- Outpatient Institutional Providers Reimbursed Under MPFS: When to Split Claims for Updated Rates
- Outpatient Services for Registered Inpatients
- Using the IVR to Avoid Eligibility and Entitlement-Related Claim Rejections and RTPs
- Allergen Immunotherapy Preparation (95144-95165)
- Ambulatory Surgical Center Approved HCPCS Codes and Payment Rates
- Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)
- Billing for Services Not Included in the FQHC Benefit
- Attention all OPPS Providers: Provider-Based Department Edits Being Implemented on/after 8/1/2023
- Billing for Drug Wastage: JW and JZ Modifier
- Billing Medicare for a Denial - Condition Code 21
- URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
- Billing Medicare Part A When Veteran’s Administration Eligible Medicare Beneficiaries Receive Services in Non-VA Facilities
- Condition Code G0 Reminder
- CPT Code 15830: Excision, Excess Skin and Subcutaneous Tissue; Abdomen, Infraumbilical Panniculectomy
- Medicare Part B Electronic Claims that Exceed the Threshold for Charges and Units of Service
- ESRD Facilities: Clarification for Providing Dialysis Services to Patients Acute Kidney Injury
- Federally Qualified Health Centers Behavioral Health Claims Job Aid
- Federally Qualified Health Centers Contracting with Medicare Advantage Plans
- Fee-For-Time Compensation Arrangement and Reciprocal Billing Job Aid
- Answers to Common Fee-for-Time Compensation Arrangements Questions
- FQHC and Group Therapy Services Job Aid
- Hospital Acquired Conditions and Present on Admission Resource for Acute Care Hospital Facilities
- Long-Term Care Hospitals: How to Request Adjustments of Claims Paid at the Site Neutral Rate
- Inhalation Treatment CPT 94640 – Billing Errors
- Immunization Roster Billing
- JK: Medicare Paid Hospital Providers Twice for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient IPPS Hospital Stays
- Nonphysician Practitioners Billing for Surgical Procedures
- Professional Services During a Patient Hospice Election
- Professional Services During a Patient Hospice Election
- Proper Billing for Finger and Toe Procedures
- Proper Submission of Fee-For-Time Compensation Arrangements and Reciprocal Billing Arrangements
- Proper Use of Taxonomy Codes
- A/B Rebilling Facts
- Common Reciprocal Billing Questions and Answers
- Reminder for Avoiding Claim Denials for Positron Emission Tomography Scans
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
- Repetitive Outpatient Services for Providers Submitting Institutional Outpatient Claims
- Reporting Multiple Qualifying Visits on the Same Date of Service for FQHC Reimbursement
- Unlisted and Not Otherwise Classified Procedure Codes
- What All Facilities Need to Know About the Long-Term Care Hospital Three-Day or Less Interrupted Stay Policy
- Fiscal Year/Calendar Year Claim Split
- Hospitals Must Correctly Assign Severe Malnutrition Diagnosis Codes to Inpatient Claims
Attention All OPPS Providers: Provider-Based Department
Table of Contents
Edits Being Implemented on/after 8/1/2023
FISS reason codes 34977, 34978, 34984, 34985, 34986, 34987 apply to claims submitted by OPPS providers with multiple service locations and will be permanently activated to edit your claims on/after 8/1/2023 according to the following implementation schedule:
Date | Jurisdiction | Region |
---|---|---|
8/1/2023 | J6 | California and Wisconsin |
8/1/2023 | JK | Maine |
8/15/2023 | J6 | Minnesota |
8/15/2023 | JK | Massachusetts |
8/29/2023 | J6 | Illinois |
8/29/2023 | JK | New Hampshire and Vermont |
9/12/2023 | JK | New York, Connecticut and Rhode Island |
Note: Claims received prior to the implementation date for your region, per the above schedule, will not edit for these reason codes.
The CMS created these FISS reason codes to allow Medicare systems to validate all off-campus, OP, PBD addresses reported on claims against the service facility (practice location) addresses in the PECOS that were reported by providers on their CMS-855A Medicare enrollment applications. The service facility address reported on the claims must exactly match the service facility address on file in PECOS.
Medicare requires OPPS providers with off-campus, OP PBDs providers to report the exact service/practice facility location on all claims submitted to your Medicare Part A MAC in the following 1450/UN-04 claim location:
- 837 institutional electronic claim submitters:
- Report the service facility address in 2310E loop of the 837I institutional claim transaction
- FISS DDE submitters:
- Report the service facility address in MAP171F, which is accessed from claim page 3 then press the PF11 key twice.
- Paper UB-04 submitters:
- Report the service facility address in Form Locator (FL) “01” on the paper claim form.
- Note that Part A facility paper claim submissions should be rare and require an approved ASCA waiver to be on file with your MAC.
Medicare systems will validate the service facility location entered on the claim to ensure that services were provided in a Medicare-enrolled location. The validation requires an exact match between the service facility address on the claim and in the PECOS.
FISS DDE users can use the Provider Practice Address Query which is based on the information in PECOS. For additional information on the Provider Practice Address Query refer to the National Government Services' FISS DDE Provider Online Guide, Chapter 4 - Inquiries Submenu (01), Provider Practice Address Query (1D).
The following reason codes are set to return the claim to the provider (RTP) for correction of the identified issue:
Reason Code 34977: Practice address issue
Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim does not match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS.
To correct:
- Please verify billing and, if appropriate, correct by updating the practice address on the claim to exactly match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS.
- Online Providers: Press PF9 to store the claim.
- Other Providers: Return to the MAC.
Reason Code 34978: PO and/or PN modifier missing
Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim matches an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS.
One (1) or more line items are present which do not contain an ER, PO, or PN Modifier (excluding the 0001 Revenue Line).
To correct:
- Please verify billing and, if appropriate correct by updating the correct modifier(s) to the applicable claim lines.
- Online Providers: Press PF9 to store the claim.
- Other Providers: Return to the MAC.
Reason Code 34984: ER modifier missing
Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS. However, the ER modifier is not present on the claim.
To correct:
- Please verify billing and, if appropriate correct by updating the ER modifier to the applicable claim line(s).
- Online Providers: Press PF9 to store the claim.
- Other Providers: Return to the MAC.
Reason Code 34985: PO modifier missing
Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS.
However, the PO modifier is not present on the claim.
To correct:
- Please verify billing and, if appropriate correct by updating the PO modifier to the applicable claim line(s).
- Online Providers: Press PF9 to store the claim.
- Other Providers: Return to the MAC.
Reason Code 34986: PN modifier missing
Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS. However, the PN modifier is not present on the claim.
To correct:
- Please verify billing and, if appropriate correct by updating the PN modifier to the applicable claim line(s).
- Online Providers: Press PF9 to store the claim.
- Other Providers: Return to the MAC.
Inpatient Claim Reason Code 34987: Condition Code A7
Condition code A7 is present on the claim but there is no mobile facility or portable unit found that matches any entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS.
Note: Condition code A7 is used to identify claims with hospital services provided in a mobile facility or with portable units.
To correct:
- Please verify billing and, if appropriate correct
- Online Providers: Press PF9 to store the claim.
- Other Providers: Return to the MAC.
Reminders
PBD modifiers used on 13X and 14X claims
- PO modifier:
- Services, procedures and/or surgeries provided in an excepted off-campus provider-based outpatient department: applies to a grandfather/excepted PBD and is paid under OPPS – grandfathered means that the facility became PD before 11/02/2015
- PN modifier:
- Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital; applies to a non-grandfathered/non-excepted PBD and triggers payment under the Medicare Physician Fee Schedule for DOS on/after 1/1/2017 – non-grandfathered means that the off-campus practice location has an effective date on or after 11/2/2015.
- ER Modifier:
- Items and services furnished by a provider-based off-campus emergency department. The ER modifier is required to be reported in provider-based off-campus emergency departments that meet the definition of a “dedicated emergency department” as defined in 42 CFR 489.24 under the Emergency Medical Treatment and Labor Act (EMTALA) regulations. Refer to CMS MLN Matters® articles MM11099 and MM11470 for additional information.
Related Content
- Note: SE19007 was updated on 7/11/2023 to announce permanent reason code implementation.
- NGS article “[UPDATE] Billing Reminders for OPPS Providers with Multiple Service Locations”
- CMS IOM Publication 100-04, Medicare Claims Processing Manual
- Chapter 1, Section 170 - Payment Bases for Institutional Claims
- Chapter 1, Section 170.1 - Services Paid on the Medicare Physician Fee Schedule (MPFS)
- Chapter 1, Section 170.1.1 - Payments on the MPFS for Providers With Multiple Service Locations
- Chapter 4, Section 20.6 - Use of Modifiers
- Chapter 4, Section 160 - Clinic and Emergency Visits
- Change Request 9930: January 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- MLN Matters® Articles:
- MM9097 April 2015 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- MM11063 Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
- MM11099 January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- MM11216 April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- MM11470 Updating FISS Editing for Practice Locations to Bypass Mobile Facility and/or Portable Units and Services Rendered in the Patient's Home
- MM13031 Hospital Outpatient Prospective Payment System: January 2023 Update
- Background information on Provider-based status:
- Change Request 2411, Transmittal A-03-030, Provider-based Status On or After October 1, 2002
- CMS IOM 100-07, State Operations Manual, Chapter 2, Section 2004, Provider-Based Determinations
- 42 CFR Ch. IV, Section 413.65, Requirements for a determination that a facility or an organization has provider-based status
- Public Law 114–74—NOV. 2, 2015: Bipartisan Budget Act of 2015, Section 603, Treatment of Off-campus Outpatient Departments of a Provider
Posted 7/25/2023