Billing

Attention All OPPS Providers: Provider-Based Department

Table of Contents

[Return to Top]

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:

[Return to Top]

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.

[Return to Top]

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.

[Return to Top]

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.

[Return to Top]

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.

[Return to Top]

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.

[Return to Top]

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.

[Return to Top]

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.

[Return to Top]

Related Content

Posted 7/25/2023