Master Core Curriculum

1. Master Core Curriculum Part A Basic Module 2 Basics of Billing & Reimbursement

2. 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

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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)

11. FL 45 Service Date FL 46 Service Units FL 47 Total Charges FL 48 Noncovered Charges Revenue Codes, Descriptions, and Charges (FLs 42-49)

12. 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)

13. 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)

14. FL 61 – Insured Group Name FL 62 – Insurance Group Number FL 63 Treatment Authorization Codes Payer, Insured and Employer Information (FLs 50-66)

15. 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

16. 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

17. FL 84 Remarks FL 85 Provider Representative Signature Remarks, Provider Signature and Date (FLs 84-85)

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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.

24. 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

25. Common UB-92 Errors • FLs 12 – FL 13 • Patient Name • Patient Address • FL 22 • Patient Status • FL 60 • Medicare Number or Identification Number

26. 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

27. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Types of EMC Tape Diskette Direct Data Entry (DDE) Direct Wire Dial-in Telephone Digital Fax Personal computer Upload Download Electronic Data Interchange (EDI)

35. 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/

36. Electronic Data Interchange (EDI) • EDI Enrollment Form • Required before submitting an Electronic Media Claim (EMC) • Submitter Number • Assigned by FI

37. Electronic Data Interchange (EDI) • EDI Testing • Required for new submitters • Claims tested for • Format • 100% pass rate • Data Edits • 95% pass rate

38. 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

39. 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

40. 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)

41. 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

42. 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

43. 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.

44. Electronic Funds Transfer • Electronic Funds Transfer (EFT) • Authorization Required • FORM CMS-588, Authorization Agreement for Electronic Funds Transfer • Quickest method of payment

45. 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/

46. 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