Latter day adjustment pathology services in Medicare 012-40020050

Place the cursor on the requesting practitioner's provider number and press [F1], to determine requesting practitioner is a general practitioner (GP).

The provider's class/speciality is displayed under the provider details. When the practitioner is not a specialist, consultant physician or dentist, the coning rule applies.

See also:

6 RST ADJ sample screen

C01 104 Medicare practitioner - medical category sample screen.

Check claims history to determine what has previously been claimed for the patient episode.

Note: when the message 8-OTH HIST displays on the history screen use the patient history modifiers with the patient's PIN.

The following modifiers may be used:

• PATH/ITEM - displays all the patient's pathology history including the incentive item
• PDOR/ddmmyy - displays all pathology test items and patient episode initiation (PEI) information for a specific request date, but does not display the bulk bill incentive information as a request date does not apply to a bulk bill incentive item
• DOS/ddmmyy - displays the bulk bill incentive item if it has already been paid

The appropriate patient history is displayed for each modifier. See also: Patient history sample screen.

Then:

• print the claims history screen, or
• copy and paste it electronically (using text font Lucinda Console size 8), or
• keep it on the swap screen to refer to

When coning has been applied to the claims in history:

• record the actual schedule fee for each item that has been paid
• cross out the restrictive item
• identify:
• any items that are exempt from coning (highlighted on screen sample).
• the 3 items with the highest schedule fee (highlighted and in bold on screen sample). See also: PI58 LDA adjustments for pathology sample screen.

• replace the relevant item on history with the restrictive payable item in the claim
• add the schedule fees for the 3 items with the highest schedule fee and the coning exempt item together

Example 1

Item Schedule Fee Highest schedule fee claim or history

65159 $70.90 2^nd highest history

73053 $19.45 coning exempt history

66638 $49.05 3^rd highest history

69360 $92.20 1^st highest history

Total $231.60

Example 2

Add the schedule fees together for the items paid on history

Item Schedule Fee

65159 $70.90

65090 $11.15

66638 $49.05

66602 $42.95

73053 $19.45

Total $193.50

See also: Restrictive payment item sample screen.

Example 3

Deduct the total from example 2 from the total in example 1 to calculate the amount to be adjusted.

$231.60 - 193.50 = $38.10

Follow the instructions in the return messages.

To pay the restrictive item on the screen:

• key PI 58
• over key the schedule fee in the Fee field with the amount calculated for the adjustment
• press [Enter] and pay the adjustment

See also: Return message instructions sample screen.

The adjusted claim is displayed on the patient's history.

Print the current claims processing screen as it contains the claim information required for the LDA in the history part of the screen. See also: Processing claim screen for claim ID screen sample.

Check claims history to determine what has previously been claimed for the patient episode.

Note: when the message 8-OTH HIST displays on the history screen, use the patient history modifiers with the patient's PIN.

The following modifiers may be used to check patient history:

• PATH/ITEM - displays all pathology items including any incentive items
• PDOR/ddmmyy - displays all pathology test items and patient episode initiation (PEI) information for specific date of request, but does not display the bulk bill incentive item
• DOS/ddmmyy - displays all items for a specific date of service including any incentive items

Note: as the incentive is associated to the PEI, once the date of service for the PEI is found, use the DOS/ddmmyy modifier to determine the incentive item has previously been paid.

When a PEI and bulk bill incentive item has:

• Previously been paid for the patient episode reject the:
• PEI with RSN 160
• bulk bill incentive item with RSN 550
• pathology tests with RSN 151
• Note: there is no need to bring the rejected PEI and incentive into adjustment.
• Not been previously paid, reject the pathology item with RSN 151. See also: No errors ok to pay sample screen.

For:

• online claims, see table:
• Online bulk bill claims non-coned patient episodes for bulk bill LDA
• Online bulk bill claims for coned patient episodes for bulk bill LDA
• manual claims, see table:
• Manual bulk bill claims non-coned patient episodes for bulk bill LDA

Park the claim on the screen using MQAI/MQRI.

MQAI CLM PARKED message appears.

• key DCEI,payee provider number,claim id to recall claim

The original claim information is returned.

For example, DHSI,1234567A,A0001,DOL=010101

• over key the control line with DHSI,provider number,claim id, DOL =ddmmyy
• press [Enter]

The adjustment screen displays the DOL change to the next day.

Example: DHSC,123457A,A0001,DOL=020101

• open the adjustment claim
• scroll [F8] through the claim to locate the patient record to be adjusted

The following fields can be brought into a bulk bill adjustment and over keyed:

• card number
• patient name
• item number
• DOS
• BN ASG
• REQ PROV
• over key the incorrect details with correct details and press [Enter]

The system returns the DHSC screen which displays:

• the original line that was adjusted - all fields are protected, except field A which contains 'O' to indicate the 'Original' line
• a restated line with correct details - all fields are unprotected and 'R' is displayed in field A to indicate the 'Restated' line:
• The system inserts 0 in the Fee and Benefit fields.
• Other PIs and all reason codes are not restated (with the exception of RSN 366) which allows the adjusted line to be completely re-assessed.
• Any error messages that relate to the accuracy of new details. See also: DHSC sample screen and Over key C and U to update sample screen.
• Press F3 to close the claim and press [Enter]
• Resolve any error messages that may display, check the correct fields have been adjusted, and correct benefits have been applied
• Over key C with U in DHAC to update adjustment and press [Enter]. See also: Benefit calculation sample screen.
• Key MQAI to return to the online claims queue and recall parked claim
• S in the A field against the appropriate claim to select the claim and complete the payment process
• Key P to Pay the claim

Procedure complete for online claims

Park the claim on the screen using MQAI/MQRI.

MQAI CLM PARKED message appears

• key DCEI,payee provider number,claim id to recall claim

the original claim information is returned.

Example: DHSI,1234567S,A0001,DOL=020101

• over key the control line with DHSA,provider number,claim id, DOL=ddmmyy
• Press [Enter]

The adjustment screen displays the DOL change to the next day.

Example DHSC,1234567A,A0001,DOL=030101

• open the adjustment claim
• scroll [F8] through the claim to locate the patient record to be adjusted

The following fields can be brought into a bulk bill adjustment and over keyed:

• card number
• patient name
• item name
• DOS
• BN ASG
• REQ PROV
• over key the incorrect details with correct details and press [Enter]

The system returns the DHSC screen which displays:

• the original line that was adjusted – all fields are protected, except field A which contains ‘O’ to indicate the ‘Original’ line
• a restated line with correct details- all fields are unprotected and ‘R’ is displayed in field A to indicate the ‘Restated’ line:
• The system inserts 0 in the Fee and Benefit fields.
• Other PIs and all reason codes are not restated (with the exception of RSN 366) which allows the adjusted line to be completely re-assessed.
• Any error messages that relate to the accuracy of new details. See also: DHSC sample screen.

A new line needs to be inserted to include any additional items for online claims:

• over key R with I in field A of any restated line and press [Enter]
• when more than 1 new line is required, over key 'N' with 'I' in field A and press [Enter]

The message INSERT is returned, together with a new line which enables new details to be keyed. 'N' in the field A indicates that this is a new line. See also: Restated line with correct details DHSC sample screen.

Note:

Nine service lines can be displayed on the DHSC screen. When 'I' is entered in field A on the 9th line, the new line is positioned on the next DHSC screen.

For example, item 65120 must be inserted as this item was also part of the patient episode in claim A0024. The date of service 030111 and benefit assigned have also been added. See also: Message insert returned sample screen 6.

To reassesses the new item numbers as part of the patient episode and apply the patient episode coning (PEC) rule correctly, over key payee code with 6 to recall all other associated lines with the adjustment screen for that patient episode.

• Press [F3] to close the claim and press [Enter].
• Resolve any error messages that may display, check the correct fields have been adjusted, and the correct benefits have been applied.
• Over key C with U in DHAC to update adjustment and press [Enter]. See also: Payment to provider final update sample screen 9.

Key:

• MQRI to return to the online claims queue and recall parked claim
• 'S' in field A against the appropriate claim to select the claim and complete the payment process
• 'P' to pay the claim

See also: Online claims sample screen 10.

Procedure complete for online claims.

When a patient episode initiation (PEI) and bulk bill incentive item has:

• previously been paid for the patient episode, reject the:
• PEI with RSN 160
• bulk bill incentive item with RSN 550
• pathology tests with RSN 151
• then photocopy the bulk bill voucher and the claim header
• not been previously paid, reject all items on the pathology voucher with RSN 151. The PEI and incentive items do not pay as the associated pathology items have been rejected.

Forward:

• the photocopy of the bulk bill header and vouchers
• a screenshot of the processing screen
• the reason for the adjustment

to MPS Assessing for adjustment.

Continue to process and pay the claim.