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HFMA October 25,2007 Understanding the UB04 Clean Claim Process UB04 Presented by Carol D. Eaton Citrus Valley Health Partners. Hospital Billing 101+UB04 Agenda. Registration Charge Description Master(CDM) Coding/Claim Creation HIPAA Electronic Transaction Process UB04 Billing Preparation

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Hospital billing 101 ub04 agenda

HFMAOctober 25,2007Understanding the UB04 Clean Claim ProcessUB04Presented byCarol D. EatonCitrus Valley Health Partners

Hospital billing 101 ub04 agenda
Hospital Billing 101+UB04Agenda

  • Registration

  • Charge Description Master(CDM)

  • Coding/Claim Creation

  • HIPAA Electronic Transaction Process

  • UB04 Billing Preparation

  • UB04 CMS-1450 Billing Process

  • Billing Information

  • Websites

  • Quality Improvements

Revenue cycle perfect picture
Revenue Cycle “Perfect Picture”

Section registration process
Section:Registration Process

  • Scheduling: Target for improvement. Look at the number of departments and patients that can be scheduled or prescheduled.

  • Pre-registration & registration: Improve your pre-registration to improve the time needed to create a clean registrations.

  • Eligibility & Authorization/Certification: Use electronic sources to obtain. Work with your area IPAs to communicate authorizations ahead of time. Assure services match certification / authorization

  • Collecting Co-payments & deductibles: The more you collect and notify upfront, the better chance you have at collecting at all. Payment arrangements also can be made. Published messages or pre-registration & verification.

  • Screening for Medical Necessity & Covered Services: Create the best system for obtaining LMRP/NCD information for Medicare patients. ABNs. Work with Utilization Review or Nursing departments to assure appropriate admissions

Section registration process1
Section:Registration Process

Training must include:

  • Corporate Compliance: Reporting, accuracy of admit/dischg coding, charity and discount guidelines

  • Insurance eligibility, certification, authorization, matrix payer information

  • Medicare: (ABN) Advanced beneficiary notice, (MSP) Medicare Secondary Payer, 3 day window rules, 1 day stay & re-admission rules, Observation requirements, Important Message for Medicare (letter), Condition of Admissions forms

  • HIPAA:(Health Insurance Portability Accountability Act of 1996, Privacy vs Security. (Electronic/Passwords, verbal info, paper shredding). Never breach patient confidentiality.

  • EMTALA: Emergency Medical Treatment Labor Act 1986

  • Clear “patient friendly billing” communication with patients. Smile and maintain eye contact. Sit & stand tall. Voice tone

  • Job Description, manuals, departmental tour (timecard, vacation, attendance, dress code, name tag, HIPAA waste disposal, overtime, tardiness, switching, holidays)

Section registration process2
Section:Registration Process


Sign up for Passwords and ID#s, make lists available to the staff involved:

AETNA www.aetna.com

BLUECROSS http://provideraccess.bluecrossca.com

BLUE SHIELD www.mylifepath.com

CIGNA www.cignaforhcp.com

CBCA ADMINISTRATOR www.cbca.com/login.page

FIRST HEALTH www.firsthealth.com

HEALTHNET www.healthnet.com

INTER VALLEY www.ivhp.com

MEDPOINT MGMT-HLA www.medpointmanagement.com

PHYSICIANS ASSOC www.physicianassoc.com


UNITED HEALTHCARE www.unitedhealthcareonline.com

UNIVERSAL CARE www.universalcare.com

Section registration process3
Section:Registration Process

Section charge master process
Section:Charge Master Process

  • Conduct annual charge master reviews

  • Updates should be quarterly or as often as changes are received

  • Assure that computer order entry is connected to each charge in the specific departments matches the CDM.

  • Review charging tickets frequently

  • Departmental involvement with charge protocols created including CCI edits

  • Develop departmental daily revenue master logs to review for accuracy and assure quality of systems

  • Team approach to charge master changes should include accounting, HIM,IS, PFS, specific department management

  • Periodic review of all coding on claims by third party to check your internal review processing

  • Review ordering practices and assure documentation is present and accurate to match billing claims

  • Education to all staff of changes, charge protocols, Federal payer documents as they arrive.

  • System capture of requests, changes, audits and education

  • Make sure the claim editor, billing staff or claim vendors are not changing your claim without you know exactly what’s changed!

Section charge master process1
Section:Charge Master Process

Newborn Screening Facilities

Department of Health Services program began dated July 11,2005.

January 1, 2007 price increased from $18.95 to $20.35.

Usually the price changes occur in January & August.

July 16,2007 82261 & 83516 added,still the same final $cost

Billing will be as follows on your Inpatient claims (Newborn and NICU):

  • Hydroxyprogestene 17-d(17-OHP) 83498 $14.50

  • Tandem mass spectrometry(MS/MS) 83789 $14.75

  • Galactose 1 phosphate uridyl transferase 82776 $14.50

  • Hemagobin fract &quant; chromatography 83021 $14.50

  • Thryoid stimulating hormone (TSH) 84443 $14.50

  • Biotinidase (BD) 82261 $14.50

  • Immunoreactive Trypsinogen(IRT) 83516 $14.50

  • Genetic screening specimen collection DHS 36415 $1.00

  • Genetic screening draw/handling DHS 99001 $6.

    Must equal a total of $102.75+$6.00 blood draw fee



Section charge master process2
Section:Charge Master Process

Revenue Code Assignment Reminder

  • CMS recommends the use of revenue codes that closely define where the procedures are performed. Revenue codes involved:

    036x Surgical,045x Emergency Room, 051x Clinic,075x GI

  • Surgical Procedures

    10021-69990, 0008T, 0016T-0024T, 0027T 0033T-0040T, 0046T-0048T, 0050T-0056T, 0061T-0063T, 0071T, 0075T-0081T, 0084T, 0088T, 0090T-0100T, 0120T-0126T, 0133T, 0138T, 0141T-0143T

  • Cardiovascular 92950-92961(Resp.& ER can’t both charge for the same encounter)

  • Photodynamic therapy96567, 96570-96571

  • Other services & procedures99170, 99185-99186, G0127

  • Critical Care99291-99292 Therapeutic 90782-90799

    Device Coding

  • Effective April 1, 2005 OPPS require providers to code device HCPCS even if many of the are status indicator “N”.

  • Devices are reported under RC 272,275,276,278,279.

Section charge master process3
Section:Charge Master Process

  • Example: Charge Master line item

    Charge# Description $ CPTHCPCS Rev Code

    4540000 Dialysis Unch/ESRD/Emerg $xx.00 90935G0257 820

    The coding comes from the Charge Master

  • Example of charge on a claim

    Group Ins Claim (CPT coding passes)

    820 Dialysis Unch/ESRD/Emerg 070107 90935 $xx.00

    Medicare Claim (HCPCS coding passes)

    820 Dialysis Unch/ESRD/Emerg 070107 G0257 $xx.00

    G0104 Expired code: January 1, 2007 for Occult Blood (use 82270 only) See CR#5292 September 22,2006 R1062CP MM5292

Section coding claim creation
Section: Coding/Claim Creation

ICD-9-CM – International Classification of Diseases 9th Revision Clinical Modification

Volume 1 – Contains five appendices & Tabular list of codes including V codes (i.e.,426.6 Other heart block):

Appendix A: Morphology of Neoplasm's

Appendix B: Deleted effective October 1 of each year

Appendix C: Classification of Drugs by AMA and their ICD9CM equivalents

Appendix D: Classification of Industrial Accidents according to agency (i.e., external causes: E828 Animal,riden)

Appendix E: List of Three-Digit categories

Volume 2 – Diagnostic terms that are not in volume 1. Index to diseases includes most diagnostic terms in use.

Volume 3 – Operations and procedures. 2 digits with one or two digits following the decimal point. (i.e.,01.31 Incision. cerebral meninges)

For information on ICD-9-CM and POA information:MM5499 CR5499



ICD-10-CM is scheduled for October 2008

Section coding claim creation1
Section: Coding/Claim Creation

CPT Level I- AMA’s physicians’ Current Procedural Terminology

Often referred to as HCPCS by the federal government payers

Evaluation and Management (99201-99499)

Anesthesiology (00100-01999, 99100-99140)

Surgery (10021-69990)

Radiology (including nuc.medicine, radiation onc., diagnostic ultrasound)(70010-79999)

Pathology & Laboratory (80048-89356)

Medicine (90281-99602)

HCPCS Level II-National-Healthcare Common Procedure Coding System.

Broad spectrum of services and supplies from patient transport to ostomy supplies, from chemotherapy drugs to durable medical equipment, and new technologies.(i.e.,G0103,J7030,Q3001)

Local Codes LevelIII-Specific State codes for Medicaid programs.

CPT & HCPCS level II Modifiers -Providescommunication with payers to indicate altered by somespecial circumstance(s) but the code description itself has not changed.

**The existence of a procedure code does not imply coverage under any given insurance plan.**

Hospital billing 101 ub04 agenda

CPT Modifiers










Medicaid: 50,51,80,99,P1,ZG,ZK,ZN

HCPCS Level II Modifiers











Section: Coding/Claim CreationModifier UsageMedicare Claims Processing Manual, Pub. 100-04, chap 4, secs.20.5.3,20.6-20.8(trans.442 01/21/05 & trans. 496,03/04/05)

Section coding claim creation2
Section:Coding/Claim Creation

The coding comes from the Medical Records Abstracting


  • -Diagnoses- ICD9 volume 1 ABS Status FINAL


  • 1 706.2 SEBACEOUS CYST



  • -Procedures- ICD9 volume 3 Date Physician Adm

  • 1 82.21 EXC LES TEND SHEATH HAND 01/04/07 EDIE E


  • 3 (837I only)POA:Y,N,U,W,1

  • -CPT Codes- CPT volume I Date

  • 1 11422 EXC H-F-NK-SP B9+MARG 1.1-2 01/04/07

  • 2 25111 REMOVE WRIST TENDON LESION 01/04/07

  • 3 00400 ANESTH, SKIN, EXT/PER/ATRUNK 01/04/07

Section coding claim creation3
Section:Coding/Claim Creation

  • Example of medical records abstracting coding on a claim.

    Group Ins Claim or Medicare claim

    360 Operating Room 010406 11422 $xx.00

    360 Operating Room 010406 25111 $.00

    370 Anesthesia 010406 00400 $xx.00

    Depending on the hospital system, coding from medical records will commonly be involved in some or all of these revenue codes.

    360 Surgery, 361 Minor/Interventional Surgery, 369 Other OR, 450 Emergency room proc, 750 Gastrointestinal Lab.

    Know your hospital’s own charge master vs. medical record (HIM) coding system and how they flow to the claims you submit.

Section coding claim creation4
Section:Coding/Claim Creation


252 DEMEROL 25MG AMP 010407 3 242.60

257 BACITRACIN OINT 15GM 010407 1 55.10

272 BANDAGE SURGICAL 010407 4 319.55

310 GROSS & MICROSCOPIC III 88304 010407 2 400.00

360 360 OR SERVICES 11422 010407 1 7131.00

360 360 OR SERVICES 25111 010407 1 0

370 370 ANESTHESIA 00400 010407 1 793.50

636 VERSED 2MG/2ML INJ J2250 010407 1 88.30

636 REGLAN INJ 10MG J2765 010407 1 73.85

636 SUBLIMAZE 2ML AMP J3010 010407 1 83.85

710 710 RECOVERY ROOM 010407 1 922.25

820 Dialysis Unch/ESRD/Emerg 90935 010407 1 1000.00

  • TOTAL CHARGE $10110.00

    Page 1 of 1 Creation date 010807 $10110.00

    NPI 1234567890


    TENDER,TEDDY 18 XDD333A66688

    12444555777 FLY BY NIGHT FINANCIAL

    Y996.73 Y403.91 U72742 WV163



    3895 010407 863 010407 1222444445 G2 A663334


Hipaa electronic transaction process
HIPAAElectronic Transaction Process

Hipaa electronic transaction process1
HIPAAElectronic Transaction Process

  • 270/271 Inquire and Receive Response providing health care eligibility or benefit information associated with a subscriber or dependent.

  • 278 Inquire and Receive a response for the following from Utilization Review units:

    • Admission certification review

    • Referral review

    • Health care services certification

    • Extend certification review

  • 837 Institutional, Professional, Dental claim

  • 276/277 Claim Status Request/Response to obtain payer status (accepted/rejected, denied, approved and pending

  • 835 Claim Payment/Advice, Explanation of Benefits (EOB) submission to providers or other payers

  • Section billing preparation ub04 cms 1450
    Section:Billing PreparationUB04 CMS-1450

    This section was developed to train you on specific FL-fields of the UB04 CMS-1450

    Not all of the FL-fields are in this text, only the fields that have heavy usage and need knowledge based training

    For more information on the new forms

    UB04 CMS-1450

    May 23,2007 Implementation

    (Transitional 3/1/07-5/22/07 CMS trans#1018 July 28, 2006)

    National Standars Insti X12N 837 I Health care claim companion document


    Go to: http://www.nubc.org

    New 1500 HICF X12N 837 (08/05)

    July 2, 2007 Implementation (Updated R1247CP)



    Go to : http://www.nucc.org

    Section billing preparation ub04 cms 14501
    Section:Billing PreparationUB04 CMS-1450

    Transitional Evolution changes from

    UB-92 to UB-04

    • Pay-to-name and address (New FL02)

    • Patient name – ID (Update FL08)

    • Accident State (New F29)

    • Page_of_Creation date (New F43-F44)

    • Creation date (New FL45)

    • Identifiers – NPI National Provider Identifier (FL56,FL76-FL79)

    • Principal diagnosis code required. (FL67 & other FL67A-Q)

    • Diagnosis indicator Field – Report if the diagnosis was present on admission (FL69)

    • Patient’s Reason for Visit Code (FL 70A 70C)

    • PPS Code Field (New FL71)

    • External Cause of Injury Code (New FL72 1-E code only)

    • Code-Code Qual/Code/Value (New FL81)

    Section billing preparation ub04 cms 14502
    Section:Billing PreparationUB04 CMS-1450


    UB-92 to UB-04

    • Increase Type of Bill to 4 digits

    • Increase filed size for HCPCS/Rate/HIPPS Rate codes-2 added modifier positions

    • Additional 3 Condition Code fields

    • Expanded diagnosis code field to prepare for ICD-10-CM

    • Additional Occurrence Span Code field

    • Usage matrix created for Type of Bill

    • Current regulations and industry standards restated on the back of the form

    Section billing preparation ub04 cms 14503
    Section:Billing PreparationUB04 CMS-1450

    CMS Related Publications/Articles

    SE0608 – CMS Subpart Policy:


    SE0659 - Guidance for Reporting NPI In Medicare claims


    MM4023- CMS policy for NPI-stage 2 implementation:


    MM5229 – Modification of NPI editing requirements of CR4023/MM4023


    MM5243 - R1024CP-Reporting Taxonomy Codes for Subpart NPI’s


    CR5436 –Trans#1154 Healthcare Provider Taxonomy Codes Update

    Section billing preparation ub04 cms 14504
    Section:Billing PreparationUB04 CMS-1450

    CMS Related Publications/Articles continued

    MM5072 – UB-04 Implementation:


    MM5081 revised – Stage 2 NPI Changes for 835 transactions:


    CR5318 Trans#183 Jan 24,2007- Update the MCS System to Validate NPI in place of UPIN

    CR4191 Trans#141 Feb 24,2006-Modification to the UPIN process

    CR5072 Trans#1104 Nov 3,2006-Uniform Billing (UB-04) Implementation

    SE0659-Important Guidance regarding NPI usage in Medicare claims

    MM5499 / CR5499 – Present on Admission Indicator POA

    MM5378 Revised-Claims submitted with only a NPI during the Stage 2NPI Transition Period

    MM5452 Trans#R1241CP Stage 3 NPI changes for transactions 835 & RA

    Section billing preparation ub04 cms 14505
    Section:Billing PreparationUB04 CMS-1450

    CMS Related Publications/Articles continued

    MM5072 Revised-Uniform Billing (UB-04)Implementation-UB92 Replacement

    MM5584-Discontinuance of the UPIN Registry

    MM5411-Institutional Value Code Changes

    Federal Register Vol.72 #103,Wed. May 30,2007 –HIPAA National Plan and Provider Enumeration System Data Dissemination

    MLN SE0725 NPI Errors, using NPI on claims and 835 Remittance advices changes http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf


    NPI REGISTRY SEARCH!!! Look up all your Individual or Organizational Provider

    https://nppes.cms.hhs.gov CLICK on REGISTRY SEARCH

    CMS Related Publications/Articles CMS1500 08-05

    MM5060 - CMS1500 08-05 Implementation


    Medi-Cal website to Register NPI(s) MEDI-CAL will still require Provider#!!!!!!!!


    Section billing process ub04
    Section:Billing ProcessUB04

    FL 2 Pay-to-Address City State-Pay to ID

    (SE0659 has information regarding this field)

    1C-City position,left justified

    1D-State Position

    1E-Zip code position

    1F-Phone Position

    3A Patient Control #(acct#)

    3B Medical Records Number-Unit Number

    FL 4 Type of Bill(4 digits,1st is 0)

    First digit:Type of Facility(Expanded from size 3 to 4)

    Second digit:Bill Classification(Inpatient,Swing bed)

    Third digit: Sequence/Frequency for a specific episode of care

    2 Interim 5 Late Charges

    3 Interim Continued 7 Replacement of prior claim

    4 Interim last claim 8 Void

    5 Late charges 9 Final HH PPS

    Section billing process ub041
    Section:Billing ProcessUB04

    FL 4 Continued

    Common Examples:

    11x Hospital Inpatient

    12x Hospital Inpatient (Medicare Part B Only)

    13x Hospital Outpatient

    21x Skilled Nursing Inpatient (Including Medicare Part A)

    DISCONTINUED Medicare 10/01/05: 17x. 24x, 27x, and 5xx

    Section billing process
    Section:Billing Process

    FL 6 Statement Covers Period

    • Report the beginning and ending dates of service for the entire period reflected on the bill.

    • Outpatient hospital claims where the from and through dates are equal and a HCPCS code is reported, a line-item date of service must be reported also in FL45.

    • SNF inpatient claims must equal the total units reported in FL46 for accommodation.

    Section billing process1
    Section:Billing Process

    FL7 Unlabeled(UB92 FL7 Replace w/ Value code 80)

    ”Medicare Covered Days”

    FL8 Patient Name & ID(8a) UB92 FL 8 Replace w/Value code 81)

    FL8(a)=Patient Identifier-Patients insurance policy number

    FL9 Street, City, State, Zip & Country(outside USA)Code (UB92 FL 9 Replace w/Value code 81)

    FL10 Patient Birthdate(UB92 FL10 Replace w/Value code 83)

    Section billing process2
    Section:Billing Process

    FL11 Patient Sex

    Old: FL08,09,10 replaced=value codes

    Marital status has been eliminated

    FL12 Admission Date

    FL13 Admission Hour

    FL14 Type of Admission /Visit (old FL19)

    1 Emergency

    2 Urgent

    3 Elective

    4 Newborn

    5 Trauma

    9 Info not available

    Note: Date of death can not be changed by Medicare Intermediaries/Carriers. Death certificates must be sent with a request directly to the Social Security Administration office.

    Section billing process3
    Section:Billing Process

    FL15 Source of Admission

    (Reorganized to focus on patients’ place or point of origin rather than source of physician order or referral)

    1 Physician Referral

    2 Clinic Referral

    3 HMO Referral (Discontinued 10/01/07)

    4 Transfer from a hospital (Different facility)

    5 Transfer from a SNF-Skilled Nursing or ICF-Intermediary Care Facility

    6 Transfer from Another Health Care Facility

    7 Emergency Room

    8 Court/law enforcement

    A Transfer from a Critical Access Hospital (Discontinued 10/1/07)

    B Transfer from Another HHA

    C Readmission to same HHA

    D Transfer from one Dist.Unit of the Hospital to Another Distinct unit, (resulting in a separate claim to the payer)

    E Transfer from Ambulatory Surgery Center

    F Transfer from Hospice under Plan of Care or enrolled in Hospice Program

    ADDITIONAL FL Coding Structure: NEWBORN 1 Normal Delivery (Normal) (Discontinued 10/01/07)

    2 Premature Delivery (Premie) (Discontinued 10/01/07)

    3 Sick baby (Sick) (Discontinued 10/01/07)

    4 Extramural Birth (Born in non-sterile envirn.)(Discont.10/01/07)

    5 Born inside the Hospital (NEW 10/01/07)

    6 Born outside the Hospital (NEW 10/01/07)

    9 Unknown

    Section billing process4
    Section:Billing Process

    FL 17 Patient Status

    Hospitals are responsible for ensuring that patient status codes are accurate. This is an OIG audit target for PPS reimbursement

    01 Discharged to Home or Self-Care

    02 Discharged/Transferred to a Short-Term General Hospital for Inpatient Care

    03 Discharged/Transferred to SNF w/Medicare Certification (TCU)

    04 Discharged/Transferred to an Intermediate Care Facility (ICF)

    05 Discharged/Transferred to a Non-Medicare PPS Children’s hospital or PPS Cancer Hospital for Inpatient Care

    06 Discharged/Transferred to Home under Care of organized Home Health Service Organization in anticipation of covered skilled care

    Code when patient is disch/transf to home with a written plan of care for home care services. Not used for HHA provided by a DME supplier or from a home IV provider for Home IV services. See also condition 42 or 43

    07 Left against Medical Advice or Discontinued Care

    08 (Discontinued 10/1/05)

    09 Admitted as an Inpatient to this hospital

    Section billing process5
    Section:Billing Process

    FL17 Patient Status- Continued

    20 Expired (*accepted by Medi-Cal)

    30 Still a Patient

    40 Expired at home

    41 Expired in a Medical Facility such as a hospital, SNF,ICF or Free standing hospice (TOB 81x,82x)

    42 Expired, Place Unknown (TOB 81x, 82x)

    43 Discharged/Transferred to a Federal Health Care Facility (VA, Dept Of Defense Hospital)

    61 Discharged/Transferred within this institution to a Hospital-Based Medicare Approved Swing Bed

    62 Discharge/Transferred to an Inpatient Rehabilitation Facility (IRF) Including Rehab. Distinct part units of a hospital

    63 Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH)

    64 Discharged/Transferred to a Nursing Facility Certified Under Medicaid but not certified under Medicare

    65 Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital

    Section billing process6
    Section:Billing Process


    Conditions (FL 26,27,28 New condition codes):

    The codes communicate to the payer employment and eligibility conditions that affect the claims processing


    01 Military service related

    02 Condition is employment related

    06 ESRD patient in first 18 months of entitlement covered by employer group health insurance

    Special Conditions:

    09 Neither patient nor spouse is employed (MSP)

    17 Homeless

    18 Maiden Name Retained

    19 Child Retains Mother’s Name

    20 Beneficiary requested billing ”Demand”

    44 Inpatient Admission Changed to Outpatient (documentation & physician agreement is required before billing)

    Section billing process7
    Section:Billing Process

    FL18-28 Conditions:

    49 Product replacement within product lifecycle (Nov 4, 2005 MM4058 CR 4058) *CMS to track costs

    50 Product replacement for know recall of product (Nov 4, 2005 MM4058 CR 4058) *CMS to track costs

    GO Multiple ER visits occur on the same day (see modifiers 25,27)

    Claims reviewed by QIO or QIC with denial or preauthorization see codes: C3-C7

    in Transmittal 632 July 29,2005 Effective 01/03/06,after service dates 07/01/05

    Medicaid claims:

    81 Emergency certification A1 EPSDT/CHDP

    A4 Family Planning AI Sterilization/Consent Form(PM330)

    • There are many codes under this section, refer to the UB92-UB04 manual

    Section billing process8
    Section:Billing Process

    FL 29 Accident State


    31A= A1-Ins 1 subscriber birth date

    32A= B1 Ins 2 subscriber birth date

    33A= C1 Ins 3 subscriber birth date

    Occurrence & Dates:

    The codes & dates communicate to the payer specific events to determine liability and coordinate benefits that will affect the claims processing


    01 Accident/Medical coverage w/date of accident

    06 Crime Victim

    10 Last Menstrual Period (Maternity related condition claims)

    11 Onset of symptoms or exacerbation/illness w/date treatment started(Rev codes: 041x,042x,043x,044x,0943)

    27 Date of Hospice certification or recertification

    35 Date Treatment Started for Physical Therapy

    44 Date Treatment Started for Occupational Therapy

    45 Date Treatment Started for Speech Therapy

    46 Date Treatment Started for Cardiac Rehab

    Section billing process9
    Section:Billing Process


    Occurrence Span codes & Dates:

    (2 new Occurrence Span codes)

    The codes & dates communicate to the payer specific events that SPAN over time to coordinate benefits that will affect the claims processing


    70 Qualifying stay dates for SNF(3 day hospital that qualifies the patient for Medicare SNF)

    72 Actual dates of the first and last outpatient services visit (if dates in FL6 are different)


    Responsible Party (for the bill) Name and Address

    Section billing process10
    Section:Billing Process


    Value codes & Amounts:

    The codes & amounts communicate specific codes and related monetary amounts that will affect the claims processing


    01 Most common semi-private room rate,$$$

    02 Hospital has no semi-private rooms (0.00)

    12 Working aged beneficiary/spouse with EGHP, $$$

    13 ESRD Beneficiary in Medicare Coordination Period w/EGHP

    14 No-Fault, Including auth/other

    15 Work Compensation,$$$

    41 Black Lung (BL)

    42 Veterans Affairs (VA)

    43 Disabled Beneficiary Under Age 65 w/LGHP

    45 Accident Hour(non Medicare) 2pm=14 00 in cents

    Section billing process11
    Section:Billing Process


    Value codes & Amounts:

    50 Physical Therapy Visits (# from onset from billing provider through this billing period)

    51 Occupation Therapy Visits “

    52 Speech Therapy Visits “

    53 Cardiac Rehabilitation Visits “

    54 Newborn birth weight in grams

    55 Eligibility Threshold for Charity Care

    68 EPO Drug-Amount reflect the #EPO units admin or supplied

    69 State Charity Care Percent - Amount reflect the % of charity care eligibility for the patient

    75-79 These codes are set aside for payer use ONLY

    80 Covered Days 81-Noncov.Days 82-Co-ins Days 83-LTR

    A4-A6 Self-Administrable Drug codes to support revenue 0637

    July 1,2007 A1,A2,A7,B1,B2,B7,C1,C2,C7 now restricted to paper claims only,no longer X12N 837 Insti.claims MM5411

    Section billing process12
    Section:Billing Process


    Revenue Codes

    There are 22 lines available on a single UB-04 claim form to list revenue codes and charges. The codes consist of 4 digits. Many systems drop the first digit from paper claims. Each facility must decide to program these codes with either a “General” revenue code (ending in 0) OR “Detail” revenue code (ending in 1-9 as appropriate).


    250 “General” Pharmacy

    251-259 “Detail” Pharmacy

    In most cases it is to your advantage to code detail for Medicare and Payer requirements. Accuracy is important to your facilities cost reporting. Avoid manual changes to your claims.

    Under Home Health PPS one revenue code line is used for the request for anticipated payment (RAP) The line is used to report the Health Insurance Prospective Payment System (HIPPS) code(FL44)

    Certain revenue codes are contracted with payer to pay with invoice or requisition forms. 278 Implants, 636 Specifically coded drugs

    This requires some step by step review by your facility to ease the process for the billing staff to deal with the carve-out contract requirements

    Section billing process fl42 revenue codes common

    0001 Total Charges

    002X HIPPS PPS codes-Subcategory

    2 Skilled Nursing Facility (TCU) SNF PPS(RUG)

    3 Home Health PPS HHS PPS (HRG)

    4 Inpatient Rehabilitation PPS IRF PPS (CMG)

    01XX&02xx Room & Board charges

    025x Pharmacy

    027x Supplies

    03xx Lab

    032x Radiology Diagnostic

    033x Radiology Therapeutic

    034x Nuclear Medicine

    0343 Diagnostic Radiopharm.

    0344 Therapeutic Radiopharm.

    035x CT Scan

    036x Surgery

    037x Anesthesia

    041x Respiratory

    042x Physical Therapy

    043x Occupational Therapy

    044x Speech-LanguagePathology

    045x Emergency Room

    046x Pulmonary Function

    048x Cardiology

    049 Ambulatory Surgical Care

    061x MRI

    063x Pharmacy(HCPCS required)

    072x Labor Room/Delivery

    073x EKG/ECG

    075x Gastro-Intestinal Services

    076x Treatment or Observation

    080x Inpatient Renal Dialysis

    092x Other Diagnostic Services

    Section:Billing ProcessFL42 Revenue CodesCommon

    Section billing process13
    Section:Billing Process

    FL43 - 44 Page__of __Creation Date *NEW*

    FL44 Rates/HIPPS/HCPCS-CPT Codes

    (Expanded to 4 modifiers =14 digits)

    Almost all revenue codes require a HCPCS/CPT code. This field is to report appropriate codes for the service performed. Some payers have edits that will require a specific “detail” revenue code for a specific HCPCS/CPT

    • This field is also for reporting Room and Board Rates

    • RC 0022=Skilled Nursing Facility HIPPS Rate/RUG code

    • RC 0023=Home Health HHPPS Rate/HRG code

    • RC 0024=Inpatient Rehab.Facility IRF HIPPS Rate/CMG code

    • NDC-National Drug Code #s(11 digits) for specific drugs (See Federal Register Feb 20,2003 Vol.68,number 34 Page 8381-8399) No standard code set at this time for non-retail. Trading partners must carefully make agreements. Medicare requires NDC# with the use of C9399 newly approved FDA drugs/ biologicals. CDHS (Calif.Dept.Health Services) is in the process of discussions with providers regarding the implementation of NDC’s on Medi-cal claims. CalHospital Association-Sherreta Lane is working on a provider communication panel.

    Section billing process14
    Section:Billing Process

    FL 45 Service Date – Creation Date

    Required Outpatient

    Report line item dates of service on all bills containing revenue codes, procedure codes or drug codes. This includes claims where the “from” and “through” dates are equal. This was due to HIPAA requirements

    This line is also used for transmitting:

    • SNF MDS assessment reference date RC 0022

    • HHPPS date of first billable services provided RC 0023

    • IRF must enter the date the final assessment was transmitted to CMS national assessment collection database RC 0024

      Late assessment policy will affect your Rehabilitation payments eff.01/01/06 (28 days or more from Dischg):


    Section billing process15
    Section:Billing Process

    FL46 Units of Service

    • Number of services that relate to the HCPCS/CPT codes reported

    • Rehabilitation Therapy Services modalities that have time increments are to report each 15min in unit measurements. Example: 1 unit = 8mins. To <23 mins.

    • OPPS Emergency Room exceeds 24 hour, see Trans#881 CR4252 March 3,2006,eff April 3,2006

    • Maximum allowable unit OCE edits will require system programming to avoid rejected claims

    • Drugs- Facility CDM description vs. HCPCS/CPT description. Many drugs need to be multiplied to equal the HCPCS description on the claim.

      Example: CDM Description rev.636 : Insulin inj.100 units

      CDM HCPCS/CPT:J1815 Inj. Insulin per 5 units

      MULTIPLY 20 to get paid for the 100 units

    Section billing process16
    Section:Billing Process

    FL46 Units of Service Continued:

    • Observation: Service units will equal the number hours rounded to the nearest hour and counted from the time the physician wrote the order to admit and discharge. PM Transmittal A-02-129 January 3,2003

    • Infusion Therapy and Chemo Therapy: Make sure to charge & count units appropriately by rules made in Pub 100-04 Medicare claim processing December 16,2005 Trans#785 CR4258 & April 7, 2006 Trans#902 CR4388

    • Outpatient Therapy Visits-0410, 0420, 0430,044, 0480, 0910, and 0943 (Units=number of times the proc/service is performed)Trans#805 CR4226 Jan.06,2006

    Section billing process17
    Section:Billing Process

    FL48 Non-covered Charges

    • Non-covered days (FL8) must have Non-covered charges placed in this field

    • Modifiers that pertain to reporting ABN signed items, must have reported non-covered charges

      (report occurrence code & date in FL32-35)

      (modifiers EY,GA,GL,GY,GZ,KB or TS along w/ HCPCS in FL44)

      FL49 Unlabeled

      FL50 Payer Identification

    • Payer must be placed in position 50A,50B,50C. A being the primary and B secondary, C tertiary

    • Proof of MSP screening to support Medicare placement position is critical (GHP working aged,ESRD,LGHP disabled beneficiary,auto or liability ins.,workers’ compensation,black lung, VA)

    • Medicaid utilizes “Type of Claim” in this field. See manuals

    Section billing process18
    Section:Billing Process

    FL50 Provider Number

    • This field has 13 alphanumeric characters in each of the three lines

    • Yearly checks of your claim forms and facilities to assure correct provider numbers are used.

    • CMS is now processing new applications for the national provider identifier (NPI) to each provider. This will replace the current provider numbering system by May 23, 2007 for most health care providers. Small plans May 23, 2008

    • Make sure no hyphens

    • Medicaid utilizes nine characters in their assigned number system

      FL51 A-C Health Plan ID

      Will be used after the National Plan ID rule is published. NPPES will also issue these numbers. Electronic vendors may already submit using these payer tables currently.

      FL54 Prior payments-Payers / Patients

    • Prior payments should be entered up to 10 digits

    • Amounts should be entered is titled “due from patient” (deductibles,co-ins, prior payments from primary payers)

    Section billing process19
    Section:Billing Process


    Effective 5/23/2007 NPI rule is mandatory in all electronic & paper healthcare transactions for all but small health plans

    Many payers have different implementation dates for the NPI.

    Beginning May 1, 2006 CMS announces the capability for health industry organizations to submit health care providers’ applications for NPIs o the National Plan and Provider Enumeration System (NPPES) via Electronic File Interchange (EFI).

    Hospitals should have received NPI information from most of the Physicians (Attending/Rendering;Operating;Referring)

    Apply for NPI:

    https://nppes.cms.hhs.gov 1-800-465-3203

    CMS NPI Pagehttp://www.cms.hhs.gov/NationalProvIdentStand/

    Useful sites of information:



    FAQ NPI- htt;://questions.cms.hhs.gov (search NPI term/phrase)

    Section billing process20
    Section:Billing Process


    • NPI will be permanent for a Health Care Provider. One NPI for a lifetime

    • A new NPI will NOT be required for change of ownership, change to corporation, or change name, tax id#, address, Taxonomy classification, state of licensure, or state license number.

    • Entity type codes for NPI: (2 types)

      • Type Code 1 = HCP that are humans-doctor, ARNP, PA, PT

      • Type Code 2 + HCP that is organization-non-human such as physician group, hospital, HHA, pharmacies, nursing homes

    • Subparts:

      • You only obtain a NPI for a “subpart” IF the subpart currently is required for identification in processing of electronic transactions such as claims processing (this isn’t for group practice satellite offices)

    Section billing process21
    Section:Billing Process


    Listing Existing Legacy Numbers:

    It is important for you to list in the NPI application all current legacy numbers

    NPI: WILL “replace” all “legacy/OSCAR” numbers such as Medicare, Medicaid, UPIN, Blue-Cross, Blue Shield, etc.

    NPI: Does NOT replace tax identification or “Pay to address”.

    Health Plans are NOT required to have NPI. The health plan IS required to use your NPI in electronic transactions, one of which is claims processing.

    FL57 A-C Other Provider ID

    May include Legacy#s

    FL58 Insured’s Name

    • Last name, Middle name and middle initial

    • The name entered must be exactly what is on the health insurance card or eligibility websites

    • 25 alphanumeric characters are allowed for the three lines

    • No spaces, hyphens or titles (Mr.,Sir, Dr.)

    • Medicaid uses the recipient’s name (mother’s ID for infants)

    Section billing process22
    Section:Billing Process

    FL59 Patient’s Relationship to Insured

    This field is for the relationship to the insured (make sure billing staff do not use their memory of prior coding, these have been updated)

    01 Spouse

    02 Grandfather or Grandmother

    05 Grandson or Granddaughter

    07 Nephew or Niece

    10 Foster Child

    15 Ward (due to court order)

    17 Stepson or Stepdaughter

    18 Self

    19 Child

    20 employee

    21 Unknown

    22 Handicapped Dependent

    23 Sponsored Dependent

    24 Dependent of a Minor Dependent

    29 Significant other

    32 Mother

    33 Father

    36 Emancipated Minor

    39 Organ door

    40 Cadaver Donor

    41 Injured Plaintiff

    43 Child Where Insured Has No Financial Responsibility

    53 Life Partner

    G8 Other Relationship

    Section billing process23
    Section:Billing Process

    FL60 Insured’s Unique ID

    This field allows for 20 alphanumeric characters on the three lines

    • Id#s must include alpha prefixes, no spaces, dashes, no blanks, no 99999

    • Medicare uses HIC numbers and prefix & suffix to indicate eligibility status

    • Medicaid utilizes the 10-character recipient ID number as it appears on the BIC card

      A Retired worker over 65

      B Wife over 65

      C Child or Grandchild

      D Widower

      E Widowed mother

      F Parent category

      J Special beneficiary due w/quarters of employment under SSI

      K Beneficiary entitled due to quarters of employment

      M Individual enrolled in Part B,no elig. for Part A, but may have purchased Part A benefits

      T Individual entitled to Part A or entitled to Medicare based on Chronic renal disease

      W Disabled Widow

    Section billing process24
    Section:Billing Process

    FL60 Insured’s Unique ID# *Continued*

    Railroad Retirement Board Prefixes

    A Retired railroad worker

    MA Spouse

    WA Widow or widower

    WCA Widow w/child or child alone

    PA Parent of deceased

    JA Survivor

    WD Widow or widower of an employee who is 60+

    WCD Widow w/ child in her care or child alone(of employee)

    PD Parent of deceased employee

    H Retired worker

    MH Spouse of retired worker

    WH Widow or widower of retired worker

    WCCH Widow w/child of retired worker

    PH Parent of deceased retired worker

    Section billing process25
    Section:Billing Process

    FL61 Insurance Group Name

    Group name that relates to the health insurance coverage

    FL62 Insurance Group Number

    Insurance companies assign group policy codes

    • Champus-enter military status and pay grade

    • Champva, enter veteran’s military status

    • BlueCard-enter 999999 in Grp field,NO MORE: “ITSPPO”

    • Check cards and internet eligibility for group#s

      FL63 Treatment Authorization Code

    • IPA authorization

    • Medi-cal TAR#

      FL64 Document Control Number

      (Employer Location deleted from the UB04)

      FL66 DX Version Qualifier

      (9=ICD-9-CM or 10 = ICD-10-CM)

    Section billing process26
    Section:Billing Process

    *All of this coding comes from Medical Records Department*

    FL67A-C Principal & FL67I-Q Other Diagnosis Code

    • Use the highest level of ICD-9-CM DIAGNOSIS code specificity to avoid claim errors. No decimals (i.e.,47870 not 478.70)

    • Screen for medical necessity edits and utilize the Advanced Beneficiary Notice for Medicare patients.

    • The sign/symptoms that prompt the ordering of diagnostic tests should be used in the absence of a diagnosis.

    • Medicare will ignore data sumitted in 67I-67Q, 17 secondary allowed however CMS will only identify 8.

    • POA(Present on Admission) Indicator applies to inpatient admissions to general acute-care hospitals or other facilities, as required by law or regulation for public health reporting.Health plans should not reject the claim if they have no use for the POA info. Medicare began to accept POA October 1,2007 indicator for every diagnosis on IP claims.(MM5499 May 11,2007)(837I claims only!!)

    • Reporting Options:

      Y-Yes(present at the time of inpatient admission

      N-No (not present at the time of inpatient admission

      U-Unknown(documentation is insufficient to determine if present upon IP admission

      W-Clinically undetermined(provider unable to determine if present on admission or not

      1- Unreported/not used-Exempt from POA reporting(1 is equal to blank for 4010A1 data)

      FL68 Unlabeled

      FL70 Admitting Diagnosis/Patient’s Reason for Visit

    • Required for Inpatient Hospital swing-bed & Skilled Nursing Facility claims

    • April 1, 2005, OPPS reimbursed observation must be reported in FL76 or FL67 to be reimbursed appropriately

    • Global Release 08/03/05 California Blue Shield(G94036), required on all Outpatient claims. Check with your EDI department.

    Section billing process27
    Section:Billing Process

    *All of this coding comes from Medical Records Department*

    FL71 PPS Code – Required for inpatient claims when contracted to provide MS-DRG(4 digit leading w/zeros, all zeros if no DRG defined)

    Can be used for MS-DRG,RUG,IRF,APC,HHRG PPS identification

    FL72 External Cause of Injury (E codes=ECI)

    • Not required by all payers, but worth adapting to. Diagnosis related to injury, poisoning, or adverse effect. CMS will ignore.

      FL73 Unlabeled

      FL74 Principal Procedure Code & Date

    • Principal ICD-9-CM PROCEDURE and date required during inpatient stays. Date must fall within 3 days prior to the date of admission and/or within the statement period (FL6)

    • Denials may occur if these are placed on Outpatient Medicare claims. Check with your specific payer guidance's. See FL 44 for TOB(FL4)13x claims (HIPAA electronic compliant claim)

      FL74 a-e Other Procedure Codes & Dates

    • Do not repeat codes unless bilateral procedures are performed OR payer specific instructions require repeats

      FL75 Unlabeled

    Section billing process28
    Section:Billing Process

    FL76 Attending NPI/QUAL/ID,

    Last/First Name


    OB= State License numer

    1G=Provider UPIN

    G2=Provider commercial number

    The licensed physician entered is the one that certifies and recertifies the medical necessity of services

    NPI-National provider identifier is currently being processed by CMS for implementation.

    No apostrophe or hyphens. Only alphabetic characters.

    Medicare: UPIN and name of the attending physician

    Self-referred use SLF000 (self referred clinic or mammography)

    Medicaid-Check with your state requirements (CA Medi-cal provider number or State license number i.e.,00A987654)

    Others-Check with specific contract & bill requirements

    Section billing process29
    Section:Billing Process

    FL77 Operating Provider/NPI (Qualifier)

    FL78 Other Provider/NPI (Qualifier)

    FL79 Other ID Qual/NPI/Qual/ID

    FL81A-E Code overflow fields

    B3(Qualifier)=Billing Provider Taxonomy & #(i.e.,B3282N00000X)

    (Other procedures and dates) Do not repeat codes unless they are bilateral procedures

    TAXONOMY CODES (Facility)

    MM5243, CR# 5243 Sept 8,2006 Eff. 1/1/07

    Section billing process30
    Section:Billing Process

    Values-Qualifiers (UB04 vs. 837I/NM108)

    BQ – HCPCS procedure Code

    BQ – ICD-9-CM

    OB – State License number (UB04)

    1A – Blue Cross Provider number

    1B – Blue Shield Provider number

    1C – Medicare provider number

    1D – Medicaid Provider number

    1G – Provider UPIN number (UB04)

    1H – TRICARE identification number

    EI – Employer’s identification number

    G2 – Provider commercial number(UB04)

    LU – Location number

    N5 – Provider plan network identification number

    SY – Social Security number (not for Medicare)

    X5 – State industrial accident provider number

    Section billing process31
    Section:Billing Process

    CMS website Q&A (9/12/06)

    • FeedbackShould all institutional providers submit a taxonomy code on their claims after the implementation of the National Provider Identifier (NPI)?

    • Answer Only institutional providers that currently bill Medicare using more than one legacy identifier in order to identify sub-parts of their facility are required to submit a taxonomy code on all of the claims they submit to Medicare. Medicare legacy identifiers are six digit Medicare provider numbers, also called OSCAR numbers. A table of legacy identifiers that were used to identify sub-parts is included as an attachment to CMS Change Request 5243. Taxonomy codes shall be reported by these facilities whether or not the facility has applied for individual NPI for each of their subparts. Institutional providers that do not currently bill Medicare for sub-parts are not required to use taxonomy codes on their claims to Medicare.

      Taxonomies for physicians will be obtained by electronic claim vendors to submit when payer-specific requirements apply.

    Section billing information common reasons for rejection


    Member ID number & Group is incorrect

    ICD-9-CM Codes missing or invalid

    Date of injury missing

    Untimely filing

    Alpha prefix of the ID number missing

    Inappropriate Utilization Mgmt. info

    HCPCS/CPT codes missing/invalid/unlisted

    Services were not medically necessary

    Request for medical records

    Duplicate billings (overlap DOS, within 30 days last billed)


    Local billing limit exception codes-condition codes (FL19-28)

    Missing value codes and amounts (FL39-41)

    Missing payer info. “I/P” indicator (FL50)

    Missing/incorrect Health Plan ID (FL51)

    ID number incorrectly (verify using POS or AEVS) (FL60)

    EVC# entered instead of TAR (FL63)

    Incorrect attending physician 9 digit (FL76-79)

    Reducing font size or abbreviating terminology to fit in field when attachments should be created instead (FL80)

    Section:Billing InformationCommon Reasons for Rejection

    Section billing information
    Section:Billing Information

    Basics to Know

    • CMS Manual Pub 100-04 Medicare claims processing Transmittal #407 CR3633 Dec.17,2004 Eff.1/1/05

    • “Hospital Billing for Repetitive Services”

    • Know your admit and discharge status’ and how they impact your claims (transfer rules for PPS)

    • DRG Payment Window Requirements(3 day window & 1 day pre-admission diagnostic services) must be included in the inpatient DRG stay claim. Medicare Billing Manual 40.3 Rev#714 implementation 4/3/06

    • NCCI (National Correct Coding Initiatives)& Outpatient Code Editor (OCEs)

    • Revenue codes, Value Codes, Condition/Occurrence codes, HCPCS, CPT, Bill types, modifiers.

    • Medicare Secondary Payer (MSP)

    • Observation rules and regulations

    • Consolidated billing for Skilled Nursing Facilities

    • Make sure families have enrolled babies within 30 days with health plans

    Section billing information1
    Section:Billing Information

    Basics to Know

    • Most companies are now using scanning equipment, this means that we should not use Highlighters.

    • Check for COB-Coordination of Benefits-secondary insurance

    • Injury coding and principal diagnosis

    • Do not use photocopies of claims, use laser forms or “red drop out ink” forms

    • No stamps should be used unless you are sending the claim to a specified unit for “Carve-outs”, “Appeal” or “Stop-loss” processing

    • Discharge date must be consistent w/DOS-for Inpatient & Outpatient

    • Group plans-CA license number-not UPIN

    • Auth. number for all scheduled, elective admissions-available on admission-precert would have been done

    • Split bill if the baby stays after the mother is discharged (Unless contract requires other action)

    Section billing information2
    Section:Billing Information

    • Transmittal 515

      Subject: Update to 100-04 and Therapy Code Lists

      • CMS identifies specific CPT codes as therapy services

        • Physical Therapy – Modifier -GP

        • Occupational Therapy – Modifier -GO

        • Speech Therapy – Modifier –GN

      • Paragraph B identifies specific CPT codes which are:

        • Not priced from fee schedule, priced by carrier. FI contacts the carrier to obtain the appropriate fee schedule amount

        • Codes that are bundled

        • Paid by Outpatient Prospective Payment System (OPPS)

        • Always therapy codes regardless who performs them (PT/OT/ST)

        • Codes that sometimes represent therapy services

      • All codes on this table always represent therapy services when performed by therapists

    • Revisions to benefit policy for therapy services: http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3648.pdf

    • Physical & Occupational Therapy Billing Guide Oct. 2006: http://www.medicarenhic.com/providers/pubs/ptotguide_oct06.pdf


    Beneficiary Notice Initiative:


    CMS Claims processing Manual: http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS018912

    Clinical Lab Information: http://www.cms.hhs.gov/suppliers/clinlab/default.asp

    Federal Register:


    HIPAA EDI:www.hipaadocs.com ,http://nchica.org, http://www.wpc-edi.com/codes

    HMO Help: http://www.hmohelp.ca.gov/

    Intermediaries/Carriers: California (Regional Office: San Francisco) http://www.cms.hhs.gov/contacts/incardir.asp#1

    Part A - United Government Services, LLC; Mutual of Omaha Insurance Company

    Part B - National Heritage Insurance Company

    RHHI -   United Government Services, LLC

    DMERC - Connecticut General Life Insurance Company

    Intermediaries/Carriers/DMERC’s may change in the near future

    Inmate Info by County Sheriff Inmate Info (booking#search):

    LA: http://app1.lasd.org/iic/ajis_search.cfm


    SB: http://app1.sbsd.org


    Lifetime Reserve Days: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0663.pdf

    Medicare/Medicaid Manuals:



    Medicare Hospital Payment System,Policies,NPI & More:


    Medlearn: http://www.cms.hhs.gov/medlearn/pubs.asp

    Medi-Cal: http://www.medi-cal.ca.gov/

    Medical Review Strategy:


    NUCC & NUBC:1500: www.nucc.org , UB04: www.nubc.org

    837I 5010: www.wps-edi.com

    2007 Transmittals:http://www.cms.hhs.gov/Transmittals/2007Trans/list.asp

    NCD/LCD & Basic Coverage Issues: http://www.cms.hhs.gov/center/coverage.asp


    NPI: https://nppes.cms.hhs.gov/NPPES/Welcome.do & http://www.cms.hhs.gov/NationalProvIdentStand/01_overview.asp

    Lab NCD coverage manuals (Great for physician offices) http://www.cms.hhs.gov/CoverageGenInfo/04_LabNCDs.asp#TopOfPage

    Transmittals: http://www.cms.hhs.gov/Transmittals/

    Quality improvement organizations are watching
    Quality Improvement Organizations are watching!

    • March 2005, CMS began 3 year pilot DRG revenue recovery demonstration project in the 3 states with highest Medicare expenditures- CA, FL, and NY. Common DRG findings 416, 217, 397, 188.2010 CMS plans to phase in the RACs among all states.

    • One-day stays for: DRG 127 (heart failure and shock), DRG 143 (chest pain), DRGs 182/183(esophagitis, gastroenteritis and other digestive disorders with and without complications or co morbidities, respectively), DRGs 296/297 (nutritional and metabolic dis­orders with and without complications or co morbidities) and other one-day stays excluding transfers. Because one-day stays are so short, CMS is concerned that they may be medically unnecessary or that the patient could have been treated in a less costly setting.

    • DRG 217 (Wound Debridement & Skin Graft) Need physician documentation ie.e.,sharp, excisional as well as the depth and site of all excisional wound debridement procedures.

    • DRG 188 (Other digestive system disorders with cc)578,.x Target:Only CC

    • DRG 397 (Coagulation Disorders) Coding clinic 2004 Qtr 3 provides explicit guidelines regarding the specific bleeding disorders resulting from Coumadin therapy. Watch use of 599.7,784.7,578.x

    • DRG 416 (septicemia). This is often confused with kidney and urinary tract infections with or without complica­tions or co morbidities. Watch use of 790.7, 599.0, 996.62

    • Higher-weighted DRGs in a complications or co-morbidity pair. If you always bill for the higher paying DRG with complications or co morbidity after discharge, it may raise fraud suspicions.

    • Three-day qualifying skilled nursing facility admissions. OIG revealed hundreds of overpayments to SNFs nationwide that occurred because there was no three-day stay at an inpatient hospital prior to admission.

    • Readmissions for the same health problem within seven days of discharge. If a patient is readmitted for the same problem soon after discharge, it suggests that the original treatment did not work and therefore Medicare should not pay for it.

    Quality improvement
    Quality Improvement

    • Quality data captured in your hospital system upfront will determine much of your success in your hospital revenue cycle.

    • Formal employee training, auditing, policies & procedures for functional productivity and goal setting.

    • Fine-tune your hospital system so it’s user friendly, incorporates internet access and good communication for the flow of information

    • Creating a committee that reviews and reports all findings and accomplishes solutions to reimbursement and workflow issues.

    What can we offer in future seminars to help you
    What can we offer in future seminars to help you?





    Disclaimer: This document was designed to provide accurate information as a tool for your use. HFMA, AAHAM , agents and staff, make no representation, guarantee or warranty, express or implied, that this is error-free, and will bear no

    responsibility or liability for the results of it’s use. However, the ultimate responsibility for accuracy lies with the user.


    • Ambulatory Payment Classification Groups (APCs):A classification system that groups outpatient visits and procedures into payment categories for payment under the Medicare Outpatient Perspective Payment System (OPPS)

    • CDM: Charge Description Master AKA Chargemaster

    • Clearinghouse: Processes information for health care providers and sends batches of claims to multiple payers

    • Diagnosis-related Groups (DRGs):A classification system that groups patient according to diagnosis, type of treatment, age, and other relevant criteria. MS-DRG Medicare Severity DRG’s eff 10/01/07

    • EDI: Electronic Data Interchange is the computer-to-computer transfer of business-to-business document transactions and information between trading partners

    • EGHP: Employer Group Health Plan

    • Final Claim: Final itemized bill form from an institutional provider detailing all the charges for which the institutional provider is seeking payment

    • HIM: Health Information Management/Medical Records

    • HIPAA: Health Insurance Portability & Accountability Act

    • HIPPS: Health Insurance Perspective Payment System rate codes-Home Health HHPPS

    • HIS: Hospital Information Systems/Information Services

    • HRG code: HealthCare Resource Groups-Rehab Medicare PPS

    • LGHP: Large Group Health Plan

    • Medically Necessary: Services or supplies that: are proper and needed for diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.


    • Medicare Contractor: A Medicare Part A fiscal intermediary (institutional), a Medicare Part B Carrier (professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)

    • MSP: Medicare Secondary Payer

    • NCD: National Coverage Determinations (previously LMRP-Local Medical Review Policies=LCD)

    • National Provider Identifier (NPI): Beginning May 23, 2005, health care providers may apply for an NPI. May 23, 2007 all covered health care providers and clearinghouses must use NPI. Small plans May 23, 2008

    • OCE edits: Outpatient Code Editor

    • PFS: Patient Financial Services AKA Business Services

    • RC: Revenue Code

    • RUG code: Resource Utilization Groups, SNF/TCU-PPS

    • Unbilled charges: Charges or services provided for and not billed.

    • UPIN-Unique Physician Identification Number

    • Unbundling: Submitting bills using separate billing codes for multiple treatments or services that were billed separately, or fragmenting one treatment or service into its component parts and coding each component part as if it were a separate treatment or service. A common example of unbundling is when a provider performs surgery and then bills for the pre- and post-operative visits that are included in the billing of the surgery

    • Up-coding: Using a diagnosis or billing code that does not best represent the patient's actual condition or the treatment or service actually performed. A common example of up-coding is billing for a higher code than justified by the complexity of the case

    • Vendor: Develops software application to enable claims to be submitted electronically

    Corporate compliance oig workplan 2008
    Corporate ComplianceOIG WorkPlan 2008

    • Hospital Capital Payments are appropriate levels

    • Adjustment for Graduate Medical Education payments

    • Inpatient Prospective Payment System wage indices, analyze data and assure accurate reporting

    • Payments for Organ Procurement Organizations

    • Inpatient Hospital Payment for New Technologies

    • Special payment provisions for patient who are transferred to onsite providers and readmitted to LTC hospitals (Long Term Care)

    • Special Payment Provisions for LTC hospitals discharging beneficiaries to collocated or satellite providers

    • Critical Access Hospitals-review payments

    • Medicare Disproportionate Share Payments review, eligibility, States use and distribution

    • Inpt Psychiatric Facility ER dept adjustments

    • Provider Bad Debts

    • Compliance with Medicare’s Transfer Policy.

    • Payments for diagnostic x-rays in hospital emergency departments

    • Patient care and safety in physician-owned specialty hospitals

    • Oversight of the Joint Commission Hospital Accreditation Process

    • Medicare Secondary Payer

    Corporate compliance oig workplan 20081
    Corporate ComplianceOIG WorkPlan 2008

    • Cyclical Noncompliance in Medicare Home Health Agencies

    • Accuracy of Home Health Data & coding/claims resource groups (HHRG)

    • Medicare Hospice Care for nursing home residents, appropriate services and payments

    • Physicians: Place of Service errors, E&M during global surgery periods

    • Medicare payments for selected physician services

    • Medicare “Incident to” Services

    • Medicare payment of Polysomnography

    • Business Relationships with use of MRI under Physician fee schedule

    • Accept assignment rules for physician providers

    • Geographic areas: high utilization of Ultrasound

    • Physician Reassignment of Benefits

    • Medicare Part B drug reimbursement & Part D

    • Medicare payments for Observation vs. Inpatient for dialysis services

    • Laboratory Rendered during an Inpatient stay

    • Therapy Services provided by Comprehensive Outpatient Rehabilitation facilities

    • Emergency Services for Undocumented Aliens

    • Separately billable Lab under End Stage Renal Disease Program

    • Pricing of Clinical Laboratory tests

    • Medicare Advantage: Stabilization fund, rates, bids, encounter data

    • Recovery Audit Contractors

    • Medicaid-much of the same issues as Medicare

    • Credit balances for Medi-Medi beneficiaries

    • Public Health, oversight, Lab preparedness, vaccines

      Disclaimer: This document was designed to provide accurate information as a tool for your use. HFMA, AAHAM , agents and staff, make no representation, guarantee or warranty, express or implied, that this is error-free, and will bear no

      responsibility or liability for the results of it’s use. However, the ultimate responsibility for accuracy lies with the user.