FQHC RTP and Reject Reason Code Webinar Top RTP and Reject Reason Codes April 2011 through July _0911

2 National Government Services, Inc. Today’s Presenter Charles Wiley, Provider Education and Outreach Representative

3 National Government Services, Inc. Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at

4 National Government Services, Inc. Acronyms CMSCenters for Medicare & Medicaid Services CPTCurrent procedural terminology FFS Fee-for-Service FQHCFederally qualified healthcare center HCPCSHealthcare Common Procedure Coding System HMOHealth maintenance organization

5 National Government Services, Inc. Acronyms ICD-9-CMInternational Classification of Diseases, Clinical Modification, 9th Revision IOMInternet-Only Manual MUCMedicare University Credit PTANProvider Transaction Access Number RTPReturn to provider TOBType of bill

6 National Government Services, Inc. Objectives Educate the FQHC community on top reason codes that may cause claims to reject or RTP and provide ways to avoid them.

7 National Government Services, Inc. Agenda Top reason codes for rejected and RTP claims Benefits of avoiding rejected and RTP claims Reason code descriptions Provider action required Tips for correction Tips for preventing reason codes Questions & Answers

8 National Government Services, Inc. Benefits of Preventing Medicare Claim Rejects and RTPs Increase timeliness of Medicare cash flow Decrease time spent correcting RTP claims Decrease time spent submitting adjustments Decrease time spent submitting new claims

9 National Government Services, Inc. Impact of Claim Rejections and RTP Cash flow –No claim payment Rejected claims –Delays in claim payments RTP claims Staff time –Correcting RTP claims –Submitting adjustment claims –Submitting new claims

Rejected Claims

11 National Government Services, Inc. Top FQHC Reject Codes April 2011 – July

12 National Government Services, Inc. Did You Know… Consistently submitting duplicate claims could result in providers being referred to the Program Safeguard Contractor –Duplicate claim submissions can and should be avoided by providers at all times

13 National Government Services, Inc. Rejection Reason Code Why did the claim reject? –This claim is an possible duplicate of a previously submitted outpatient claim and the following conditions exist Statement FROM and THROUGH dates overlap Provider number are the same At least one revenue code line matches Diagnosis code on the history claim are the same

14 National Government Services, Inc. Provider Action for Reason Code No action required –If claim is exact duplicate to processed claim Adjust original claim –If original claim needs to be adjusted Submit new claim –If submitted two claims at the same time and both rejected as duplicate to each other for 38031

15 National Government Services, Inc. Tips for Preventing Reason Code Educate –Know when to adjust rather than submit new claims Adjust claims when making change to original claim Check educational calendar on our Web site Check internal system, processes and/or procedures –Develop and implement process to ensure duplicate claims are not being submitted Check claim submission history Maintain accuracy of accounts receivable

16 National Government Services, Inc. Detection of Duplicate Claims Medicare –Maintains history file containing information about each processed claim –Looks for Match on beneficiary information Match on provider information One-day or more overlap in billing period CMS IOM Publication , Chapter 1, Section 120

17 National Government Services, Inc. Rejection Reason Code U5233 Why did the claim reject? –Services on this claim fall within or overlap an enrollment period in a Medicare HMO

18 National Government Services, Inc. Provider Action for Reason Code U5233 Verify HMO enrollment –Verify per system (Option Code C) Submit claim to HMO –If beneficiary enrolled at time of service

19 National Government Services, Inc. Tips for Preventing Reason Code U5233 Educate –Know how and when to check for HMO enrollment and where to submit claims for HMO enrollees Check internal system, processes and/or procedures

20 National Government Services, Inc. Rejection Reason Code Why did the claim reject? –The requested medical additional development information was never received from the provider. The time allotted for receipt of the requested data has elapsed, so the claim is being returned. –*The reason code has been changed to

21 National Government Services, Inc. Provider Action for Reason Code Resubmit a new claim Make sure that the claim has the PTAN number that is associated with the site where the services were rendered

22 National Government Services, Inc. Tip for Preventing Reason Code Make sure the PTAN that’s on the claim is the site where the patient received their services

23 National Government Services, Inc. Rejection Reason Code U5210 Why did the claim reject? –The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim therefore, no Medicare payment can be made

24 National Government Services, Inc. Provider Action for Reason Code U5210 Review the beneficiary’s entitlement If you are billing for a rejection in order to bill another insurer, you have accomplished what you wished to do –No further action required

25 National Government Services, Inc. Tip for Preventing Reason Code U5210 Educate –Know how and when to check for HMO enrollment and where to submit claims for HMO enrollees Check internal system, processes and/or procedures

26 National Government Services, Inc. Rejection Reason Code Why did the claim reject? –Routine foot care is not covered unless a complicating medical condition exists making normally routine foot care procedures hazardous when performed by a nonprofessional

27 National Government Services, Inc. Provider Action for Reason Code If it is indeed routine foot care –Not covered/not billable If a complicating medical condition exist –Indicate the appropriate ICD-9-CM diagnosis code describing the condition on your bill and resubmit

28 National Government Services, Inc. Tip for Preventing Reason Code Educate –Know that routine foot care is not a covered/billable benefit Check internal system, processes and/or procedures

Return to Provider (RTP) Claims

30 National Government Services, Inc. Top FQHC RTP Codes April 2011 – July 2011

31 National Government Services, Inc. RTP Reason Code Why did the claim RTP? –According to the revenue code table, a HCPCS is required for the line-item being edited.

32 National Government Services, Inc. Provider Action for Reason Code HCPCS codes are required when a revenue code is submitted on a claim effective January 1, 2011 Correct claim and resubmit

33 National Government Services, Inc. Tips for Preventing Reason Code Educate –Inform staff of proper FQHC billing procedures –Take advantage of trainings offered by the fiscal intermediary. Check educational calendar on our Web site.

34 National Government Services, Inc. RTP Reason Code Why did the claim RTP? –The HCPCS code entered on the claim is not a valid HCPCS/CPT code

35 National Government Services, Inc. Provider Action for Reason Code Verify that the HCPCS code on the claim is valid. If the code is valid and is not on the Intermediary’s file, contact customer care Correct claim and resubmit

36 National Government Services, Inc. Tips for Preventing Reason Code Verify bill HCPCS code through current ICD-9-CM Return corrected claim

37 National Government Services, Inc. RTP Reason Code Why did the claim RTP? –Effective with date of service April 1, 2010, FQHCs, free-standing and provider-based (XX1000- XX1199 and XX1800-XX1989) must enter all claims with TOB 77X

38 National Government Services, Inc. Provider Action for Reason Code Verify billing of correct type of bill 77X with the clearinghouse or vendor Correct claim and resubmit

39 National Government Services, Inc. Tip for Preventing Reason Code Verify bill type through vendor or clearinghouse before submission of claims Return corrected claim

40 National Government Services, Inc. RTP Reason Code Why did the claim RTP? –For independent FQHC providers (‘S’ in facility code field on the provider record), or for hospital-based FQHC providers (‘M’ in the facility code and a claim ‘From’ date 12/31/97); the claim must have at least one occurrence of revenue code 521 or a revenue code within the 52X series (X=variable) or 900, and must be billed with units

41 National Government Services, Inc. Provider Action for Reason Code Check claim to insure it has at least one occurrence of revenue code 521 or a revenue code within the 52X series (X=variable) or 900, and is billed with units Resubmit the claim (F9)

42 National Government Services, Inc. Tips for Preventing Reason Code Educate –Inform staff of proper FQHC billing procedures –Take advantage of trainings offered by the fiscal intermediary. Check educational calendar on our Web site

43 National Government Services, Inc. RTP Reason Code Why did the claim RTP? –Effective with dates of service on or after 10/01/04, an ICD-9-CM procedure code cannot be billed on an outpatient claim.

44 National Government Services, Inc. Provider Action for Reason Code Remove the ICD-9-CM procedure code Correct claim and resubmit

45 National Government Services, Inc. Tips for Preventing Reason Code Educate –Inform staff of proper FQHC billing procedures –Take advantage of trainings offered by the fiscal intermediary. Check educational calendar on our Web site

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Medicare University Credit Self-Reporting Instructions

52 National Government Services, Inc. Medicare University Training Information will be sent by Topic = FQHC RTP and Reject Reason Code Webinar Medicare University Credits (MUCs) = 1 Catalog Number = Sent via

53 National Government Services, Inc. Medicare University Self-Reporting Instructions To earn MUCs, you must self-report your attendance after this training event has ended: –Go to select your business type and region, then select Gohttp:// –On the lower-right side of the page, select the Medicare University logo Alternatively, go directly to the Medicare University Web site at

54 National Government Services, Inc. Medicare University Self-Reporting Instructions –Log on to the National Government Services Medicare University site Note: You will be prompted to enter your Medicare University log on ID and password; if you don’t already have one, you may obtain one at this point –Select Course Catalog from the left-side menu –Select the Details button for the appropriate course To locate and self-report today's training event either look for the name of the event or look for the “Catalog ID” number provided for this event

55 National Government Services, Inc. Medicare University Self-Reporting Instructions –A new window will open providing the event description and information; select the Enroll button (the screen will then refresh) –Next, select Curriculum List from the left side menu; locate the self-reporting course you just enrolled in and select Go –A new page will open; select the Launch button on the new page and the course will load in a new window –Enter the training event number (Sent via ) and select the Submit button

56 National Government Services, Inc. Assessment Providers will receive a link for feedback and information to register in Medicare University after the session.

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