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UB04 Update
Effective July 1, 2010
Point of Origin Codes
Three codes are
eliminated will no longer be valid for use:
Code 7 -
Emergency Room
Code B -
Transfer from Another Home Health Agency
(Replaced
with new Condition Code 47)
The recommendation is that in replacement of
Code 7 use Admission Source code '1'. Example: a patient visits the ER and he/she arrives coming from a non-health care facility (i.e. home) episode would be reported using Priority Type of
Visit '1' to further support patient's point of origin.
Code C - Readmission to Same Home Health Agency
Code E -
Transfer from Ambulatory Surgical Center
Code F - Transfer from
Hospice and is Under Hospice
Plan of Care or Enrolled in a
Hospice Program
P7 Direct Inpatient Admission from ER For Public Health
Reporting Only | NEW DEFINITION: Patient Discharge Status 01
Discharged to Home or Self Care (Routine Discharge)
Usage Note: Includes discharge to home; home on oxygen if DME only; any other DME only; group home, foster care, independent living and other residential care arrangements; outpatient programs, such as partial hospitalization or outpatient chemical dependency programs.
NEW DEFINITION: Patient Discharge Status 04
Discharged/transferred to a Facility that Provides Custodial or Supportive Care
Usage Note: Includes intermediate care facilities (ICFs) if specifically designated at the state level. Also used to designate patients that are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification and for discharges/transfers to Assisted Living Facilities.
NEW DEFINITION:Patient Discharge Status 21
Discharged/transferred to Court/Law Enforcement
Usage Note: Includes transfer to incarceration facilities such as jail, prison or other detention facilities.
Learn more... UB04 Version 5.00 Update
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United Healthcare
Clean Claims
Additional information needed for a complete UB04
| · Date and hour of admission and discharge as well as member status-at-discharge code
· Type of bill code
· Type of admission (e.g. emergency, urgent, elective, newborn)
· Current four-digit revenue code(s)
· Current principal diagnosis code (highest level of specificity) with the applicable Present of Admission (POA) indicator on hospital inpatient claims per CMS guidelines
· Current other diagnosis codes, if applicable (highest level of specificity), with the applicable Present on Admission
(POA) indicator on hospital inpatient claims per CMS guidelines
· Current ICD-9-CM (or its successor) procedure codes for inpatient procedures
· Attending physician ID
· Bill all outpatient surgeries with the appropriate revenue and CPT or HCPCS codes
· Provide specific CPT or HCPCs codes and appropriate revenue code(s) (e.g. laboratory, radiology, diagnostic or therapeutic) for outpatient services
· Complete box 45 for physical, occupational or speech therapy services (revenue code 420-449) submitted on a UB-04
· Attach an itemized statement if submitting a claim that will reach the contracted stop loss
· Submit claims according to any special billing instructions that may be indicated in your agreement (or letter of agreement)
· On an inpatient hospital bill type of 11x, the admission date and time should always reflect the actual time the member was admitted to inpatient status
· If charges are rolled to the first surgery revenue code line on hospital outpatient surgery claims, a nominal monetary
amount ($.01 or $1.00) must be reported on all other surgical revenue code lines to assure appropriate adjudication
United Healthcare Administrative Guide 2010
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| Medicare Quarterly Update |
Medically Unlikely Edits (MUEs)
An MUE is a unit of service (UOS) edit for a HCPC/CPT code for services that a single provider/supplier rendered to a single beneficiary on the same date of service. CMS developed the MUE program to reduce the paid claims error rate for Medicare claims. It was designed to reduce errors due to a clerical entries and incorrect coding based on anatomic considerations, HCPC/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, prescribing information and unlikely clinical diagnostic or therapeutic services. See detailed changes in Transmittal. CMS Transmittal 652 CR 6712
Informational Only IP Claims for Advantage Beneficiaries
Effective: June 7, 2010 Deadline: August 31, 2010
CMS is requiring certain non-teaching hospital subject to the IPPS, as well as IRF's, and the LTC hospitals which have until August 31, 2010 to submit FY2007 & FY2008 Medicare Advantage informational only claims. Billing required use: 111 Bill Type with Condition Code 04. In addition, hospitals are required to submit a written attestation to their Medicare contractor attesting that they have submitted all of their Medicare Advantage claims, or that they have no Medicare Advantage claims on or before August 31, 2010. CMS Transmittal 696 CR 6821
MLN Matters MM6821
Removal of the Provider Reporting Requirement for Total Number of Therapy Visits using Value Codes 50-53Effective: October 1, 2010
The requirement for providers to report the total number of therapy visits using value codes 50(PT),51(OT) 52(ST) or 53(CR) has been removed. Providers will no longer REQUIRED to submit aforementioned value codes when billing for therapy services. MLN Matters MM6899 Billing and Claims Processing for Automatic Implantable Cardiac Defibrillator (ICD) Services Effective: August 1, 2010Coding requirements: 33240, 33241, 33243, 33244, 33249. For inpatient claims, ICD-9 CM procedure code 37.94 shall be used to report the implantable cardiac defibrillator. CMS Transmittal 1994 CR 7015New Medicare Secondary Payer Insurer Type CodesEffective: October 1, 2010 Medicare as Secondary Payer Insurer Type codes are specific codes that indicate the source of a beneficiary's primary insurance. Example "A" = Insurance or Indemnity, "J"= Hospitalization Only Plan. The new codes will be "R" for HRA (Health Reimbursement Arrangement) and "S" for HSA (Health Savings Account). CMS Transmittal 74 CR 6768Additional ICD-9 codes (Institutional Claims Only)
Effective: January 1, 2011
CMS is expanding the number of ICD-9/POA codes (diagnosis & procedure) processed on institutional claims.
Adding additional (other) secondary diagnosis codes (from 8 to 24 codes) as well as additional present on admission (POA) codes.
Adding additional ICD-9 (other) secondary procedure codes (from 5 to 24 codes).
CMS Transmittal 648 CR 6851MLN Matters MM6851Maximum Period for Submission of Medicare Claims Reduced to Not More Than 12 Months
Implementation: October 1, 2010
*As a result of PPACA, claims with dates of service on or after January 1, 2010 received later than one calendar year beyond the date of service will be denied by Medicare.
*Claims with date of service prior to October 1, 2009 will be subject to PRE-PPACA timely filing rules and associated edits;
*Claims with dates of service October 1, 2009 through December 31, 2009 will be denied as being past the timely filing limit received after December 31, 2010 and;
*For claims with services that require the reporting of a line item date of service, the line item date is issued to determine the date of service. For other claims, the claims statement "From" date is used to determine the date of service.
MLN Matters MM6960
Discarded Drugs & Biologicals Update
Effective: July 30, 2010
When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicates on the vial or package label. When processing claims, except for drugs provided under the CAP program local contractors MAY require the use of the modifier "JW" to identify unused drug or biological. This modifier billed on a separate line, will provide payment for the amount of discarded drugs or biologicals.
Pulmonary Rehabilitation (PR) Service
Implementation: October 1, 2010
Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 added payment and coverage improvements for patients with chronic obstructive pulmonary disease (COPD) and other conditions. Effective January 1, 2010 MIPPA provisions added a physician-supervised, comprehensive PR program under Medicare Part B.
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Revenue Cycle Performance Metrics
Pre-Service Financial Clearance: Eligibility and authorization secured prior to service
High 95%+secured
Medium 90%-95% secured
Low <90% secured
Pre-Service/Point of Service Cash Collections: Percentage of patient-responsible balances collected prior to or at the point of service
Best 90%+collected
Average 75%-90% collected
Low <75% collected
Average Time to Bill: Includes hold days ply billing edits:
Best <5days
Average 5-7 days
Low 7 + days
Clean Claim Rate:
Best 80% + clean claims
Average 75%-80% clean claims
Low <75% clean claims
Average Time to Pay: Average aging's from bill submission
Medicare
Best 17 days
Average 24 days
Low 24 + days
Managed Care
Best 45 days
Average 60 days
Low 60 + days
Self Pay
Best 0-30 days
Average 30-60 days
Low 60 + days
Denials: Denials that fall within the scope of the revenue cycle (technical only)
Best <5% Net Patient Revenue (NPR)
Average 5%-1-% NPR
Low 10% NPR
Administrative Write-offs: Write-offs that fall within the scope of the revenue cycle
Best <0.15% NPR
Average 0.5%-1% NPR
Low 1% + NPR
Bad Debt: Includes true self-pay and third-party residual self-pay balances
Best <2% NPR
Average 2%-3% NPR
Low 3% + NPR
Source: Huron Consulting Group
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Cirius Group, Inc and Dancing Heads  | | | | HFMA ANI
Join us at Future CIRIUS EVENTS |
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Denial Prevention
| Based on hospitals survey, managed care claims in a 'denied state' range between 10-20% of open A/R.
At any given time, a hospital with $50 million monthly managed care net revenue will have $5-10 million in an open state of denial.
Hospitals reported 55-98% of denied claims are overturned and ultimately paid correctly.
Review::::::::::::::
Payer specific edits
Software solutions
Manual review process
DNFB
Timely Filing Limits
Initial Claim Submission
Corrected Claim Submission
COB Submission
Special Billing Requirements
Separate stop loss billing requirements Hard copy vs. electronic billing
Attachments
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RAC Demonstration High-Risk Vulnerabilities
Top Five
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1. RAC's must clearly indicate deadlines for submission of medical records in ADR letters.
2. RAC's must initiate one additional contact with the provider before issuing a denial for a failure to submit documentation.
3. RACs must accept and review extensions requests if providers are unable to submit documentation timely.
4. RACs must clearly indicate in ADR letters suggested documentation will assist them in adjudicating the claim.
5. RAC's must allow provider to submit medical records on CD/DVD or to fax the needed medical records.
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Metric Calculations for Revenue Cycle | |
Trended Aged A/R as % of Billed A/R >30,60,90,120 days divided by: Total A/R
Cost to Collect Total revenue cycle cost divided by: Total cash collected Aged A/R as a % of Billed A/R by Payer Group Payer by Aging >30,60,90,120 days divided by: Total A/R by payer
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5010 UPDATE
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REMEMBER that HIPAA standards include the X12 Version 5010 and Version D.0 standards. These are national standards and apply to transactions with ALL payers not just Fee-For Service (FFS) Medicare.
BENEFITS to 5010
1. Standard acknowledgements and rejection transactions across jurisdictions (TA1, 999, 277CA transactions). 2. Assigning claim numbers closer to the time of receipt. 3. Returning claim needing correction earlier in process. 4010 to 5010 CROSSWALK
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