April 1, 2010, Home Health & Hospice Medicare A Newsline - CGS

Submitting Medicare Secondary Payer (MSP) Claims Where a Deductible orCoinsurance Payment is Due to the Primary InsurerCahaba has received some questions from home health and hospice providers about how to submit MSPclaims when the primary insurer applied the charges to the deductible or the beneficiary is responsible for acoinsurance. In particular, the providers inquired about the use of a specific code to report the primaryinsurer’s deductible or coinsurance amount on their Medicare claims. While there is no specific coding toreflect the amount applied to the deductible or the coinsurance amount, it is important that this informationis captured through the usual MSP coding. Below is an example of how this information is captured on anMSP claim.Example: A beneficiary has a working aged insurance (value code 12) where their deductible amount is$1,000.00; however, none of the deductible has been met. The beneficiary received 12 skilled nursing visitsat $100.00 per visit for total charges by the provider of $1,200.00. These charges are subject to thedeductible amount. The working aged insurance will only allow $75.00 per visit, and the provider agrees toaccept this as payment in full (value code 44). Since none of the deductible was met, the primary insurerapplied the $900.00 (12 visits @ $75.00 per visit) to the deductible.When submitting the claim to Medicare, the provider will report the following information, in addition tothe other data as required by their type of bill (TOB):UB-04 Form Locator Code Entered Dollar AmountOccurrence Code/Date (FL31-3424Date on the explanation ofbenefits (EOB) received fromthe primary insurer. (Note:Occurrence code 24 is onlyused when $0000.00 isreceived from the primaryinsurer.)Value Code (FL 39-41) 12 $0000.00Value Code (FL 39-41) 44 $900.00Note: Value code 44 is defined as the amount a provider agreed to accept from a primary insurer aspayment in full. Value code 44 should be submitted on a claim to Medicare when the amount agreed to is:• less than the charges; and• higher than the payment received from the primary insurer.In our example, the $900.00 that the provider agreed to accept as payment in full is less than the provider’stotal charges of $1,200.00, and is higher than the payment of $0000.00 received from the primary insurer.Value code 44 should not be used when:• the provider did not agree to accept a lesser amount than their charges from the primary payer aspayment in full; or• charges are equal to the amount the provider agreed to accept; or• payment from primary insurance is more than the amount they agreed to accept.Home Health & Hospice April 1, 2010 33Medicare A Newsline Vol. 17, No. 7