Remark code M28 indicates that the service or item billed does not qualify for payment under Medicare Part B because either Medicare Part A coverage has been exhausted or is not available for the beneficiary. Providers should review the patient's current Medicare coverage status to determine the appropriate billing pathway.
Common causes of code M28 are:
1. Services billed were covered under the inpatient hospital benefit of Medicare Part A, but the patient's Part A benefits have been exhausted.
2. The patient is enrolled in Medicare Part A, but the specific services billed are not covered because they are not deemed medically necessary under Part A.
3. There may have been an error in billing where services that should have been billed under Part A were incorrectly billed under Part B.
4. The patient may not have had Part A coverage at the time the services were provided, and the provider mistakenly billed under Part B.
5. The services were provided during an inpatient stay, and the provider failed to bill Medicare Part A before attempting to bill Part B.
6. The claim was submitted for a patient in a skilled nursing facility (SNF) under a consolidated billing arrangement, which requires certain services to be billed through Part A.
7. The provider did not properly coordinate benefits when the patient has both Medicare and another type of insurance, leading to a billing error.
8. The claim lacks the necessary documentation to support the transition from Part A to Part B billing, such as a notice that Part A benefits have been exhausted.
Ways to mitigate code M28 include ensuring that claims are submitted with accurate patient eligibility information. Before filing a claim, verify the patient's coverage to determine if Part A benefits have been exhausted and if Part B is applicable. Additionally, maintain clear communication with the patient about their coverage limits and benefits to prevent services from being rendered that are not covered under their current plan. It's also crucial to stay updated on the latest Medicare guidelines to understand the conditions under which Part B can be billed when Part A is exhausted. Implementing a robust pre-authorization process can help identify coverage issues before services are provided, reducing the likelihood of receiving an M28 denial.
The steps to address code M28 involve verifying the patient's eligibility and benefits for Medicare Part A and Part B. First, review the patient's admission and discharge dates to ensure that Part A coverage should have been available during the service period. If Part A was indeed exhausted or unavailable, confirm that the services billed are covered under Part B. If they are, update the billing information to reflect Part B coverage and resubmit the claim. If the services are not covered under Part B, or if there is another issue with Part A coverage, contact the patient or their representative to discuss alternative payment options or the need for additional documentation to support the claim. Ensure that all communication and actions taken are documented in the patient's account for future reference.