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  • CMS Reports 'Moderate' Number of Part B Outpatient Therapy Claims Rejected in Error

    The Centers for Medicare and Medicaid Services (CMS) recently reported that physical therapists and other providers who bill Medicare for outpatient therapy services may have recently noticed an increase in the frequency of Health Insurance Portability and Accountability Act rejection codes on their provider notification letters. Medicare routinely mails these letters to providers when various identified claims cannot be successfully crossed over to their patient’s supplemental insurance companies.

    The codes are:

    • 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.'

    (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.) 

    CMS states that the new functional G-codes, new severity/complexity modifiers, and new Claim Adjustment Reason Code (CARC) 246 for the January 2013 Healthcare Common Procedure Coding System (HCPCS) and CARC updates were inadvertently not loaded. As a result, a moderate number of Part B outpatient therapy claims (claims for physical therapy, speech-language pathology services, and occupational therapy) were rejected in error. The newly added severity/complexity modifiers were as follows:  CH, CI, CJ, CK, CL, CM, and CN.  The new functional G-codes fall within the following ranges:

    • G8978—G8999
    • G9158—G9176
    • G9186

    To remedy this issue, the Coordination of Benefits Contractor (COBC) HIPAA validation vendor added the new G-codes to its HCPCS table as of January 28. The vendor then added the new severity/complexity modifiers to its HCPCS table as of February 11. Lastly, the vendor added the new CARC 246 to its table as of February 25. Thus, Medicare participating therapists, physicians, and nonphysician providers should now see a drastic decrease in the incidence of error codes H51000, H51061-H51064, and H51108 reflected 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 described above, there unfortunately is not a way for Medicare to retransmit the affected claims to your patients’ supplemental insurers. Therefore, you will need to bill your patients' supplemental insurers directly. 

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

    This notice, titled CMS Reports Problem Impacting Crossover of Medicare Part B Outpatient Therapy Claims, can be found in the March 7 issue of Provider e-News.   


    • My case load is totally wound care. How do the caps and "G" codes apply to wound care when the outcomes and goals are not functionally based?

      Posted by Pamela Connor on 3/15/2013 3:53 PM

    • Please help: Can an assistant write a portion of the 10th visit Progress Report. The registered clinician, of course, would do their parts and sign.

      Posted by jackie on 3/15/2013 9:10 PM

    • I have sent in G codes incorrectly for some medicare patients secondary to my misjudgement on which codes were to be used on first, tenth and d/c visits. Is there any way to go back and fix this issue?

      Posted by Connie on 11/20/2013 10:12 PM

    • H51108 '2' code is not valid line level???? what exactly does that mean? even Availity was not quite sure of its meaning.

      Posted by SUSAN on 12/21/2015 12:22 PM

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