CEDI Top 15 5010A1 Edits General Information

Transcription

CEDI Top 15 5010A1 Edits
General Information
This document provides a list of the top 15 edits received by CEDI Trading Partners during the submission of production ANSI X12
837 version 5010A1 claims. The edits are listed in numerical order by the first CSC in the edit. As a reminder, edits listed in the Edits
Received on the 277CA column can be triggered by more than one issue. We have attempted to include all reasons that may cause
the edit with the most “frequently received” as the first explanation.
These edits will be updated monthly to provide you with accurate information. This document is intended to be used as a reference
in addition to the CMS 5010 Edit Spreadsheet located on the CMS Web site http://www.cms.gov at the following link:
http://www.cms.gov/MFFS5010D0/20_TechnicalDocumentation.asp.
Edit List Table of Contents
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
CSCC
A7:
A7:
A7:
A8:
A7:
A7:
A8:
A7:
A7:
A7:
A7:
A7:
A7:
A8:
A7:
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
CSC
164: EIC IL ............................................................................................................................................ 2
187 ....................................................................................................................................................... 3
254 ....................................................................................................................................................... 3
306 ....................................................................................................................................................... 4
453 ....................................................................................................................................................... 5
480 ....................................................................................................................................................... 5
496: EIC 85 ........................................................................................................................................... 6
500: EIC DK ........................................................................................................................................... 7
500: EIC IL ........................................................................................................................................... 7
507 ....................................................................................................................................................... 7
510: CSC 187 ......................................................................................................................................... 8
562: EIC 82 ........................................................................................................................................... 9
562: EIC 85 ........................................................................................................................................... 9
562: CSC 128: EIC 85 ........................................................................................................................... 10
698 ..................................................................................................................................................... 11
Last Revision: November 11, 2014
Page 1 of 11
The Edit Reference column is organized in the following fashion: (TR3 document.Page #.Loop.Segment & Element.Sequence #)
Edits Received on the
277CA
CSCC A7:
"Acknowledgement
/Rejected for Invalid
Information…"
CSC 164: "Entity's
contract/member number"
EIC IL: Subscriber
Edit Logic
General Description
If Medicare IDs:
2010BA.NM109 must be 10 11 positions in the format of
NNNNNNNNNA or
NNNNNNNNNAA or
NNNNNNNNNAN where “A”
represents an alpha character
and “N” represents a numeric
digit.
OR
If Railroad IDs:
2010BA.NM109 must be 7 - 12
positions in the format of
ANNNNNN, AANNNNNN,
ANNNNNNNNN,
AANNNNNNNNN, AAANNNNNN,
or AAANNNNNNNNN where “A”
represents an alpha character
and “N” represents a numeric
digit.
The subscriber HICN is
invalid.
Verify the HICN is entered
exactly as it appears on the
beneficiary's red, white,
and blue Medicare card.
If Medicare ID:
Subscriber Primary
Identifier must be 10 - 11
NNNNNNNNNA or
NNNNNNNNNAA or
NNNNNNNNNAN where “A”
represents an alpha
character and “N”
represents a numeric digit.
-ORIf Railroad ID:
Subscriber Primary
Identifier must be 7 - 12
ANNNNNN or AANNNNNN or
ANNNNNNNNN or
AANNNNNNNNN or
AAANNNNNN or
AAANNNNNNNNN where “A”
represents an alpha
character and “N”
represents a numeric digit.
Page 2 of 11
Edit Reference
X222.121.2010BA.NM109.020
277CA
CSCC A7:
"Acknowledgement
Information…"
CSC 187: "Date(s) of
service"
Edit Logic
General Description
Reject the claim if 2400.DTP02
= "RD8" and the first date is
not = the second date and
SV101-2 is not "E0935" or
"E0936", & the proc option
"GL" or "IS" does NOT exist, &
the proc option "DF", "DI",
"DR", "LP", "OC", "OG", "OL" or
"OP does exist.
Reject the claim if
2400.DTP02=D8 or
2400.DTP02 = RD8 and the
CCYYMM portion of the first
date and the CCYYMM portion
of the second date are equal
and 2400.SV101-3, SV101-4,
SV101-5 or SV101-6 = "RR"
and 2400.SV104 is not = "1".
The procedure code
submitted for this line does
not allow for spanned dates
of service. Verify the
start/from and end/to dates
for this line are equal.
X222.380.2400.DTP03.090
The number of services
entered for this line is
invalid. In general, rentals
can only have one unit of
service.
Questions regarding proper
billing policy of rental items
should be directed to the
DME MAC where the claim
would be processed based
on the patient’s state code
in the address provided on
the claim.
If Date Time Period Format
Qualifier is RD8, the "From"
date service must be a date
prior to the "To" date of
service provided.
The diagnosis code pointed
to by diagnosis code pointer
1 (SV107‐1, SV107-2,
SV107-3, or SV107-4) is
invalid for the claim line
date of service.
X222.380.2400.DTP03.070
If 2400.DTP02 is RD8, the first
date listed in 2400.DTP03 must
be a date prior to the second
date listed in 2400.DTP03.
CSCC A7:
"Acknowledgement
Information…"
CSC 254: "Primary
diagnosis code"
If 2400.SV107-1, SV107-2,
SV107-3, or SV107-4 is "1"
and 2300.HI01-1 is "BK" then
2300.HI01-2 must be a valid
ICD-9-CM Diagnosis code on
the date in 2400.DTP03 when
Page 3 of 11
Edit Reference
X222.380.2400.DTP03.060
X222.226.2300.HI01-2.030
277CA
CSCC A8:
"Acknowledgement /
Rejected for relational field
in error"
CSC 306: Detailed
description of service
Edit Logic
General Description
DTP01 = "472", based on the
ICD-9-CM Diagnosis Code list.
Questions regarding the
effective dates of a
diagnosis code should be
directed to the DME MAC
where the claim would be
processed based on the
patient’s state code in the
address provided on the
claim.
If 2400.SV107-1, SV107-2,
SV107-3 & SV107-4 are not
"1" and 2300.HI01-1 is "BK",
2300.HI01-2 must be a valid
ICD-9-CM Principal Diagnosis
code for every date in the DOS
range for this claim based on
the CMS subset of the ICD-9CM Diagnosis Code list.
The first diagnosis code's
effective dates fall entirely
outside the claim’s dates of
service.
effective dates of a
diagnosis code should be
claim.
Description must be
present when Procedure
Code requires a
description/additional
information.
2400.SV101-7 must be present
when 2400.SV101-2 is present
on the table of procedure codes
that require a description.
Page 4 of 11
Edit Reference
X222.226.2300.HI01-2.070
X222.351.2400.SV101-7.020
277CA
CSCC A7:
"Acknowledgement
Information…"
CSC 453: "Procedure Code
Modifier(s) for Service(s)
Rendered"
CSCC A7:
"Acknowledgement
Information…"
CSC 480: "Other Carrier
Claim filing indicator is
missing or invalid"
Edit Logic
General Description
2400.SV101-3 must be valid
procedure modifier on the date
in 2400.DTP03 when DTP01 =
"472".
Procedure Modifier must be
valid for the Service Date.
(DTP01 = "472")
X222.351.2400.SV101-3.010
X222.351.2400.SV101-3.020
"472".
"472".
"472".
2320.SBR09 must not = "MA"
or "MB".
(DTP01 = "472")
X222.351.2400.SV101-4.020
(DTP01 = "472")
X222.351.2400.SV101-5.020
(DTP01 = "472")
X222.351.2400.SV101-6.020
Claim Filing Indicator Code
must not = "MA" or "MB".
Non-Medicare insurances
will need to choose a valid
code for the type of
insurance being included in
the claim file. "MA" and
"MB" are not valid for NonMedicare insurances.
X222.295.2320.SBR09.020
Page 5 of 11
Edit Reference
277CA
CSCC A8:
“Acknowledgement /
in error”
CSC 496: "Submitter not
approved for electronic
claim submissions on
behalf of this entity."
EIC 85: Billing Provider
Edit Logic
General Description
2010AA.NM109 billing provider
must be "associated" to the
submitter (from a trading
partner management
perspective) in 1000A.NM109.
The Billing Provider NPI not
associated with submitter.
The Trading
Partner/Submitter ID is not
authorized to submit claims
for the supplier.
If this error is received, the
supplier must complete and
sign the appropriate form
on the CEDI Web site
(www.ngscedi.com) and
return to CEDI for
processing.
Suppliers who use a third
party (e.g. a clearinghouse
or billing service) must
complete the Supplier
Authorization Form.
Suppliers who submit their
own claims and do not use
a third party biller must
complete the CMS EDI
Enrollment Agreement.
Payer Additional Identifier
billing provider must be
"associated" to the
submitter NPI.
2010BB.REF02 billing provider
must be "associated" to the
submitter (from a trading
partner management
perspective) in 1000A.NM109.
Page 6 of 11
Edit Reference
X222.087.2010AA.NM109.050
X222.140.2010BB.REF02.075
277CA
CSCC A7:
"Acknowledgement
Information…"
CSC 500: "Entity's
Postal/Zip Code"
EIC DK: Ordering
Physician
CSCC A7:
"Acknowledgement
Information…"
CSC 500: "Entity's
Postal/Zip Code"
EIC IL: Subscriber
CSCC A7:
"Acknowledgement
Information…"
CSC 507: "HCPCS"
Edit Logic
General Description
Edit Reference
2420E.N403 must be a valid
Zip Code.
Ordering Provider Postal
Zone ZIP Code must be a
valid US Postal Service Zip
Code.
X222.458.2420E.N403.020
2010BA.N403 must be a valid
postal/zip Code
Subscriber Postal Zone or
ZIP Code must be a valid
US Postal Service Zip Code.
X222.125.2010BA.N403.020
When 2400.SV101-1 = "HC",
2400.SV101-2 must be a valid
HCPCS Code on the date in
2400.DTP03 when DTP01 =
"472".
When Product or Service ID
Qualifier = "HC", the
Procedure Code must be a
valid HCPCS Code for the
Service Date. (DTP01 =
"472"). The HCPCS can be
verified with PDAC. If
additional information is
needed concerning the valid
combination, please contact
the Jurisdiction where the
claim will be processed.
The HCSPCS must be valid
for the date of service and
the modifiers attached must
be a valid combination.
Verify that all required
modifiers are sent if
X222.351.2400.SV101-2.020
When 2400.SV101-1 = "HC",
"472".
OR
Page 7 of 11
X222.351.2400.SV101-2.030
277CA
Edit Logic
When 2400.SV101-1 = "HC",
HCPCS Code from the DME
subset on the date in
"472".
When 2400.HCP09 = "HC",
2400.HCP10 must be a valid
"472".
CSCC A7:
"Acknowledgement
Information…"
CSC 510: "Future date"
CSC 187: "Date(s) of
service"
When 2400.DTP02 = RD8 and
the second date is a future
date, one of the following proc
options must exist for the
procedure: "IS", "PA", "PE",
"PI", "PK", "PL", "PP", "PS" or
"PX".
If 2400.DTP02 is
D8,2400.DTP03 must not be a
future date.
Page 8 of 11
General Description
modifiers are required.
The HCPCS can be verified
with PDAC. If additional
information is needed
concerning the valid
combination, please contact
the Jurisdiction where the
claim will be processed.
When Product or Service ID
Qualifier = "HC", Procedure
Code must be a valid
HCPCS Code on the Date of
Service when DTP01 =
"472".
The service end/to date is
greater than the date this
claim was received.
Questions regarding proper
billing policy should be
claim.
Qualifier is D8, Service
Date must not be a future
date.
Edit Reference
X222.416.2400.HCP10.020
X222.380.2400.DTP03.080
X222.380.2400.DTP03.040
277CA
Edit Logic
General Description
If 2400.DTP02 is RD8, the first
date listed in 2400.DTP03 must
not be a future date.
Qualifier is RD8, the "From"
date of service must not be
a future date.
X222.380.2400.DTP03.050
CSCC A7:
"Acknowledgement
Information…"
CSC 562: " Entity's
National Provider Identifier
(NPI)”
EIC 82: Rendering
Provider
2420A.NM109 must be valid
according to the NPI algorithm.
Rendering Provider
Identifier must be a valid
NPI on the Crosswalk when
evaluated with Receiver
Primary Identifier.
Medicare DME claims do not
require the Rendering
Provider information to be
sent. It is recommended
that the information is
removed from the claim.
For more information on
how to remove the
information, please contact
your software vendor,
billing service, or
clearinghouse.
X222.262.2310B.NM109.030
CSCC A7:
"Acknowledgement
Information…"
CSC 562: "Entity's
(NPI)"
2010AA.NM109 must be a valid
NPI on the Crosswalk when
evaluated with 1000B.NM109.
Billing Provider Identifier
must be a valid NPI on the
Crosswalk. Verify that the
NPI and DME PTAN are
linked together. To
establish a crosswalk, verify
the supplier's information
listed on the NPPES web
site matches the
X222.087.2010AA.NM109.030
Page 9 of 11
Edit Reference
277CA
Edit Logic
General Description
Edit Reference
information at the NSC.
If you have questions about
these matches please
contact NPPES at 800-4653203 or the NSC at 866238-9652.
Note: PECOS can also affect
your crosswalk. PECOS is
the system used by the
NSC for DME suppliers to
enroll in Medicare.
Suppliers can log in to and
verify that their NPI is listed
correctly. For assistance
with PECOS, call 866-4848049.
CSCC A8:
"Acknowledgement /
in error"
CSC 562: "Entity's
(NPI)"
CSC 128: "Entity's tax id"
2010AA.NM109 must be valid
according to the NPI algorithm.
Billing Provider Identifier
must be a valid NPI.
X222.087.2010AA.NM109.020
The first position of
2010AA.NM109 must be a "1".
The first position of Billing
Provider NPI must be a "1".
X222.087.2010AA.NM109.040
2010AA.REF must be
associated with the provider
identified in 2010AA.NM109
Billing Provider Tax
Identification Number must
be associated with the
billing provider's NPI.
Verify that the information
you are submitting matches
the information on file with
the NPPES and NSC.
X222.094.2010AA.REF02.050
Page 10 of 11
277CA
CSCC A7:
"Acknowledgement
Information…"
CSC 698: "Form Type
Identifier."
Edit Logic
General Description
2440.LQ02 must be a valid
form for the procedure code in
2400.SV102.
The CMN form number
must be a valid form for the
procedure code.
Edit Reference
X222.492.2440.LQ02.030
CMN form number should
be directed to the DME MAC
claim.
2440.LQ02 must be a valid
DMERC CMN Form.
The CMN form number
must be a valid DMERC
CMN Form.
X222.492.2440.LQ02.020
CMN form number should
be directed to the DME MAC
claim.
If 2400.PWK with PWK01 =
"CT" and PWK02 = "AD" is
present, 2440.LQ must be
present.
Page 11 of 11
If DME Certificate of
Medical Necessity Indicator
with PWK01 = "CT" and
PWK02 = "AD" is present,
the CMN form number must
be present.
X222.492.2440.LQ.030

CEDI Top 15 5010A1 Edits General Information

Transcription

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