Transmittal 829 Date: FEBRUARY 2, 2006

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1 anual ystem Pub edicae laims Pocessing Depatment of ealth & uman evices (D) entes fo edicae & edicaid evices () Tansmittal 829 Date: EBUAY 2, 2006 hange equest 4242 This instuction escinds and eplaces 3735, Tansmittal 542 peviously eleased on Apil 29, t emoves the equiement fo epoting the dischage date on oste billing fo mass immunizes billing fo inpatient Pat B sevices. UBJET: odification of oste Billing fo ass mmunizes Billing fo npatient Pat B evices (Type of Bills (TOB) 12X and 22X). UAY O ANGE: This instuction escinds and eplaces 3735 peviously eleased on Apil 29, updated the oste billing to include additional data elements, including the dischage date, in the oste billing. This instuction emoves the equiement fo epoting the dischage date on oste billing fo mass immunizes billing fo inpatient Pat B sevices. NEW/EVED ATEAL EETVE DATE: Octobe 01, 2005 PLEENTATON DATE: July 03, 2006 Disclaime fo manual changes only: The evision date and tansmittal numbe apply only to ed italicized mateial. Any othe mateial was peviously published and emains unchanged. oweve, if this evision contains a table of contents, you will eceive the new/evised infomation only, and not the entie table of contents.. ANGE N ANUAL NTUTON: (N/A if manual is not updated) = EVED, N = NEW, D = DELETED /N/D APTE/ETON/UBETON/TTLE 18/10/10.3.2/laims ubmitted to ntemediaies fo ass mmunizations of nfluenza and PPV. UNDNG: No additional funding will be povided by ; ontacto activities ae to be caied out within thei Y 2006 opeating budgets.

2 V. ATTAENT: Business equiements anual nstuction *Unless othewise specified, the effective date is the date of sevice.

3 Attachment - Business equiements Pub Tansmittal: 829 Date: ebuay 2, 2006 hange equest 4242 This instuction escinds and eplaces 3735, Tansmittal 542 peviously eleased on Apil 29, t emoves the equiement fo epoting the dischage date on oste billing fo mass immunizes billing fo inpatient Pat B sevices. UBJET: odification of oste Billing fo ass mmunizes Billing fo npatient Pat B evices (Type of Bills (TOB) 12X and 22X). GENEAL NOATON A. Backgound: The cuent oste billing pocess fo mass immunizes billing inpatient Pat B sevices utilizing TOBs 12X and 22X does not equie the epoting of additional data elements that ae mandated by the ealth nsuance Potability and Accountability Act (PAA). As a esult this instuction updates the oste billing to include the PAA mandated data elements. B. Policy: is committed to implementing additional data elements to oste billing as mandated by PAA.. BUNE EQUEENT hall" denotes a mandatoy equiement "hould" denotes an optional equiement equiement Numbe equiements ontactos shall edit to ensue that the following additional data elements ae pesent on the oste when billing inpatient Pat B sevices (TOBs 12X and 22X) effective Octobe 1, 2005 and the haed ystem aintaines should add a new field fo povide enty: admission date admission type admission diagnosis patient s status code admission souce code esponsibility ( X indicates the columns that apply) a D haed ystem aintaines Othe E V W i e X X X N

4 equiement Numbe equiements s shall instuct povides that conduct mass immunizations to epot the following additional data elements on the oste when billing fo inpatient Pat B sevices (TOBs 12X and 22X) effective Octobe 1, admission date admission type admission diagnosis patient s status code admission souce code esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe X a i e D E V W. POVDE EDUATON equiement Numbe equiements A povide education aticle elated to this instuction will be available at shotly afte the is eleased. You will eceive notification of the aticle elease via the established "medlean mattes" listsev. ontactos shall post this aticle, o a diect link to this aticle, on thei Web site and include infomation about it in a listsev message within 1 week of the availability of the povide education aticle. n addition, the povide education aticle shall be included in you next egulaly scheduled bulletin and incopoated into you outeach activities, as appopiate. ontactos ae fee to supplement edlean attes aticles with localized infomation that would benefit thei povide community in billing and administeing the edicae pogam coectly. esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe X a i e D E V W

5 V. UPPOTNG NOATON AND POBLE DEGN ONDEATON A. Othe nstuctions: N/A X-ef equiement # nstuctions B. Design onsideations: N/A X-ef equiement # ecommendation fo edicae ystem equiements. ntefaces: N/A D. ontacto inancial epoting /Wokload mpact: N/A E. Dependencies: N/A. Testing onsideations: N/A V. EDULE, ONTAT, AND UNDNG Effective Date*: Octobe 1, 2005 mplementation Date: July 3, 2006 Pe-mplementation ontact(s): William uiz , William.uiz@cms.hhs.gov No additional funding will be povided by ; ontacto activities ae to be caied out within thei Y 2006 opeating budgets. Post-mplementation ontact(s): egional Office *Unless othewise specified, the effective date is the date of sevice.

6 laims ubmitted to ntemediaies fo ass mmunizations of nfluenza and PPV (ev. 829, ssued: ; Effective: ; mplementation: ) ome potential "mass immunizes," such as hospital outpatient depatments and As, have expessed concen about the complexity of billing fo the influenza vius vaccine and its administation. onsequently, to incease the numbe of beneficiaies who obtain needed peventive immunizations, simplified (oste) billing pocedues ae available to mass immunizes. The simplified (oste) claims filing pocedue has been expanded fo PPV. A mass immunize is defined as any entity that gives the influenza vius vaccine o PPV to a goup of beneficiaies, e.g., at public health clinics, shopping malls, gocey stoes, senio citizen homes, and health fais. To qualify fo oste billing, immunizations of at least five beneficiaies on the same date ae equied. (ee fo an exception to this equiement fo inpatient hospitals.) The simplified (oste) claims filing pocedue applies to povides othe than s and Qs that conduct mass immunizations. ince independent and povide base Qs and Qs do not submit individual om -1450s fo the influenza vius vaccine, they do not utilize the simplified billing pocess. nstead, payment is made fo the vaccine at the time of cost settlement. The simplified pocess involves use of the povide billing fom (om -1450) with pepinted standadized infomation elative to the povide and the benefit. ass immunizes attach a standad oste to a single pe-pinted om that contains the vaiable claims infomation egading the sevice povide and individual beneficiaies. Qualifying individuals and entities must attach a oste, which contains the vaiable claims infomation egading the supplie of the sevice and individual beneficiaies. The oste must contain at a minimum the following infomation: Povide name and numbe; Date of sevice; Patient name and addess; Patient date of bith; Patient sex; Patient health insuance claim numbe; and Beneficiay signatue o stamped "signatue on file." n addition, fo inpatient Pat B sevices (12x and 22X) the following data elements ae also needed: Admission date; Admission type; Admission diagnosis;

7 Admission souce code; and Patient status code. NOTE: A stamped "signatue on file" can be used in place of the beneficiay's actual signatue fo all institutional povides that oste bill fom an inpatient o outpatient depatment povided the povide has a signed authoization on file to bill edicae fo sevices endeed. n this situation, they ae not equied to obtain the patient signatue on the oste. oweve, the povide has the option of epoting "signatue on file" in lieu of obtaining the patient's actual signatue on the oste. The PPV oste must contain the following language to be used by povides as a pecaution to alet beneficiaies pio to administeing PPV. Waning: Beneficiaies must be asked if they have been vaccinated with PPV. ely on the patients' memoy to detemine pio vaccination status. f patients ae uncetain whethe they have been vaccinated within the past 5 yeas, administe the vaccine, f patients ae cetain that they have been vaccinated within the past 5 yeas, do not evaccinate. o povides using the simplified billing pocedue, the modified om shows the following pepinted infomation in the specific fom locatos (Ls): The wods "ee Attached oste" in L 12, (Patient Name); Patient tatus code 01 in L 22 (Patient tatus); ondition code 1 in Ls (ondition ode) (ee NOTE below); ondition code A6 in Ls (ondition ode); evenue code 636 in L 42 (evenue ode), along with the appopiate P code in L 44 (P ode); evenue code 771 in L 42 (evenue ode), along with the appopiate "G" P code in L 44 (P ode); "edicae" on line A of L 50 (Paye); The wods "ee Attached oste" on line A of L 51 (Povide Numbe); and Diagnosis code V03.82 fo PPV o V04.8 fo nfluenza Vius vaccine in L 67 (Pincipal Diagnosis ode). o influenza vius vaccine claims with dates of sevice Octobe 1, 2003 and late, use diagnosis code V nfluenza vius vaccines equie the UPN L000 in L 82. Povides conducting mass immunizations ae equied to complete the following Ls on the pepinted om -1450: L 4 (Type of Bill); L 47 (Total hages); L 85 (Povide epesentative); and

8 L 86 (Date). NOTE: edicae econday Paye (P) utilization editing is bypassed in W fo all mass immunize oste bills. oweve, if the povide knows that a paticula goup health plan coves the PPV and all othe P equiements fo the edicae beneficiay ae met, the pimay paye must be billed. ist claim development alets fom W ae not geneated fo PPV and influenza vius vaccines. ntemediaies use the beneficiay oste list to geneate om -1450s to pocess PPV claims by mass immunizes indicating condition code 1 in Ls to avoid P editing. tandad ystem aintaines must develop the necessay softwae to geneate om ecods that will pocess though thei system. Povides that do not mass immunize must continue to bill fo PPV and influenza vius vaccines using the nomal billing method, e.g., submission of a om o electonic billing fo each beneficiay.

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