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Top Billing Issues and Errors and How to Avoid them for Institutional Providers

Claims processing experts identified the common adjudication errors that cause claims to be suspended or denied. To ensure timely and accurate processing of claims please review these recommendations.

Some common issues…


Bilateral Procedures

When billing a bilateral procedure that requires a modifier, if done bilaterally use modifier 50 and bill one unit per left/right combination. Do not bill an RT and LT modifier separately. If multiple distinct bilateral procedures are done on a patient, for example, multiple bilateral spine injections, it is permissible to bill multiple units.

Invalid Other Carrier Payer ID

Applicable coordination of benefits/other insurance information and/or documentation is not accompanying the claim level.

Other Payer Primary ID must match the line level Other Payer ID.

Present on Admission

Present on Admission Indicator must be submitted. Report POA indicators in diagnosis segments.

Invalid Operating Physician ID

An Operating Physician must be reported on outpatient claims when the Revenue Code = 360- 369, 490-499, or 750-759 and a HCPCS code = 10000-69999.

Invalid Patient Status Code

Patient Status must be 30 (still patient) if using a Bill type of **2 or **3 (interim bill).

Service Included in Payment for Another Service

Payment for this service is included in the allowance for the service with which it is provided. This service cannot be paid separately.

Out of Network Benefit Denial

The patient’s coverage does not provide for services when performed by an out of network provider. Therefore, no payment can be made.

Medicare Crossover Issue

Patient has effective Medicare Part A or B coverage but the claim does not contain Medicare payment information.


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