General

1. Is it appropriate to appeal a claim that rejects due to an overlap with a Home-Health Agency claim?
2. Is it appropriate to appeal a claim that rejects due to an overlap with a Hospice claim?
3. Are reason codes W7020, W7027, W7047, W7039, and W7040 appealable?
4. My claim was not paid because I submitted the line items as non-covered in error. Do I need to appeal this claim so Medicare will consider payment?
5. Our inpatient SNF claim was denied so we submitted an appeal. Based on our appeal, the denial was overturned. Our claim has not been reprocessed yet and when I called the Customer Contact Center, I was advised that we never completed and returned the Letter of Assurance. How can I obtain a copy of the Letter of Assurance?

1. Is it appropriate to appeal a claim that rejects due to an overlap with a Home-Health Agency claim?

   No, services rendered during a Home-Health episode must be billed to the Home-Health Agency provider.

   (Question based on October 2008 top written inquiries)

   Date Posted: 11/19/2008, Date Reviewed/Revised: 12/16/2008

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2. Is it appropriate to appeal a claim that rejects due to an overlap with a Hospice claim?

   No, services rendered during a hospice election period must be billed to the hospice provider. However, if the claim is not related to the terminal illness which resulted in the hospice enrollment, you should bill your claim with condition code 07 indicating the services are not related.

   (Question based on October 2008 top written inquiries)

   Date Posted: 11/19/2008, Date Reviewed/Revised: 12/16/2008

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3. Are reason codes W7020, W7027, W7047, W7039, and W7040 appealable?

   No, these reason codes are not appealable.  Please see below for the explanation of the reason code(s) and how each should be handled:

   W7020- Code 2 of a pair not allowed even if the appropriate modifier is present. This is a National Correct Coding Initiative (NCCI) edit that is not appealable.

   W7027, W7047- Incidental services reported only/Services not separately payable. This is a National Correct Coding Initiative (NCCI) edit that is not appealable.

   W7039- Mutually exclusive procedure that would be allowed if the appropriate modifier were present. Adjust the claim with the appropriate modifier.

   W7040- Code 2 of a pair that would be allowed by NCCI if the appropriate modifier were present. Adjust the claim with the appropriate modifier.

   (Question based on October 2008 top written inquiries)

   Date Posted: 11/19/2008, Date Reviewed/Revised: 12/16/2008

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4. My claim was not paid because I submitted the line items as non-covered in error. Do I need to appeal this claim so Medicare will consider payment?

   No, if you submitted your charge as non-covered in error, you can do an adjustment to the claim.  You will need to delete the non-covered line and rekey as covered.  Appeals should only be requested on medically denied charges.

   (Question based on September 2008 top written inquiries)

   Date Posted: 10/28/2008, Date Reviewed/Revised: 12/16/2008

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5. Our inpatient SNF claim was denied so we submitted an appeal. Based on our appeal, the denial was overturned. Our claim has not been reprocessed yet and when I called the Customer Contact Center, I was advised that we never completed and returned the Letter of Assurance. How can I obtain a copy of the Letter of Assurance?

   If your facility did not complete and return the Letter of Assurance, you may call the Customer Contact Center at 1-877-235-8048 to request a duplicate copy be sent to you. 

   (Question based on September 2008 top telephone inquiries)

   Date Posted: 10/28/2008, Date Reviewed/Revised: 12/16/2008

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