CWF Duplicate Claim Edit

Effective April 01, 2007, CMS will install systems edits (Common Working File) to prevent improper payments to independent laboratories for the Technical Component (TC) of pathology laboratory services provided to beneficiaries during a covered inpatient hospital stay or provided on the same date of service as an outpatient service. This change applies to claims with dates of service on or after January 01, 2007, where the claim is received on or after April 01, 2007.

Key Points

• Effective for claims received on or after April 01, 2007, Medicare will reject/deny a Part B TC or globally billed pathology service with a service date on or after January 01, 2007, that falls within the admission and discharge dates of a covered hospital inpatient stay when billed by a physician/supplier. Such services will also be rejected/denied when they match with a date of service of a hospital outpatient bill (bill types 13X and 85X0 previously processed by Medicare).
• If providers submit a TC of a pathology service with a service date that falls within the admission and discharge dates of a covered hospital inpatient stay the carrier will use Remittance Advice Reason Code 109 “Claim not covered by this payer/contractor.” when denying a service line item.
• Where Medicare systems detect that a Part B TC or globally billed physician pathology service has been paid and Medicare subsequently receives a hospital inpatient bill for the same date of service, the Medicare carrier will adjust a TC of a physician pathology service line item and recoup the payment made for that service from the physician/supplier. The Medicare carrier will also adjust a TC of a pathology service for an outpatient claim. The same Remittance Advice Reason Code of 109 will be used in such cases.