Posted 2-13-2011
J14 A/B MAC: 
NHIC, Corp. Special Message
The new Version 5010A1/D.0 of standard transactions to be used for submitting electronic claims to payers was implemented on January 1, 2012. Although the Office of E-Health Standards and Services (OESS) at the Centers for Medicare & Medicaid Services has announced an enforcement discretionary period of 90 days for Version 5010 compliance, the deadline remained January 1, 2012. Enforcement will not be exercised until April 1, 2012; however, it is important that organizations continue to complete the transition to Version 5010 as soon as possible, if they have not done so already.

If you have not been approved for Version 5010A1 production, you should have submitted your transition plan to NHIC, Corp. by February 1, 2012, outlining how you will complete your transition by March 31, 2012.

In order to ensure a smooth upgrade prior to April 1, you will need to complete both phase I internal and phase II external testing of Version 5010 transactions. As part of your external testing, you will need to conduct tests with outside trading partners, which include vendors, clearinghouses, billing services, and payers. Your vendor is a critical partner in achieving Version 5010 compliance.

You should take the following steps to evaluate your vendor and vendor products to ensure a timely Version 5010 upgrade:
  • Establish a tracking system and timeline for milestones

  • Review existing and new contractual obligations with vendors

  • Coordinate vendor capabilities with your practice needs and expectations

  • Evaluate ease of use of vendor products

You might want to also ask your vendor some of the following questions about the Version 5010 upgrade to help assess your readiness for this upgrade:

  1. Have they upgraded their systems to meet Version 5010 standards?

  2. If they have not yet upgraded, when will they do so?

  3. What will be the cost for each upgrade?

  4. What versions of their software will be upgraded, and will these upgrades require any additional hardware upgrades?

  5. How often will updates occur and what is the delivery method?

  6. How are issues logged and how will they be addressed?

  7. Is there training available for new system changes and/or functionalities?

Please visit the CMS website for additional Version 5010A1 information and resources about the Version 5010 upgrade.

Posted 2-22-2011
J14: Avoid CERT Errors: Get Paid Right the First Time  

CERT is the Comprehensive Error Rate Testing Program established in November of 2003.  The CERT program helps Medicare reduce the amount of improper payments by randomly sampling claims and determining if claims submission and payment is correct. There are 3 very common errors that result in CERT requesting additional documentation from providers.

Common Errors:  

 Insufficient Documentation - this is error Code 21 - documentation submitted does not include pertinent patient facts - overall condition, diagnosis, or extent of services performed. An example:  Payment was made for physical therapy visits - the claim was pulled in the CERT sample - the documentation submitted included the initial evaluation signed by the physical therapist, however, missing were the order, plan of care and treatment notes signed by the ordering physician. CERT counted the claim as an error and the amount paid was retracted from the provider.   

Medically Unnecessary - this is error Code 25- the CERT review identifies enough documentation in the medical records submitted to make an informed decision that the services billed were not medically necessary based on Medicare coverage policies. An example: for laboratory services/diagnostic tests, if documentation submitted does not contain explicit evidence - for example signed progress notes - that the treating physician intended the tests to be performed; the reviewers will determine that there was no medical necessity for the tests and the claim is counted as an error.  

New information from CMS regarding signature requirements on clinical diagnostic laboratory requests:

Reference: Signature on Requisitions for Clinical Diagnostic Laboratory Tests


 "In the November 29, 2010, Medicare Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) finalized its proposed policy to require a physician's or qualified non-physician practitioner's (NPP) signature on requisitions for clinical diagnostic laboratory tests paid under the clinical laboratory fee schedule effective January 1, 2011. A requisition is the actual paperwork, such as a form, which is provided to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient.

 Although many physicians, NPPs, and clinical diagnostic laboratories may be aware of, and are able to comply with, this policy, CMS is concerned that some physicians, NPPs, and clinical diagnostic laboratories are not aware of, or do not understand, this policy. As such, CMS will focus in the first quarter of this year on developing educational and outreach materials to educate those affected by this policy. As they become available, we will post this information on our Web site at http://www.cms.gov/ClinicalLabFeeSched and use the other channels we have to communicate with providers to ensure this information is widely distributed. Once our first quarter educational campaign is fully underway, CMS will expect requisitions to be signed."

This means that all clinical diagnostic laboratory tests such as CBC, Urinalysis, etc. must have paperwork signed by the physician ordering the labs. As of today, we do not have an implementation date for this rule. CMS has designated lead time to provide education on this.

Service Incorrectly Coded - this is error Code 31- medical documentation submitted supports a lower or higher code than the code submitted on the claim. An example: payment was made for transthoracic echocardiography with contrast, real time, with exercise stress test. The submitted documentation showed that the study was performed without the use of contrast material. This was a coding error which resulted in an overpayment, which was retracted by CERT.

Please remember to verify that all necessary signed documentation is present on all medical records before documentation is filed and/or claims have been submitted. 

Avoid errors - Get Paid Right the First Time! 

Posted 2-21-2011
J14 Part B Medicare FFS 5010A1 Companion Guide

The J14 Part B Medicare FFS 5010A1 Companion Guide has been published.

This document is intended to provide information from the author of this guide to trading partners to give them the information they need to exchange EDI data with the author. This includes information about registration, testing, support, and specific information about control record setup.
An Electronic Data Interchange (EDI) Trading Partner is defined as any Medicare customer (e.g., provider/supplier, billing service, clearinghouse or software vendor) that transmits to, or receives electronic data from, Medicare. Medicare's EDI transaction system supports transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as well as additional supporting transactions as described in this guide.
Medicare FFS is publishing this Companion Guide to clarify, supplement and further define specific data content requirements to be used in conjunction with, and not in place of, the ASCX12N TR3s for all transactions mandated by HIPAA and/or adopted by Medicare FFS for EDI.
This Companion Guide provides communication, connectivity and transaction specific information to Medicare FFS trading partners and serves as the authoritative source for Medicare FFS specific EDI protocols.
Additional information on Medicare FFS EDI practices are referenced within Pub. 100-04 Medicare Claims Processing Manuel, Chapter 24 on General EDI and EDI Support, Requirements, Electronic Claims and Mandatory Electronic Filing of Medicare Claims. This document can be accessed at: http://www.cms.gov/manuals/downloads/clm104c24.pdf.


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