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Medicare Billing - Common Mistakes

Most of you are aware of the Medicare covered services to include TPN, Enteral, IVIG, External Infusion Pump (Chemotherapy, Pain Management, Deferoxamine).  You prepare and submit your bill to Medicare and expect payment.  Seems pretty simple.  Yet why do so many claims get rejected?  This is truly a case of “the devil is in the details”.  Prior to claim submission it is of utmost importance that you obtain all the necessary documentation required to submit the bill.  Here are some common billing errors that create a bottleneck in the processing of your claims:

  • Incorrect HCPCS codes (updated annually)
  • Incorrect or missing modifiers
  • Failure to meet coverage criteria
  • Billing by ship date (should be the date the patient receives the drugs/supplies/formula and is indicated as the “from” date
  • Failure to include the CMN or DIF on the initial claim submittal (must be accurate per physician orders)
  • Failure to send updated CMN or DIF when there is a change in provider or prescription (i.e. frequency change, formula change, administration route change)
  • Knowing whether single date or date range is required

HCPCS Codes and Modifiers 

  • HCPCS

    • TPN

      • Bill TPN in a Gram Range
      • 10-51grams (B4189)
      • 52-73 grams (B4193)
      • 74-100 grams (B4197)
      • 100+ grams (B4199)
      • Bill Supplies in Kits
      • Admin Kit (B4224)
      • Tubing, ext. sets
      • Supply Kit (B4220)
      • Alcohol prep pads, gloves
      • Bill Lipids in HCPCS
      • 10 grams (B4185)
    • Enteral Therapy

      • Bill Formula in HCPCS (B4149, B4150, B4152, B4153-B4157, B4161, B4162)
      • 100 Cal units
      • Code is determined by which category based on composition of the formula
      • Manufactured
      • Calorie dense
      • Pediatric
      • Diabetic
      • Etc.
      • Bill Supplies in Kits
      • Pump Kit (B4035)
      • Gravity Kit (B4036)
      • Syringe Kit (B4034)
    • Modifiers

      • GY : Item or service statutorily excluded or does not meet the definition of any Medicare benefit
      • GA : Typically covered item or service is expected to be denied as not reasonable and necessary.  ABN and DIF are on file
      • GZ : Typically covered item or service expected to be denied as not reasonable and necessary.  DIF is on file but ABN is not on file 
      • RR : Recurring Rental
      • NU : New DME purchase
      • UE : Used DME purchase
      • KH : 1st month rental
      • KI : 2nd – 3rd month rental
      • KJ : 4th -15th month rental Documentation required to have on file for each Medicare patient is far more extensive than what may be required to submit a claim.  Make sure you have “all your ducks in a row”.

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