Did You Know? – Provider Based Billing
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- Can you confirm if Medicare scrubs up to the allotted characters for the Pecos Location names? Which form do they use, 855 A or B?
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At this time, the practice location address edits only apply to off-campus, outpatient, provider-based departments of a hospital reported on the CMS-855A provider enrollment form. Although the service facility location name must be reported on an 837I claim, the service facility location name does not have to be an exact match to the provider practice location name in PECOS.
Reviewed 09/22/2021
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- We were told that the new edits will look for either a 'PO' or 'PN' modifier on all off campus claims. If a claim has only lab or only therapy charges that are not paid through OPPS, we would not use one of those modifiers, correct?
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The most recent guidance in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 4, sections 20.6.11 and 20.6.12 states:
- Modifier PO is required to be reported with every HCPCS code for all outpatient hospital items and services furnished in an excepted off-campus provider-based department of a hospital.
- Modifier PN is required to be reported on each claim line with each nonexcepted item and service, including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.
Reviewed 09/22/2021
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- Can we add suite numbers to correct a street addresses in current PECOS location(s) without affecting PBB grandfathered status?
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Correcting errors in PECOS (i.e., add/correct the 4-digit extension of a ZIP code, spelling/formatting changes) will not affect the facility's grandfathered status. Changes to the facility's location (i.e., change of address, including suite numbers) will affect the facility's grandfathered status.
Reviewed 09/22/2021
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- Can we correct a current address in PECOS to the postal address without affecting our PBB grandfathered status due to spelling, incorrect city, or formatting issues?
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Correcting errors in PECOS (i.e., add/correct the 4-digit extension of a ZIP code, spelling/formatting changes) will not affect the facility's grandfathered status. Changes to the facility's location (i.e., change of address, including suite numbers) will affect the facility's grandfathered status.
Reviewed 09/22/2021
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- Is CGS matching only on the Service Facility address or on Service Facility Name as well? Does the Service Facility NPI play a role at all?
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Although the service facility location name must be reported on an 837I claim, the service facility name does not have to be an exact match to the provider practice location name in PECOS. The service facility NPI on the claim must match the NPI in PECOS.
Reviewed 09/22/2021
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- Is punctuation (i.e. comma, period) part of the match?
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Punctuation is part of the match in the address field, but not the ZIP code. If punctuation is present/not present in PECOS, it is required to be present/not present on the claim.
Reviewed 09/22/2021
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- If there is a hyphen in the zip code in PECOS, does the hyphen need to be submitted on the claim?
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Hyphens are not required in the ZIP code, but they are required in the address field, if present.
Reviewed 09/22/2021
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- How can we obtain a copy of our PECOS file so we can ensure our claims data matches?
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There are several options:
- Contact someone at your facility who has access to PECOS and/or request your own access.
- Use the Direct Data Entry (DDE) Provider Practice Address Query (Inquiry Option 1D).
- Use the myCGS Claims Practice Addresses option in our portal.
Reviewed 09/22/2021
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- I have a question regarding the claims submission for multiple service locations. My question is regarding zip codes. Per UB guidelines the zip code must be 9 digits however most PECOS addresses listed only have the 5 digit zip code. Will providers be required to update PECOS to a 9 digit zip code or will the 5 digit zip code be sufficient as long as it matches PECOS (not recognizing the last 4 digits).
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DDE will accept 4 zeros as the 4-digit extension of the ZIP code. However, an 837I claim will only accept a 5digit ZIP + a valid 4digit extension. If reason code 34977 is received may choose one of the following options:
- Update PECOS to include a valid 4-digit extension to avoid the edit.
- Access the RTP claim in the DDE Claim Corrections screen, change the 4-digit extension to 4 zeros, and F9 the claim.
Reviewed 09/22/2021
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- How do we bill if we have two different locations on the same claim?
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- If any services on the claim were rendered at the billing provider address
- Report the billing provider address only in the billing provider loop 2010AA
- Do not report the service facility location in loop 2310E (or in DDE MAP 171F screen for DDE submitters).
- If any services on the claim were rendered at more than one of the campus locations of a multi-campus provider that is not the main billing provider address:
- Report the service facility address in loop 2310E if all of the service facility addresses are different from the billing provider address in loop 2010AA (or in DDE MAP 171F screen for DDE submitters) from the first registered campus encounter of the "From" date on the claim.
- If any services on the claim were rendered at one of the campus locations of a multi-campus provider that is not the main billing provider address and services were also rendered at other off-campus department practice locations:
- Report the campus address where the services were rendered in the service facility location in loop 2310E if the service facility address is different from the billing provider address in loop 2310AA (or in DDE MAP 171F screen for DDE submitters).
- If no services on the claim were rendered at the billing provider address or any campus location of a multi-campus provider:
- Report the service facility address in loop 2310E (or in DDE MAP 171F screen for DDE submitters) from the first registered department practice location encounter of the "From" date on the claim.
Reference: CMS MLN Matters article SE19007
Reviewed 09/22/2021 - If any services on the claim were rendered at the billing provider address
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- If PECOS is missing a space between street #/street name and claim is submitted with a space, will it RTP?
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Yes, each character in the address, including spaces, must be an exact match.
Reviewed 09/22/2021
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- Are there certain characters (ie #, -, /, .) that will not be accepted?
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The following table includes the basic character set for 837I/DDE claims:
Reviewed 09/22/2021
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- Are there instructions on how to register and navigate PECOS?
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Please reference the Internet-based PECOS page on the CMS website.
Reviewed 09/22/2021
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- Will the claim RTP if the address is reported with all CAPS but is not all CAPS in PECOS?
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Both upper- and lowercase letters are accepted in PECOS and the 837I. FISS translates letters as a letter and is not case sensitive.
Reviewed 09/22/2021
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- If we have an HOPD that terminates and/or moves locations and we delete or edit the department in PECOS. What will happen to the address match if we have to submit a claim after the changes are made to the PECOS system? This definitely will happen due to timing and adjusted claims or re-billed claims etc.
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Once the address is updated in PECOS, any claims submitted with the previous address will RTP. At this time, you have the option to hold claims or correct/resubmit any RTP claims later. This concern has been brought to CMS' attention and is being researched. Further guidance will be provided once it is received.
Reviewed 09/22/2021
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