2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and PaymentSpecify the original date of serviceSubmit late charges within 12 months of the date ofserviceSubmitting Corrections on a CMS 1500 (02-12)formSubmit all corrections for a CMS 1500 (02-12) formon paper. Clearly indicate that the resubmission isa corrected claim.Submitting Unlisted/Unclassified CodesAn unlisted/unclassified Current ProceduralTerminology (CPT) or Healthcare CommonProcedural Coding System (HCPCS) code may bebilled if no other appropriate code exists or a codehas not been assigned. If a code exists for aservice or procedure you are performing, you mustuse the correct code and not theunlisted/unclassified procedure code. This includesboth CPT and HCPCS Level II (alpha numeric)codes.Unlisted/unclassified CPT/HCPCS codes can beaccepted in the electronic 837 claim format. Whensubmitting an unlisted/unclassified codeelectronically, information may be entered as aservice note or claim level note.When submitting an unlisted/unclassified code on apaper claim, include the description on the claim oras an attachment.If the description is incomplete, Presbyterian mayrequire written documentation with the report andthe invoice for review and pricing.If the description of the unlisted/unclassified code isnot submitted, the service will be denied.Guidelines for Submitting Hemoglobin A1cClaims and Test ResultsPresbyterian requires the reporting of the actualresult of hemoglobin A1c tests (CPT code 83036)so that there is an accurate assessment of thedegree of control of the Presbyterian diabeticmember’s blood glucose. This helps Presbyteriandevelop or maintain diabetes-related qualityimprovement programs.When submitting charges for the A1c test, pleasefollow these guidelines:Report the test result as a three-digit number withno decimal point and a leading zero. For example,a test result of 5.8 is entered as 058.Presbyterian edits for valid values between 3.0 and20.0 (030 and 200). If the result is not within thisrange, the test is invalid.For UB-04 claims, the test date is the service date(field location 45, Service Date). If a service date isnot entered, the test date is the from date (fieldlocation 6, Statement Covers Period).Requirement for 837 ProfessionalThe following information outlines where the A1ctest results need to be reported in the 837professional and institutional electronic claimtransactions. Provide this information to yoursoftware vendors in order to properly configure yourelectronic claims submission software.This information pertains to claims submitted byproviders to the clearinghouse in the 837professional formats.Place the A1C data in the NTE02 segment of the2400 loop with the code qualifier of ADD18-52014 Practitioner and Provider Manual - Ver. 3