CEDI Top 15 5010A1 Edits
Transcription
CEDI Top 15 5010A1 Edits
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 A7: CSC 21: CSC 153: EIC PR: CSC 153: EIC 40 ..................................................................................................... 2 CSCC A7: CSC 164: EIC IL ............................................................................................................................................ 2 CSCC A7: CSC 187 ....................................................................................................................................................... 3 CSCC A7: CSC 254 ....................................................................................................................................................... 4 CSCC A8: CSC 306 ....................................................................................................................................................... 5 CSCC A7: CSC 453 ....................................................................................................................................................... 5 CSCC A7: CSC 480 ....................................................................................................................................................... 5 CSCC A8: CSC 496: EIC 85 ........................................................................................................................................... 6 CSCC A7: CSC 500: EIC IL ............................................................................................................................................ 7 CSCC A7: CSC 507 ....................................................................................................................................................... 7 CSCC A7: CSC 510: CSC 187 ......................................................................................................................................... 8 CSCC A7: CSC 535 ....................................................................................................................................................... 9 CSCC A7: CSC 562: EIC 85 ........................................................................................................................................... 9 CSCC A8: CSC 562: CSC 128: EIC 85 ........................................................................................................................... 10 CSCC A7: CSC 698 ..................................................................................................................................................... 10 Last Revision: February 6, 2015 Page 1 of 10 CEDI Top 15 5010A1 Edits 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 21: "Missing or Invalid Information" CSC 153: "Entity ID Number" EIC PR: "Payer" CSC 153: "Entity ID Number" CSC 40: "Receiver" CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 164: "Entity's contract/member number" EIC IL: Subscriber Last Revision: February 6, 2015 Edit Logic General Description Edit Reference 2010BB.NM109 must be the same value as 1000B.NM109. Payer ID sent for the Medicare insurance information indicated with the patient's claim must be the same value as the Receiver Primary Identifier sent for the file. Verify that the numbers match and are one of the following Payer ID Numbers for Medicare DME: Jurisdiction A – 16003 Jurisdiction B – 17003 Jurisdiction C – 18003 Jurisdiction D – 19003 X222.133.2010BB.NM109.025 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, 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 positions in the format of NNNNNNNNNA or NNNNNNNNNAA or NNNNNNNNNAN where “A” represents an alpha character and “N” X222.121.2010BA.NM109.020 Page 2 of 10 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 187: "Date(s) of service" Last Revision: February 6, 2015 Edit Logic General Description AANNNNNNNNN, AAANNNNNN, or AAANNNNNNNNN where “A” represents an alpha character and “N” represents a numeric digit. represents a numeric digit. -ORIf Railroad ID: Subscriber Primary Identifier must be 7 - 12 positions in the format of ANNNNNN or AANNNNNN or ANNNNNNNNN or AANNNNNNNNN or AAANNNNNN or AAANNNNNNNNN where “A” represents an alpha character and “N” represents a numeric digit. 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 X222.380.2400.DTP03.070 Page 3 of 10 Edit Reference CEDI Top 15 5010A1 Edits Edits Received on the 277CA Edit Logic 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 /Rejected for Invalid 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 DTP01 = "472", based on the ICD-9-CM Diagnosis Code list. 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. Last Revision: February 6, 2015 Page 4 of 10 General Description 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. 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. The first diagnosis code's effective dates fall entirely outside the claim’s dates of service. 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 Edit Reference X222.380.2400.DTP03.060 X222.226.2300.HI01-2.030 X222.226.2300.HI01-2.070 CEDI Top 15 5010A1 Edits Edits Received on the 277CA Edit Logic General Description Edit Reference patient’s state code in the address provided on the claim. CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 306: Detailed description of service 2400.SV101-7 must be present. when 2400.SV101-2 is present on the table of procedure codes that require a description. Procedure Code sent requires a description/additional information. This description must be sent in the SV101-7 field. X222.351.2400.SV101-7.020 Please contact your software vendor for more information on how to place the description in this field if needed. Note: This description field is different than the NTE (general narrative) field. CSCC A7: "Acknowledgement / Rejected for relational field in error" CSC 453: "Procedure Code Modifier(s) for Service(s) Rendered." 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.SV101-3.020 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 480: "Other Carrier 2320.SBR09 must not = "MA" or "MB". Claim Filing Indicator Code must not = "MA" or "MB". Non-Medicare insurances will need to choose a valid code for the type of X222.295.2320.SBR09.020 Last Revision: February 6, 2015 Page 5 of 10 CEDI Top 15 5010A1 Edits Edits Received on the 277CA Claim filing indicator is missing or invalid" CSCC A8: “Acknowledgement / Rejected for relational field in error” CSC 496: "Submitter not approved for electronic claim submissions on behalf of this entity." EIC 85: Billing Provider Edit Logic Edit Reference insurance being included in the claim file. "MA" and "MB" are not valid for NonMedicare insurances. 2010AA.NM109 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. 2010BB.REF02 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. Last Revision: February 6, 2015 General Description Page 6 of 10 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. X222.087.2010AA.NM109.050 X222.140.2010BB.REF02.075 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 500: "Entity's Postal/Zip Code" EIC IL: Subscriber CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 507: "HCPCS" Edit Logic Edit Reference 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 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. X222.351.2400.SV101-2.020 When 2400.SV101-1 = "HC", 2400.SV101-2 must be a valid HCPCS Code on the date in 2400.DTP03 when DTP01 = "472". OR When 2400.SV101-1 = "HC", 2400.SV101-2 must be a valid HCPCS Code from the DME subset on the date in 2400.DTP03 when DTP01 = "472". Last Revision: February 6, 2015 General Description Page 7 of 10 X222.351.2400.SV101-2.030 CEDI Top 15 5010A1 Edits Edits Received on the 277CA Edit Logic When 2400.HCP09 = "HC", 2400.HCP10 must be a valid HCPCS Code on the date in 2400.DTP03 when DTP01 = "472". CSCC A7: "Acknowledgement /Rejected for Invalid 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. If 2400.DTP02 is RD8, the first date listed in 2400.DTP03 must not be a future date. Last Revision: February 6, 2015 Page 8 of 10 General Description Edit Reference 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 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. X222.416.2400.HCP10.020 If Date Time Period Format Qualifier is D8, Service Date must not be a future date. If Date Time Period Format Qualifier is RD8, the "From" date of service must not be a future date. X222.380.2400.DTP03.040 X222.380.2400.DTP03.080 X222.380.2400.DTP03.050 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 535: "Claim Frequency Code." CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 562: "Entity's National Provider Identifier (NPI)" EIC 85: Billing Provider Last Revision: February 6, 2015 Edit Logic General Description Edit Reference 2300.CLM05-3 must be "1". Claim Frequency Code must be "1". X222.157.2300.CLM05-3.020 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 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. X222.087.2010AA.NM109.030 Page 9 of 10 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC 85: Billing Provider CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 698: "Form Type Identifer." Last Revision: February 6, 2015 Edit Logic General Description Edit Reference 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 2440.LQ02 must be a valid form for the procedure code in 2400.SV102. Form Identifier must be a valid form for the procedure code. X222.492.2440.LQ02.030 Page 10 of 10