In the Thursday March 7, 2013 CMS FFS Provider e-News reports problems impacting crossover of Medicare Part B Outpatient Therapy Claims. 

CMS reports that providers who bill Medicare for outpatient therapy may have recently noticed an increase in the frequency of Health Insurance Portability and Accountability Act rejection codes on their provider notification letters.  Medicare will routinely mail these letters out to providers when various identified claims cannot be successfully crossed over to their patient’s supplemental insurance companies.

The codes are listed below:

  • H51000: The Procedure Code ____ is not a valid CPT or HCPCS Code for this date of service
  • H51061: ‘Procedure Modifier 1’ ____ is not a valid CPT or HCPCS Modifier Code
  • H51062: ‘Procedure Modifier 2’ ____ is not a valid CPT or HCPCS Modifier Code
  • H51063: ‘Procedure Modifier 3’ ____ is not a valid CPT or HCPCS Modifier Code
  • H51064: ‘Procedure Modifier 4’ ____ is not a valid CPT or HCPCS Modifier Code
  • H51108: ____ is not a valid ‘Line Level Adjustment Reason Code’
  • Note:  Where you see “____” directly above, the value (for example, G8978; modifier CH; or CARC 246) was reported, when applicable, on the outbound provider notification letter that billing offices would have received.

The new functional G-codes and new severity modifiers, and new claim adjustment reason code (CARC) 246 for the January 2013 Healthcare Common Procedure Coding System (HCPCS) and CARC updates were inadvertenly not loaded.  This caused a moderate number of Part B outpatient therapy claims to be rejected in error.

The Coordination of Benefits Contractor HIPAA validation vendor has added the new G-Codes to its HCPCS table as of January 28, 2013.  They then added the new severity modifiers to its HCPCS table as of February 11th.  The vendor also added the new CARC 246 to its table as of February 25th.  Therefore Medicare providers should now see a drastic decrease in the incidence of error code H51000, H51061-H51064 and H51108 on their provider notification letters.

If your billing office received a provider notification letter from Medicare indicating that claims could not be crossed over due to one of the H- series error messages as noted above, unfortunately there is not a way for Medicare to re-transmit the affected claims to your patient’s supplemental insurers.  You will need to bill your patients’ supplemental insurers directly.  CMS regrets that this is necessary.

In order to help avoid this kind of problem in the future, CMS will implement a fail-safe strategy well in advance of the scheduled installation of new HCPCS or other code updates.  This fail-safe strategy will ensure that any incorrectly rejected Medicare crossover claims will be repaired by all A/B MACs, minimizing the impact to the provider.

2013-03-07-eNews