How to Avoid and Correct Duplicate Claim Denials
A duplicate claim submission occurs when a physician or other qualified healthcare professional resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same provider to the:
- same beneficiary; for the
- same item(s) or service(s); for the
- same date(s) of service.
To help you avoid submitting duplicate claims, please adhere to the CMS payment floor standards:
- Paper Claims - 29 days
- Electronic Claims - 14 days
If the payment floor standard time has elapsed and you have not received a response to your original claim submission, please use one of our self-service features (Interactive Voice Response [IVR] or NGSConnex) to determine the status of your claim.
Note: It is inappropriate to rebill another claim without knowing the status of your original claim.
A Remittance Advice will indicate Group Code OA and Reason Code 18 (exact duplicate claim/service).
Remark code examples you may see with OA18:
| *Remark Code | Description |
|---|---|
| N20 | Service not payable with other service rendered on the same date. |
| N347 | Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer. |
| M86 | Service denied because payment already made for same/similar procedure within set time frame. |
*Not an all-inclusive listing
How to Avoid Duplicate Denials when Billing for Multiple Services on the Same Day:
To avoid a duplicate denial, it may be necessary to add an appropriate modifier to the subsequent services.
| Modifier | Appropriate Use | Inappropriate Use |
|---|---|---|
| 59 | Different session, patient encounter, different procedure or surgery, different anatomical site, separate injury or area of injury. Medical record documentation indicates two separate distinct procedures performed on the same day by the same physician. Used with the secondary/lesser procedure on the NCCI table Only when there is no other more appropriate modifier to use. |
Code combination does not appear on the NCCI tables. NCCI lists the procedure code with a modifier indicator of “0.” Not appropriate on E/M services. |
| 76 | Repeat procedure or service by the same physician. (Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.) Use on procedure codes which the quantity or number of units cannot be billed. Bill each service on a separate line on the same claim, using a quantity of one and append modifier 76 to the subsequent procedures. Indicate the total number of services performed in Item 19 of the CMS-1500 claim form or the electronic narrative record. |
Do not add to each line of service. Do not use for repeat services due to equipment or other technical failure. Do not use for services repeated for quality control purposes. Do not use with “add-on” codes. Do not use on E/M codes. |
| 77 | Repeat procedure or service by a different physician. Add to the professional component of an X-ray or EKG procedure when a different physician repeated the reading as the physician performing the initial interpretation believes another physician’s expertise is needed. Add to the professional component of an X-ray or EKG procedure when the patient has two or more tests, and more than one physician provides the interpretation and report. Add when billing for multiple services on a single day and the service cannot be quantity billed. Bill each service on a separate line on the same claim, using a quantity of one and append modifier 77 to the subsequent procedures performed by a different physician. Indicate the total number of services performed in Item 19 of the CMS-1500 claim form or the electronic narrative record. |
Do not add to each line of service. Do not use for repeat services due to equipment or other technical failure. Do not use for services repeated for quality control purposes. Do not use with “add-on” codes. Do not use on E/M codes. |
| 91 | Use to indicate a repeat laboratory procedure/service on the same day to obtain subsequent reportable test values. Use to indicate that a laboratory procedure/service was distinct or separate from another laboratory service. Use to indicate that a repeat clinical diagnostic laboratory test was distinct or separate from another lab panel or other lab services performed on the same day and was performed to obtain subsequent reportable test values. |
Do not use for testing problems for the specimen or testing problems of the equipment. Rerun laboratory test to confirm results. When the procedure code describes a series of a test. |
| Anatomical Modifiers FA, F1–F9 TA, T1–T9 E1–E4 LT/RT LC, LD, LM, RC, RI |
Use when the services are performed unilaterally. Sometimes an anatomical modifier maybe the most appropriate modifier to use. |
Do not use for services with a bilateral indicator of 1. (These services should be indicated with a 50 modifier.) |
| XE, XS, XP, XU | Used to provide greater reporting specificity in circumstances where modifier 59 was used: XE: Separate Encounter XS: Separate Structure XP: Separate Practitioner XU: Unusual Non-Overlapping Service |
Medical record documentation does not support the separate and distinct status. NCCI lists the procedure code with a modifier indicator of “0”. Exact same procedure code was performed twice on the same day, see modifier 76 or 77. A more appropriate modifier exists to identify the services. Do not use on E/M codes. |
Reopening versus Redeterminations
A reopening or a redetermination should be submitted for any corrections on a service after the initial claim has been submitted and processed for payment or denial. These services should NOT be refiled as a new claim.
| Reopening (Clerical Error) | Redetermination |
|---|---|
| To correct a claim(s) determination resulting from minor errors, you should use the reopening process. | For partially paid or denied claim(s) resulting from more complex issues that require analysis of documentation. |
| Mathematical or computational mistakes. | Coverage of furnished items and services. |
| Transposed procedure or diagnostic codes. | Medical necessity claim denials. |
| Inaccurate date entry. | Determination of limitation of liability provision. |
| Computer errors. | Overpayment determinations. |
| Incorrect data items. | N/A |
View full detailed information on our website at Reopening versus Redetermination
Note: The only time it is appropriate to submit another claim for consideration is when a code was missing from the initial submission or if information was missing from the claim and you have received a rejection.
| Methods of Rejections | Action |
|---|---|
| Paper Claims | Screened and mailed back with a form letter indicating what is missing. |
| Electronic Claims | Will fail the edit and by returned means of the acceptance report. |
| Remittance Advice | MOA code MA130 and additional remark codes will identify what must be corrected. |
Consequences of Submitting Duplicate Claims
- May delay payment
- Increases administrative costs to the Medicare Program
- Could be identified as an abusive biller; or
- May result in an investigation for fraud if a pattern of duplicate billing is identified
Related Content
- Medicare Learning Network® Fact Sheet: Proper Use of Modifiers 59, XE, XP, XS, and XU
- Repeat Procedures - Modifiers 76 and 77
- MLN® Booklet: How to Use the Medicare National Correct Coding Initiative (NCCI) Tools
- Part B Provider Interactive Voice Response User Guide
- Part B Interactive Voice Response Touch-Tone Instructions
- NGSConnex Resources
- Reopening versus Redetermination
- External Code Lists | X12
- CMS IOM Publication 100-04 Medicare Claims Processing Manual, Chapter 1, Section 80
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1
- Claims and Appeals - NGSMEDICARE
- NGS’ Provider Outreach and Education Staff hosts the How to Avoid Duplicate Claims webinar monthly. Visit our Events page and register for an upcoming session.
Revised 9/16/2024