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Institutional Claim UB04 Update
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National Uniform Billing Committee (NUBC)
Effective: October 1, 2012
FL 31-34 - Required new occurrence code '55' with the date of death whenever the patient discharge status is: 20, 40, 41, or 42.
Discharge Hour - Discharge Hour is required on all final inpatient claims, except for 021x. This includes claims with a Frequency Code of 1 (Admit through Discharge), 4 (Interim-Last Claim) and 7 (Replacement of Prior Claim) when the replacement is for a prior final claim.
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Payer Update
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United Healthcare
Effective October 1, 2012, UHC Cardiology Notification Program for Medicare Advantage benefit plans is changing from a notification program to a prior authorization program. Services to require prior authorization for UHC Medicare Advantage members: Echocardiogram, Stress Echo, Diagnostic Catheterizations, and Electrophysiology Implants.
Important Changes
Quick Reference Guide for Hospitals & Health Care Facilities
Network Bulletin
Aetna
Look for the "MA18" or "N89" codes on your Medicare Explanation of Payment. That means Medicare automatically
sent us the claim.
September Bulletin by Region
Mid America
West
Cigna
Except as noted, we routinely require clinical documentation at the time a claim is submitted for the following categories of claims to be considered complete:
codes appended with a modifier additional or unusual services(e.g., 22, 23, 24, 53, 59, or 66)
Exception: the following modifiers do not require clinical records is: Any HCPCS modifiers or CPT modifiers 25, 26, 52, 63, or 90.
Network Bulletin
Tricare
The UBO Policy manual last updated in November 2006 has undergone an extensive revision.
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Medicare Quarterly News
New Occurrence Code to Report Date of Death
Effective: October 1, 2012
Implementation: October 2, 2012
Transmittal 1079 CR7792
MLN Matters MM7792
Manual Medical Review of Therapy Services
Effective: October 1, 2012
All requests for therapy services above $3700.00 provided by speech language therapists, physician therapists, occupational therapists and physicians must be approve in advance.
MLN Matters MM8036 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
MLN Maters MM7502
| 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.
MLN Matters MM7794Implement Fraud Prevention Predictive Modeling Prepayment edits for share systems
Effective: January 7, 2013 Reversing the traditional pay and chase term, sustainable approach that incorporates innovative technologies in integrated solutions. The National Fraud Prevention Program (NFPP) is being implemented by the Center for Program Integrity (CPI), the CMS component that is accountable for the prevention and detection of fraud, waste, abuse and other improper payments under the Medicare and Medicaid programs. Transmittal 1115 CR 7861
Updating Beneficiary Information with the Coordination of Benefits Contractor A new Medicare Secondary Payer (MSP) initiative will affect how you may update beneficiary information to the Coordination of Benefits Contractor (COBC).
Phone: 800-999-1118 8am-8pm EST Fax: 734-957-9598
Mailing Address: Medicare-Coordination of Benefits
P.O. Box 33847 Detroit, MI 48232
MLN Matters SE1205
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.
CMS Transmittal 991 CR417
Handling Form CMS 1500 Hard Copy Claims where an ICD9 "E" code or where and ICD10 V00-Y99 code is reported as the first diagnosis on the claim.
Effective January 1, 2013
Contractors shall return as unprocessable claims for items or services given the above criteria.
Transmittal 2515 CR7700
MLN Matters MM7700
New FISS Consistency Edit to Validate Attending Physician National Provider Identifier (NPI)
Effective for claims received on or after January 1, 2013
you must submit the NPI of the attending provider in the Attending Provider Name and Identifiers Field (FL76) of your claims. That NPI must not be your billing NPI, unless the claim is for institutional billing of influenza and pneumococcal vaccinations and their administrations. In addition this edit will not be applied to an institutional claim for a self-referred screening mammogram.
Transmittal 2560 CR7902
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 Report
- 97% of denied dollars were for complex denials. See page 20.
- Average dollar amount of an automatic denial is $548.00 whereas the average dollar amount of a complex denial is $5,564.00. See page 22.
- 3 of 4 RAC regions ranked Outpatient billing error as top reason for automated denials. See page 27-31.
- Most commonly sited reason for complex denials was 'short stay medically unnecessary'. See page 32.
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AHA Q2 RAC Results
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Denied Claims Part B SNF
|  A Medicare Part B claims processing issue has been identified with the 2012 annual update of HCPCs codes for SNF's. Medicare Part B Services may have been erroneously denied by Medicare's claims processing system. In other instances, the claims processing system may have paid and then identified a Medicare "overpayment" on these claims. The situation has been corrected as of July 30th, 2012 but services meeting the following may have been impacted: HCPCS for dates of service on or after, claims processed January 3, 2011 through July 29, 2012:
21554 until March 11, 2012
96522 & 96571 until July 29, 2012
HCPCs for dates of service January 3, 2012 until July 29, 2012:
21554 - until March 11, 2012
96522 - until July 29, 2012
96571 - until July 29, 2012
CMS is working with its MACs to identify all claims that were denied in error as well as any over payments that were identified erroneously and resulted in a demand letter so that appropriate payment adjustments can be made.
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What sets Cirius Prebill apart from other claim scrubbers?
- We deliver clean claims DIRECTLY to the payer. We are NOT a clearinghouse
- Compliant vendor maintained all payer edits delivered TIMELY.
And SO much more.....Call 925.685.9300 or revenue@ciriusgroup.com.
Regards, Jayne Kroner, Editor
www.ciriusgroup.com
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Breast Cancer Awareness Month
Mother, Daughter, Sister or Friend
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Revenue Cycle Key Performance Results
HARA Results
First Quarter 2012
Percentage of Discharge A/R over 90 Days
23.95
Discharge to Bill Time in Days
12.21
Days Revenue in Credit Balances
0.85
Average Cost to Collect
$2.09
How do you compare? |
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Navigating 5010
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Department of Health Care Service (DHCS) has identified by
December 31, 2012 as the final date that providers can submit claims in the ASC X12N 4010A1 and NCPDP 5.1/1/1 formats.
Effective on or after January 1, 2013, all 4010A1, NCPDP5.1 or 1.1 batch transactions submitted will be rejected due to HIPAA non-compliance and will not be processed. This will result in nonpayment.
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On the Horizon
ICD10
The ICD-10-related implementation date is now October 1, 2014, as announced in final rule CMS-0040-F issued on August 24, 2012. The compliance dates are firm and not subject to change.
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Compliance Corner
OIG Workplan 2013
| Hospitals
1. Inpatient Billing for Medicare Beneficiaries (New)
2. Diagnosis Related Group Window (New)
3. Same-Day Readmissions
4. Non-Hospital-Owned Physician Practices Using Provider-Based Status (New)
5. Compliance With Medicare's Transfer Policy (New)
6. Payments for Discharges to Swing Beds in Other Hospitals (New)
7. Acute-Care Inpatient Transfers to Inpatient Hospice Care
8. Payments for Canceled Surgical Procedures (New)
9. Admissions With Conditions Coded Present on Admission
10. Inpatient Outlier Payments: Trends and Hospital Characteristics
11. Reconciliation of Outlier Payments
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NEW Billing & Reimbursement Tips for
Hospital Inpatient Billing
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Medicare will allow billing of some new technology items detailed in the 837I that will be considered an add on payment. Example: If patient has CDAD and diagnosis code of 008.45 is applied, if treatment used was DIFICID then a NDC code of 52015-0080-01 may be used and will be read and reimbursed by Medicare in the amount of $868.00.
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 | 1500 Health Insurance Claim Form
Version 8.0
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