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National Uniform Billing Committee Update
Effective: July 1, 2011
Form Locator 67, FL 67A-Q, FL 72a-c: New Indicator ("1") for Present on Admission for UB-04 claims only
March 2010 Background: When the Present on Admission ("POA") indicator was approved by the NUBC, there were only four codes available for use in the X12 transaction: Y,N,U and W. A fifth variable was deemed necessary to identify diagnosis codes that were exempt for POA reporting. This attribute was denoted by the absence of data, i.e., a blank field (" ") on the UB-04 and a non-populated ("Not Used") value in the applicable 837 segment. Exempt diagnosis codes are predetermined and published in the "Coding Guidelines on ICD-9-CM"; therefore validating the appropriateness of missing data is viable. Proposal: Add a new discrete code to the UB-04 to represent that the diagnosis code is exempt from reporting POA. "E" has been suggested because many group systems use this as an internal marker for codes that are exempt.
Final Determination: "1" was preferred by a large majority of NUBC members and to be used for paper UB-04 claims ONLY.
4010 837 a "1" is to be used.
5010 837 a " " is to be used.
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Form Locator 06 Statement Covers Period (From-Through)
The Statement Covers Period "From Date" found within Form Locator 06 ("From Date") may be the same or a different date than the "Admission Date" found within Form Locator 12. The dates may coincide in some circumstances, but should not be confused.
Issue: When a patient receives outpatient services 3 calendar days prior to an inpatient admission, the outpatient charges may need to be included on the inpatient bill. On an initial bill the "From Date" would be prior to the "Admission Date" FL 12. Some payers will not accept a claim in this format.
Today, Medicare has edits prohibiting a PRIOR "Admission Date" to the Statement "From Date" and will reject claims for submission.
Resolution: Medicare will modify edits October 2011.
NUBC Billing Alert
MLNSE1117
Form Locator 46: Field attributes changed to "Decimal"; New usage notes added
Effective July 1, 2011: Allow billing with a decimal to match the X12 standard. CMS will begin requiring fractional mileage on Medicare ambulance 5010 837's on 1/1/11. In addition, there will likely be future regulations that require fractional reporting, such as decimals in the reporting for drugs.
Pay-to-Provider
Released February 2011, as written by NUBC regarding the 5010 claim format, the Pay-to-Provider loop has been renamed and is now called the Pay-to-Address Name loop (Loop ID-2010AB); its one and only purpose is to supply an alternate location to send reimbursement. The Pay-to-Provider is not a separate entity.
Reference Material from NUBC
UB-04 Change Implementation Calendar
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Payer Update
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United Healthcare-
Is proud to be the first national entity to achieve CAQH CORE Certification on the updated 5010 platform.
Submit Inpatient Admission Notices the Easy Way with the EDI 278N.
UHC Network Bulletin
Tricare
Observation Billing Policy and User's Guide Update
Uniform Business Office Newsletter
New Reimbursement Rule Proposed
Full Article
Aetna
National Precertification List
Effective: August 1, 2011
Aetna Link |
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Medicare Quarterly News
OPPS Update of Hospital OPPS
Effective: July 1, 2011
Reporting Hours of Observation: We are revising our billing instructions to state that in situations where such a procedure interrupts observation services, hospitals may determine the most appropriate way to account for this time.
Payment Window for Outpatient services Treated as an Inpatient: CMS will not pay for 'inpatient-only' procedures that are provided to a patient in the outpatient setting on the date of the patient's inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission.
CMS Transmittal 2234 CR 7443
MLN Matters MM7443
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Manual Clarifications for Skilled Nursing Facility (SNF) Part A Billing
Effective: August 1, 2011 Clarification of the usage of occurrence code 16 and the definition of billed therapy units on Part A SNF claims. In addition, the effective and implementation dates were revised to allow providers time to adjust their billing systems. MLN Matters MM7339
Auto Denial of Claims with a GZ Modifier Effective: July 1, 2011 Medicare Contractors will automatically deny institutional and professional claim line(s) items submitted with a GZ modifier, effective for dates of service on or after July 1, 2011. Further your contractor will not perform complex medical review on any claim line item(s) submitted with a GZ modifier. CMS Transmittal 2148 CR 7228 MLN Matters MM7228 Medicare Preventative and Screening ServicesEffective: January 1, 2011 Implementation: June 28, 2011 The PPACA amended the definition of "Preventative Services" available in Medicare and included two additional preventive physical examination services: the initial preventive physical examination (IPPE) and the annual wellness visit (AWV). CMS Transmittal 2233 CR 7243
Updates to Pub 100-4, Medicare Claims Processing Manual, Chapter 3: Inpatient Hospital Billing
Implementation Date: July 23, 2011
Payment for Blood Clotting Factor Administered to Hemophilia Inpatient claims. If a beneficiary is in a covered Part A stay in a PPS hospital, the clotting factors are paid in addition to the DRG/HIPPS payment.
Clarifies application of the Code First policy in Section 190.5.2.
Clarifies instructions for the non-outlier period after regular benefit days are exhausted in Section 40. IPPS uses Occurrence Span code 70 for the covered non-utilization period after regular benefit days are exhausted.
CMS Transmittal 2193 CR 7385
MLN Matters MM7385
Currently Not Collectible (CNC) and Write-Off Closed Recommendations for claims Eligible for Section 935 Limitation on Recoupment of the Medicare Modernization Act (MMA)
Effective: July 1, 2011 Implementation: July 5, 2011 The purpose of this change request is to combine claims recommended for CNC reclassification in the same aggregation sequence as the demand letter aggregation sequence to amount to more than the $25 threshold amount.
Correct Provider Billing of Admission Date and Statement Covers Period Implementation: October 1, 2011
Based on UB-04 definitions of these two data elements, CMS has modified FISS edits so Admission Date and "From" Dates are not required to match.
Based on UB-04 definitions of these two data elements, CMS has modified FISS edits so as not to compare the number of days in the Statement Covers Period to any other data element (e.g., total accommodation days reporting in the revenue code section).
MLN Matters SE1117
MLN Matters Articles 2004 Index Through 2011
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Are you tired of being hung out to dry with RAC audits?
AHA New RAC Report
 - The majority of medical necessity denials reported were for one (1) day stays where the care was found to have been provided in the the wrong setting, not because the care was medically unnecessary.
- Hospital respondents reported Syncope & Collapse as the top MS-DRG denied by RACs for both medical necessity denials and incorrect coding denials.
- 52% of hospital respondents reported problems with reconciling RAC recoupments and untimely RAC correspondence.
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AHA RAC Vendors
AHA RAC Report See new pages 4,5,17,34,40,46,56-62
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Our partners at the Cirius Group, Inc. have been most helpful and attentive throughout the entire process.
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NUCC Releases Annual Updated Version of the 1500 Claim Form Reference Instruction Manual
| | Click here and Public Comment Survey for 1500 Potential Future Revisions available. |
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HIPAA 5010
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Version 5010 Implementation Changes to Present on Admission (POA) Indicator '1' and the K3 segment.
Transmittal R851OTN CR 7280
MLN Matters 7280
Current Medicare:
4010 to 5010 CROSSWALK 837I |
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Best Hospitals
U.S. News & World Report
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Just 17 of the 5,000 hospitals evaluated for the 2011 rankings qualified.
Honor Roll
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On the Horizon
APR-DRG
Medicaid plans are adjudicating claims according to APR-DRG's, NY, PA, MD, MT, RI, CO, SC and ND. Will your state Medicaid reimbursement be next and what impact will it have on reimbursement?
ICD-10
CMS states ambulatory and physician services on or after 10/01/2013 will require an ICD-10-CM.
Inpatient discharges occurring on or after 10/01/2013 will require an ICD-10-CM and ICD-10-PC.
ICD-10 codes will not be accepted PRIOR to 10/01/2013.
Per National Committee on Vital and Health Statistics testimony, many non-covered entities such as workers compensation, property & casualty insurers are working towards ICD-10.
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 | Compliance Corner
Medicare Quarterly Compliance Newsletter Here | |
A new fast fact has been posted to the CMS MLN provider compliance webpage.
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Medicaid No Medicaid payments for health care acquired conditions beginning July 1, 2011. Applies to hospitals and other facilities. All State Medicaid websites |
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