership   F - Beneficiary Initiated Adjustment Claim (For A/B MAC (A) use only)   G - CWF Initiated Adjustment Claim (For A/B MAC (A) use only)   H - CMS initiated Adjustment Claim (For A/B MAC (A) use only)   I - A/B MAC (A) Adjustment Claim (Other than QIO or Provider) (For A/B MAC (A) use only)   J - Initiated Adjustment Claim- Other (For A/B MAC (A) use only)   K - OIG Initiated Adjustment Claim (For A/B MAC (A) use only)   M - MSP Initiated Adjustment Claim (For A/B MAC (A) use only)   P - QIO Adjustment Claim (For A/B MAC (A) use only)   Q  Claim Submitted for Reconsideration Outside of Timely Limits (For A/B MAC (A) use only)   0 - Nonpayment/zero claims   1 - Admit Through Discharge Claim   2 - Interim -  First Claim  3 - Interim  Continuing Claims (Not valid for PPS bills.  Exception:  SNF PPS bills)   4 - Interim  Last Claim (Not valid for PPS bills. Exception:  SNF PPS bills)   5 - Late charge   7 - Correction   8 - Void/Cancel   9 - Final Claim for a Home Health PPS Episode   FL 6. Statement Covers Period (From -  Through)   a. Cannot exceed eight positions in either From or Through portion allowing for separations (nonnumeric characters) in the third and sixth positions.   b. The From date must be a valid date that is not later than the Through date.   c. The Through date must be a valid date that is not later than the current date.   d. With the exception of Home Health PPS claims, the statement covers period may not span 2 accounting years.   FL 09. Patients Address   a. The address of the patient must include:   City State (P.O. Code)  ZIP  b. Valid ZIP Code must be present if the type of bill is 11X, 13X, 18X, or 83X or   85X.  c. Cannot exceed 62 positions.   FL 10. Birthdate   a. Must be valid if present.  b. Cannot exceed 10 positions allowing for separations (nonnumeric characters) in the third and sixth positions.  FL 11. Sex   a. One alpha position.  b. Valid characters are M or F.   c. Must be present.   FL 12. Admission Date   a. Must be valid if present.  b. Cannot exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions.   c. Present only if the type of bill is 11X, 12X, 18X, 21X, 22X,  32X, 33X, 41X, 81X or 82X.    FL 14. Priority (Type) of Admission or Visit   a. One numeric position.  b. Required only if the type of bill is 11X, 12X, 18X, 21X, 22X, or 41X.   FL 15. Point of Origin for Admission or Visit.  a. One numeric position  b. Must be present   FL 17. Patient Discharge Status.  a. Two numeric positions   b. Present on all Part A inpatient, SNF, hospice, home health agency, and outpatient hospital services.  Types of bill:  11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 33X, 34X, 41X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, 83X, or 85X.   FL 03b. Medical/Health Record Number   a. If provided by the hospital, must be recorded by the A/B MAC (A) for the QIO.   b. Must be left justified in CWF record for QIO.   FLs 18 thru 28. Condition Codes.  a. Each code is two numeric digits.  b. If code 07 is entered, type of bill must not be hospice 81X or 82X.  c. If codes 36, 37, 38, or 39 are entered, the type of bill must be 11X and the provider must be a non-PPS hospital or exempt unit.  d. If code 40 is entered, the From and Through dates in FL 6 must be equal, and there must be a 0 or 1 in FL 7 (Covered Days).  e. Only one code 70, 71, 72, 73, 74, 75, or 76 can be on an ESRD claim.  FLs 31, 32, 33, and 34. Occurrence Codes and Dates  a. All dates must be valid.