Reopening or Redetermination?
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A recent reminder notice from NHIC, Corp. for Medicare DME MAC A, outlined common issues to help providers decide whether a claim Reopening or Redetermination request is appropriate.
A "Clerical Error Reopening" should be done for the following:
--Math/computation errors --Code transposition errors --Data entry errors --Carrier errors
A "Redetermination" request would involve the following:
--Analysis of support documents
--Limitation of liability issues
--Dispute a recoupment
For more information, refer to this article from NHIC, Corp.-- "Click Here"However, it is extremely vital that you obtain the latest billing instructions from your specific Medicare Jurisdiction. For example, a new memo from Cigna for DME MAC C states that as of December 1, 2009 a Redetermination request will be required to add, change, or remove KX, GA, GZ, or GY on a processed claim. |
VISIT FUTURA AT
UPCOMING EVENTS
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Maui, HI
Jan. 24-27, 2010
AAOP Annual Meeting
Chicago, IL
February 24, 27, 2010
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Claim Submission Requirements Continue To Change
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Greetings!
As a follow-up to our recent articles about seeking out
vital information from all available resources, this issue also contains
reminders about claim submission requirements that have recently gone into
effect.
The Futura team continues to encourage our clients to be aware of data elements
necessary for proper claim processing by carriers to prevent avoidable cash
flow difficulties.
The Futura Team
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Diabetic and Orthopedic Shoe Claim Modifier Requirements
As
outlined in the October 20th issue of AOPA InAdvance, specific service line
modifiers are required for shoe claims. As a reminder, please share the
following information with your data entry and/or billing staff members.
Diabetic Shoes
When
billing for a pair of diabetic shoes and/or inserts/modifications, you now
must use the LTRT modifier and indicate two units of service (prior to
this, you billed two units, but did not use the LTRT modifier).
This
change in policy went into effect for claims submitted with a date of
service of September 1, 2009 and forward. If a pair of shoes or inserts is
billed without the LTRT modifier, the claim will be rejected.
Orthopedic Shoes
Beginning
with claims submitted on October 1, each claim line for orthopedic shoes
must include the KX or the GY modifier, in addition to either an LT or
RT. If the items you are providing meet the coverage criteria set
forth in the policy, each claim line would include a KX modifier.
If an item
does not meet the coverage criteria or is a non-covered item (i.e. shoes
not attached to a brace), the claim line must include the GY modifier.
Therefore,
each shoe, insert or modification must include either the KX or the GY
modifier. If a claim line doesn't include a modifier, then that line will
be rejected and you will have to resubmit that claim line with the
appropriate modifier.
Claim
lines with the GY modifier will be denied and the patient is liable for
payment.
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Did You Know ?
 You have the option within the Futura software to set modifiers so that they will automatically pull into a service line of a transaction.This can be done within the individual HCPC master file record on the "Billing & Modifers" tab to either occur each time the code is used on a service line or only when used in conjunction with an "Account Type" selection on the Patient master file record. These settings can be changed one-by-one on each HCPC record or globally by utilizing a feature within the "Utilities" menu under "Database Changes". In addition, specific modifiers may also be set to auto-fill for a HCPC code when only a certain Fee Schedule is attached to the transaction. If you are not familiar with using the advanced "Utilities" features, we caution you to seek assistance from our Technical Support team for further instruction to avoid unintentional changes to your database. As always, if a modifier auto-fills on a service line and it is not appropriate for that particular patient or service to include it on the claim, it can be removed manually from the service line by the user. Once these types of
auto-fill features are in place, it can assist users in saving time and
unfortunate claim denials from failing to include a required modifier. |
Proud Members
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