Ubwatch process central control llc
1 / 28

ubWATCH Process Central control, llc - PowerPoint PPT Presentation

  • Uploaded on

ubWATCH Process Central control, llc. UBWatch Process. Key Roles. Corporate Coding Specialist/Gatekeeper Accounts Receivables/Billing Corporate MDS Director . Corporate Coding Specialist/ Gatekeeper. Approves all therapy diagnosis codes Creation of Diagnosis sheets Primary sheets

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'ubWATCH Process Central control, llc' - xia

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Ubwatch process central control llc

ubWATCH Process

Central control, llc

Key roles
Key Roles

Corporate Coding Specialist/Gatekeeper

Accounts Receivables/Billing

Corporate MDS Director

Corporate coding specialist gatekeeper
Corporate Coding Specialist/Gatekeeper

  • Approves all therapy diagnosis codes

  • Creation of Diagnosis sheets

    • Primary sheets

    • Therapy sheets

  • Coding Audits

    • MCR A, MCR B, Medicaid, Private Pay, Outpatient, etc.

    • Nurse Practitioner visits

  • Triple Check

    • Medicare Cards, H&P, Benefit Day, Treatment Grids, Weekly Therapy notes, 700/701

  • Runs exceptions

  • Corrects coding issues for reloading

  • Manages outstanding claims in UBWatch

Accounts receivable
Accounts Receivable

  • Reviews entries made into census line from PCC that feed UB04

    • Basic demographics; payer setup; qualifying stay entry; required occurrence codes and span dates; leave days documented correctly; ancillary charges are present on claim

  • Reviews signed admission documents

    • Assignment of benefits; Medicare Secondary Payer Questionnaire; Covered/Non Covered Benefits for Skilled care; ABN

  • Responsible for post review of any denied claims

    • Identify any denied claims and alert Triple Check team for further review

  • Works closely with MDS to assure COT RUGs transfer to claim correctly

Corporate mds director
Corporate MDS Director

  • Audit sample MDS’ monthly for coding accuracy and RUG support. Use MDS calendar to assist with capturing OBRA assessments that are due

  • Audit sample of certifications for skilled residents to assure completion and timely signature of MD

  • Audit skilled residents daily for setting ARDs of assessments in the system; to assure it is in timeframe which CMS allows to avoid default rates.

  • Review case mix weekly and at snapshot end

  • Work closely with coder; monitoring diagnosis for skilled residents upon admit, to assure the diagnosis relates to qualifying hospital stay.

  • Review preliminary Case mix for each facility and for any delinquent assessments noted on report, assist with correction as needed prior to final Case mix report

Triple check
Triple Check

  • Performed monthly at a corporate level

    • Corporate Coding Specialist

    • Corporate MDS Director

    • Accounts Receivable

    • Corporate Quality Coordinator

    • Chief Financial Officer

  • Performed on a select number of Medicare A residents

Triple check1
Triple Check

  • Admission Information

    • Verify Medicare number

    • Verify primary PCC diagnosis sheet

    • Verify ICD-9 codes correspond to diagnosis

    • Verify most current admission date

    • Hospital qualifying stay dates (hospital discharge/transfer summary related to 3 day qualifying stay requirements)

    • Verify that resident has benefit days available per the CWF

Triple check2
Triple Check

  • Physician’s Orders

    • Physician order to admit to skilled service

    • Initial orders for evaluation & treatment for therapy or other skilled service

    • Complete clarification order

    • Physician orders signed/updated every 30 days

    • Order to discharge off Medicare/skilled service

Triple check3
Triple Check

  • Physician Certifications/Re-certifications

    • Initial certification within 72 hours of admit (Complete information/sign/date/timely

    • Re-certification on or before Day 14

    • Re-certification on or before Day 30

    • Additional recertification complete

Triple check4
Triple Check

  • Skilled Nursing Documentation

    • Verify charting done at least once per 24 hours

    • Related to skilled service being provided

    • Related to skilled ICD-9

    • Charting supports therapy services

    • Documentation supports late loss ADL’s in MDS Section G

Triple check5
Triple Check

  • ADL’s

    • ADL’s are accurate

    • MDS accurately coded

    • ADL’s are accurately coded

    • Documentation support ADL’s

    • ADL’s are support by medical record

Triple check6
Triple Check

  • Therapy Documentation

    • Daily treatment and therapy notes are current

    • Number of minutes, units, HCPCS, modifiers are accurate for billing

    • Therapy evaluation complete with MD sign/date

    • Plan of care update or 701 complete with MD signature

    • Admission ICD-9 code matches 700 form

Triple check7
Triple Check

  • MDS

    • ARD within window for MDS cycle

    • Reason for assessment is correct

    • Other RUG related MDS items are supported by medical record, including accuracy of therapy minutes/days

    • MDS locked, transmitted, and accepted

Triple check8
Triple Check

  • ABN

    • Proper notifications at the time of admission

    • Proper notice of continued stay or discontinuation of service

    • Copy of signed notices readily available

    • Most current version of form being used

    • Form not altered as per CMS regulations

Triple check9
Triple Check

  • Payer Source

    • Assignment of benefits form is signed

    • Medicare secondary payer questionnaire completed

Triple check10
Triple Check

  • UB-04

    • Verify admission date

    • Verify discharge/transfer date

    • Verify discharge status code

    • Confirm admission dx

    • Confirm primary dx

Top 10 ubwatch exceptions
Top 10 UBWatch Exceptions

Therapies on UB inconsistent with corresponding MDS

Correction: Review DOS; check therapy software to assure therapy was received compared to what is coded on MDS

Top 10 ubwatch exceptions1
Top 10 UBWatch Exceptions

Other diagnoses in the claim do not seem to be supported by the MDSs found

Correction: Review DOS, check physician orders, care plan, chart and if diagnosis is active, request MDS to review and code active diagnosis on MDS; if diagnosis is not active, will remove from diagnosis sheet

Top 10 ubwatch exceptions2
Top 10 UBWatch Exceptions

Admitting diagnosis in the claim do not seem to be supported by the corresponding MDSs found

Correction: Review admit diagnosis and if it relates to care. Suggest MDS review and if pertinent to care with documentation support, suggest adding to MDS.

Top 10 ubwatch exceptions3
Top 10 UBWatch Exceptions

Claim type and dates inconsistent with corresponding MDSs

Correction: Review DOS to assure MDS covers time frame

Top 10 ubwatch exceptions4
Top 10 UBWatch Exceptions

Admission date is greater than 30 days from qualifying hospital stay

Correction: Verify that we have code 78, on the occurrence span code, with correct dates on claim. Also, verify that we have condition code 57 on claim.

Top 10 ubwatch exceptions5
Top 10 UBWatch Exceptions

No corresponding MDSs for claim

Correction: Review DOS and assure MDS covers time frame in question. Sometimes this is noted when a discharge occurs right after an assessment was done. Validate that an assessment was done to cover DOS prior to discharge

Top 10 ubwatch exceptions6
Top 10 UBWatch Exceptions

Incorrect principal diagnosis coding for therapy claim

Correction: Add/Remove therapy codes from principal diagnosis OR add penny charges to the claim

Top 10 ubwatch exceptions7
Top 10 UBWatch Exceptions

Claim type and date inconsistent with other claims

Correction: Reload previous claims. Some claims are stopping in suspense and were never cleared; therefore, looking for original claim

Top 10 ubwatch exceptions8
Top 10 UBWatch Exceptions

Therapy services not justified by diagnosis on Part B claim

Correction: Check LCD for diagnosis codes that justify CPTs billed

Local coverage determination lcd
Local Coverage Determination (LCD)

Medicare contractors can create guidelines for certain services to determine if they are reasonable and necessary, and covered as a Medicare benefit.

Top 10 ubwatch exceptions9
Top 10 UBWatch Exceptions

No qualifying hospital stay before admission

Correction: Add the qualifying stay which was omitted on Census line