Common Billing Errors by Medicare providers

The Centers for Medicare & Medicaid Services (CMS) recently published an article on the Medicare Learning Network about common billing errors by Medicare providers. Here are some of the tips:

  • All Medicare providers must bill electronically unless they qualify for the “small provider” exemption (see 42 CFR 424.32(d)(1)(vii)). CMS considers physicians with fewer than 10 full-time employees to be a small provider. Small providers do not lose their exemption by submitting some claims electronically (but there could be HIPAA implications).

  • Always use the Health Insurance Claim Number (HICN) and patient’s name (without any title such as Dr. or Mr.) as it appears on the Medicare card. A correct HICN has nine numeric digits followed by one alpha suffix. Relatives may share the first nine digits but each of those individual will have a different suffix. Do not use dashes or hyphens. Railroad retirement numbers generally have two alpha characters as a prefix to the numeric digits and should be billed to Railroad Medicare Services.

  • Always fill out the name and address of the place of service in item 32 on the Form CMS-1500. Make sure evaluation and management (E&M) procedure codes match the place of service recorded.

  • For diagnostic services and consultations, include the referring/ordering physician’s name and unique provider identification number (UPIN) in items 17 and 17a. There are new requirements for National Provider Identifiers (NPIs) taking effect this year.

  • When billing for more than one provider within a group, use the additional individual provider number in item 24K because item 33 can only report one provider number.

  • Use the appropriate provider identification number for the individual rendering care on each detail line, and make sure that the group number, when applicable, corresponds.

  • Don’t add digits to a diagnosis code even if there is space for five characters because some International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes are fewer than five digits.

  • Use current CPT books because procedure codes/modifiers no longer have a grace period when they are deleted.

  • When Medicare is the secondary payer, complete items 11, 11a, 11b, and 11c.

  • Do not use zeros to fill in items requiring an NPI or UPIN.

  • See for the article.

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