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March 5, 2012

Crossover Claims Rejecting Due to Unnecessary Billing of Discharge Date

According to the Technical Report Version 3 (TR-3) for 5010A1 837 claims, a discharge date is required for inpatient claims when the patient was discharged from the facility and the discharge date is known. A discharge date is not to be sent unless required. For Part B physicians/practitioners and suppliers, the key to this requirement is being able to determine if the services were ‘inpatient' by making reference to the Place of Service (POS) code, available at (No Longer Available). Only POS codes 21, 31, 51, and 61 contain either ‘inpatient' or ‘inpatient services' in their description.

Currently, Medicare does not maintain an edit for inbound 837 professional claims to check that 2300 DTP03 (Discharge Date) is only billed when POS 21, 31, 51, and 61 are billed. However, the Coordination of Benefits Contractor (COBC), which administers the Medicare claims crossover process on behalf of CMS, does have HIPAA 5010 editing that will activate when physician or practitioner billing offices include POS codes such as 11 (office), 22 (outpatient), 23 (emergency room), or 81 (independent lab) on Medicare Part B claims, as these POS codes are clearly not ‘inpatient' by definition. Consequently, many physician/practitioner offices and DME suppliers are receiving provider notification letters from their servicing A/B MAC, DME MAC, or carrier that include an H40142 error code and the following description: "Discharge Date (DTP-01=096) was not expected because this claim is not for Inpatient Services."

For physician and practitioner offices, including those that bill Medicare via hardcopy claims, the key to avoiding receipt of the above HIPAA compliance error, which prevents crossing over of the affected claims, is to only include a discharge date, when known, if you are billing a Part B claim for services with POS codes 21, 31, 51, or 61.

DME suppliers are instructed to include a discharge date on incoming claims when billing HCPCS E0935 (continuous passive motion [CPM] device). For such claims, the POS is most often 12 (home). To ensure that your DME claims for a CPM device will properly cross over, DME suppliers should include discharge date reporting within the 2400 NTE ("notes segment"), not in 2300 DTP03 on incoming version 5010A1 837 professional claims, when billing their DME MAC electronically.

CMS continues to pursue opportunities to ensure that front-end and back-end Medicare HIPAA 5010 compliance editing becomes more closely aligned.

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