CMS-1450 Billing Guidelines for Hospitals

Slide 1:CMS-1450 Billing Guidelinesfor Hospitals

December 2009 www.dmas.virginia.gov Department of Medical Assistance Services

Slide 3:Objectives

1. Medicaid Eligibility Verification Options 3. CMS-1450 (UB-04) Billing Guidelines 4. Medicare Exhausted Billing Guidelines 2. Important Contacts

Slide 4: Participating Providers Must-

Determine the patient’s identity. Verify the patient’s age. Verify the patient’s eligibility. Accept, as payment in full, the amount paid by Virginia Medicaid. Bill any and all other third party carriers.

Slide 5:The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format.

Slide 6:MediCall/Automated Response System (ARS)

Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claims Status Patient Pay Information Prior Authorization Information Primary Payer Information Medallion Participation Managed Care Organization Assignment

Slide 7:MediCall

800-884-9730 800-772-9996 804-965-9732 804-965-9733

Slide 8:Automated Response System (ARS)

Web-based eligibility verification option Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant

Slide 9:ARS Registration Process

https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf Select the ARS tab on FHSC ARS Home Page Choose “User Administration” Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’ Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process. Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process.

Slide 10:ARS – Users

ARS User’s Guide http://www.dmas.virginia.gov/prclaims_billing.htm Web Support Helpline- 800-241-8726 You are required to enroll and begin using the new Web Site by May 23, 2007. You are required to enroll and begin using the new Web Site by May 23, 2007.

Slide 11: Important Contacts

Provider Call Center Provider Enrollment Electronic Claims Coordinator

Slide 12:Provider Helpline

Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

Slide 13:Provider Enrollment

New provider enrollment, Electronic Fund Transfer (EFT) or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

Slide 14:Electronic Billing

Electronic Claims Coordinator Mailing Address First Health Services CorporationVirginia OperationsElectronic Claims Coordinator4300 Cox RoadGlen Allen, VA 23060 E-mail: edivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

Slide 15:Billing on the CMS-1450

Slide 16: MAIL CMS-1450 FORMS :

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES Facility P. O. Box 27443 Richmond, Virginia 23261-7443

Slide 17:TIMELY FILING

ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE EXCEPTIONS Retroactive/Delayed Eligibility Denied Claims NO EXCEPTIONS Accidents Other Primary Insurance

Slide 18:TIMELY FILING

Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

Slide 20:Locator 1:Provider’s Name, Address and Phone Number

Enter the provider’s name, complete mailing address and telephone number of the provider that is submitting the bill and which payment is to be sent. NOTE: DMAS will need to have the 9 digit zip code on line four, left justified for adjudicating the claim.

Slide 22:

3a PAT. CNTL # b. MED REC. # 123456789ABCDEFGH012 987654321HGFEDCBA1234567 22 Patient Control Number (not to exceed 20 characters) and Medical/Health Record Number (not to exceed 24 characters) are required for all UB-04 claim submissions. Locators 3a:Patient Control Number 3b: Medical Record Number 3a Patient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters. 3b Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters. 3a Patient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters. 3b Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters.

Slide 23:Enter the code as appropriate. Claims submitted without the required four digit bill type will be denied. Enter the code as appropriate. Claims submitted without the required four digit bill type will be denied.

Slide 24:0111- Original Inpatient Hospital Invoice 0112- Interim Inpatient Hospital Invoice* 0113- Continuing Inpatient Hospital Invoice* 0114- Last Inpatient Hospital Invoice * 0117- Adjustment Inpatient Hospital 0118- Void Inpatient Hospital Invoice Only “APROVED” claims can be adjusted or voided

Locator 4: Enter the code as appropriate. Valid codes for VA Medicaid Inpatient Bill Types 24

Slide 26:Locator 6: Statement Covered Period

For hospital admissions, the billing cycle for general medical surgical services has been expanded to a minimum of 120 days for both children and adults, except for psychiatric services. Interim claims (bill types 0112 or 0113) submitted with less than 120 days will be denied. Bill types 0111 or 0114 submitted with greater than 120 days will be denied. These guidelines also apply to SLH claims. These guidelines also apply to SLH claims.

Slide 32:Locator 12: Admission/Start of Care

The start date for this episode of care. For inpatient services this is the date of admission. For all other services, the date the episode of care began: IP- Day admitted OP- Day episode of care began

Slide 33:

Locator 12: Admission/Start of Care

Slide 35: Appropriate PRIORITY TYPE codes accepted by DMAS are:

Locator 14: Priority Type of Visit 35

Slide 37:Source of Referral for Admission or Visit

Appropriate codes accepted by DMAS are:

Slide 38:For TDO and ECO claims, your admission source should be 8.For TDO and ECO claims, your admission source should be 8.

Slide 39:TDO-Enter the hour the patient appeared at the Involuntary Detention Hearing. SLH-Enter the hour the patient was discharged from inpatient care. TDO-Enter the hour the patient appeared at the Involuntary Detention Hearing. SLH-Enter the hour the patient was discharged from inpatient care.

Slide 40: Locator 17:Patient Discharge Status

Appropriate codes accepted by DMAS in claims processing: 40

Slide 41: Locator 17:Patient Discharge Status

41

Slide 42: Locator 17:Patient Discharge Status

42

Slide 43:Locator 17: Patient Status

Correct reporting of patient status code will facilitate quick and accurate determination of DRG reimbursement. In particular, accurate reporting of the values 01,02,05, and 30 will be very important in DRG methodology.

Slide 45: Locators 18-28:Condition Codes

These codes are used by DMAS in the adjudication of claims: 45

Slide 46: Locators 18-28:Condition Codes

These codes are used by DMAS in the adjudication of claims: 46

Slide 52:DMAS will capture the number of covered or non-covered day (s) or units for outpatient services with these required value codes: 80 Enter the number of covered days for inpatient hospitalization or the number of days for re-occurring outpatient claims. 81 Enter the number of non-covered days for inpatient hospitalization

Locators 39-41:Value Codes and Amounts

Slide 53:Locators 39-41: Value Codes and Amount

Enter the appropriate code (s) to relate amounts or values to identify data elements necessary to process this claim. One of the following codes must be used to indicate coordination of third party insurance carrier benefits No Other Coverage Billed and Paid (Enter Amount Paid by Primary Carrier) 85 Billed Not Covered/No Payment (Documentation Required)

Slide 54:Locators 39-41: Value Codes and Amount

For Part A Medicare Crossover Claims, the following codes must be used with one of the third party insurance carrier codes: A1 Deductible from Part A A2 Coinsurance from Part A Other codes may be used if applicable.

Slide 56:Locator 42: Revenue Code

Enter the appropriate revenue code (s) for the service provided. Note: Multiple services for the same item, providers should aggregate the service under the assigned revenue code and then total the number of units that represent those services DMAS has a limit of five pages for one claim The Total Charge revenue code (0001) should be the last line of the last page of the claim

Slide 58:** Effective 07/01/08 **  Outpatient Hospital Setting Billing Requirements for NDC

CMS requirements related to the Deficit Reduction Act (DRA) of 2005, mandate DMAS to require hospital providers who bill drug products administered in an outpatient hospital setting to include the National Drug Code (NDC) information of the drug dispensed on all claim submissions.

Slide 59:NDCOutpatient Hospital Setting Requirements

The NDC information will be required on all electronic (ASC X12N:837I) and paper (Universal Billing “UB”) claim submissions. This requirement also applies to Medicare Crossover claim submissions. Outpatient hospital claims submitted without a valid NDC will have the revenue code line reduced to a non-covered service line.

Slide 60:NDC Outpatient Hospital Setting

Providers billing for compound medication with more than one NDC included in the medication dispensed, each applicable NDC must be submitted on a separate claim line to include both prescription and over-the-counter ingredients. Each claim line submitted with pharmacy revenue codes 0250-0259 and 0630-0639 will require the NDC information.

Slide 61:NDC Outpatient Hospital Setting

Effective 07/01/08, a valid NDC will be required for all drug products administered in an outpatient hospital setting. By definition, a valid NDC is a formatted number using the 5-4-2 format, i.e., 5-digits, followed by 4-digits, followed by 2-digits: 99999888877 Each NDC must be an 11-digit code unique to the manufacturer of the specific product administered to the patient.

Slide 62:Outpatient Hospital SettingLocator 43: NDC Requirements

Form Locator 43 must have N4 modifier as the first indicator in this field, the corresponding 11-digit NDC number, followed by the Unit of Measure Qualifier and the NDC unit quantity. Billing for the same medication dispensed in different packages, each package size MUST be listed separately using N4 modifier, the revenue code, and all the required information on separate lines. The DMAS system will not consider these drugs as duplicates.

Slide 63:NDC Outpatient Hospital Setting

If available, providers should enter the HCPCS code in Locator 44 (HCPCS/Rate/HIPPS Code) and the HCPCS units in Locator 46 (Serv Unit). DMAS will validate all HCPCS codes. Submission of an invalid HCPCS code will cause denial of the entire claim. The NDC number submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered.

Slide 71:Locator 50: Payer Name A-C

Enter the payer from which the provider may expect some payment for the bill. When Medicaid is the only payer, enter “Medicaid” on line A. If Medicaid is the secondary or tertiary payer, enter on lines B or C.

Slide 75:Note: appropriate codes accepted by DMAS are:

Locator: 59 Patient’s Relationship to Insured

Slide 79:Locator 64:Document Control Number

This locator is to be used to list the original Internal Control Number (ICN) for APPROVED claims that are being submitted to adjust or void the original claim.

Slide 82:Locator 67 Principal Diagnosis CodeLocators 67A-Q Present on Admission (POA) Indicator

The eighth digit of the Principal, Other and External Cause of Injury Codes are to indicate if: the diagnosis was know at the time of admission, or the diagnosis was clearly present, but not diagnosed, until after the admission took place or was a condition that developed during an outpatient encounter

Slide 83:Locator 67 A-Q (POA) Indicator

The POA indicator should be listed in the shaded area. This field is required for hospitals, (05/20/09 Memo). Reporting codes are: CODE DEFINITION Y YES N NO U No information in the record W Clinically undetermined

Slide 88:Locator 74: Principal Procedure Code and Date

Note: for outpatient claims, a procedure code must appear in this locator when revenue codes 0360-0369, 0420-0429, 0430-0439, and 0440-0449 (if covered by Medicaid) are used in Locator 42 or the claim will be rejected. For inpatient claims, a procedure code or one of the diagnosis codes of V64.1 through V64.3 must appear in this locator (or Locator 67) when revenue codes 0360-0369 are used in Locator 42 or the claim will be rejected.

Slide 93:Locators 78-79:Other Provider Name and Identifiers

This field will be used to list the NPI for the Primary Care Physician (PCP) who authorized the inpatient stay or outpatient visit. For MEDALLION patients referred to an outpatient clinic, enter the NPI for the PCP who authorized the outpatient visit. This information is required for all MEDALLION patients treated for non-emergency services.

Slide 94: Locators 78-79:Other Provider Name and Identifiers

For Client Medical Management (CMM) patients referred to the emergency room by the PCP or admitted for non-emergency inpatient stay, enter the provider’s ID number and attach the Practitioner Referral Form (DMAS-70).

Slide 97:TAXONOMYLocator 81: Code-Code Field

DMAS will be using this field to capture a taxonomy code for claims that are submitted for one NPI with multiple business types or locations (e.g., Rehabilitative or Psychiatric units within an acute care facility, Home Health Agency with multiple locations).

Slide 98:TAXONOMYLocator 81: Code-Code Field

The taxonomy code will be required for providers who do not have a separate NPI for each different service billed to VA Medicaid. The taxonomy code will also be required for providers who have one NPI for multiple business locations. Code B3 is to be entered in the first small space and the provider taxonomy code is to be entered in the second large space. The third space should be blank.

Slide 100:DMAS Service Types That May Require a Taxonomy Codes

100

Slide 101:Outpatient Surgery

For elective outpatient surgical procedures which require Preauthorization (PA) by Medicaid Medical Support (Physician’s Manual, Appendix B), submit paper claim. Contact the surgeon and request a copy of his PA letter ( the facility services do not required preauthorization). Attach a copy of the PA letter to the back of your claim form. Do not put the Physician’s PA # on your claim.

Slide 102:Medicare PrimaryCrossover Claims&Medicare Exhaust Claims

DMAS

Slide 103:Medicare Primary  Billing Instructions for CMS-1450

The word “CROSSOVER” must be entered in Block 30 of the UB-04 to identify Medicare crossover claims. Coordination of Benefits (COB) codes 83 and 85 must be accurately printed in Blocks 39-41 of the UB-04.

Slide 104:Medicare Primary 

In addition to Value Code 80- covered days and/or services, the following information is required for Medicare primary claims: The first occurrence code 83 indicates that Medicare paid and there should always be a dollar value associated with this code. The A1 indicates Medicare deductible and code A2 indicates Medicare coinsurance

Slide 105:Blocks 39-41

Line a 83 = Billed and Paid (enter amount paid by Medicare or other insurance). Line a A1 = Deductible Payer A. (enter Medicare Deductible Amount listed on the EOMB). Line a A2 = Co-Insurance Payer A. (enter Medicare Co-Insurance amount listed on the EOMB).

Slide 106:Medicare Primary 

Note: Complete all information in Locators 39a through 41a first (payments by Medicare or payments by other insurance) before entering information in 39b through 41b locators etc. COB code 85 is to be used when another insurance carrier is billed and there is no payment from that carrier. For the deductibles and co-insurance due from any other carrier(s) (not Medicare) the code for reporting the amount paid is B1 for the deductibles and B2 for the coinsurance.

Slide 107:Medicare Exhaust Days

MEDICARE PRIMARY/Days Exhausted Preauthorization from the Medicaid Prior Authorization Contractor is required. Proof of exhausted Medicare days must be submitted with preauthorization.

Slide 108:Medicare Exhaust Days

All days must be billed. Initial stay less than 120 days, bill type 0111. First 120 days bill type 0112 – next 120 days bill type 0113 – continue bill type 0113 for any additional 120 day periods. Final bill type 0114.

Slide 109:Medicare Exhaust Days

Providers should list the amount Medicare paid on the 0112 bill type (less than 120 days list payment on 0111 bill type). Medicare payment should be listed in Block 39a and use COB code 83 (billed and paid).

Slide 110:Medicare Exhaust Days

DO NOT WRITE the word CROSSOVER in Block 30 (Medicare is exhausted and the days billed to Medicaid were not paid by Medicare) Block 80- providers MUST put write a statement MEDICARE DAYS EXHAUSTED and attach something showing Medicare are exhausted (Medicare EOB).

Slide 111:Medicare Exhaust Days

If Medicaid has considered a crossover claim for deductible and coinsurance on days Medicare paid or any Part B charges- If the provider keeps all charges on the claim submitted for Medicare Exhaust days, all payments must be listed. If the provider deletes Part B charges, do not list any Part B payment amounts.

Slide 112:Special Note

If the Medicaid recipient does not have Part A coverage, the COB code should be 82 (No Other Coverage).

Slide 113:REMITTANCE VOUCHERSections of the Voucher

APPROVED for payment. PENDING for review of claims. DENIED no payment allowed. DEBIT (+) Adjusted claims creating a positive balance. CREDIT (-) Adjusted/Voided claims creating a negative balance. 113

Slide 114:REMITTANCE VOUCHERSections of the Voucher

FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS 114

Slide 115: THANK YOU Department of Medical Assistance Services

www.dmas.virginia.gov