Interpret ECLIPSE Claims

Interpret ECLIPSE Claims

TIme to decode Medicare error code 500 and 159: This example uses screen shots from the Genie Practice Management Software, but the interpretation can be applied to any ECLIPSE transaction.

It can be difficult to know which particular item is causing a multi-item ECLIPSE Claim to fail. But here is one common thing you can look for – the Medicare Codes:

Medicare codes can be confusing, so let’s look at two very common ones – Error 500 and Error 159.

Here is a great example: This claim has three rejected items. How can we work out which one is the problem?

Genie ECLIPSE Processing Report

Look at the rejection message against each item. There we see:

1. ITEM 30490: This item was “rejected in association with another item”. This typically means that this item was rejected because another item in the claim has a problem, and therefore all items were rejected. Medicare will reject all items rather than guess at which might be correct. This error code usually suggests that this is not the problem item but merely rejected as a consequence of the real issue.

Genie ECLIPSE service-level messages

2.  ITEM 32093: This next item error is the Medicare code 159 – “Item associated with other service on which benefit payable”. This typically means that this item is in conflict with another item on the claim. When we see this error, it it time to go looking for another item which may not be billed with this one.

3. ITEM 32084: The third item has the same error code as the previous one – Error 159. This would indicate that this item and the one above are likely to be the culprits causing the rejection.

Genie ECLIPSE service-level messages

So we have narrowed the cause down to two possible items. We can check MBSOnline to investigate further. By searching MBSOnline for item 32093 we can immediately see that it is related to item 32084. Being related generally means they cannot be billed together, unless they were two entirely separate procedures, performed at different times on the same day:

MBS item 32093

As it is important not to guess with your billing, the next step is to go back to the provider, the quote or, even better, the official Operation Report, for confirmation of the correct service performed. Resubmit the correct items and credit any remaining items that were billed in error.

If in doubt – ask for help. Sometimes a little training can go a long way!

Bulk Billing Claims trick

Bulk Billing Claims trick

Here is a great little trick for your bulk billing claims in Genie. Please note that this is only for FULLY REJECTED claims.

When a claim has been fully rejected, when retrieving your reports it causes a popup that says the Payment report is not available. You end up with claims that look something like this:

Part of correcting these claims typically involves removing items from the batch and deleting the exception resulting in an empty claim, or deleting the claim altogether. This is not very useful should you need to make investigations down the track. But, since I really don’t encourage you to delete anything in Genie, you do have another option that will keep the exceptions report intact, and still deal with your claim appropriately.

Whether you intend to write off the rejected items with a credit or correct and resubmit, you will remove the item/s from the claim. When you do this, my suggestion is to NOT to delete the exception when prompted. Instead, once all the items have been removed double-click the empty claim, and tick it as finalised.

This moves it to the finalised status where the empty claim will still have full access to the Exceptions Report and the Processing and Transmission Text. This is very useful if you ever need to look back historically to see why an item was rejected.

Very nice and tidy, with all the reports preserved. Give it a try!

Cracking the Medicare Error code 432

Cracking the Medicare Error code 432

Eureka! Thanks to the lovely ladies at Medicare and Medibank Private I have finally worked out the meaning of that elusive Error “432 – Not multi-op – more information required to pay benefit”.

If you are like me and many of my sites, occasionally you get a Medicare claim error either in the bulk billing or via ECLIPSE that you just can’t work out how to resolve. I have had some people say you need to send a report, and others just write it off. But it has all been guesswork…until today. Several people in Medicare claims had never even heard of the error and that never inspires confidence.

So what is the problem? When you see the 432 “not multi-op” error it means that for some reason the services for the procedure have been split and potentially paid separately. This might occur because a diagnostic item has been billed separately to its procedural items, or it might occur because one procedure item was claimed and then a second claim has been sent containing an item that should have been the first (100%) item on the account under the Multiple Item Rule. It might also arise because the health fund has, for some reason, split the items when they sent them to Medicare for approval. To put it another way, it means that Medicare have already paid an item that would have been paid at a lower rate (per the multiple item rule) had they received all the items together, so they can’t just pay on the extra item/s without adjusting the already paid item.

And the solution? The new item/s either need to be

Differentiated as having occurred separately. i.e. If the service/s were performed as two unique procedures, then they need to be differentiated by TIME in the item service text and by using the “not multiple procedure” Medicare override.  In this case, the items will be paid as a separate procedure.


Reconciled as having occurred together. i.e. Medicare need to know that the items were performed together and Medicare will need to perform an adjustment of the already paid item. This is done using a single form – the Medicare HW023 form for Simplified Billing or ECLIPSE
adjustment or the Medicare DB018 form for a correction to a bulk billed claim. Complete the form with as much detail as possible, attach the correct invoice with ALL the items performed, and send it to Medicare for processing. They will either make a top up payment or request reimbursement. Make sure you specify clearly and exactly what you want them to do, otherwise they will send the form back for correction. And if in doubt, call Medicare for advice.

How can you avoid this error arising?

Ensure you have ALL the services to bill before you start, and put everything on the one invoice/claim. Simples! 🙂

I love learning new things. Have a great day – I am off to reconcile some more billing…

Medicare Referral Validity: A summary for practice staff

Medicare Referral Validity: A summary for practice staff

Do you know how long an indefinite referral lasts? Do you know the rules about if and when you can bill another initial consult item on a new referral? Practice staff are encouraged to learn the Medicare rules regarding Referrals. Responsibility for the accuracy of medical billing ultimately lies with the servicing provider, however a savvy receptionist can be instrumental in identifying potential billing errors before they even occur, simply by knowing the rules and gently advising the practice manager or the doctor if you believe there is reason to bill differently.

Here are the basic essentials:

  • GP referrals last 12 months (unless clearly marked as “indefinite”) from the date of the first appointment using the new referral. An Indefinite referral can often fail via electronic transmission if it is greater than five years old.
  • Specialist referrals last 3 months from the date of the first appointment using the new referral.
  • A new consultation item can only be billed with a new referral if the patient has not been seen for the same condition within the last nine months.
  • Referrals must be signed and dated BEFORE the appointment date, and cannot be back-dated.
  • No referral = no medicare payment

This information is just a general summary. To get everything you need to know for your practice, read these articles:

  1. Medicare Referrals and Requests
  2. Referrals, initial consultations and Medicare compliance by Michael Wade, Avant Special Counsel – Medicare

Be the billing watchdog for your practice –  reduce lost income for the practice, and improve your Medicare compliance.

Here is another great article on Referrals –

Medicare Audits – The rules for initial consultations

Medicare Audits – The rules for initial consultations

Are you one of the many medical practices that have received an audit request from Medicare? You aren’t alone. Medicare has ramped up its review processes because of the many mistakes made with medical billing in both general and specialist practice.

Today I want to talk about the INITIAL CONSULT. These are typically items 104 for specialists and 110/132 for consultant physicians. The initial items in the MBS contain similar key words, Here is the 104 MBS Item description with two key phrases highlighted in red:

“Professional attendance at consulting rooms or hospital by a specialist in the practice of his or her specialty after referral of the patient to him or her—each attendance, other than a second or subsequent attendance, in a single course of treatment, other than a service to which item 106, 109 or 16401 applies”

‘Referral’ means that this service can only be supplied with the presentation of a valid referral.

A ‘single course of treatment’  is an initial attendance plus any subsequent attendances for the continuing management of the condition until the patient is referred back to the referring practitioner. That means that a new referral for the same condition does not mean you can automatically bill another initial consult item.

Another initial attendance item can be billed only if the referring doctor decides the patient’s condition needs to be reviewed and provides a new referral, and the last referral has expired, and the patient was last seen by the specialist or consultant physician more than 9 months earlier for that condition. That is a lot of ‘ands’. But, in short, it means that you cannot bill another initial consult item within 9 months of a previous visit unless the referral is for a different condition altogether.

Take a note of that: Even with a new referral, you cannot claim for another initial attendance if it has been less than 9 months since you last saw them for that same condition.

If you have received an urgent action request from Medicare to justify the 110, 132 or 104 items billed within 9 months of each other, you will need to show that they were for different conditions. If you cannot, then they need to be corrected to subsequent consult items and the monies repaid to Medicare.

If you need assistance with Medicare Audit reviews, or if you would like to get your staff billing compliantly before an audit request hits you, get in touch. We can help with review, corrective action, and training.