Tuning Up Hospital Billing Skills. Agenda. Test of knowledge Questions from Policy and Procedure Review answers and where to locate them in Policy and Procedure. Three Day Rule. Where is the Three Day Rule found? Policy and Procedures Part II, Hospital Services, Section 904
Policy and Procedures Part II, Hospital Services, Section 904
Service discharge and re-admit with like or same diagnosis that happen within 72 hours of each other.
Less than 72 hours from discharge to re-admit, like or same diagnosis
Georgia Medical Care Foundation, www.gmcf.org, yes, on the left Medicaid , Provider Educational and Training Materials , select title
Only deliveries, newborn births less than 30 days and services for members who are Medicare Part A eligible
An authorization must be recertified every 90 days.
Medical necessity and appropriateness of setting.
Yes, log on to www.ghp.georgia.gov Provider information, Claims, Prior Authorization / Pre-Certification, Request a Prior Authorization…
Six months from retro date.
Yes and yes; the extenuating circumstances are deliveries and for inpatient services if the member is Medicare Part A eligible. If the claim is an outpatient service and the member is Medicare Part B eligible a Medicaid authorization is not needed.
30 days from the authorization approval date
Yes, the responsibility will fall on the facility to request and obtain the authorization.
When a facility must seek services for Medicaid Members from another facility. The arrangement must be pre-arranged verbally and in a written manner. The receiving facility will forward their charges to the original facility who will add them to their claim and bill Medicaid. The original facility is responsible for reimbursing the receiving facility for their services rendered. Section 903.2, Policy and Procedures Part II, Hospital Services
Yes, shared agreement - the member is transported to another facility for services and returns to the original facility. Transfer cases – the member is transferred from one facility to another not to return. If BOTH facilities fall into the same DRG they will be reimbursed the lesser of the DRG or CCR (cost to charge ratio) rate. If the DRG is different for the facilities each hospital will be reimbursed the amount that a non-transfer claim would be paid. *Authorization will be required for the receiving facility. Appendix C, number 8, Policy and Procedure Part II, Hospital Services
Julian date is the number day of the year; for example today is the 9th day of 365 and there are 356 days left in the year.
The Julian date is used in the TCN number of the claim and identifies the date the claim was received and entered the claims processing protocol. Providers may use this date to prove timeliness.
http://www.fs.fed.us/raws/book/julian.shtml - for a Julian Calendar
Yes, 2 = electronic crossover, 3 = electronic (straight or vender) submissions, 4 = mass adjustments (requested and approved by DCH), 6 = web portal form, 8 = paper submissions
Services furnished by a hospital, use of a bed, periodic monitoring by nursing or other staff, which is necessary to evaluate the member/patient’s condition to determine if an inpatient admission is required.
48 hours or less
Up to 24
The setting for observation is determined using qualifying criteria such as those published by InterQual, severity of illness and intensity of service, medical necessity and the physician’s orders for the observation, inpatient admit or discharge.
Section 903.6, January 1, 2008
Revenue code 762
The inpatient admit date becomes the ‘admit date” and the from date with the observation hours reported on the claim with revenue code 762.
Short-term rehabilitation services such as, physical, occupational and speech therapy. These services must be rendered immediately following and in treatment of an acute illness, injury or impairment. Section 903.5, Policy and Procedures Part II, Hospital Services
There must be a written plan of treatment established by the physician, which must identify rehabilitation potential, realistic goals and measure progress. The plan must contain the type of modalities, procedure, frequency of visits, estimated duration, diagnosis, functional goals and recovery potential.
The physician must initially certify and re-certify every 30 days that continued therapy is needed. This must include the diagnosis, date of onset of the acute illness, injury or impairment and an estimate of how much longer the service will be needed.
Services must be performed under the supervision of a qualified therapist.
There must be an expectation that the member’s/patient’s condition will improve significantly in a reasonable and predictable amount of time.
The DMA311 is the “Certificate if Necessity for Abortion”; this document should be used only in the situations of life endangerment to the mother’s life if the fetus were carried to term, a victim of rape or incest. This document may be completed and signed by the physician before or after the procedure has been performed. Section 911.1, Policy and Procedure Part II, Hospital Services
Yes, they are:
69.01 Dilation and curettage for termination of pregnancy.
69.51 Aspiration curettage if uterus for termination of pregnancy.
74.91 Hysterectomy to terminate pregnancy
75.0 Intra-amniotic injection for abortion
Yes and these claims should be submitted paper with the following medical records:
History and Physical
The Department reserves the right to request additional documentation in order to complete the review of these claims.
Section 911.1, Policy and Procedure Part II, Hospital Services
The member must be 21 years of age at the time the document is signed.
Medicaid can not reimburse for sterilizations for those members who are not mentally competent, institutionalized in a correctional facility, mental or other rehabilitation facility.
The document must be signed by the member at least 30 days prior to the procedure being performed and the person obtaining the consent must sign at the time the member signs document.
The sterilization procedure must be completed within 180 days of signatures.
The physician must sign the DMA69 after the procedure has been performed.
Yes, they can be located in Policy and Procedure Part II, Hospital Services, sections 911.2
Yes, if the procedure was performed for medical necessity rather than sterilization purposes; these codes are found in the above referenced policy.
These claims are billed separately with their own numbers.
Never, GBHC is used for primary care physician referral to a specialty.
True, with supporting medical records that show the necessity of the additional test.
30 days without medical records, stays with a psychiatric diagnosis and more than 30 days should be submitted paper with medical records supporting that the service was not for treatment of psychiatric services.
No, valid codes may be located on the web portal, www.ghp.georgia.gov , log in with your user ID and password, Claims tab , Enter Claim , scroll down to Discharge status click on drop down box; the codes found in the drop down are the covered codes by Georgia Medicaid
No, there are certain laboratory services that must be billed to the state laboratory. These services are identified in Appendix E, Policy and Procedure Part II, Hospital Services.
Inpatient claims are reimbursed based on a DRG prospective payment system; based on the Tricare Grouper version 24.0. Chapter 1001 and Appendix C, Policy and Procedure Part II, Hospital Services,
Base rate multiplied by the DRG weight =
Answer + facility specific add on = reimbursement.
No, Medicaid will pay up to the DRG less the primary payment.
No, Medicaid will pay up to the Medicare deductible.
Outpatient services are reimbursed by either 90% or 85.6% of cost; the methodology for outpatient reimbursement is found in section 1001 for Policy and Procedure Part II, Hospital Services. *All clinical diagnostic services performed for outpatients and non-patients are reimbursed at the lesser of the submitted charges or at the Department’s fee schedule rates used for the laboratory services program. Section 1001.3, paragraph D, Policy and Procedure Part II, Hospital Services.
DMA550, Newborn Certification should be completed and signed. However, the baby’s temporary number can be obtained through the GHP web portal, www.ghp.goergia.gov
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