Exact duplicate claim/service
(DUPLICATE CHARGE PAID ?002XX ON CLAIM ?001XXXXXXXXX)
(DUPLICATE CHARGE OF CLAIM ?001XXXXXXXXX NOW BEING PROCESSED)
(THIS IS A DUPLICATE OF A CHARGE WE HAVE PROCESSED)
(MORE THAN 1 E/M SERVICE BILLED ON THE SAME DAY)
Resources/tips for avoiding this denial
Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.
• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.
• Click here to review article on new claim system edits regarding duplicate claims.
• Ensure necessary appropriate modifiers are appended to claim lines.
• Refer to the Modifier FAQs here on the First Coast Medicare provider website for additional information.
Preventing duplicate claim denials
Effective July 1, 2013, new claim system edits may result in additional duplicate claim denials to your practice. Please share this information with your billing companies, vendors and clearing houses. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare contractors to enhance claim system edits to include same claim details in its history review of duplicate procedures and/or services. The edits will search within paid, finalized, pending and same claim details in history. This means that unless applicable modifiers are included in your claim, the edits will detect duplicate and repeat services within the same claim and/or based on a claim previously submitted.
To minimize a potential increase in duplicate claim denials, please review your billing software and procedures to ensure that you are billing correctly. Some services on a claim may appear to be duplicates when, in fact, they are not. Please ensure appropriate use of modifiers to identify procedures and services that are not duplicates. A complete list of modifiers can be found in the Current Procedural Terminology (CPT®) codebook. The following are a few examples of modifiers that may be used, as applicable, to identify repeat or distinct procedures and services on a claim:
• Modifier 76 may be used to indicate a repeat procedure or service by the same provider, subsequent to the original procedure or service.
• Modifier 91 may be used to indicate repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.
• Modifier 59 may be used, as applicable, to identify procedures or services that are normally reported together but are appropriate to be billed separately under certain circumstances. Modifier 59 indicates a procedure or service by the same provider, distinct or independent from other services, performed on the same day.
Denial reason code OA18 FAQ
Q: We are receiving a denial with claim adjustment reason code (CARC) OA18. What steps can we take to avoid this denial code?
Exact duplicate claim/service
A: You will receive this reason code when more than one claim has been submitted for the same item or service(s) provided to the same beneficiary on the same date(s) of service.
• The Medicare claims processing systems contain edits which identify exact duplicate claims and suspect duplicate claims submitted by Physicians and Practitioners. Click here to review article on the claim system edits regarding duplicate claims and modifiers that may be used, as applicable to identify repeat or distinct procedures and services on a claim.
Exact duplicate claims
• Claims or claim lines that exactly match another claim or claim line with respect to the following elements: Medicare ID, provider number, from date of service, through date of service, type of service, procedure code, place of service and billed amount
• Claims or claim lines are denied
• Appeal rights
Suspect duplicate claims
• Claims or claim lines that contain closely aligned elements sufficient to suggest that duplication may be present and, as such, require that the suspect claim be reviewed
• Criteria for identifying vary according to the following: type of billing entity, type of item or service being billed, and other relevant criteria
• Appeal rights (unless an exact duplicate)
Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.
• Ensure necessary appropriate modifiers are appended to claim lines if applicable and resubmit the claim.
• Append the applicable modifier(s) to the procedure code even if the diagnosis indicates the exact site of the procedure. For example: diagnosis code M1711 is a unilateral primary osteoarthritis, right knee or diagnosis code M1712 is a unilateral primary osteoarthritis, left knee. In this example, it would be appropriate to append modifier RT (right side) or LT (left side) to the procedure code(s) along with the related diagnosis code(s).
• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.
• Do not refile a claim if the total approved amount has been applied to the patient’s deductible.
• Free Web-based training (WBT) Duplicate claims — Part B external link
• First Coast also offers free educational sessions throughout the year, focused on particular billing issues you may be experiencing. These may include webcasts or seminars on avoiding duplicate claims for Part B.
• Visit the First Coast Medicare provider Events page to learn about upcoming events and our Webcast recordings page to link to encore presentations of webcasts conducted on this topic.
