Issues in Encounter Submission
Remember that Full Encounter Data (FED) submission closely mirrors Fee-for-Service (FFS) claims submission. Therefore, you should run reports against encounters submitted under FED that were rejected by CMS:
· While the Companion Guides help with creating and submitting an EDI transaction, there are a number of billing guides produced by Medicare Administrative Contractors that give advice on claim submission.
· In addition, the cms.gov website also has instructions for claim submissions as well. Check the Claims Processing Manual chapter(s) that relates to your type of service.
· The focus of the guidelines on the CMS website is more on claims submission and payer processing of claims/encounters for adjudication. Following the instructions on both of these websites will help you produce encounters which can be processed successfully.
The following websites have billing information to help you file correctly:
Possible Systemic Issues to Identify and Correct
· Incorrect modifier for HCPCS/CPT code (e.g. surgical modifier on an E/M code).
· Incorrect dates of service - Many DMEPOS services require a span of dates of service—for example, rentals and a month’s worth of supplies. The dates of service should be the 30 day span that represents the rental or supply period.
o Note that the number of services should reflect the number of days for a rental, or the number of units for supplies. Do not default to “1” in these situations.
· Use the correct place of service. The place of service for DME must be the patient’s home (POS 12). Rarely, a Skilled Nursing Facility or Nursing Facility is appropriate (POS 31 or 32)
· Some services have specific diagnosis requirements—“CPAP” or “BiPAP” machines require specific diagnoses. All services except the few screening services allowed require a specific diagnosis related to the service.
· Incorrect number of services (e.g., 1 service for 30 day span). Number of services should be evenly divisible by the date span.
· Missing critical information—e.g. ordering provider, rendering provider on a medical group or DME claim/encounter.
· Incompatible place of service (i.e. Outpatient service like 99214 billed with Place of service 21, 31 or 32).
· Incorrect or missing origin/destination for ambulance claims.
We hope that this information helps you in your goal of submitting clean FED claims/encounters.
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