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Institutional Claim UB04 Update
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National Uniform Billing Committee (NUBC)
Effective July 1, 2012
FL 04 -- The IP/OP General Designation of Freestanding Birthing Centers (084X) changes from "TBD" to "OP".
FL 43 -- To be consistent with 5010/837 format, "ME" (Milligram) is a valid unit of measure qualifier for Medicaid Drug Rebate Reporting.
FL 36-36 -- New Occurrence Span Code of "81" for Antepartum Days at Reduced Level of Care.
Definition: Code and corresponding dates indicate the from and through dates of an antepartum hospital stay where the level of care is non-acute.
FL 18-28 -- New Hospice Condition Code "52" for Out of Service Area Discharges.
Definition: Code used when the patient is discharged for moving out of the hospice service area, including patients admitted to a hospital without contractual arrangements with the hospice.
FL 04 & FL 16 -- Addition of Type of Bill Frequency Code "7" to Discharge Hour Reporting Requirements.
Usage note in 5010/837: Required on all final inpatient claims. Required on inpatient claims with a Frequency code of 1, 4, AND "7"), except for TOB 021x.
Implemented July 1, 2012 but retroactive to January 1, 2012, Medicare will apply the multiple procedure payment reduction (MPPR) policy to CAHs billing method II professional fees for certain diagnostic imaging procedures. The MPPR on diagnostic imaging applies when multiple physician servers are furnished by the same physician to the same patient in the same session on the same day.
October 1, 2012
FL 31-34 - Report new occurrence code 55 with the date of death whenever the patient discharge status is: 20, 40, 41, or 42.
Summary of Changes
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Payer Update
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United Healthcare
Enhances Provider Remittance Advice for UB04/837 Institutional Claims. Effective during the third quarter UHC will begin reporting financial information at the revenue code/detail line level instead of the current UHC service level.
Tricare awards UnitedHealth Military & Veterans Services (UMVS) as the carrier for the western region responsible for customer service, claims processing, management support including cost trend risk management, fraud and abuse detection, and quality management services.
Network Bulletin
Aetna
Beginning July 1, 2012, REVISED Participating Provider Pre-certification List released for inpatient admissions and/or selected ambulatory procedures and services.
Detailed List here
Cigna
Timely filing, new for some states effective August 1, 2012.
Unless a longer time period is required by applicable state law, the time frame to submit claims will change to 90 days for participating health care professionals who have received a notification and an amendment to their agreement in these affected states: DC, FL, MD, NC, NJ, NY, and TN.
The 90 day claim filing time frame was implemented last year in the following states for all claims: AK, AR, AZ, CA, CO, CT, DE, GA, IL, IN, KS, KY, LA, MA, ME, MI, MO, MS, NH, NV, PA, OK, RI, SC, TX*, UT, VT, WA, WI, AND WV.
*Texas has a 95 day claim filing limit, per state law.
Network Bulletin
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Medicare Quarterly News
Process for Handling Electronic Submission of Medical Documentation (esMD)
Effective: July 16, 2012
Implementation: July 16, 2012
A. Prepayment Review Time Frames
When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers...
B. Postpayment Review Time Frames
When requesting documentation for postpayment review, the MAC, CERT and RAC shall notify providers that the requested...
C. For esMD submissions
The esMD Review contractor shall use the Content Transport Services receipt date as the date the documentation...
Transmittal 426 CR7835
Reporting of Recoupment for Overpayment on the RA with Patient Control Number instead of HIC Number
Effective: January 2012
Implementation: April 1, 2012
Instructs Medicare's claims processing systems maintainers to replace the HIC number being sent on the 835 with the Patient Control Number received on the original claim, whenever the electronic remittance advice is reporting the recovery of an overpayment.
Transmittal 1099 CR7499
MLN Matters MM7499 Revised
Physician Practices--Tightening of Medicare Three Day Window
Effective: January 1, 2012
Compliance: July 1, 2012
CMS states it will enforce the Medicare inpatient hospital PPS requirement that a hospital must bundle all charges for outpatient diagnostic and 'clinically-related' non-diagnostic services delivered within three days prior to an inpatient admission into that admission, if the service was delivered at an entity that is wholly owned or wholly operated by the admitting hospital, including off-site physician offices. The worry is that existing billing systems do not adequately link the services delivered at many off-site, wholly owned offices and payment delays and compliance problems will result.
Hospitals and physician practices (or other part B entities) MUST have coordinated billing procedures for services subject to the 3-day (or 1-day) payment window in place no later than July 1, 2012.
Transmittal 2373 CR7502
Revised Editing for Hepatitis B Administration Code G0010
Implementation: July 2, 2012
OPPS providers should report code G0010 for the administration of hepatitis B vaccine rather than 90471 or 90472 to ensure the correct waiver of coinsurance and deductible for the administration of hepatitis B vaccine.
MLN Matters MM7692
CMS Transmittal 2390 CR7692
| New Influenza Virus Vaccine Code
Effective: July 1, 2012
Implementation: October 1, 2012 Effective for claims with dates of service on or after July 1, 2012, Medicare carriers will begin accepting the influenza virus vaccine code Q2034.
Hospice Condition Code for out of service area discharges
Effective: July 1, 2012
Implementation: July 2, 2012
Hospices that bill Medicare contractors RHHIs or MACs must discontinue use of occurrence code '42' for situations when a provider initiates the termination of hospice care.
Hospices must begin to use new condition code '52' to indicate a discharge due to the patents' unavailability or inability to receive hospice serves from the hospice that has been responsible.Analysis & Design of Edits to Correct Recovery Auditors Identified Improper Payments in MCS
Effective: July 1, 2012
Implementation: July 2, 2012
Issues have been identified by the recovery auditors as significant improper payments and require the development of edits to prevent. Issues identified: pulmonary diagnostic procedures, IV hydration, a new patient, use of modifier 62.Transmittal 1052 CR7673
Expansion of the current scope of editing for ordering/referring providers for claims processed by Medicare Carriers and Part B MACs.
Medicare requires implementation of system edits to assure that Part B providers and suppliers bill for ordered or referred items or services ONLY when those items or services are ordered or referred by physician and on-physician practitioners who are eligible to order or refer such services.
MLN Matters MM6417
Clarification of Medicare conditional payment policy and billing procedures for liability, no-fault and workers' compensation (WC) Medicare secondary payer (MSP) claims.
Promptly Definition: For no-fault insurance and worker's compensation, promptly means payment within 120 days after receipt of the claim (for specific items and services) by the no-fault insurance or WC carrier.
Transmittal 85 CR7355
MLN Matters MM7355
New Occurrence Code to Report Date of Death
Effective: October 1, 2012
Implementation: October 2, 2012
The NUBC approved a new occurrence code to report date of death with an effective/implementation date of October 1, 2012. Medicare systems will accept and process new occurrence code '55' used to report date of death. Occurrence code '55' and the date of death must be present when patient discharge status code 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expires-place unknown) is present.
Transmittal 1079 CR7792
MLN Matters MM7792
Guidance for correct claims submission when secondary payers are involved
Medicare is denying an increasing number of secondary claims, because providers are not identifying the correct primary payer prior to claims submission. Medicare would like to remind providers, physicians, and suppliers that they have the responsibility to bill correctly and to ensure claims are submitted to the appropriate primary payer.
ABN, Form CMS R-131, Updated Manual Instructions
Editorial changes have been made to Chapter 30, Section 50 regarding issuance of the ABN form.
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Claims hung out to dry with RAC audits?
AHA RAC TRAC Current Survey Results:
- More than half of all hospitals with a RAC denial overturned had a denial overturned because the care was found to be medically necessary. See page 54.
- The average cost of managing the RAC process varies by regions. See page 58.
- Hospital staffs are spending an increasing amount of time responding to RAC activity. Average hours spent. See page 60.
- Summary of Claims Pending Appeals Determination by RAC auditor. Of the claims that have completed the appeals process, 75% were overturned in favor of the provider. See page 50.
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Detailed report here
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George Halvorson, Chairman and CEO of Kaiser Permanente states "CFO's should be thinking about both the investments required for connectivity and the cash-flow implications of doing that."
Cirius connectivity is designed to accelerate and improve cash flow. Your business success is our business success.
Regards, Jayne Kroner, Editor
www.ciriusgroup.com
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UV Safety Month
UV Safety Month is a great time to spread the message of sun, fun, and UV safety to your community. Ultraviolet (UV) radiation is the main cause of skin cancer. UV rays can also damage your eyes.
Anyone can get skin cancer, but the risk is greatest for people with: white or light-colored skin with freckles, blonde or red hair, and blue or green eyes.
You can take these steps to help prevent skin cancer:
Stay out of the sun between 10 a.m. and 4 p.m.
Use sunscreen with SPF 15 or higher.
Cover up with long sleeves and a hat.
Check your skin regularly for any changes.
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US Healthcare Efficiency Index
The USHEI seeks to provide a national reference to track and measure the transition from a paper based healthcare system to an electronic based system.
Healthcare Billing & Payment Electronic Transactions Overview
Claims Submission: 85%
Eligibility Verification: 40%
Claim Status Inquiries: 40%
Claim Payment: 10%
Claim Remittance: 46%
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Navigating 5010
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4010 transactions rejections
began July 1, 2012 by Medicare.
Version 4010 will be turned off to comply with the mandated date. Rejection responses will vary between Medicare Administrative Contractors (MACs) since version 4010 did not standardize the acknowledgement responses. Version 4010 transactions submitted after June 30th will be rejected either with proprietary messages, 997s Functional Acknowledgement or TA1s Interchange Acknowledgement stating that the transaction version submitted is not supported.
Outbound transactions such as the Remittance Advice (835) and Claim Status will only be available in the 5010 format. Receivers of these transactions must be prepared to accept the 5010 version.
National
Transaction Levels
CMS Volume Percentages
Part A Claims at 95.3%
Part A Submitters 86.4%
Part B Claims 97.6%
Part B Submitters 79.1%
Medicaid 4010 & 5010 Dual Processing will continue until June 20, 2012 for 24 states. Two states have no update for CMS on transition.
Per CMS, If any entity is experiencing difficulty reaching a MAC, they should send a message describing their issue to
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On the Horizon
Why are we changing ICD10?
ICD9 code set has currently run out of space for additional codes to be added.
Additionally the diagnosis set cannot offer the level of specificity required for quality, abuse detection and reimbursement purposes.
Fundamental structural problems using ICD9 codes with new technologies and/or terminologies.
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Compliance Corner
| Two-thirds of health care organizations place the responsibility of RAC audits in the Compliance Department.
57% of organizations with 250-5,000 employees or less commit one employee to RAC audits.
Those organizations with 5,000 or more employees report 3-4 employees dedicated to RAC audits.
Guide to Privacy and Security of Heath Information Full report here April 1, 2012 CMS places new medical record reimbursement cap on hospitals. Reimbursement cap of $25.00 per medical record to include $0.12/page copying costs, PLUS first class postage. |
AHA
Hospital Billing and Collection Practices Statement of Principles and Guidelines
May 12, 2012
The billing and collections guidelines were recently updated because several of the original tenets were incorporated into law at the same time the promise of health insurance coverage was extended to 32 million Americans.
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Billing Tips for
Hospital Outpatient Billing
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Tip #1
Medicare requires reference lab claims to be billed using a TOB 014X; however, other insurers may use a TOB 013X.
Tip #2
Medicare required a TOB 014X for a screening mammogram but NOW requires a TOB 013X, along with other payers.
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These 17 medical centers are standouts in half a dozen or more specialties.
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