CMS guidance allows MAOs and other entities, in certain circumstances, to add modifiers to lines within a record to bypass the line-level duplicate check, when each line represents a unique service. Is it acceptable for MAOs and other entities to modify the encounter on the backend for EDPS submission purposes? Or does the billing provider need to rebill with those modifiers?


Answer:

Since the Encounter Data Record (EDR) is a report to CMS from the MAO or other entity, and not a provider bill, the MAO or other entity can report data on the EDR that was not submitted by a provider, per CMS guidance. See Tables 1 and 2 below for CMS’ guidance on how to bypass the line-level duplicate check in the back-end Encounter Data Processing System (EDPS) when the MAO or other entity has determined that the lines represent distinct items or services, but will be identified as duplicates by the CMS line-level duplicate logic. The bypass logic described is not intended to be instructions for how providers should bill the MAO or other entity.

MAOs and other entities are permitted to use the CMS-specified procedure code modifiers so that the duplicate logic is bypassed. Another option for preventing a duplicate line rejection is to include the actual payment amount on each line (assuming the actual payment amount for each line differs).

Table 1. EDPS - Data Elements Used to Identify Duplicate Lines (Edit 98325)
Professional/Durable Medical Equipment Institutional - Outpatient
Beneficiary identifier Beneficiary identifier 
Date of Service Date of Service
Procedure Code and up to 4 modifiers Procedure Code and up to 4 modifiers
Paid Amount (2320 AMT02/2430 SVD02)  Paid Amount (2320 AMT02/2430 SVD02)
Billed Amount  Billed Amount
Place of Service (POS)  Type of Bill (TOB)
Rendering Provider NPI  Billing Provider NPI
   Revenue Code

 

Table 2. EDPS - Data Elements Used in Bypass Logic for Edit 98325
Professional/Durable Medical Equipment Institutional - Outpatient
 59 - Distinct Procedural Service  59 - Distinct Procedural Service
 76 - Repeat Procedure by Same Physician  62 - Two Surgeons
 77 - Repeat Procedure by Another Physician  66 - Surgical Team
 91 - Repeat Clinical Diagnostic Laboratory Test  76 - Repeat Procedure by Same Physician
   77 - Repeat Procedure by Another Physician
   91 - Repeat Clinical Diagnostic Laboratory Test

 

Note:    There is an additional by-pass condition for Ambulatory Surgery Center (ASC) Fee Schedule EDRs: populate the field “Multiple Procedure Discount Indicator” with a value of “1” in order to by-pass the duplicate line edit.

In situations in which none of the data elements included in the Encounter Data System’s (EDS’) duplicate logic check are changing, but other data elements on a line (edit 98325) or record (edit 98300) may have changed, CMS recommends that the subsequent encounter data record be submitted as a replacement or that the previously submitted and accepted encounter data record be voided and a new original record resubmitted in order to prevent rejection for duplicate submission.

Source: CMS HPMS Memo with subject “Guidance for Encounter Data Submission” (October 30, 2017)
Last Updated: 10/30/2017