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Master Core Curriculum. Part A Basic Module 2 Basics of Billing & Reimbursement. FISS Fiscal Intermediary Shared System OCE Outpatient Code Editor RA Remittance Advice UB-92 Uniform Billing Form RTP Return to Provider. DDE Direct Data Entry EDI Electronic Data Interchange EMC

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master core curriculum

Master Core Curriculum

Part A Basic

Module 2

Basics of Billing & Reimbursement

acronyms
FISS

Fiscal Intermediary Shared System

OCE

Outpatient Code Editor

RA

Remittance Advice

UB-92

Uniform Billing Form

RTP

Return to Provider

DDE

Direct Data Entry

EDI

Electronic Data Interchange

EMC

Electronic Media Claim

FI

Fiscal Intermediary

Acronyms
acronyms1
HIPAA

Health Insurance Portability and Accountability Act of 1996

ANSI

American National Standards Institute

EFT

Electronic Funds Transfer

SPR

Standard Paper Remittance

ERA

Electronic Remittance Advice

ASC

Accredited Standards Committee

Acronyms
learning outcomes
Learning Outcomes

At the end of this module, participants will

be able to:

  • complete applicable portions of the claim form
  • identify common claim form completion and submission errors
  • research and resolve claim filing errors independently
  • understand timely filing requirements
  • recognize different electronic claim submission methods
  • comprehend elements of the Remittance Advice (RA)
overview
Overview
  • Institutional providers bill for services based on the UB-92
    • CMS-1450
  • The UB-92 has 86 data elements
  • Bill Medicare via the institutional 837 V4010A1 transmission format
provider and patient information fls 1 23
FL 1

Provider Name, Address and Telephone Number

FL 3

Patient Control Number

FL 4

Type of Bill (TOB)

TOB 111

FL 6

Statement Covers Period

FL 7

Covered Days

FL 8

Noncovered Days

Provider and Patient InformationFLs 1 - 23
provider and patient information fls 1 231
FL 9

Coinsurance Days

FL 10

Lifetime Reserve Days

FL 12

Patient Name

FL 13

Patient Address

FL 14

Patient Birth Date

FL 15

Patient Sex

Provider and Patient InformationFLs 1 - 23
provider and patient information fls 1 232
FL 17

Admission/Start of Care Date

FL 19

Type of Admission/Visit

FL 20

Source of Admission

FL 22

Patient Status

FL 23

Medical/Health Record Number

Provider and Patient InformationFLs 1 - 23
condition occurrence and value codes fls 24 41
FLs 24-30

Condition Codes

FLs 32-35

Occurrence Codes and Dates

FL 36

Occurrence Span Codes and Dates

FLs 39 -41

Value Codes and Amounts

Condition, Occurrence and Value Codes FLs (24-41)
revenue codes descriptions and charges fls 42 49
FL 42 – Revenue Codes

Accommodation Codes

010X – 021X

Ancillary Service Codes

022X-999X

FL 44

HCPCS/Rates/HIPPS Rate Codes

Revenue Codes, Descriptions, and Charges (FLs 42-49)
revenue codes descriptions and charges fls 42 491
FL 45

Service Date

FL 46

Service Units

FL 47

Total Charges

FL 48

Noncovered Charges

Revenue Codes, Descriptions, and Charges (FLs 42-49)
payer insured and employer information fls 50 66
FL 50

Payer Identification

FL 51

Provider Number

FL 52

Release of Information Certification Indicator

FL 54

Prior Payments–Payers and Patient

Payer, Insured and Employer Information (FLs 50-66)
payer insured and employer information fls 50 661
FL 58

Insured’s Name

FL 59

Patient’s Relationship to Insured

FL 60

Medicare Number or Identification Number

Payer, Insured and Employer Information (FLs 50-66)
payer insured and employer information fls 50 662
FL 61 – Insured Group Name

FL 62 – Insurance Group Number

FL 63

Treatment Authorization Codes

Payer, Insured and Employer Information (FLs 50-66)
diagnosis and procedure coding and physician information fls 67 83
FL 67

Principal Diagnosis Code

FL 68-75

Other Diagnosis Codes

FL 76

Admitting Diagnosis/Patient’s Reason for Visit

Diagnosis and Procedure Coding and Physician Information FLs 67-83
diagnosis and procedure coding and physician information fls 67 831
FL 80

Principal Procedure Code and Date

FL 81

Other Procedure Code and Dates

FL 82

Attending Physician ID

FL 83

Other Physician ID

Diagnosis and Procedure Coding and Physician Information FLs 67-83
remarks provider signature and date fls 84 85
FL 84

Remarks

FL 85

Provider Representative Signature

Remarks, Provider Signature and Date (FLs 84-85)
slide18
OCE
  • The outpatient code editor (OCE) is a software package supplied to the fiscal intermediaries by CMS
    • Two versions
      • Outpatient PPS (OPPS) version
      • Non-OPPS version
slide19
OCE
  • The OCE performs these functions
    • Edits patient data to help identify possible errors in coding
      • Applicable for OPPS OCE and Non-OPPS OCE
    • Assigns Ambulatory Payment Classification (APC) numbers based on the HCPCS codes for payment under the OPPS
      • Only applicable for OPPS OCE
slide20
OCE
  • The following OCE error types will be rejected or returned to the provider for correction
    • Invalid Diagnoses or Procedure Codes
    • Invalid Fourth or Fifth Digit for Diagnoses Codes
    • E-Code as Principal Diagnosis
slide21
OCE
  • The following OCE error types will be rejected or returned to the provider for correction
    • Sex Conflict
    • Questionable Covered Procedures
    • Non-covered Procedures
    • Medicare as Secondary Payer - MSP Alert
slide22
OCE
  • The following OCE error types will be rejected or returned to the provider for correction
    • Invalid Age
    • Invalid Sex
    • Date Range
    • Valid Date
    • Unlisted Procedures
    • Quality Improvement Organization (QIO)
slide23
OCE
  • An updated version of OCE is generally installed into the FISS every quarter
  • CMS releases quarterly updates to the OCE Specifications via the Medicare Claims Processing Manual
    • See Pub 100-4, Chapter 4
      • www.cms.hhs.gov/manuals/cmsindex.asp.
claims correction
Claims Correction
  • A return to provider (RTP) is issued when an incorrect claim is submitted to Medicare
    • Perform one of these actions to correct a claim error
      • Write correction on hardcopy RTP and return to FI
      • Correct via Direct Data Entry (DDE)
      • Correct the error within the electronic claim and submit a new claim
  • Adjustment and cancellation claims
  • Reject = non-medical
  • Denial = medical
common ub 92 errors
Common UB-92 Errors
  • FLs 12 – FL 13
    • Patient Name
    • Patient Address
  • FL 22
    • Patient Status
  • FL 60
    • Medicare Number or Identification Number
common ub 92 errors1
Common UB-92 Errors
  • FLs 67-76
    • Principal Diagnosis Code
    • Other Diagnosis Codes
    • Admitting Diagnosis/Patient’s Reason for Visit
  • FLs 82 – FL 83
    • Attending Physician ID
    • Other Physician ID
timely limitations for filing part a claims
Timely Limitations for Filing Part A Claims
  • File claims on, or before, December 31st following the year in which the services were furnished
    • Services from October 1st – December 31st are considered furnished in the following year
  • Important dates
    • Line-item dates
    • “From” dates
reimbursement
Reimbursement
  • Prospective Payment System
    • A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount
    • A payment amount for a particular service is derived based on a classification system for that service
reimbursement of acute hospital benefits
Reimbursement of Acute Hospital Benefits
  • Prospective Payment System (PPS)
  • Paid fixed dollar amount according to Diagnostic Related Group (DRG)
    • Hospital’s geographic location
    • Diagnoses/procedures
    • Patient’s age, sex, discharge status
  • Not necessarily impacted by patient’s length of stay or amount billed
  • Outlier payment may be made when actual charges exceed DRG formula
reimbursement of snf benefits
Reimbursement of SNF Benefits
  • Skilled Nursing Facility Prospective Payment System (SNF PPS)
  • Paid fixed dollar amount according to Resource Utilization Group (RUG)
    • Determined by Minimum Data Set (MDS)
    • Screening status
    • Clinical status
    • Functional status
reimbursement of outpatient hospital benefits services
Reimbursement of Outpatient Hospital Benefits Services
  • Provided at acute care hospital
  • Reimbursed under Outpatient Prospective Payment System (OPPS)
  • Similar services grouped into Ambulatory Payment Classifications (APCs)
  • Fixed amounts for each APC
    • Reimbursement amount
    • Coinsurance amount
  • Multiple APCs may be performed in one procedure
reimbursement of outpatient hospital benefits
Reimbursement of Outpatient Hospital Benefits
  • Services provided at Critical Access Hospital (CAH)
    • Outpatient services are reimbursed at cost
  • Reference laboratory services are paid at fee schedule
electronic data interchange edi
Types of EMC

Tape

Diskette

Direct Data Entry (DDE)

Direct Wire

Dial-in Telephone

Digital Fax

Personal computer

Upload

Download

Electronic Data Interchange (EDI)
electronic data interchange edi1
Electronic Data Interchange (EDI)
  • Health Insurance Portability and Accountability Act of 1996 (HIPAA)
    • American National Standards Institute (ANSI)
    • Approved HIPAA vendors
      • http://www.cms.hhs.gov/providers/edi/
electronic data interchange edi2
Electronic Data Interchange (EDI)
  • EDI Enrollment Form
    • Required before submitting an Electronic Media Claim (EMC)
  • Submitter Number
    • Assigned by FI
electronic data interchange edi3
Electronic Data Interchange (EDI)
  • EDI Testing
    • Required for new submitters
    • Claims tested for
      • Format
        • 100% pass rate
      • Data Edits
        • 95% pass rate
electronic data interchange edi4
Electronic Data Interchange (EDI)
  • EDI Testing Errors
    • Errors in data element NM109
    • Enveloping issues
      • ISA and GS segments
    • Missing/out of order N3 and N4 segments
    • Submitter’s contact phone number missing
    • SBR (subscriber) data elements missing
      • SBR09 identifies the incorrect payer
electronic data interchange edi5
Electronic Data Interchange (EDI)
  • Free Claim Submission Software
    • $25 Fee for post and handling
    • Creates records in either
      • UB-92 Format
      • Accredited Standards Committee (ASC) x12N837
    • “User Friendly” qualities
      • Low initial investment
      • Easy installation
      • Minimal training required
      • Clear and understandable software documentation
direct data entry dde
Inquire

Medicare patient eligibility

Part A and Part entitlement

MSP info

Enter

Key electronic claims and submit directly

Correct

Correct RTP claims

Adjust claims incorrectly paid

Cancel/void claims incorrectly paid

Access

Revenue Codes

HCPCS Codes

ICD-9-CM Codes

Fiscal Intermediary Shared (FISS) Reason Codes

Adjustment Reason Codes

Research

DRGs for Inpatient Hospital PPS Claims

Direct Data Entry (DDE)
remittance advice ra
Remittance Advice (RA)
  • RA explains payments and adjustments
    • Paper
    • Electronic
  • There is an RA item for each of the following
    • Line-item payment
    • Reduction to payment
    • Denial of payment
remittance advice ra1
Remittance Advice (RA)
  • Standard Paper Remittance (SPR)
    • Uniform in both content and format
    • Ease transition to ERA
  • Electronic Remittance Advice (ERA)
    • Accredited Standards Committee (ASC) X12N 835 format
remittance advice ra2
Remittance Advice (RA)
  • PC-Print software
    • Receive, via a wire connection, an 837 electronic remittance advice transmission on a personal computer (PC)
    • Write the 837 file in American National Standard Code for Information Interchange (ASCII) to the provider’s “A:” drive;
    • Print 837 claims and provider payment summary information;
    • View and print remittance information for a single claim; and
    • View and print a sub-total by bill type.
electronic funds transfer
Electronic Funds Transfer
  • Electronic Funds Transfer (EFT)
    • Authorization Required
      • FORM CMS-588, Authorization Agreement for Electronic Funds Transfer
    • Quickest method of payment
references
References

CMS References

  • Publication 100-4 in the CMS Online Manual
    • www.cms.hhs.gov/manuals/cmsindex.asp
  • CMS EDI Page
    • www.cms.hhs.gov/providers/edi/
  • CMS Medicare Learning Network webpage
    • www.cms.hhs.gov/medlearn/
references1
References

Other websites

  • Fiscal Intermediary Home Pages
  • State Hospital Associations
    • Produce UB-92 manuals at a reduced cost
  • Publishers
    • Produce updateable UB-92 Editors in electronic and hardcopy formats