Medicare: What is a Duplicate?

Each Medicare claims processing system contains criteria to evaluate all claims received for potential duplication.  The claims can be placed into two categories: exact duplicate or suspect duplicate.  Each category is processed uniquely by the Medicare contractor.

CMS has recently updated the Medicare Claims Processing Manual, Chapter 1, Section 120: “Detection of Duplicate Claims” based on change request (CR) 8121.

An exact duplicate claim is denied or rejected, if missing applicable modifiers, automatically by the claims processing system.

For exact duplicate denials, professional providers do have appeal rights, but institutional and DME providers do not.

If a claim is deemed suspect by the initial system review, the claim is suspended for further review by the Medicare contractor.

If suspect duplicate is denied after review, all providers have right to appeal.

 Due to the nature of the service, some claims may only appear to be duplicates.  Proper coding of the service with the applicable condition codes or modifiers will identify the claim as a separate payable service, not a duplicate.  An example could be modifiers “LT” and “RT” for bilateral procedures.

 By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, duplicate claims submissions are easily prevented.  A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record.  This gives the user the opportunity to determine if the service is a true duplicate or if the service qualifies for an appropriate addition of a modifier.

See the information below for details on the process Medicare utilizes to identify duplicate claims.

Provider of Service	Exact Duplicate	Suspect Duplicate
Institutional	Claim matches identically on the following data: 1. Health insurance claim (HIC) number 2. Type of bill 3. Provider identification number  4. From date of service 5. Through date of service 6. Total charges (on the line or on the bill) 7. HCPCS,  CPT-4, or procedure code/modifiers	Claim matches on the following data: 1. Beneficiary information 2. Provider identification 3. Same date of service or overlapping dates of service
Professional	Claim matches identically on the following data: 1. HIC number 2. Provider number 3. From date of service 4. Through date of service 5. Type of service 6. Procedure code 7. Place of service 8. Billed amount	The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.
DME	Claim matches identically on the following data: 1. HIC number 2. From date of service 3. Through date of service 4. Place of service 22 5. HCPCS 6. Type of service 7. Billed amount 8. Supplier	The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

You can find the official instruction, CR 8121, issued to your FI, carrier, A/B MAC, RHHI, or DME MAC by clicking here.