Briefing: New Billing Forms – The UB-04 and New CMS 1500 Date: 20 March 2007 Time: 1510-1600
Objectives • Understand the new requirements for the new UB-04 claim form, including new fields, modified fields, and NPI • Review why field locators are filled in, and why the payer requires them • Understand the new requirements for the CMS1500 claim form, including NPI • Briefly address TPOCS changes for new billing form changes
History of the Uniform Bill • Between 1968 and1972, thirteen different form designs were developed and later discarded in an effort to develop a uniform bill for hospitals • The 14th version was field tested in Georgia in 1973, modified again and introduced for a second trial in Wyoming • HCFA (aka CMS) agreed to participate in a five-state pilot test of this latest version, known as UB-16-78 • A similar form was being used in NY State, known as UBF-1 • South Carolina was using a form known as A-92-R • In May of 1982, The National Uniform Billing Committee reviewed the various forms and developed/approved the UB-82 -Continued-
History of the Uniform Bill • The UB-92 was formed and fully implemented in 1994 • The UB-04 was approved as the replacement for the UB-92 at the February 2005 meeting • Health plans and clearinghouses need to be ready to receive the new UB-04 by March 1, 2007. Submitters can begin to use the UB-04 on March 1, 2007 • There is a transitional period between March 1, 2007, and May 22, 2007, when both UB-92 and UB-04 can be used • Starting May 23, 2007, all institutional paper claims must use the UB-04. The UB-92 will no longer be available for use after this date
UB-04 Differences Standardization: • All Form Locators (FL) will be nationally “controlled” • All Code Ranges will be reserved for national assignment • The UB-04 data specs will be the principal content used in the HIPAA electronic format • The UB-04 is designed to accept the forthcoming ICD-9-CM changes and support both National Payer and Provider ID #’s • A national UB-04 manual is now available and published with hyperlinks to individual State Uniform Billing manuals
FL 01 FL 01: Provider Information Required The name and service location of the provider submitting the bill
FL 02 FL 02: Pay-to Information New Field - Situational Used when the pay-to name and address information is different from the Billing Provider in FL1. Can only identify a 5-digit zip code. Line 4 is not used, and is reserved for assignment by NUBC
FL 03 FL 03a-b: Patient Control Number and Medical Record Number Required Moved/New Field Previously in FL 23
FL 04-05 FL 04: Type of Bill Required Expanded by 1 Digit. The first digit is a leading zero, the next 2 digits indicate the type of bill (i.e. 011 = Hospital Inpatient). The fourth digit defines frequency of the bill FL 05: Federal Tax Number Required Upper line is the federal sub-ID # assigned by the Provider. Lower line is entered as NN-NNNNNNN (w/ hyphen)
FL 06-07 FL 06: Statement Covers Period From/Through Required The From date should not be confused with the Admission Date (FL 12) FL 07: Unlabeled Not Used On the UB-92: FL07 used to be Covered Days, and FL08 was Non/Covered Days; FL09 used to be Co-insurance Days, and FL10 was L/T RSV Days. All have been eliminated from the UB-04 and substituted with new Value Codes
FL 08 FL 08a: Patient Identifier Required Report if number is different from the subscriber/insured’s ID (FL60) FL 08b: Patient Name Required On the paper form, use a comma or space to separate last and first names. Record hyphenated names with the hyphen as in Smith-Jones, Rebecca
FL 09 FL 09 a-e: Patient Address Required Previously in a single field Zip code is 9 positions Country Codes are available from: American National Standards Institute 11 West 42nd St. 13th Floor New York, NY 10036
FL 10-11 FL 10: Birthdate Required If full birth date is unknown, use zeros for all eight digits, for paper claims. Enter: “MMDDYYYY” format FL 11: Sex Required The sex of the patient as recorded at admission, outpatient service, or start of care. FL 11 on the UB-92 used to be Unlabeled
FL 12-17 FL 12: Admission/Start of Care Date FL 13: Admission Hour FL 14: Priority (Type) of Visit FL 15: Source of Referral for Admission or Visit FL 16: Discharge Status (required on IP claims) FL 17: Patient Discharge Status All are required fields, except FL 13 and FL 16, which are situational fields. FL 16 on the UB-92 “Patient Martial Status” has been eliminated from the UB-04
FL 18-28 FL 18-28: Condition Codes Situational 11 total Condition Codes. Codes are entered in alphanumeric sequence (numbered codes precede alphanumeric codes). No specific dates are associated with these codes. If all of the Condition Codes fields are filled, used FL 81 Code-Code Field with the appropriate qualifier (A1) to indicate that a Condition Code is being reported FL 23 on the UB-92 used to be Medical Record Number, which has now been moved to FL3b on the UB-04
FL 29-30 FL 29: Accident State New Field - Situational Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code named in X12 code source 22 FL 30: Unlabeled Not used Reserved for assignment by NUBC
FL 31-34 FL 31-34: Occurrence Codes Situational 8 total Occurrence Codes. Codes should be entered in alphanumeric sequence (numbered codes precede alpha codes). Enter all dates as month, day and year: MMDDYYYY FL 31 on the UB-92 was an Unlabeled Field If all Occurrence Codes are filled, then use FL 81 (Code-Code field) using the appropriate qualifier (A2) to indicate than an Occurrence Code is being reported
FL 35-37 FL 35: Occurrence Span Code/From/Through Situational If all Occurrence Span Codes are filled, then use FL 81 (Code-Code field) using the appropriate qualifier (A3) to indicate than an Occurrence Span Code is being reported FL 36: Occurrence Span Code/From/Through Added Additional Occurrence Span Code FL 37: Unlabeled The ICN/DCN on the UB-92 (FL 37), has been Relocated to FL 64 on the UB-04
FL 38 FL 38: Responsible Party Name/Address Situational Used to print the name and mailing address of the party responsible for the bill if a window envelope is utilized
FL 39-41 FL 39-41: Value Code / Amount Situational 12 total Value Codes. Value Codes are entered in alphanumeric sequence. Fields 39a through 41a must be completed before “b” line fields, etc. Negative numbers are not permitted except in FL 41. Report values in whole numbers, right justified to the left of the dollars/cents delimiter. The decimal is implied. If all of the Value Code Fields are filled, use FL 81 (Code-Code) with the appropriate qualifier code (A4) to indicate that a Value Code is being reported
FL 42-45 FL 42 (lines 1-23)Revenue Code: Required FL 43 (lines 1-22) Revenue Code Description: Required FL 43 (line 23) Page ___ of ___: Required. Previously inside the Charge Body of the UB-92 Form. Required on all pages. FL 44 (lines 1-22) HCPCS/Rates/HIPPS Rate Codes: Situational Expanded by 5 Digits – 1 HCPCS and 4 modifiers. FL 44-45 (line 23) Creation Date: Required New Field FL 45 (lines 1-22) Service Date: Situational (Required on OP Claims)
FL 46-49 FL 46 (lines 1-22) Service Units: Required FL 47 (lines 1-23) Total Charges: Required. Removed Sign Field. Reduced 1 Digit. FL 48 (lines 1-23) Non-Covered Charges: Situational. Removed Sign Field. Reduced 1 Digit. Revenue Code 0001 is used on the final page to indicate total covered & non-covered charges. FL 49 (lines 1-23) Unlabeled: Not Used
FL 50-52 FL 50: a. Payer Name: Prime, b. Payer Name: Secondary, c. Payer Name: Tertiary Line A is required, Lines B & C are situational (FL 50 and FL 51) FL 51: Health Plan ID (a,b,c) Situational Report to HIPAA national health plan identifier when it becomes mandatory FL 32: Release of Information (a,b,c) Required.
FL 53-54 FL 53: Assignment of Benefits Required. Primary, Secondary and Tertiary. FL 52: Prior Payments Situational. Primary, Secondary and Tertiary. The “Patient Prior Payment Field” has been eliminated.
FL 55-57 FL 55: Estimated Amount Due Situational. Primary, Secondary and Tertiary. Eliminated the “Due From Patient Field” from the UB-04. FL 56: National Provider ID Situational. FL 57: Other Provider ID Situational. Primary, Secondary and Tertiary. Other Provider identifiers are assigned by the health plan.
FL 58-59 FL 58: Insured’s Name Required. Primary, Secondary and Tertiary. List last names first and use a comma or space to separate last and first names. FL 59: Patient’s Relationship Line A is a Required Field, Lines B & C are situational. Primary, Secondary and Tertiary.
FL 60 FL 60: Insured’s Unique ID Line A is a Required Field Lines b & C are situational. Primary, Secondary and Tertiary.
FL 61-62 FL 61: Insurance Group Name Situational. Primary, Secondary and Tertiary. FL 62: Insurance Group Number Situational. Primary, Secondary and Tertiary.
FL 63-64 FL 63: Treatment Authorization Code Situational. Primary, Secondary and Tertiary. FL 64: Document Control Number Situational. Primary, Secondary and Tertiary. FL 64 “Employment Status Code” on the UB-92 has been deleted from the UB-04
FL 65 FL 65: Employer Name Situational Primary, Secondary and Tertiary.
FL 66-68 FL 66: DX Version Qualifier Required. Denotes ICD Version. FL 66 on the UB-92 “Employer Location” has been deleted from the UB-04. FL 67: Principal DX Code & Present on Admission Indicator Required. Positions 1-7 are for the DX code(s); Position 8 (shaded area) are for POA indicator’s) FL 67 A-Q: Other Diagnosis Required. 18 total DX’s (9 New) Note the Shadowed Fields. FL 68: Unlabeled Not used.
FL 69-71 FL 69: Admitting Diagnosis Code Situational. The ICD Diagnosis code describing the patient’s diagnosis at the time of admission. Required on IP Claims. FL 70: Patient’s Reason for Visit Code Required for all unscheduled OP visits FL 71: Prospective Payment System Code The PPS code assigned to the claim to ID the DRG based on the grouper software called for under contract with the primary payer.
FL 72-73 FL 72: External Cause of Injury Code Situational. The ICD DX codes of pertaining to external cause of injuries, poisoning, or adverse effects. 2 new FL’s (total of 3 E-Codes) on the UB-04. Positions 1-7 are for the DX code; position 8 (shaded area) is for the POA Indicator. FL 73: Reserved for Assignment by the NUBC Not used
FL 74-75 FL 74: Principal Procedure Code/Date Situational. Required for IP Claims (when a procedure was performed). Reporting the decimal between the 2nd and 3rd digits of the ICD is unnecessary because it is implied. Not used on OP Claims. FL 74 a-e: Other Procedure Code/Date Situational. Not used on OP claims. FL 75: Reserved for Assignment by the NUBC Not used
FL 76-79 FL 76: (1) Attending - NPI/QUAL/ID (2) Last/First Name All Situational FL 77: (1) Operating - NPI/QUAL/ID (2) Last/First Name FL 78 & 79: (1) Other ID - NPI/QUAL/ID (2) Last/First Name
FL 80-81 FL 80: Remarks Situational. Reduced Field Size. FL 81a-d: Code-Code QUAL/CODE/VALUE New Field. See Qualifiers on next page. FL 79 on the UB-92, “Procedural Coding Method Used”, has been eliminated from the UB-04. UB-92 Form Locators 85 “Provider Rep Signature” and Form Locator 86 “Date Bill Submitted” have been eliminated from the UB-04 –Continued–
FL 81 Code Code Qualifiers • A1 NUBC Condition Codes (FL 18-28) • A2 NUBC Occurrence Codes (FL 31-34) • A3 NUBC Occurrence Span Codes (FL 35-36) • B1 Standards for the Classification of Federal Data on Race and Ethnicity (for public health data reporting only when required by state or federal law or regulations) • B2 Marital Status (for public health data reporting only when required by state or federal law or regulations) • B3 Health Care Provider Taxonomy Code (code source: ASC X12 External Code Source 682) (National Uniform Claim Committee)
Thank you for your Attention! Any Questions?
Revised CMS-1500 Overview • Although many providers now submit electronic claims, many of their software/hardware systems depend on the existing 1500 Claim Form in its current image. Minor changes have been made to the form to accommodate the National Provider Identifier (NPI), as well as current identifiers for a transition period until the NPI is implemented. • In addition to modifying the 1500 form, the National Uniform Claim Committee drafted a reference instruction manual detailing how to complete the form. The updated 1500 manual, version 1.3 7/06 is currently available at http://www.nucc.org/.
CMS-1500 Billing Form Requirements • CMS-1500 Billing Form • CMS-1500 billing form has 33 items or data fields; 21 of which are required • Required Data Elements are data elements that must be entered on the billing form • Conditional Data Elements these are elements that depend on other data before required • Blank data fields do not require data
Claim Form Formats and Versions • There are currently two versions of the Form CMS-1500 (12-90 and 08-05) • The current CMS-1500 form has the numbers “(12-90) RRB -1500” in the lower right corner and four black alignment bars in the upper left corner • The revised CMS-1500 form has the 1500 symbol and the approval date (08/05) in the upper left margin • CMS-1500 (08-05) can be used as of 1 January 2007 but will not be mandatory until 2 April 2007 • NOTE: There will be a period when both versions of the CMS-1500 will be accepted by payers
CMS-1500 Implementation Timeline • 2 January 2007 - 30 March 2007 Providers can use either the current Form CMS-1500 (12-90) or the revised Form CMS-1500 (08-05). Note: Health plans, clearinghouses, and other information support vendors should be able to handle and accept the revised Form CMS-1500 (08-05) by January 2, 2007 • April 2, 2007 The 12-90 version of CMS-1500 is discontinued. Only the 08-05 CMS-1500 is to be used • Note: All rebilling of claims should use the revised CMS-1500 (08-05) from this date forward, even though earlier submissions may have been on the current Form CMS-1500 (12-90)
CMS-1500 - Current Version (12-90) Four (4) bars OMB Approval date
Revised CMS 1500 (08/05) 1500 symbol & OMB approval date
Key Changes Referring Physician Information Items 17, 17a, & 17b
Item 17 Item 17:Name of referring provider or other source who referred or ordered the service (Conditional Data Element) Revised - Title was changed from “Referring Physician” to “Referring Provider” Note:TPOCS will populate the referring provider information in Items 17, 17a and/or 17b
Item 17a: Other Id# / Qualifier (Conditional Data Element) The Other ID Number of referring or ordering provider, the provider taxonomy code of the referring or ordering provider should be reported in the shaded area The qualifier (PX- Provider Taxonomy) identifies the type of Other ID being reported in the shaded area and is entered in the qualifier field Revised - This area was shaded and a new field was added to hold the two-digit qualifier for other ID Number Qualifier field Item 17a
Item 17b • Item 17b: Provider NPI # Required,if applicable • (Required Data Element) • NPI Type 1 of the referring or ordering provider will appear in this field, if available. If NPI is missing, then the Current Provider ID and/or Tax ID will be reported in Item 17a until the NPI is provided. New item – Additional field to accommodate the National Provider Identifier
Key Changes – Service Line Key Changes Service Line Information Section 24 Section 24 Revised – To accommodate submission of both the NPI and other Provider Identifier during the NPI transition
If the MEPRS code is BIA*, then place of service code will be 23-Emergency Room 23 Item 24B • Item 24B: Place of Service • (Required Data Element) • The place of service code identifies the location of where the service occurred. For DoD, the place of service code 26-Military Treatment Facility is hard coded in TPOCS for all 1500 claims with the exception ofemergency room services. Note: TPOCS will provide users the option to determine if the encounter is related to ER services. When saving the bill TPOCS will assign the place of service code based on MEPRS code BIA*