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Hospital Billing 101+UB04 Agenda

HFMA October 25,2007 Understanding the UB04 Clean Claim Process UB04 Presented by Carol D. Eaton Citrus Valley Health Partners. Hospital Billing 101+UB04 Agenda. Registration Charge Description Master(CDM) Coding/Claim Creation HIPAA Electronic Transaction Process UB04 Billing Preparation

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Hospital Billing 101+UB04 Agenda

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  1. HFMAOctober 25,2007Understanding the UB04 Clean Claim ProcessUB04Presented byCarol D. EatonCitrus Valley Health Partners

  2. Hospital Billing 101+UB04Agenda • Registration • Charge Description Master(CDM) • Coding/Claim Creation • HIPAA Electronic Transaction Process • UB04 Billing Preparation • UB04 CMS-1450 Billing Process • Billing Information • Websites • Quality Improvements

  3. Revenue Cycle “Perfect Picture”

  4. Section:Registration Process • Scheduling: Target for improvement. Look at the number of departments and patients that can be scheduled or prescheduled. • Pre-registration & registration: Improve your pre-registration to improve the time needed to create a clean registrations. • Eligibility & Authorization/Certification: Use electronic sources to obtain. Work with your area IPAs to communicate authorizations ahead of time. Assure services match certification / authorization • Collecting Co-payments & deductibles: The more you collect and notify upfront, the better chance you have at collecting at all. Payment arrangements also can be made. Published messages or pre-registration & verification. • Screening for Medical Necessity & Covered Services: Create the best system for obtaining LMRP/NCD information for Medicare patients. ABNs. Work with Utilization Review or Nursing departments to assure appropriate admissions

  5. Section:Registration Process Training must include: • Corporate Compliance: Reporting, accuracy of admit/dischg coding, charity and discount guidelines • Insurance eligibility, certification, authorization, matrix payer information • Medicare: (ABN) Advanced beneficiary notice, (MSP) Medicare Secondary Payer, 3 day window rules, 1 day stay & re-admission rules, Observation requirements, Important Message for Medicare (letter), Condition of Admissions forms • HIPAA:(Health Insurance Portability Accountability Act of 1996, Privacy vs Security. (Electronic/Passwords, verbal info, paper shredding). Never breach patient confidentiality. • EMTALA: Emergency Medical Treatment Labor Act 1986 • Clear “patient friendly billing” communication with patients. Smile and maintain eye contact. Sit & stand tall. Voice tone • Job Description, manuals, departmental tour (timecard, vacation, attendance, dress code, name tag, HIPAA waste disposal, overtime, tardiness, switching, holidays)

  6. Section:Registration Process HEALTH PLAN ADDRESSES(Use for NPI news) Sign up for Passwords and ID#s, make lists available to the staff involved: AETNA www.aetna.com BLUECROSS http://provideraccess.bluecrossca.com BLUE SHIELD www.mylifepath.com CIGNA www.cignaforhcp.com CBCA ADMINISTRATOR www.cbca.com/login.page FIRST HEALTH www.firsthealth.com HEALTHNET www.healthnet.com INTER VALLEY www.ivhp.com MEDPOINT MGMT-HLA www.medpointmanagement.com PHYSICIANS ASSOC www.physicianassoc.com PACIFICARE/SECURE HORIZONS www.pacificare.com UNITED HEALTHCARE www.unitedhealthcareonline.com UNIVERSAL CARE www.universalcare.com

  7. Section:Registration Process

  8. Section:Charge Master Process • Conduct annual charge master reviews • Updates should be quarterly or as often as changes are received • Assure that computer order entry is connected to each charge in the specific departments matches the CDM. • Review charging tickets frequently • Departmental involvement with charge protocols created including CCI edits • Develop departmental daily revenue master logs to review for accuracy and assure quality of systems • Team approach to charge master changes should include accounting, HIM,IS, PFS, specific department management • Periodic review of all coding on claims by third party to check your internal review processing • Review ordering practices and assure documentation is present and accurate to match billing claims • Education to all staff of changes, charge protocols, Federal payer documents as they arrive. • System capture of requests, changes, audits and education • Make sure the claim editor, billing staff or claim vendors are not changing your claim without you know exactly what’s changed!

  9. Section:Charge Master Process Newborn Screening Facilities Department of Health Services program began dated July 11,2005. January 1, 2007 price increased from $18.95 to $20.35. Usually the price changes occur in January & August. July 16,2007 82261 & 83516 added,still the same final $cost Billing will be as follows on your Inpatient claims (Newborn and NICU): • Hydroxyprogestene 17-d(17-OHP) 83498 $14.50 • Tandem mass spectrometry(MS/MS) 83789 $14.75 • Galactose 1 phosphate uridyl transferase 82776 $14.50 • Hemagobin fract &quant; chromatography 83021 $14.50 • Thryoid stimulating hormone (TSH) 84443 $14.50 • Biotinidase (BD) 82261 $14.50 • Immunoreactive Trypsinogen(IRT) 83516 $14.50 • Genetic screening specimen collection DHS 36415 $1.00 • Genetic screening draw/handling DHS 99001 $6. Must equal a total of $102.75+$6.00 blood draw fee www.DHS.CA.gov/GDB ph#510/412-1502

  10. Section:Charge Master Process Revenue Code Assignment Reminder • CMS recommends the use of revenue codes that closely define where the procedures are performed. Revenue codes involved: 036x Surgical,045x Emergency Room, 051x Clinic,075x GI • Surgical Procedures 10021-69990, 0008T, 0016T-0024T, 0027T 0033T-0040T, 0046T-0048T, 0050T-0056T, 0061T-0063T, 0071T, 0075T-0081T, 0084T, 0088T, 0090T-0100T, 0120T-0126T, 0133T, 0138T, 0141T-0143T • Cardiovascular 92950-92961(Resp.& ER can’t both charge for the same encounter) • Photodynamic therapy96567, 96570-96571 • Other services & procedures99170, 99185-99186, G0127 • Critical Care99291-99292 Therapeutic 90782-90799 Device Coding • Effective April 1, 2005 OPPS require providers to code device HCPCS even if many of the are status indicator “N”. • Devices are reported under RC 272,275,276,278,279.

  11. Section:Charge Master Process • Example: Charge Master line item Charge# Description $ CPTHCPCS Rev Code 4540000 Dialysis Unch/ESRD/Emerg $xx.00 90935G0257 820 The coding comes from the Charge Master • Example of charge on a claim Group Ins Claim (CPT coding passes) 820 Dialysis Unch/ESRD/Emerg 070107 90935 $xx.00 Medicare Claim (HCPCS coding passes) 820 Dialysis Unch/ESRD/Emerg 070107 G0257 $xx.00 G0104 Expired code: January 1, 2007 for Occult Blood (use 82270 only) See CR#5292 September 22,2006 R1062CP MM5292

  12. Section: Coding/Claim Creation ICD-9-CM – International Classification of Diseases 9th Revision Clinical Modification Volume 1 – Contains five appendices & Tabular list of codes including V codes (i.e.,426.6 Other heart block): Appendix A: Morphology of Neoplasm's Appendix B: Deleted effective October 1 of each year Appendix C: Classification of Drugs by AMA and their ICD9CM equivalents Appendix D: Classification of Industrial Accidents according to agency (i.e., external causes: E828 Animal,riden) Appendix E: List of Three-Digit categories Volume 2 – Diagnostic terms that are not in volume 1. Index to diseases includes most diagnostic terms in use. Volume 3 – Operations and procedures. 2 digits with one or two digits following the decimal point. (i.e.,01.31 Incision. cerebral meninges) For information on ICD-9-CM and POA information:MM5499 CR5499 http://www.cms.hhs.gov/Transmittals/downloads/R1240CP.pdf http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf ICD-10-CM is scheduled for October 2008

  13. Section: Coding/Claim Creation CPT Level I- AMA’s physicians’ Current Procedural Terminology Often referred to as HCPCS by the federal government payers Evaluation and Management (99201-99499) Anesthesiology (00100-01999, 99100-99140) Surgery (10021-69990) Radiology (including nuc.medicine, radiation onc., diagnostic ultrasound)(70010-79999) Pathology & Laboratory (80048-89356) Medicine (90281-99602) HCPCS Level II-National-Healthcare Common Procedure Coding System. Broad spectrum of services and supplies from patient transport to ostomy supplies, from chemotherapy drugs to durable medical equipment, and new technologies.(i.e.,G0103,J7030,Q3001) Local Codes LevelIII-Specific State codes for Medicaid programs. CPT & HCPCS level II Modifiers -Providescommunication with payers to indicate altered by somespecial circumstance(s) but the code description itself has not changed. **The existence of a procedure code does not imply coverage under any given insurance plan.**

  14. CPT Modifiers 25 27 50 52 59 73 74 76 77 Medicaid: 50,51,80,99,P1,ZG,ZK,ZN HCPCS Level II Modifiers E1-E4 FA F1-F9 LC LD LT RC RT TA T1-T9 Section: Coding/Claim CreationModifier UsageMedicare Claims Processing Manual, Pub. 100-04, chap 4, secs.20.5.3,20.6-20.8(trans.442 01/21/05 & trans. 496,03/04/05)

  15. Section:Coding/Claim Creation The coding comes from the Medical Records Abstracting Coding • -Diagnoses- ICD9 volume 1 ABS Status FINAL • ADM 782.2 LOCAL SUPERFICIAL SWELLNG • 1 706.2 SEBACEOUS CYST • 2 727.42 GANGLION OF TENDON • 3 V16.3 FAMILY HX-BREAST MALIG • -Procedures- ICD9 volume 3 Date Physician Adm • 1 82.21 EXC LES TEND SHEATH HAND 01/04/07 EDIE E • 2 86.3 OTHER LOCAL DESTRUC SKIN 01/04/06 EDIE Y • 3 (837I only)POA:Y,N,U,W,1 • -CPT Codes- CPT volume I Date • 1 11422 EXC H-F-NK-SP B9+MARG 1.1-2 01/04/07 • 2 25111 REMOVE WRIST TENDON LESION 01/04/07 • 3 00400 ANESTH, SKIN, EXT/PER/ATRUNK 01/04/07

  16. Section:Coding/Claim Creation • Example of medical records abstracting coding on a claim. Group Ins Claim or Medicare claim 360 Operating Room 010406 11422 $xx.00 360 Operating Room 010406 25111 $.00 370 Anesthesia 010406 00400 $xx.00 Depending on the hospital system, coding from medical records will commonly be involved in some or all of these revenue codes. 360 Surgery, 361 Minor/Interventional Surgery, 369 Other OR, 450 Emergency room proc, 750 Gastrointestinal Lab. Know your hospital’s own charge master vs. medical record (HIM) coding system and how they flow to the claims you submit.

  17. Section:Coding/Claim Creation GROUP INS. FINAL CLAIM CREATED 252 DEMEROL 25MG AMP 010407 3 242.60 257 BACITRACIN OINT 15GM 010407 1 55.10 272 BANDAGE SURGICAL 010407 4 319.55 310 GROSS & MICROSCOPIC III 88304 010407 2 400.00 360 360 OR SERVICES 11422 010407 1 7131.00 360 360 OR SERVICES 25111 010407 1 0 370 370 ANESTHESIA 00400 010407 1 793.50 636 VERSED 2MG/2ML INJ J2250 010407 1 88.30 636 REGLAN INJ 10MG J2765 010407 1 73.85 636 SUBLIMAZE 2ML AMP J3010 010407 1 83.85 710 710 RECOVERY ROOM 010407 1 922.25 820 Dialysis Unch/ESRD/Emerg 90935 010407 1 1000.00 • TOTAL CHARGE $10110.00 Page 1 of 1 Creation date 010807 $10110.00 NPI 1234567890 BLADEGRASS INSURANCE H23 Y Y 923459 TENDER,TEDDY 18 XDD333A66688 12444555777 FLY BY NIGHT FINANCIAL Y996.73 Y403.91 U72742 WV163 9 7062 3895 010407 863 010407 1222444445 G2 A663334 HEALME GINA

  18. HIPAAElectronic Transaction Process

  19. HIPAAElectronic Transaction Process • 270/271 Inquire and Receive Response providing health care eligibility or benefit information associated with a subscriber or dependent. • 278 Inquire and Receive a response for the following from Utilization Review units: • Admission certification review • Referral review • Health care services certification • Extend certification review • 837 Institutional, Professional, Dental claim • 276/277 Claim Status Request/Response to obtain payer status (accepted/rejected, denied, approved and pending • 835 Claim Payment/Advice, Explanation of Benefits (EOB) submission to providers or other payers

  20. Section:Billing PreparationUB04 CMS-1450 This section was developed to train you on specific FL-fields of the UB04 CMS-1450 Not all of the FL-fields are in this text, only the fields that have heavy usage and need knowledge based training For more information on the new forms UB04 CMS-1450 May 23,2007 Implementation (Transitional 3/1/07-5/22/07 CMS trans#1018 July 28, 2006) National Standars Insti X12N 837 I Health care claim companion document http://www.cms.hhs.gov/transmittals/downloads/R1116CP.pdf Go to: http://www.nubc.org New 1500 HICF X12N 837 (08/05) July 2, 2007 Implementation (Updated R1247CP) http://www.cms.hhs.gov/transmittals/downloads/R899CP.pdf http://www.cms.hhs.gov/transmittals/downloads/R1247CP.pdf Go to : http://www.nucc.org

  21. Section:Billing PreparationUB04 CMS-1450 Transitional Evolution changes from UB-92 to UB-04 • Pay-to-name and address (New FL02) • Patient name – ID (Update FL08) • Accident State (New F29) • Page_of_Creation date (New F43-F44) • Creation date (New FL45) • Identifiers – NPI National Provider Identifier (FL56,FL76-FL79) • Principal diagnosis code required. (FL67 & other FL67A-Q) • Diagnosis indicator Field – Report if the diagnosis was present on admission (FL69) • Patient’s Reason for Visit Code (FL 70A 70C) • PPS Code Field (New FL71) • External Cause of Injury Code (New FL72 1-E code only) • Code-Code Qual/Code/Value (New FL81)

  22. Section:Billing PreparationUB04 CMS-1450 Modifications UB-92 to UB-04 • Increase Type of Bill to 4 digits • Increase filed size for HCPCS/Rate/HIPPS Rate codes-2 added modifier positions • Additional 3 Condition Code fields • Expanded diagnosis code field to prepare for ICD-10-CM • Additional Occurrence Span Code field • Usage matrix created for Type of Bill • Current regulations and industry standards restated on the back of the form

  23. Section:Billing PreparationUB04 CMS-1450 CMS Related Publications/Articles SE0608 – CMS Subpart Policy: http://www.cms.hhs.gov/MLNMattersArticles/Downloads/SE0608.pdf SE0659 - Guidance for Reporting NPI In Medicare claims http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0659.pdf MM4023- CMS policy for NPI-stage 2 implementation: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4023.pdf MM5229 – Modification of NPI editing requirements of CR4023/MM4023 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5229.pdf MM5243 - R1024CP-Reporting Taxonomy Codes for Subpart NPI’s http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5243.pdf CR5436 –Trans#1154 Healthcare Provider Taxonomy Codes Update

  24. Section:Billing PreparationUB04 CMS-1450 CMS Related Publications/Articles continued MM5072 – UB-04 Implementation: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5072.pdf MM5081 revised – Stage 2 NPI Changes for 835 transactions: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5081.pdf CR5318 Trans#183 Jan 24,2007- Update the MCS System to Validate NPI in place of UPIN CR4191 Trans#141 Feb 24,2006-Modification to the UPIN process CR5072 Trans#1104 Nov 3,2006-Uniform Billing (UB-04) Implementation SE0659-Important Guidance regarding NPI usage in Medicare claims MM5499 / CR5499 – Present on Admission Indicator POA MM5378 Revised-Claims submitted with only a NPI during the Stage 2NPI Transition Period MM5452 Trans#R1241CP Stage 3 NPI changes for transactions 835 & RA

  25. Section:Billing PreparationUB04 CMS-1450 CMS Related Publications/Articles continued MM5072 Revised-Uniform Billing (UB-04)Implementation-UB92 Replacement MM5584-Discontinuance of the UPIN Registry MM5411-Institutional Value Code Changes Federal Register Vol.72 #103,Wed. May 30,2007 –HIPAA National Plan and Provider Enumeration System Data Dissemination MLN SE0725 NPI Errors, using NPI on claims and 835 Remittance advices changes http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf http://www.cms.hhs.gov/NationalProvIdentStand/06a_DataDissemination.asp NPI REGISTRY SEARCH!!! Look up all your Individual or Organizational Provider https://nppes.cms.hhs.gov CLICK on REGISTRY SEARCH CMS Related Publications/Articles CMS1500 08-05 MM5060 - CMS1500 08-05 Implementation http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5060.pdf Medi-Cal website to Register NPI(s) MEDI-CAL will still require Provider#!!!!!!!! http://files.medical.ca.gov/pubsdoco/npi/articles/npi_8806.asp

  26. Section:Billing ProcessUB04 FL 2 Pay-to-Address City State-Pay to ID (SE0659 has information regarding this field) 1C-City position,left justified 1D-State Position 1E-Zip code position 1F-Phone Position 3A Patient Control #(acct#) 3B Medical Records Number-Unit Number FL 4 Type of Bill(4 digits,1st is 0) First digit:Type of Facility(Expanded from size 3 to 4) Second digit:Bill Classification(Inpatient,Swing bed) Third digit: Sequence/Frequency for a specific episode of care 2 Interim 5 Late Charges 3 Interim Continued 7 Replacement of prior claim 4 Interim last claim 8 Void 5 Late charges 9 Final HH PPS

  27. Section:Billing ProcessUB04 FL 4 Continued Common Examples: 11x Hospital Inpatient 12x Hospital Inpatient (Medicare Part B Only) 13x Hospital Outpatient 21x Skilled Nursing Inpatient (Including Medicare Part A) DISCONTINUED Medicare 10/01/05: 17x. 24x, 27x, and 5xx

  28. Section:Billing Process FL 6 Statement Covers Period • Report the beginning and ending dates of service for the entire period reflected on the bill. • Outpatient hospital claims where the from and through dates are equal and a HCPCS code is reported, a line-item date of service must be reported also in FL45. • SNF inpatient claims must equal the total units reported in FL46 for accommodation.

  29. Section:Billing Process FL7 Unlabeled(UB92 FL7 Replace w/ Value code 80) ”Medicare Covered Days” FL8 Patient Name & ID(8a) UB92 FL 8 Replace w/Value code 81) FL8(a)=Patient Identifier-Patients insurance policy number FL9 Street, City, State, Zip & Country(outside USA)Code (UB92 FL 9 Replace w/Value code 81) FL10 Patient Birthdate(UB92 FL10 Replace w/Value code 83)

  30. Section:Billing Process FL11 Patient Sex Old: FL08,09,10 replaced=value codes Marital status has been eliminated FL12 Admission Date FL13 Admission Hour FL14 Type of Admission /Visit (old FL19) 1 Emergency 2 Urgent 3 Elective 4 Newborn 5 Trauma 9 Info not available Note: Date of death can not be changed by Medicare Intermediaries/Carriers. Death certificates must be sent with a request directly to the Social Security Administration office.

  31. Section:Billing Process FL15 Source of Admission (Reorganized to focus on patients’ place or point of origin rather than source of physician order or referral) 1 Physician Referral 2 Clinic Referral 3 HMO Referral (Discontinued 10/01/07) 4 Transfer from a hospital (Different facility) 5 Transfer from a SNF-Skilled Nursing or ICF-Intermediary Care Facility 6 Transfer from Another Health Care Facility 7 Emergency Room 8 Court/law enforcement A Transfer from a Critical Access Hospital (Discontinued 10/1/07) B Transfer from Another HHA C Readmission to same HHA D Transfer from one Dist.Unit of the Hospital to Another Distinct unit, (resulting in a separate claim to the payer) E Transfer from Ambulatory Surgery Center F Transfer from Hospice under Plan of Care or enrolled in Hospice Program ADDITIONAL FL Coding Structure: NEWBORN 1 Normal Delivery (Normal) (Discontinued 10/01/07) 2 Premature Delivery (Premie) (Discontinued 10/01/07) 3 Sick baby (Sick) (Discontinued 10/01/07) 4 Extramural Birth (Born in non-sterile envirn.)(Discont.10/01/07) 5 Born inside the Hospital (NEW 10/01/07) 6 Born outside the Hospital (NEW 10/01/07) 9 Unknown

  32. Section:Billing Process FL 17 Patient Status Hospitals are responsible for ensuring that patient status codes are accurate. This is an OIG audit target for PPS reimbursement 01 Discharged to Home or Self-Care 02 Discharged/Transferred to a Short-Term General Hospital for Inpatient Care 03 Discharged/Transferred to SNF w/Medicare Certification (TCU) 04 Discharged/Transferred to an Intermediate Care Facility (ICF) 05 Discharged/Transferred to a Non-Medicare PPS Children’s hospital or PPS Cancer Hospital for Inpatient Care 06 Discharged/Transferred to Home under Care of organized Home Health Service Organization in anticipation of covered skilled care Code when patient is disch/transf to home with a written plan of care for home care services. Not used for HHA provided by a DME supplier or from a home IV provider for Home IV services. See also condition 42 or 43 07 Left against Medical Advice or Discontinued Care 08 (Discontinued 10/1/05) 09 Admitted as an Inpatient to this hospital

  33. Section:Billing Process FL17 Patient Status- Continued 20 Expired (*accepted by Medi-Cal) 30 Still a Patient 40 Expired at home 41 Expired in a Medical Facility such as a hospital, SNF,ICF or Free standing hospice (TOB 81x,82x) 42 Expired, Place Unknown (TOB 81x, 82x) 43 Discharged/Transferred to a Federal Health Care Facility (VA, Dept Of Defense Hospital) 61 Discharged/Transferred within this institution to a Hospital-Based Medicare Approved Swing Bed 62 Discharge/Transferred to an Inpatient Rehabilitation Facility (IRF) Including Rehab. Distinct part units of a hospital 63 Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH) 64 Discharged/Transferred to a Nursing Facility Certified Under Medicaid but not certified under Medicare 65 Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital

  34. Section:Billing Process FL18-28 Conditions (FL 26,27,28 New condition codes): The codes communicate to the payer employment and eligibility conditions that affect the claims processing Examples: 01 Military service related 02 Condition is employment related 06 ESRD patient in first 18 months of entitlement covered by employer group health insurance Special Conditions: 09 Neither patient nor spouse is employed (MSP) 17 Homeless 18 Maiden Name Retained 19 Child Retains Mother’s Name 20 Beneficiary requested billing ”Demand” 44 Inpatient Admission Changed to Outpatient (documentation & physician agreement is required before billing)

  35. Section:Billing Process FL18-28 Conditions: 49 Product replacement within product lifecycle (Nov 4, 2005 MM4058 CR 4058) *CMS to track costs 50 Product replacement for know recall of product (Nov 4, 2005 MM4058 CR 4058) *CMS to track costs GO Multiple ER visits occur on the same day (see modifiers 25,27) Claims reviewed by QIO or QIC with denial or preauthorization see codes: C3-C7 in Transmittal 632 July 29,2005 Effective 01/03/06,after service dates 07/01/05 Medicaid claims: 81 Emergency certification A1 EPSDT/CHDP A4 Family Planning AI Sterilization/Consent Form(PM330) • There are many codes under this section, refer to the UB92-UB04 manual

  36. Section:Billing Process FL 29 Accident State FL31-36 31A= A1-Ins 1 subscriber birth date 32A= B1 Ins 2 subscriber birth date 33A= C1 Ins 3 subscriber birth date Occurrence & Dates: The codes & dates communicate to the payer specific events to determine liability and coordinate benefits that will affect the claims processing Examples: 01 Accident/Medical coverage w/date of accident 06 Crime Victim 10 Last Menstrual Period (Maternity related condition claims) 11 Onset of symptoms or exacerbation/illness w/date treatment started(Rev codes: 041x,042x,043x,044x,0943) 27 Date of Hospice certification or recertification 35 Date Treatment Started for Physical Therapy 44 Date Treatment Started for Occupational Therapy 45 Date Treatment Started for Speech Therapy 46 Date Treatment Started for Cardiac Rehab

  37. Section:Billing Process FL35-36 Occurrence Span codes & Dates: (2 new Occurrence Span codes) The codes & dates communicate to the payer specific events that SPAN over time to coordinate benefits that will affect the claims processing Examples: 70 Qualifying stay dates for SNF(3 day hospital that qualifies the patient for Medicare SNF) 72 Actual dates of the first and last outpatient services visit (if dates in FL6 are different) FL38 Responsible Party (for the bill) Name and Address

  38. Section:Billing Process FL39-41 Value codes & Amounts: The codes & amounts communicate specific codes and related monetary amounts that will affect the claims processing Examples: 01 Most common semi-private room rate,$$$ 02 Hospital has no semi-private rooms (0.00) 12 Working aged beneficiary/spouse with EGHP, $$$ 13 ESRD Beneficiary in Medicare Coordination Period w/EGHP 14 No-Fault, Including auth/other 15 Work Compensation,$$$ 41 Black Lung (BL) 42 Veterans Affairs (VA) 43 Disabled Beneficiary Under Age 65 w/LGHP 45 Accident Hour(non Medicare) 2pm=14 00 in cents

  39. Section:Billing Process FL39-41 Value codes & Amounts: 50 Physical Therapy Visits (# from onset from billing provider through this billing period) 51 Occupation Therapy Visits “ 52 Speech Therapy Visits “ 53 Cardiac Rehabilitation Visits “ 54 Newborn birth weight in grams 55 Eligibility Threshold for Charity Care 68 EPO Drug-Amount reflect the #EPO units admin or supplied 69 State Charity Care Percent - Amount reflect the % of charity care eligibility for the patient 75-79 These codes are set aside for payer use ONLY 80 Covered Days 81-Noncov.Days 82-Co-ins Days 83-LTR A4-A6 Self-Administrable Drug codes to support revenue 0637 July 1,2007 A1,A2,A7,B1,B2,B7,C1,C2,C7 now restricted to paper claims only,no longer X12N 837 Insti.claims MM5411

  40. Section:Billing Process FL42 Revenue Codes There are 22 lines available on a single UB-04 claim form to list revenue codes and charges. The codes consist of 4 digits. Many systems drop the first digit from paper claims. Each facility must decide to program these codes with either a “General” revenue code (ending in 0) OR “Detail” revenue code (ending in 1-9 as appropriate). Example: 250 “General” Pharmacy 251-259 “Detail” Pharmacy In most cases it is to your advantage to code detail for Medicare and Payer requirements. Accuracy is important to your facilities cost reporting. Avoid manual changes to your claims. Under Home Health PPS one revenue code line is used for the request for anticipated payment (RAP) The line is used to report the Health Insurance Prospective Payment System (HIPPS) code(FL44) Certain revenue codes are contracted with payer to pay with invoice or requisition forms. 278 Implants, 636 Specifically coded drugs This requires some step by step review by your facility to ease the process for the billing staff to deal with the carve-out contract requirements

  41. 0001 Total Charges 002X HIPPS PPS codes-Subcategory 2 Skilled Nursing Facility (TCU) SNF PPS(RUG) 3 Home Health PPS HHS PPS (HRG) 4 Inpatient Rehabilitation PPS IRF PPS (CMG) 01XX&02xx Room & Board charges 025x Pharmacy 027x Supplies 03xx Lab 032x Radiology Diagnostic 033x Radiology Therapeutic 034x Nuclear Medicine 0343 Diagnostic Radiopharm. 0344 Therapeutic Radiopharm. 035x CT Scan 036x Surgery 037x Anesthesia 041x Respiratory 042x Physical Therapy 043x Occupational Therapy 044x Speech-LanguagePathology 045x Emergency Room 046x Pulmonary Function 048x Cardiology 049 Ambulatory Surgical Care 061x MRI 063x Pharmacy(HCPCS required) 072x Labor Room/Delivery 073x EKG/ECG 075x Gastro-Intestinal Services 076x Treatment or Observation 080x Inpatient Renal Dialysis 092x Other Diagnostic Services Section:Billing ProcessFL42 Revenue CodesCommon

  42. Section:Billing Process FL43 - 44 Page__of __Creation Date *NEW* FL44 Rates/HIPPS/HCPCS-CPT Codes (Expanded to 4 modifiers =14 digits) Almost all revenue codes require a HCPCS/CPT code. This field is to report appropriate codes for the service performed. Some payers have edits that will require a specific “detail” revenue code for a specific HCPCS/CPT • This field is also for reporting Room and Board Rates • RC 0022=Skilled Nursing Facility HIPPS Rate/RUG code • RC 0023=Home Health HHPPS Rate/HRG code • RC 0024=Inpatient Rehab.Facility IRF HIPPS Rate/CMG code • NDC-National Drug Code #s(11 digits) for specific drugs (See Federal Register Feb 20,2003 Vol.68,number 34 Page 8381-8399) No standard code set at this time for non-retail. Trading partners must carefully make agreements. Medicare requires NDC# with the use of C9399 newly approved FDA drugs/ biologicals. CDHS (Calif.Dept.Health Services) is in the process of discussions with providers regarding the implementation of NDC’s on Medi-cal claims. CalHospital Association-Sherreta Lane is working on a provider communication panel.

  43. Section:Billing Process FL 45 Service Date – Creation Date Required Outpatient Report line item dates of service on all bills containing revenue codes, procedure codes or drug codes. This includes claims where the “from” and “through” dates are equal. This was due to HIPAA requirements This line is also used for transmitting: • SNF MDS assessment reference date RC 0022 • HHPPS date of first billable services provided RC 0023 • IRF must enter the date the final assessment was transmitted to CMS national assessment collection database RC 0024 Late assessment policy will affect your Rehabilitation payments eff.01/01/06 (28 days or more from Dischg): http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3885.pdf

  44. Section:Billing Process FL46 Units of Service • Number of services that relate to the HCPCS/CPT codes reported • Rehabilitation Therapy Services modalities that have time increments are to report each 15min in unit measurements. Example: 1 unit = 8mins. To <23 mins. • OPPS Emergency Room exceeds 24 hour, see Trans#881 CR4252 March 3,2006,eff April 3,2006 • Maximum allowable unit OCE edits will require system programming to avoid rejected claims • Drugs- Facility CDM description vs. HCPCS/CPT description. Many drugs need to be multiplied to equal the HCPCS description on the claim. Example: CDM Description rev.636 : Insulin inj.100 units CDM HCPCS/CPT:J1815 Inj. Insulin per 5 units MULTIPLY 20 to get paid for the 100 units

  45. Section:Billing Process FL46 Units of Service Continued: • Observation: Service units will equal the number hours rounded to the nearest hour and counted from the time the physician wrote the order to admit and discharge. PM Transmittal A-02-129 January 3,2003 • Infusion Therapy and Chemo Therapy: Make sure to charge & count units appropriately by rules made in Pub 100-04 Medicare claim processing December 16,2005 Trans#785 CR4258 & April 7, 2006 Trans#902 CR4388 • Outpatient Therapy Visits-0410, 0420, 0430,044, 0480, 0910, and 0943 (Units=number of times the proc/service is performed)Trans#805 CR4226 Jan.06,2006

  46. Section:Billing Process FL48 Non-covered Charges • Non-covered days (FL8) must have Non-covered charges placed in this field • Modifiers that pertain to reporting ABN signed items, must have reported non-covered charges (report occurrence code & date in FL32-35) (modifiers EY,GA,GL,GY,GZ,KB or TS along w/ HCPCS in FL44) FL49 Unlabeled FL50 Payer Identification • Payer must be placed in position 50A,50B,50C. A being the primary and B secondary, C tertiary • Proof of MSP screening to support Medicare placement position is critical (GHP working aged,ESRD,LGHP disabled beneficiary,auto or liability ins.,workers’ compensation,black lung, VA) • Medicaid utilizes “Type of Claim” in this field. See manuals

  47. Section:Billing Process FL50 Provider Number • This field has 13 alphanumeric characters in each of the three lines • Yearly checks of your claim forms and facilities to assure correct provider numbers are used. • CMS is now processing new applications for the national provider identifier (NPI) to each provider. This will replace the current provider numbering system by May 23, 2007 for most health care providers. Small plans May 23, 2008 • Make sure no hyphens • Medicaid utilizes nine characters in their assigned number system FL51 A-C Health Plan ID Will be used after the National Plan ID rule is published. NPPES will also issue these numbers. Electronic vendors may already submit using these payer tables currently. FL54 Prior payments-Payers / Patients • Prior payments should be entered up to 10 digits • Amounts should be entered is titled “due from patient” (deductibles,co-ins, prior payments from primary payers)

  48. Section:Billing Process FL56 NATIONAL PROVIDER IDENTIFIER Effective 5/23/2007 NPI rule is mandatory in all electronic & paper healthcare transactions for all but small health plans Many payers have different implementation dates for the NPI. Beginning May 1, 2006 CMS announces the capability for health industry organizations to submit health care providers’ applications for NPIs o the National Plan and Provider Enumeration System (NPPES) via Electronic File Interchange (EFI). Hospitals should have received NPI information from most of the Physicians (Attending/Rendering;Operating;Referring) Apply for NPI: https://nppes.cms.hhs.gov 1-800-465-3203 CMS NPI Pagehttp://www.cms.hhs.gov/NationalProvIdentStand/ Useful sites of information: http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Training_Package.pdf http://www.cms.hhs.gov/EducationMaterials/Downloads/NationalProviderIdentifierRoundtable.pdf FAQ NPI- htt;://questions.cms.hhs.gov (search NPI term/phrase)

  49. Section:Billing Process NATIONAL PROVIDER IDENTIFIER • NPI will be permanent for a Health Care Provider. One NPI for a lifetime • A new NPI will NOT be required for change of ownership, change to corporation, or change name, tax id#, address, Taxonomy classification, state of licensure, or state license number. • Entity type codes for NPI: (2 types) • Type Code 1 = HCP that are humans-doctor, ARNP, PA, PT • Type Code 2 + HCP that is organization-non-human such as physician group, hospital, HHA, pharmacies, nursing homes • Subparts: • You only obtain a NPI for a “subpart” IF the subpart currently is required for identification in processing of electronic transactions such as claims processing (this isn’t for group practice satellite offices)

  50. Section:Billing Process NATIONAL PROVIDER IDENTIFIER Listing Existing Legacy Numbers: It is important for you to list in the NPI application all current legacy numbers NPI: WILL “replace” all “legacy/OSCAR” numbers such as Medicare, Medicaid, UPIN, Blue-Cross, Blue Shield, etc. NPI: Does NOT replace tax identification or “Pay to address”. Health Plans are NOT required to have NPI. The health plan IS required to use your NPI in electronic transactions, one of which is claims processing. FL57 A-C Other Provider ID May include Legacy#s FL58 Insured’s Name • Last name, Middle name and middle initial • The name entered must be exactly what is on the health insurance card or eligibility websites • 25 alphanumeric characters are allowed for the three lines • No spaces, hyphens or titles (Mr.,Sir, Dr.) • Medicaid uses the recipient’s name (mother’s ID for infants)

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