CMS Rejects of Full Encounter Data Encounters

Even after more than a year, we continue to see a number of CMS rejects of submitted encounters.  These rejects occur in all types of encounters, and for a number of reasons.  One of the most common rejects we see is for the referring physician's NPI.  This happens in a number of types of encounters, but most commonly in DMEPOS encounters.  Let's look at encounters missing a referring physician NPI,  and the various errors we see in them:

1)      Incorrect DOS—most DMEPOS are rentals, or represent a monthly supply.  Almost all of the encounters I saw were for a single date of service, and should be a 30 day  span—e.g. from January 1-30. 

2)      Incorrect # of services—many of the DMEPOS encounters have a # of services “1”—when it should be “30”.

3)      Incorrect place of service—in almost all cases, DMEPOS requires a POS of 12 (sometimes 31 or 32 if that’s the patient’s home).  Many of these encounters have a POS 11 or 99.

4)      Missing modifiers (things like Anesthesia always requires a modifier, some surgeries require a modifier to indicate if they are RT, LT or bilateral –50. Most DMEPOS have modifier requirements as well)

5)      Unlisted E/M (99499).  While this code would be expected for a chart review submission, many of these are WITH another E/M on the same date, which makes no sense--generally only one E/M service is allowed on a given day.

Remember that your encounter data to MA plans should be submitted as you were submitting to your MAC, FI or DMERC--because in effect you are.  We must submit all of your encounters to CMS for processing on the same claims processing systems that the MAC, FI and DMERC use.  So, if the claim or encounter won't pass your Medicare contractor's processing system edits, then it won't pass the encounter data processing system edits either. 

The closer your encounter data submissions are to FFS Medicare, the more likely they are to be processed by CMS.