Claims Processing Issues Log

Here is a list of current system-related claims payment and processing issues. These issues have been reported to the Centers for Medicare & Medicaid Services (CMS) and/or the Multi-Carrier System (MCS). Please check often for updates before contacting the provider contact center. The issues are identified by stand alone articles and will be updated as needed.

Telehealth Procedure Codes and Skilled Nursing Facility Consolidated Billing Edits
Telehealth Procedure Codes and Skilled Nursing Facility Consolidated Billing Edits
Current Status
Date
 
Status
07/29/2020
Status: Part B Medicare Administrative Contractors (MACs) will reprocess claims for CPT codes 99441, 99442 and 99443, with dates of service on or after March 1, 2020, until notified that changes made for the PHE are to be discontinued.
Initial
07/29/2020
Provider Action:
If you have already received payment from the SNF for these services, that payment should be returned to the SNF once your claims have been reprocessed.   
Identified
07/29/2020
Issue
During the COVID-19 Public Health Emergency CPT codes 99441, 99442 and 99443, are not excluded from File 1 (Part A Stay – Physician Services) on the Skilled Nursing Facility Consolidated Billing (SNF CB) Part B file. As these three codes have now been added to the list of covered codes under the telehealth waiver during the COVID-19 PHE, they would also qualify for SNF CB exclusion and, thus, would be separately billable under Part B when furnished to a SNF’s Part A resident.

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This was last updated on 08/06/2020

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Ustekinumab (Stelara)
Ustekinumab (Stelara®)
Current Status
Date
 
Status
07/29/2020
Status: This Claims Payment Issue (CPI) will be updated when Palmetto GBA has updated the necessary editing and again when the adjustments have been completed.
Initial
07/29/2020
Provider Action:
Providers are asked to hold new claims for this code until this CPI is updated indicating editing has been updated.
Identified
07/29/2020
Issue
The drug Ustekinumab (Stelara®) billed with HCPCS codes J3357 is denying as a self-administered drug when it should be excluded as indicated in the Self-Administered Drug Exclusion List Article #A53066. This issue affects claims with dates of service April 20, 2020, and after.

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This was last updated on 07/30/2020

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Audio-Only Telephone Evaluation and Management (E/M) Visits

Audio-Only Telephone Evaluation and Management (E/M) Visits
Current Status
Date
Update
07/02/2020

Status:

  • Jurisdiction J and M claim adjustments necessary to allow CPT codes 99441, 99442 and 99443 previously denied prior to CMS instruction to make these services covered, have been completed. Railroad claim adjustments are ongoing. 
  • Editing updates to make 99441, 99442 and 99443 primary codes, as noted in this CPI, have been completed
  • Palmetto GBA will complete all adjustments related to the CPI as quickly as possible and no later than August 11, 2020. (This clarifies CMS instruction to complete all adjustments with 60 business days.
  • Update
5/15/2020
Status: CMS has notified Medicare Administrative Contractors the deadline for completion of claim adjustments has been extended to 60 days. Based on CMS direction, Palmetto GBA is actively working on this issue and will update this claim payment issue when adjustments have been completed.
Initial
5/13/2020
Status:
On May 8, 2020, CMS instructed Medicare Administrative Contractors to make the necessary updates to system editing and pricing and to adjust claims affected by each of these updates within 30 days.  
Provider Action:
There is no provider action required.
Identified
Various Dates
Issue
CMS has made several retroactive changes surrounding CPT codes 99441, 99442 and 99443.
For services performed on/after 3/1/2020:
  • CPT 99441-99443 are now covered services;
  • Medicare Physician Fee Schedule amounts for CPT 99441-99443 have increased; and
  • CPT 99441-99443 are considered primary codes for add-on codes 90785, 90792, 90833, 90836, 90838, 96160, 96161, 99354, 99355, 99358, 99359 and G0506.

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This was last updated on 07/02/2020

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Pembrolizumab Injection Medically Unlikely Edit

Pembrolizumab Injection Medically Unlikely Edit
Current Status
Date
 
Status
07/02/2020
Status:
Providers that chose to hold claims may now submit these services. Adjustments will begin in the next few weeks.
Status
05/19/2020
Status:
Following implementation of the July 1, 2020, MUE quarterly update files and within 60 business days, MACs will adjust any claims submitted with units of service greater than 300 and < 400 for dates of services on or after April 1, 2020.
Initial
5/19/2020
Provider Action:
No action is required, however; providers have the option to delay submission of claims for this code until after the July 1, 2020, implementation of the April 1, 2020, retroactive date or appealing claims denied due to the MUE edit of 300 including supporting documentation (see MM8853 (PDF, 99 KB)). 
Identified
5/19/2020
Issue
Due to the Public Health Emergency and COVID-19, the FDA on April 28, 2020, approved an optional increased dose for pembrolizumab of 400 mg using an extended dosing interval. As a result of this issue, CMS increased the MUE for HCPCS code J9271, from its previous value of 300 to a revised value of 400, effective with the implementation of the July 1, 2020 MUE files, retroactive to April 1, 2020. Within five days, Medicare Administrative Contractors will begin holding new claims submitted with units of service > 300 and ≤ 400 for dates of service on or after April 1, 2020, and process these claims when the July 1, 2020, MUE quarterly update file is in production.

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This was last updated on 07/02/2020

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Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model

Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model
Current Status
Date
 
Status  7/30/2020 Status:
To address this issue, adjustments must be completed in two phases. Phase one, to adjust the ambulance base code has been completed. Phase two adjustments to address the mileage code have begun. 
Status 7/2/2020

Status:
Adjustments have begun and will continue over the next several weeks.

Status
6/4/2020
Status:
Editing updates have been completed. Claim adjustments will begin in the next few weeks and this issue will be updated when all adjustments have been completed.
Status
5/19/2020
Status:
Palmetto GBA is working with CMS to address the editing causing these rejections.
Initial
5/19/2020
Provider Action:
No provider action is required at this time. Palmetto GBA will identify and adjust all affected claims.  
Identified
5/19/2020
Issue
Due to COVID-19 related pause in the repetitive scheduled non-emergent ambulance transport (RSNAT) prior authorization model, claims for RSNAT transports submitted on or after March 29, 2020 and before the end of the PHE for the COVID-19 pandemic, should not reject if a provisional affirmative prior authorization (PA) decision period ends and a new Prior Authorization request is not submitted. Currently, system driven editing is rejecting these services.

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This was last updated on 06/05/2020

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Ambulance Services Billed With the Modifier GY

Ambulance Services Billed With the Modifier GY  
 
Current Status
Date
 
Status
06/02/2020
Editing has been updated in the claims processing system. Suppliers may resume submission of claims with the GY modifier. This issue will be updated when the adjustment of affected claims has been completed.
 
Initial
 
5/6/2020
Status:
Editing is being updated to prevent these claims from paying in error.
 
Initial
 
5/6/2020
 Provider Action:
Ambulance providers are asked to hold new claim submissions with the modifier GY until the editing is updated. This issue will be updated once the editing has been updated and again once the affected claims have been adjusted.
 
Dated Identified
 
05/06/2020
 
Issue
  
Ambulance services submitted with the GY modifier began paying in error on April 8, 2020. Palmetto GBA will perform adjustments on claims that were paid incorrectly. These adjustments will result in the recoupment of dollars previously paid in error. Overpayment demand letters will be issued once the adjustments have been completed.

Please notify me when this article has been updated.

This was last updated on 06/02/2020

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