CO 16

Last Modified: 1/8/2010 Location: FL, PR, USVI Business: Part B

CO 16

Claim/service lacks information which is needed for adjudication.

(REFERRING NAME AND UPIN REQUIRED. RESUBMIT AS A NEW CLAIM)

(DENIED-RENDERING PHYSICIAN #INVALID/MISSING. SUBMIT A NEW CLAIM)

(DATES FILED ON CMS-1500 ARE NOT CONSISTENT 6 DIGIT VS 8 DIGIT)

(DENIED-EXACT DATES AND CHARGES NEEDED. REKEY ELECTRONIC CLAIM)

(FACILITY ZIP CODE OR STATE CODE INVALID OR MISSING)

(FACILITY/LABORATORY NAME AND ADDRESS OR PIN MISSING)

(DENIED-FIELD 11 OF HCFA 1500 MUST BE COMPLETED)

(DENIED-INVALID/INCORRECT ICD-9 CODE. RESUBMIT AS A NEW CLAIM)

(DENIED-CLIA NUMBER INVALID OR MISSING)

Resources/tips for avoiding this unprocessable claim

Referring or Ordering Physician

• Only authorized non-physician practitioners (NPPs) and the following physicians are authorized, per CMS guidelines, to refer and/or order services for a Medicare patient:

• A doctor of medicine or osteopathy (M.D. or D.O.)

• A doctor of dental surgery or dental medicine (D.D.S. or D.D.M.)

• A doctor of podiatric medicine (D.P.M.), but only with respect to functions which he/she is legally authorized to perform

• A doctor of optometry (O.D.), but only with respect to the provision of items or services which he/she is legally authorized to perform

• A chiropractor (D.C.) legally authorized to perform services in the jurisdiction in which he/she performs such services, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation).

• If you perform services in a laboratory, radiology department, or other entity to which the patient or their service(s) may have been referred, ensure to report the referring or ordering physician's information as indicated below.

• Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to the physician’s or non-physician practitioner’s service.

• Diagnostic and clinical laboratory tests may require a Clinical Laboratory Improvement Amendments (CLIA) number to be included on the claim. For further instruction, refer to the "CLIA Number" information below.

• Referring or ordering provider information must be included in the 2310A Referring Provider Loop, segments NM1 [Name], NM108 [XX], and NM109 [NPI] of the 837P electronic claim or Item 17 & 17b of the CMS-1500 paper claim form.

Rendering Physician

• If the practitioner rendering the service is part of a billing group, the individual practitioner’s National Provider Identifier (NPI) must be reported in 2310B loop, segments NM108 [XX] and NM109 [NPI], of the 837P electronic claim (Item 24J of the CMS-1500 paper claim form). Note: If you submit claims on the CMS-1500 paper claim form, report the NPI of the individual practitioner in the lower, non-shaded portion of Item 24J.

• Providers can utilize the First Coast Service Options Inc. (FCSO) PC-ACE Pro32® software to avoid this returned claim. PC-ACE Pro32® software has built-in edits to avoid submitting claims without this information being included. Click here for additional information on PC-ACE Pro32®.

Billing Entity

• The billing entity’s National Provider Identifier (NPI) must be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form. Do not place any information in the 837P 2010AA loop, REF02 (item 33b of the paper form), as it is no longer used.

Dates on the claim

• Dates on the 837P electronic claim or CMS-1500 (08/05) paper form, may be either 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY), but the format must be consistent throughout the claim.

• e.g., if you choose to use 6-digit format in one date field, you must use 6-digit format in all date fields in the provider portion of the claim; you may not include 8-digit date format on the claim.

• Ensure date(s) of service (DOS) correspond to the number of units/days billed.

Facility ZIP code

• Ensure to include the state and ZIP code when reporting Service facility information. This information is used when pricing claims.

• Click here

to see if a 9-digit ZIP code is needed for the facility.

Facility/Laboratory Name and Address or PIN

• For services rendered in a facility, the facility’s name, address, and NPI must be included in the 2310D Service Facility Location Information Loop segments NM101 (entity identifier code), NM103 (name), N301 (address), N302 (address 2), N401 (city), N402 (state), N403 (ZIP) and in the 2310D NPI# segment NM109 of the 837P electronic claim or item 32 and 32a of the CMS 1500 paper form.

• Providers can utilize the FCSO PC-ACE Pro32® software to avoid this returned claim. PC-ACE Pro32® software has built-in edits to avoid submitting claims without this information being included. Click here for additional information on PC-ACE Pro32®.

Field 11 of CMS-1500

• Insured’s Policy Group, or FECA Number Loop 2000B segment SBR03 of the 837P electronic claim or item 11 of the CMS-1500 is a required element and thus must be completed.

• Note: If Medicare is primary enter the word NONE.

ICD-9 Codes

• Before submitting your claim, ensure you use the most current year's ICD-9-CM codes.

• Diagnoses must be coded to the highest level of specificity

• Example: If a five-digit code exists, do not submit the three-digit code on the claim; choose and submit the highest level five-digit code.

• Providers can utilize the FCSO PC-ACE Pro32® software to avoid this returned claim. PC-ACE Pro32® software is updated with the most current ICD-9 codes, to help you avoid submitting claims without a valid ICD-9 code. The software does not implement or check against billing guidelines, but will help avoid a claim completion error. Click here for additional information on PC-ACE Pro32®.

CLIA Number

• Regarding Clinical Laboratory Improvement Amendments (CLIA), see Internet Only Manual (IOM) Publication 100-04, Chapter 26

pertaining to Item 23

• Click here

for information regarding CLIA

• Diagnostic and clinical laboratory tests requiring a CLIA number may require a referring or ordering provider's information to be included on the claim. For further instruction, refer to the "Referring or Ordering Physician" above.

Tips to correct the unprocessable claim

In all instances above, correct the claim and submit the corrected claim for payment.

• Refer to the Claim completion FAQs on the FCSO Medicare provider Web site for additional information.

Please use your browser's back button to return to the referring page.

Source: FCSO Education Action Team

Location: All

Quick Find

Popular Links

CO 16

Claim/service lacks information which is needed for adjudication.