CRCP Exam Study Manual Update for 2016

Transcription

1 CRCP Exam Study Manual Update for 2016 This document reflects updates made to the instructional content from the AAHAM Certified Revenue Cycle Professional (CRCP-I, CRCP-P) Exam Study Manual to the 2016 version of the manual. This does not include updates to Knowledge Checks and Answers or the Glossary. Table of Contents Edit to page 2 1: Federal Agencies... 3 Federal Agencies... 3 U.S. Department of Health & Human Services (HHS)... 3 Edit to page 2 8: Telephone Consumer Protection... 3 Edit to page 2 10: Clinical Laboratory Improvement Act (CLIA)... 4 Edit to page 2 11: The Joint Commission... 4 Edit to page 3 5: Medicare 30 Day Readmissions... 4 Edit to page 3 7: Handling the Important Message from Medicare... 4 Edit to page 3 24: Observation... 5 Edit to page 3 24: Recurring or Series... 5 Edit to page 3 34: Electronic Records... 5 Edit to page 3 35: National and Local Coverage Determinations... 6 Edit to page 3 35: Advance Beneficiary Notice of Noncoverage... 6 Edit to page 3 37: Medicare Secondary Payer... 7 Edit to pages 4 3 to 4 10: Medicare... 7 Edit to page 4 11: Part D Medicare Prescription Drug Plan Edit to page 4 14: Health Insurance Claim Number Edit to page 4 15: Self Insurance Edit to page 4 16: Workers Compensation Edit to page 4 28: Medicare as Primary vs. Secondary Edit to page 4 29: Conditional Payment Edit to page 4 31: Mandated Transaction Code Sets Edit to page 4 31: ICD

2 Edit to page 4 34: HCPCS and CPT Modifiers Edit to page 4 35: Ambulatory Payment Classification (APC) Edit to page 4 36: Critical Access Hospital (CAH) Edit to page 4 48: Chargemaster Edit to page 4 49: UB 04 and 837I Edit to page 4 52: National Correct Coding Initiative (NCCI) Edit to page 4 53: Medically Unlikely Edits (MUE) Edit to page 4 54: Calculating Payer and Patient Obligations

3 Edit to page 2-1: Federal Agencies Deleted text struck through and inserted text highlighted in yellow: Federal Agencies The federal agencies addressed in this manual are: U.S. Department of Health & Human Services (HHS), which includes the following: Centers for Medicare & Medicaid Services (CMS) Office of Inspector General (OIG) U.S. Department of Health & Human Services (HHS) HHS is the U.S. government's principal agency for protecting the health of all Americans. HHS is one of the primary governing bodies effecting healthcare change. The work of HHS is conducted by the Office of the Secretary and 11 operating divisions, all of which have a major impact on healthcare services including those listed below. Edit to page 2-8: Telephone Consumer Protection The Telephone Consumer Protection Act of 1991 (TCPA) restricts telephone solicitations (in other words, telemarketing) and the use of automated telephone equipment. The TCPA prohibits contact with a debtor on a cell phone using automated dialing equipment without express consent and limits the use of artificial or prerecorded voice messages, SMS (Short Message Service, or text) messages, and fax machines. It also specifies several technical requirements for fax machines, auto dialers, and voice messaging systems principally requiring identification and contact information of the entity using the device to be contained in the message. Thanks to the ongoing and continuing efforts of AAHAM, the Federal Communications Commission adopted conditions (FCC 15 72) for calls made by or on behalf of a healthcare provider. Some of those conditions include: Text message and voice calls should only be sent to the wireless telephone number that has been provided by the patient. Any voice calls or text messages must include the name and contact information of the healthcare provider and must comply with HIPAA privacy rules. All calls should be one minute in length or less, and text messages should be no longer than 160 characters. Limit provisions state that healthcare providers can initiate only one call or text per day and no more than three per week. An opt out must be offered and, should a patient elect to use it, the healthcare provider must honor the opt out request immediately. 3

4 Edit to page 2-10: Clinical Laboratory Improvement Act (CLIA) Clinical Laboratory Improvement Act (CLIA) Ensuring quality laboratory testing is the main objective of the CLIA program. The CLIA imposed regulations that provide for the registration, certification, and inspection of all laboratory sites. It defined performance, personnel, quality control, quality assurance, and patient test management standards. Failure to meet standards may result in sanctions to include withholding Medicare reimbursement. Edit to page 2-11: The Joint Commission Updated text highlighted in yellow: TJC will conduct an audit of a hospital every 39 months and of a laboratory every two years. The organization can audit a healthcare facility without advance notice, as early as 9 30 months after its initial audit. Edit to page 3-5: Medicare 30-Day Readmissions Preventable readmissions can result in financial penalties, so it is important to track and monitor Medicare 30 day readmissions as part of the registration/admission process. Hospitals with excess readmissions are liable for payment reductions in accordance with the Hospital Readmissions Reduction program. Edit to page 3-7: Handling the Important Message from Medicare Deleted text struck through and inserted text highlighted in yellow: The Patient Access department has other important responsibilities. In many facilities, Patient Access is responsible for handling the Important Message from Medicare that hospitals are required to give to all Medicare beneficiaries who are hospital inpatients. This notice is required to be issued within two days of admission and again within two days of discharge. The notice explains to inpatients their rights regarding Medicare covered services and involvement in decisions regarding the hospital stay and who will pay for those services, and information needed to report Quality of Care concerns to the Quality Information Organization. In addition, it explains what patients should do if they feel what to do if they feel they are being discharged too soon. It protects them from financial liability until they have had a chance to appeal. (Some facilities make this part of the Case Management process rather than handling it in Patient Access.) Documentation that the patient received and signed this notice should be maintained in the patient s records. 4

5 Edit to page 3-24: Observation Deleted text struck through and inserted text highlighted in yellow: Observation Though these patients occupy a bed, they are outpatients. Observation time is intended for monitoring of the patient s acute condition, which may resolve or worsen. Because of this, observation is not the kind of service that can be scheduled in advance. It is also not intended for routine use such as surgical recovery. Many commercial insurance payers require most one day stays to be classified as observation. Some limit these stays to 23 hours. The Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, enacted in 2015, states that hospitals must inform patients who are hospitalized for more than 24 hours that they are in observation status. No later than 36 hours after a patient begins to receive observation services, the patient must be informed, both orally and in writing, of his or her observation status. Except in very rare instances, Medicare limits them to 48 hours. Edit to page 3-24: Recurring or Series Deleted text struck through and inserted text highlighted in yellow: Recurring or Series These are common terms for outpatients who will be coming regularly for repetitive types of treatment. Physical therapy, chemotherapy, and radiation oncology are common types is a common type of series accounts. Edit to page 3-34: Electronic Records Deleted text struck through and inserted text highlighted in yellow: In 2011, most providers began projects that would qualify them to receive federal or state funds for meaningful use (MU) of an EHR. ("Meaningful use" means providers are using certified EHR technology to achieve health and efficiency goals including reducing errors; making records and data available; generating reminders and alerts; supporting clinical decisions; and automating e prescribing/refills.) According to the Centers for Disease Control and Prevention (CDC), MU is based on these five pillars: 1. Improving coordination of care 2. Improving public and population health 3. Improving quality, safety, and efficiency, and reducing health disparities 4. Engaging the patients and their families 5. Ensuring privacy and security protection for PHI Meeting MU requirements will be done in four three stages, with each stage depending at least in part on the Patient Access/Front Office areas gathering demographic information such as race and ethnicity. 5

6 Edit to page 3-35: National and Local Coverage Determinations Deleted text struck through and inserted text highlighted in yellow: National coverage determinations (NCDs) and local coverage determinations (LCDs) are policies that CMS and fiscal intermediaries Medicare Area Contractors use to pay or deny claims based on medical necessity. NCDs An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision. For example, NCDs set forth Medicare's coverage of abortion (only when the pregnancy is the result of an act of rape or incest, or when a woman suffers from a life-threatening pregnancy-related condition) or of biofeedback therapy (only when it is reasonable and necessary for muscle re-education and more conventional treatments have not been successful). LCDs An LCD is a decision by a fiscal intermediary Medicare Area Contractor or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis. (U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services, Glossary) Edit to page 3-35: Advance Beneficiary Notice of Noncoverage Patients sign and date the ABN after indicating their decision to proceed with the service (knowing they will have to pay personally if Medicare denies payment) or to forego the service. An ABN signed by the patient serves as proof that the beneficiary was aware prior to receiving the service that Medicare may not pay for the service(s) being rendered. If a valid and signed ABN is not obtained prior to the services being rendered, the provider cannot bill the beneficiary for those services and will be held financially liable if payment is not received by Medicare. 6

7 Edit to page 3-37: Medicare Secondary Payer Medicare is also secondary if the beneficiary has coverage through an employed spouse of any age. (In a new provision made in January 2015, CMS changed the definition of spouse in the context of the working aged to include couples in same sex marriages.) Edit to pages 4-3 to 4-10: Medicare Updated/inserted text highlighted in yellow: Part A Deductibles, Coinsurance, and Copayments A patient s total financial obligation is determined by deductibles, coinsurance, and copayments. That information for Part A services is outlined below. Medicare Part A Service Beneficiary Obligation 2016 Amount Hospital stay Semiprivate room, meals, general nursing, other hospital services, and supplies. This includes care in critical access hospitals. This does not include private duty nursing or a television or telephone in the room. It also does not include a private room, unless medically necessary. Inpatient mental healthcare in an independent psychiatric facility is limited to 190 days in a lifetime. SNF care Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a three-day hospital stay). Days 1 through 60*: Part A current year inpatient deductible *Renewable during the next benefit period Days 61 through 90*: Part A coinsurance (1/4 or 25% of current year inpatient deductible) *Renewable during the next benefit period Days 91 through 150*: Part A lifetime reserve (LTR, 1/2 or 50% of current year inpatient deductible) *Nonrenewable; hospitals alert patients when they have 5 days of coinsurance left so they can choose whether to use LTR Days 1 through 20: No deductible or coinsurance Days 21 through 100: 1/8 of current year inpatient deductible $1,288 per spell of illness $322 per day $644 per day $0 per benefit period $161 per day 7

8 Medicare Part A Service Beneficiary Obligation 2016 Amount Home health care Part-time skilled nursing care, physical therapy, occupational therapy, speechlanguage therapy, home health aide services, durable medical equipment (DME, such as wheelchairs, hospital beds, oxygen, and walkers) and supplies, and other services. Hospice care Medical and support services; drugs for symptom control and pain relief; shortterm respite care; care in a hospice facility, hospital, or nursing home, when necessary; and other services not otherwise covered by Medicare. Home care is also covered. This does not include room and board when hospice care is provided in the home or another facility in which the patient lives, such as a nursing home. Blood Blood received at a hospital or SNF during a covered stay. Home health care services: No deductible or coinsurance DME: Coinsurance (20% of Medicare-approved amount) Hospice care: No deductible or coinsurance Outpatient prescription drugs: Current year prescription copayment Inpatient respite care: Current year respite care coinsurance Blood: Current blood deductible (unless the patient or someone else donates to replace the blood received) $0 Depends on value of DME $0 Up to $5 per prescription 5% of Medicareapproved amount First 3 pints per year Part B Deductibles, Coinsurance, and Copayments The beneficiary obligations for Part B services are shown below. 8

9 Medicare Part B Service Beneficiary Obligation 2016 Amount Medical and other services Doctors services (except for routine physical exams); outpatient medical and surgical services; supplies; diagnostic tests; ambulatory surgery center facility fees for approved procedures; and DME. Also covers second surgical opinions; outpatient physical, occupational, and speech therapy; and outpatient mental healthcare. Clinical laboratory service Blood tests, urinalysis, and more. Home health care Part-time skilled care, home health aide services, DME when supplied by a home health agency while getting Medicare-covered home health care, and other supplies and services. Outpatient hospital services Services for the diagnosis or treatment of an illness or injury. Blood Blood received as an outpatient or as part of a Part B covered service. Medical and other services: Current year deductible, then coinsurance (20% of Medicare-approved amount, except in the outpatient setting) Outpatient physical, occupational, and speech-language therapy services: Coinsurance Outpatient mental healthcare: Coinsurance Medicare-approved service: No deductible or coinsurance Medicare-approved service: No deductible or coinsurance DME: Coinsurance (20% of Medicare-approved amount) Medicare-approved service: Coinsurance or fixed copayment, which varies according to the service Blood: Current blood deductible (unless the patient or someone else donates to replace the blood received), then coinsurance 9 $166 per year, then 20% of Medicare-approved amount 20% of Medicare-approved amount 20% of Medicare-approved amount $0 $0 Depends on value of DME Varies First 3 pints per year, then 20% of the Medicareapproved amount

10 Part B Preventive Services Medicare Part B also covers certain preventive services, outlined below. All services are based on the provider accepting assignment. Medicare Part B Covered Preventive Services Service Who Is Covered Beneficiary Obligation in the Original Medicare Plan Bone mass measurements Varies with health status; covered once every 24 months unless determined to be medically necessary. Colorectal cancer screening Fecal occult blood test (FOBT): once every 12 months; flexible sigmoidoscopy: once every 4 years or once every 10 years after having a screening colonoscopy; screening colonoscopy: once every 24 months if at high risk for colon cancer or once every 10 years if not at risk; barium enema: once every 24 months if at high risk or once every 4 years if not at high risk. Diabetes screening test Coverage for glucose monitors, test strips, and lancets; diabetes self-management training; 2 screening tests per year for beneficiaries diagnosed with pre-diabetes or 1 screening per year if previously tested but not diagnosed with pre-diabetes, or if never tested. Diabetes Self-Management Training (DSMT) Up to 10 hours of initial training within a 12-month period. In subsequent years, up to 2 hours of follow-up training are allowed each year. Certain beneficiaries at risk for losing bone mass or developing osteoporosis Beneficiaries age 50 and older (However, there is no age limit for having a colonoscopy.) Beneficiaries who have certain risk factors for diabetes or who have been diagnosed with prediabetes Beneficiaries who have been diagnosed with diabetes, or who have previously been diagnosed with diabetes FOBT, flexible sigmoidoscopy, colonoscopy - Copayment, coinsurance, and Barium enema - Coinsurance applies; Multitarget stool DNA test - if polyp found and removed, 20% copayment applies deductible apply 10

11 Medicare Part B Covered Preventive Services Service Who Is Covered Beneficiary Obligation in the Original Medicare Plan Glaucoma screening Once every 12 months. Must be done or supervised by an eye doctor who is legally allowed to do this service in the beneficiary s state of residence. Mammogram, screening Once every 12 months for females over age 40 plus one baseline mammogram between ages 35 and 39. Mammogram, diagnostic Pap smear and pelvic examination (including a clinical breast exam) Once every 24 months or once every 12 months if at risk for cervical or vaginal cancer or of childbearing age with an abnormal Pap smear in the preceding 36 months. Prostate cancer screening Digital rectal examination: once every 12 months; prostate-specific antigen (PSA) test: once every 12 months. Vaccinations Flu shot: once a year, in the fall or winter; pneumonia shot: once in a lifetime. Beneficiaries at high risk of glaucoma, including people with diabetes or a family history of glaucoma; African- Americans who are age 50 and older; and Hispanic- Americans age 65 and older Female beneficiaries age 35 and older Female beneficiaries, when the service is medically necessary Female beneficiaries Male beneficiaries age 50 and older (beginning the day after the 50th birthday) All beneficiaries with Part B coverage deductible apply Coinsurance and deductible may apply Digital rectal exam - Copayment, coinsurance, and deductible apply PSA test - Copayment, coinsurance, and 11

12 Medicare Part B Covered Preventive Services Service Who Is Covered Beneficiary Obligation in the Original Medicare Plan Hepatitis B (HBV) vaccine and administration - Scheduled dosages, as required. Hepatitis C Virus (HCV) screening Annually for highrisk beneficiaries with continued illicit drug use with injection, or once in a lifetime if born between 1945 and 1965 and not at high risk. Initial preventive physical examination (IPPE, the Welcome to Medicare Physical Exam ) - Once in a lifetime. Ultrasound screening for abdominal aortic aneurysm (AAA) Once in a lifetime. Cardiovascular disease screening (lipid panel, cholesterol, lipoprotein, and triglycerides) Once every 5 years. Medical nutrition therapy (MNT) First year: 3 hours of one-on-one counseling; subsequent years: 2 hours of one-on-one counseling. Beneficiaries who are at intermediate or high risk for contracting Hep B (but beneficiaries who are currently positive for antibodies for Hep B are not eligible for this benefit) Beneficiaries who are at high risk for HCV infection or who were born between 1945 and 1965 All new Medicare beneficiaries who are within the first 12 months of their first Medicare Part B coverage period Beneficiaries with certain risk factors for AAA (Those eligible must receive a referral only as a result of an IPPE.) All asymptomatic Medicare beneficiaries Beneficiaries diagnosed with diabetes or a renal disease or who have received a kidney transplant within the last 3 years IPPE: Copayment and coinsurance apply; IPPE with EKG: deductible apply 12

13 Medicare Part B Covered Preventive Services Service Who Is Covered Beneficiary Obligation in the Original Medicare Plan Annual wellness visit (AWV) Initial visit for AWV once in a lifetime; subsequent visits allowed annually. Human immunodeficiency virus (HIV) screening Annually for high-risk cases and three times per pregnancy (one screening per trimester) for those beneficiaries who are pregnant. Smoking and tobacco use cessation counseling - 2 cessation attempts per year; each attempt includes a maximum of 4 intermediate or intensive sessions; up to 8 sessions within a 12-month period. Intensive behavioral therapy (IBT) for cardiovascular disease (CVD) - One CVD risk reduction visit annually. Screening and behavioral counseling to reduce alcohol misuse - Annually for all beneficiaries; face-to-face counseling up to four times per year. Screening for depression - Annually for all beneficiaries. All Medicare beneficiaries who are more than 12 months after the effective date of their Medicare Part B coverage and who also have not received an IPPE or AWV within 12 months Beneficiaries who are at an increased risk for HIV, who may be pregnant, or who are between ages and ask for the test Beneficiaries who use tobacco and have a disease or adverse health effect linked to tobacco use All Medicare beneficiaries who are competent and alert at the time that counseling is provided, and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting All Medicare beneficiaries All Medicare beneficiaries 13

14 Medicare Part B Covered Preventive Services Service Who Is Covered Beneficiary Obligation in the Original Medicare Plan Sexually transmitted infection (STI) screenings and high intensity behavioral counseling to prevent STIs - Annually for all beneficiaries; frequency of coverage depends on the type of STIs being treated. Intensive behavioral therapy for obesity - Annually for all beneficiaries; frequency of coverage includes one visit every week for month 1; one visit every other week for months 2-6; and one visit every month for months Lung cancer screening - Annually for beneficiaries between ages Adolescent and adult beneficiaries who are sexually active and are at an increased risk for STIs Beneficiaries with a BMI 30 kg/m 2, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting Beneficiaries who show no signs or symptoms of lung cancer and who have a history of smoking at least 30 pack years (one packyear is equal to smoking one pack per day for one year; one pack equals 20 cigarettes); who are current smokers; or who have quit smoking within the past 15 years. There also must be a written order for the service that meets specific criteria established by CMS. Behavioral counseling sessions conducted in an inpatient setting will not be covered as preventive services. CMS does not state the beneficiary obligation but references the following site to obtain additional information: Items Not Covered by Part A or Part B in the Original Medicare Plan The original Medicare plan does not cover everything. Out of pocket costs for healthcare will include, but are not limited to: Acupuncture Applicable deductibles, coinsurance, or copayments Dental care and dentures (in most cases) Cosmetic surgery 14

15 Custodial care (help with bathing, dressing, toileting, and eating) at home or in a nursing home Healthcare while traveling outside of the United States (except in limited cases) Hearing aids and the exam for fitting them Edit to page 4-11: Part D Medicare Prescription Drug Plan Deleted text struck through and inserted text highlighted in yellow: Part D, Medicare Prescription Drug plan, covers medications subject to an annual deductible and a donut hole (when drug expenses reach the initial coverage limit, which has changed every year, an Out of Pocket Threshold must be reached, which also changes each year; after that, plans pay 95%). Healthcare reform of 2010 will eliminate the donut hole when it is fully in effect. The Medicare Drug Plan selected has a list of covered drugs, which is known as the formulary. Drugs are placed into tiers and each tier can have a difference cost. Part D coverage rules include: The drugs must have a prior authorization before a prescription can be filled in order to show medical necessity. There are limits on how much medication a beneficiary can receive at one time. Sometimes the beneficiary is required to try a lower cost drug, similar in nature to the one being prescribed, before a higher cost drug will be covered. Edit to page 4-14: Health Insurance Claim Number F4 F5 Stepmother Adopting Father Edit to page 4-15: Self-Insurance Many companies do not purchase group insurance, but rather put premium payments into a fund to cover services and pay a third party to administer benefits from the fund. In this way, the plan benefits can be tailored to the needs of the company and money is often saved. On the other hand, a high volume of unexpected claims can be a burden on a self insured company. To help alleviate this risk, a company usually buys stop loss coverage through a reinsurer. Self insured health plans are regulated under federal law through the Employee Retirement Income Security Act of 1974 (ERISA). 15

16 Edit to page 4-16: Workers Compensation When billing for a workers compensation claim, it is important to: Gather as much information as possible regarding the patient s coverage, including any group health insurance (Sometimes workers compensation cases spend many years in the court system, so it can be helpful to secure payment from the health insurance.) Secure a workers compensation claim number for the case (The claim number, and sometimes medical records, are needed for processing the claim for payment.) Edit to page 4-28: Medicare as Primary vs. Secondary Services are payable through the VA. Veterans who are entitled to Medicare may choose which program will be responsible for payment of services that are covered by both programs. To have services paid by a non VA facility, the VA must authorize the services. If the VA does authorize the services in a non VA facility but does not pay for all of the services, then Medicare may pay for the Medicare covered part of the services that the VA does not pay for. Edit to page 4-29: Conditional Payment Conditional Payment When another payer is responsible, but the claim is not expected to be paid promptly (usually within 120 days from receipt of the claim), Medicare will make a conditional payment to prevent the beneficiary from having to pay out of pocket. These conditional payments often apply to workers compensation, automobile, no-fault, or liability claims. Medicare then has the right to recover any payments that should have been made by another payer. Providers must indicate they are requesting conditional payment from Medicare by using the correct value code on the claim. 16

17 Edit to page 4-31: Mandated Transaction Code Sets Deleted text struck through and inserted text highlighted in yellow: Code Set Acronym Use International Classification of Diseases Current Procedural Terminology Healthcare Common Procedure Coding System ICD ICD-9, for the ninth revision ICD-10, for the 10th revision CPT (CPT-4, for the fourth revision) HCPCS Diagnoses and inpatient procedures (As of October 2015, the HHS has mandated that providers must code all claims using ICD-10 codes.) Outpatient procedures National Provider Identification NPI Provider identification, as dictated by CMS s Administrative Simplification Identifier Standards Taxonomy Code Type and specialty of a provider * Much of the rest of the world already uses the tenth revision, ICD 10. It does not just expand codes; the entire format and methodology has changed. HHS has mandated that the U.S. switch from ICD 9 by October Edit to page 4-31: ICD-10 Updated text highlighted in yellow: ICD 10 The ICD 10 code set consists of tabular lists, inclusion and exclusion terms, an alphabetical index, descriptions, guidelines, and resources to assist with the accurate coding of claims. While the previous ICD 9 code set averaged a little over 17,000 codes, the ICD 10 contains more than 141,000 codes. This increase allows for greater specificity to identify and track the services being offered in the medical field. When assigning ICD 10 codes: Code the primary diagnosis first, followed by the secondary, tertiary, and so on. Code any coexisting conditions that affect the visit or procedure as supplemental information. Code the principal diagnosis and discharge diagnosis to the highest level of specificity. Code any coexisting diagnosis to the lowest level of specificity. 17

18 Edit to page 4-34: HCPCS and CPT Modifiers Deleted text struck through and inserted text highlighted in yellow: Other modifiers deal specifically with the use of ABNs: GA used when it is expected that Medicare will deny the item or service and there is a signed ABN on file GX used to report that a voluntary ABN was issued for a service ( Notice of Liability Issued, Voluntary Under Payer Policy ) GY used when it is known that the item or service is noncovered or is not a Medicare benefit GZ used when it is expected that Medicare will deny the item or service and there is no ABN was obtained Edit to page 4-35: Ambulatory Payment Classification (APC) TIP: You should know in what circumstances Medicare will pay an inpatient-only procedure on an outpatient claim. The only time this would happen is if the patient died before admission. In that circumstance the facility would need to add the CPT code for the inpatient-only procedure and then add a CA modifier to indicate that the patient died prior to admission as an inpatient. Edit to page 4-36: Critical Access Hospital (CAH) CAHs are small hospitals that serve rural communities. They must have 25 or fewer beds and an ALOS of 96 hours or less. They must be located a certain minimum distance from other hospitals and must maintain 24/7 emergency room service. CAHs are not subject to Medicare MS DRGs or APCs, but instead are paid 101% of allowable Medicare costs. CAHs can negotiate any contract terms they wish with other payers. Edit to page 4-48: Chargemaster The chargemaster is an electronic file that resides in the provider s information system and that contains all of the charges that might be posted to a patient account. It is also called the Charge Description Master (CDM), fee schedule, item master, and other similar names. Each item has a system entry that includes the description and price of the item, its CPT codes, what general ledger account it impacts, and, in the case of supplies and medications, inventory control information such as supplier and cost. 18

19 Edit to page 4-49: UB-04 and 837I The UB is the standard paper form used by many providers for billing insurance. The UB 04, or UB, replaced the UB 92 in 2007 and is also known as the CMS The 837I is the HIPAA standard transaction used by hospitals to submit institutional claims electronically. TIP: Be prepared to describe the purpose and general use of the following codes: Type of Bill (TOB, including the meaning of each digit in the code: first digit is Type of Facility; second digit is Bill Classification; and third digit is Frequency) Condition (including common codes) Occurrence (including dates, such as those for an auto accident, date of onset of symptoms, and date of retirement) Other Provider Name and Identifiers (including the name and ID number of the referring provider, other operating physician, or rendering provider) Edit to page 4-52: National Correct Coding Initiative (NCCI) NCCI Procedure to Procedure (PTP) edits were introduced to: Establish standards of medical billing with CPT and HCPCS codes. Identify codes that may be a potential for fraud and abuse. Identify codes that are components of another code and should not be unbundled and billed on the same encounter by the same physician. Edit to page 4-53: Medically Unlikely Edits (MUE) In many cases, an MUE cannot be appealed. A provider who disagrees with an MUE should contact Correct Coding Solutions, the contractor who developed the program. MUE Adjudication Indicator In 2013, CMS modified the MUE program so that some MUE values are date of service edits rather than claim line edits. There is a data field in the MUE edit table termed "MUE adjudication indicator, or MAI. There is an MAI assigned to each HCPCS code and there are three levels of MAI: Level 1 indicates the MUE will continue to be adjudicated as a claim line edit. Level 2 indicates the MUE will be based on an absolute date of service. These are per day edits based on policy. Level 3 indicates the MUE will be based on date of service. These are per day edits based on clinical benchmarks. 19

20 Edit to page 4-54: Calculating Payer and Patient Obligations Deductible an amount that a patient must pay for healthcare before the payer begins to pay. Deductibles are usually applied yearly, by person or by family. 20