Medical Care Billing Basics The form UB04/CMS 1450

Transcription

1 Slide 1 Medical Care Billing Basics The form UB04/CMS 1450 A Step by Step approach to Successfully Submit HIPAA Compliant Claims on Paper

2 Slide 2 Today s Speaker: Lori-Lynne A. Webb CPC, CCS-P, CCP, CHDA, COBGC, AHIMA Accredited ICD-10 Trainer AHIMA ACE mentor

3 Slide 3 Introduction to Billing Basics The CMS 1450/UB-04 I will be presenting information regarding the Billing basics for Facility and Facility based services (such as a nursing home, assisted care center etcc) I will help you understand the basic functions of the billing processes from the time services are rendered, to the completion of the service, when all payment is billed and received. Today s session will provide information in an easy-to-understand format for medical personnel who are not familiar with the billing processes of submitting medical claims for inpatient, out patient and facility based practices specifically with the usage of the CMS UB04 claim form.

4 Slide 4 Learning Objectives Pre-service Work plan - Getting the background information on your patient Acquiring the minimum basic billing information getting it right the first time - correctly entering it on the CMS 1450/UB-04 Facility Payments Can I collect pre-payment AND bill the claim to a 3 rd party payer? Documentation and the Claim Submission process

5 Slide 5 Our basic objective for today s presentation Provide complete explanation of how to fill out the UB-04 paper claim form for: Primary Medicaid Medicaid secondary to a Third Party Liability (TPL) HMO co-payments Medicare replacement plans Additional information Medicare Crossovers Inpatient claims for Medicare Part B-only clients. Medicaid Tertiary

6 Slide 6 Let s get started! The Patient accesses your facility or emergency department area Patient Arrives Confirm all demographic and billing info with patient Make copy of Insurance cards/information Phone insurance carrier for Authorization/additional information such as Co-pays or Deductibles that need to be collected at the time of service. Patient Checks out Collect any Co-Pays or Deductibles from your patient Time to file the claim. Even though you are going to be billing for the facility side of the claims, it is extremely important that you have the correct demographic information and correct insurance/3 rd party payer information on file. If this is not collected and verified when the patient is in the facility (especially if it is an emergency department) you may never get the opportunity to see the patient face to face, or be able to collect this information again. This is YOUR PRIME OPPORTUNITY TO GET IT RIGHT!! If you fail to provide valid information matching the insured s ID card to what is on your claim could result in a denial or rejection of your claim.

7 Slide 7 A bit of background CMS 1450/UB04 The standard, uniform bill (UB) for institutional healthcare providers that s used throughout the U.S. is known as the UB-04/CMS1450 The UB-04 replaced the UB-92 following a four-year study involving National Uniform Billing Committee (NUBC) members and various public surveys. The UB form is used by hospitals, nursing homes, hospice, home health agencies, and other institutional providers

8 Slide 8 A bit of background CMS 1450/UB04 In 1975, in an effort to simplify healthcare billing in the U.S. and develop one standard, nationallyaccepted billing form, the American Hospital Association brought together all national payer and provider organizations and developed the National Uniform Billing Committee (NUBC). After an 8-year moratorium on changes to the UB-82, NUBC oversaw numerous state surveys in an effort to implement improvements on the UB-82 design. As a result, the UB-92 was created incorporating the best of the UB-82 along with needed improvements on the data set design.

9 Slide 9 A bit of background CMS 1450/UB04 Again, more changes were needed and the UB-04 was approved as the new form starting March 1, 2007 and mandated May 23, The primary purpose of this revised form is to align the paper form to the electronic data standards, both the current 5010 HIPAA compliance electronic and paper versions. The Official UB-04 Data Specifications Manual 2013 is the official source of UB-04 billing information adopted by the National Uniform Billing Committee (NUBC). National Uniform Billing Committee Official Data Specifications Manual The Official UB-04 Data Specifications Manual 2013 is the official source of UB-04 billing information adopted by the National Uniform Billing Committee (NUBC). This manual, available by annual subscription license, contains the updated specifications for the data elements and codes included on the UB-04 claim form and used in the electronic HIPAA Institutional 837 Health Care Claim transaction standard. The design and updates of the UB-04 form and manual are approved by the NUBC, a voluntary committee chaired by the American Hospital Association that includes the major national provider and payer organizations. The AHA holds the copyright to the Official UB-04 Data Specifications Manual and makes it available through Health Forum, its data and publishing subsidiary. The UB-04 manual is available through two types of licenses: single-user and multi-user. Both license types provide online access to the manual in the form of a PDF e-book. This subscription also entitles you to access a searchable 12-year archive of the NUBC meeting minutes posted to the Subscribers Only section of the NUBC website

10 Slide 10 Who Bills on a CMS1450/UB04 Ambulatory Surgery Centers (ASC) End-Stage Renal Disease (ESRD) Clinics Home Health Agencies (HHA) Hospice Providers Hospitals Long-Term Care (LTC) Facilities Rehabilitation Hospital Facilities

11 Slide 11 Coding the Claim The documentation is reviewed, verified through the charge data master, and coded appropriately The services and facilities used must be documented by the unit secretary, nursing staff and/or physician-provider. This information needs to be carefully reviewed by the facility biller/coder to accurately reflect services utilizing CPT, ICD-9 and HCPCS codes.

12 Slide 12 Keying the charges to the claim The charges are keyed and processed Biller/Keyers/coders will enter the billing data into the patient management system to include all fees Once entered, the claims management software should initiate a scrub of the coded charge entries for correctness Charges are to be entered in a timely manner for prompt payment by 3rd party payers In a best practice your charge entry should happen within 1-2 days

13 Slide 13 Claim forms filled out Claims are created by the billing software and edited to be complete and correct (an additional scrub) Claims are then sent electronically to the payer, or the insurance clearinghouse daily, or go out via a paper process utilizing the CMS 1450/UB-04 form

14 Slide 14 Let s fill out our CMS 1450-UB04 As you see the form to the right, take note of all the areas that need to be correctly completed prior to billing the claim Note the open triangle represents the required fields The solid triangle represents the required if applicable fields The circle s represent fields that are not used. ** Note that this information is accessed from the NUBC (National Uniform Billing Committee) at and is an additional resource that we will include at the end of this webinar. The term FL means Form Locator and corresponds directly to the area(s) on the UB-04 as you can see in the previous slide.

15 Slide 15 Let s get started. Completing the forms The term FL means form locator or field locator and corresponds directly to the area(s) on the UB-04 as you can see in the previous slide.

16 Slide 16 Let s begin with the basic information and where it goes on the claim form As we look at FL 1 the billing provider s name address and tele # s go in there, but FL # 2 is for who the PAYER needs to sent the remittance address to. As you can see these may or may not be different addresses. For boxes 3a and 3b - These are the patients account numbers that you ( the hospital or facility) have assigned to this patient. In Box 3b, this is the MEDICAL RECORD/MEDICAL HEALTH account that maybe required for the facility to compile all records on the same patient over multiple stays or encounters.

17 Slide 17 Let s begin with the basic information and where it goes on the claim form In FL4 this is where you enter the type of bill code. Type of bill 0111 designates and Inpatient hospital service, code 0131 is an outpatient type of bill, and a long term care could be a 653. FL5 is the TIN or Tax identification # that have been assigned to your facility. This could also be an EIN or Employer identification number FL6 is the Statement covers period As you can see this shows the MMDDYY format, but this has been updated in April of 2012 to be required for 5010 to be the MDDYYYY format. In this statement period, it is a required field, but my advice is to not span months or years within these dates. FL7 is currently not being used and has been reserved for assignment by the NUBC for future use.

18 Slide 18 Let s begin with the basic information and where it goes on the claim form In FL s 8, 9 and 10 the patients name, address and DOB need entered. This is also mandatory fields to be entered per our HIPAA 5010 guidelines. It is critical that you have the patient s name entered on the form EXACTLY as it appears on the patient s ID card. - CMS has stated that this is one of the areas of the highest claim denial rates, is due to incorrect patient and subscriber information submitted on the claim forms.

19 Slide 19 Critical admission information In FL these are again required fields to be completed. FL11 you need to record the sex of the patient Again in this reference, be sure to denote the date in FL12 with MMDDYYYY format. FL 13 denotes the hour in which the patient was admitted. You will need to use a 24 hour time designation, rather than AM/PM designations. In FL 14 the Admission type is needed this field is also known as a priority box. You can see these codes (go to next slide here!!!) In fl 15 this again is not a mandatory field, but denotes the source of who referred the patient in for this visit.

20 Slide 20 Types of codes for FL14 & FL15 This is the listing of the codes for FL 14 and FL 15

21 Slide 21 Critical admission information In FL 16 the discharge hour needs noted (again in 24 hour time increments (aka military time) rather than the a.m/p.m. format FL 17 is the status code for the discharge of the patient - those status codes are from a full listing of these codes can be found at the end of this presentation. In FL These fields are not mandatory, but do help paint the picture of what happened during the stay. Enter these codes in alpha numeric sequence, and you will need to refer and coordinate these code with those in FL 81 for the appropriate qualifier code to indicate that a condition code is being reported. In FL 29, If this claim is due to an accident, be sure to notate the state abbreviation code. If you do not know your state abbreviation code these can be found at In FL 30 - the NUBC has reserved this for later use.

22 Slide 22 Critical admission information For FL and 35-36: For a detailed billing examples that outline possible billing scenarios, please go to and refer to CR 6777 located on the 2010 Transmittals page The occurrence codes and dates for FL a-b and the FL codes for span dates have very detailed information that is required. This information can be found at For a detailed billing example that outlines possible billing scenarios, please go to and refer to CR 6777 located on the 2010 Transmittals page ****************************************************************************** ****************************** Below is the detailed explanation: GUIDELINES FOR OCCURRENCE AND OCCURRENCE SPAN UTILIZATION Due to the varied nature of Occurrence and Occurrence Span Codes, provisions have been made to allow the use of both type codes within each. The Occurrence Span Code can contain an occurrence code where the Through date would not contain an entry. This allows as many as 10 Occurrence Codes to be utilized. With respect to Occurrence Codes, complete field 31a - 34a (line level) before the b fields. Occurrence and Occurrence Span codes are mutually exclusive. An example of Occurrence Code use: A Medicare beneficiary was confined in hospital from January 1, 2005 to January 10, 2005, however, his Medicare Part A benefits were exhausted as of January 8, 2005, and he was not entitled to Part B benefits. Therefore, Form Locator 31 should contain code A3 and the date The provider enters code(s) and associated date(s) defining specific event(s) relating to this billing period. Event codes are two alphanumeric digits, and dates are six numeric digits (MMDDYY). When occurrence codes and

23 24 are entered, the provider must make sure the entry includes the appropriate value code in FLs 39-41, if there is another payer involved. Occurrence and occurrence span codes are mutually exclusive. When FLs 36 A and B are fully used with occurrence span codes, FLs 34a and 34b and 35a and 35b ma y b e used to contain the From and Through dates of other occu r rence sp an codes. In this case, the code in FL 34 is the occurrence span code and the occurrence span F rom dates is i n t he d ate field. FL 35 contains the same occurrence span code as the code in F L 34, and th e occur ren ce span Thro ugh date is i n the date field. Other payers may require other codes, and while Medicare does not use them, they may be entered on the bill if convenient. FLs 35 and 36 - Occurrence Span Code and Dates Required For Inpatient. The provider enters codes and associated beginning and ending dates defining a specific event relating to this billing period. Event codes are two alpha-numeric digits and dates are shown numerically as MMDDYY. Codes used for Medicare claims are available from Medicare contractors. Codes are also available from the NUBC ( via th e NU BC s Offici al UB -04 Data Specifications Manual. Special Billing Procedures When more than Ten Occurrence Span Codes (OSCs) Apply to a Single Stay The Long Term Care Hospital (LTCH), Inpatient Psychiatric Facility (IPF), and Inpatient Rehabilitation Facility (IRF) Prospective Payment Systems (PPSs) requires a single claim to be billed for an entire stay. Interim claims may be submitted to continually adjust all prior submitted claims for the stay until the beneficiary is discharged. In some instances, significantly long stays having numerous OSCs may exceed the amount of OSCs allowed to be billed on a claim. When a provider paid under the LTCH, IPF or IRF PPSs encounters a situation in which ten or more OSCs are to be billed on the CMS-1450 or electronic equivalent, the provider must bill for the entire stay up to the Through date of the 10 th OSC for the stay (the Through date for the Statement Covers Period equals the Through date of the tenth OSC). As the stay continues, the provider must only bill the 11th through the 20 OSC for the stay, if applicable. Once the twentieth OSC is applied to the claim, the provider must only bill the 21s through the 30 th OSC for the stay, if applicable. The Shared System Maintainers (SSMs) retain the history of all OSCs billed for the stay to ensure proper processing (i.e., as if no OSC limitation exists on the claim).

24 Slide 23 Critical admission information These fields are not absolutely required to be filled out, but may be mandated by a non-medicare or 3 rd party payer FL 38 - Responsible Party Name and Address Not Required. For claims that involve payers of higher payer priority (such as Medicare is a secondary payer, not a primary payer) than Medicare. FLs 39, 40, and 41 - Value Codes and Amounts Required. Code(s) and related dollar or unit amount(s) identify data of a monetary nature that are necessary for the processing of this claim. The codes are two alphanumeric digits, and each value allows up to nine numeric digits ( ). Negative amounts are not allowed except in FL 41. Whole numbers or non-dollar amounts are right justified to the left of the dollars and cents delimiter. Some values are reported as cents, so the provider must refer to specific codes (and the 3 rd party payer itself) for instructions. If more than one value code is shown for a billing period, codes are shown in ascending numeric sequence. There are four lines of data, line a through line d. The provider uses FLs 39A through 41A before 39B through 41B (i.e., it uses the first line before the second). Note that codes (Covered days, Non-Covered Days, Co-insurance Days, and Lifetime Reserve Days) are only available for use on the UB-04.

25 Slide 24 Critical admission information In FL 42 - the Revenue codes need to be listed in ascending numerical order so be sure to sequence them appropriately. FL 43 is the alpha descriptor of the revenue code. FL44 is the actual room/board rate for your inpatient claim (or LTC claim) If appropriate, HCPCS or HIPPS codes can be entered here in addition to the $ amounts (but only when appropriate for certain 3 rd party payers)

26 Slide 25 Critical admission information In FL 45 the service date is required for OUTPATIENT services. This needs to be reported in the mm/dd/yyyy format. However in line 23 of this area that refers to the CREATION date of the bill. This is different than the SERVICE DATE (dos) FL 43 is the alpha descriptor of the revenue code. FL44 is the actual room/board rate for your inpatient claim (or LTC claim) If appropriate, HCPCS or HIPPS codes can be entered here in addition to the $ amounts (but only when appropriate for certain 3 rd party payers) If a particular service is rendered 5 times during the billing period, the revenue code and HCPCS code must be entered 5 times, once for each service date. In FL 46 this is mandatory field, and the units of service must be whole numbers. Round up, if you have a partial amount. In FL 47 this much represent the total amount for that LINE ITEM. The total charge for the claim should be reported on the 23 rd line FL48 is for non-covered charges so if they are known to be non-covered, they need entered in this location. DO NOT USE NEGATIVE NUMBERS WITHIN THIS FIELD.

27 Slide 26 Payer Information area In FL These are mandatory fields, and need to be entered exactly as per the patient information contained in the patient s insurance card. In FL 52 and 53 for release of information and assignments of benefits these need notated as Y = yes N = no. This is an important HIPAA mandate. If the assignment of benefits is not filled out as Yes. The payment for the services on the claim will not go back to the facility. They will be forward to the subscriber on the insurance policy.

28 Slide 27 Payer Information area FL are not considered mandatory but are used if the patient does have payments that have been paid by either the patient, or a primary or secondary payer. This is important x-over information the carriers will use in adjudicating the claim. In the example it shows if blue cross is secondary it would need the original EOB (explanation of benefits) to be submitted with a paper claim. In FL 56 the NPI number of the provider (facility) needs to be entered in this area For FL 57 if there is another identifier associated with this billing provider, it can be entered here. Some 3 rd party payers designate a unique identifier to specific payers, and if so, they are reported in this area of the claim form.

29 Slide 28 Insured s information FL These are mandatory fields, again, the name needs reported here identical as it appears on the pt s insurance card. In this area, the last name is reported first, then the first name separated by a comma. In FL 59 - this field is to report the Patient s relationship to the insured. The patient and the insured may be the same person. However, if they are different, this still needs reported in this mandatory field. Please reference that these codes are the only codes that are appropriate for FL 59 In FL60 this is the INSURED s identification # that needs entered here. Again. This must be identical to how it appears on the insurance card

30 Slide 29 Insured s information FL 61/62 - straightforward needs entered identical to how the insurance card has this reported.

31 Slide 30 Treatment pre-authorizations In FL these fields are non-mandatory, so enter this information as appropriate. If you are performing pre-authorization from the 3 rd party payers, this authorization code needs entered in fl 63. FL64 this is a non-mandatory field, and is not commonly used, but if your facility does utilize a DCN then this should be entered here. FL65 is only used if the EMPLOYER of the INSURED IS KNOWN. This field is commonly left blank, as many facilities do not obtain this information At the time of registration.

32 Slide 31 Diagnosis and indicator codes In FL 67, the diagnosis/procedure code must be those valid ICD-9cm codes. DO NOT ADD A DECIMAL POINT. If this is an inpatient claim the first diagnosis must be the POA (Present on admission ) indicator code. As we look at boxes FL68 73 these all revolve around the diagnoses that the patient has pertaining to this particular stay.

33 Slide 32 Procedure codes In FL 74 these procedure codes must be reported with the ICD-9 CM volume 3 procedure codes (do not use CPT codes) do not use any periods or punctuation in these codes. As per hipaa 5010, the date must now be reported as mmddyyyy. FL 74 a-3 are for additional procedure codes to be reported.

34 Slide 33 Physician information/ancillary information FL 75 is to be used to report the ATTENDING PROVIDER (NPI number) MANDATORY FIELD FL 76 is to be used to report the OPERATING PROVIDER/PHYSICIAN Fl 78 AND 79 are only included if appropriate and necessary for the completion of the claim. FL 80 is a remarks or Notes field to be included with information that is not reported in other areas of the claim.

35 Slide 34 Frequent Claim Denials Emergency Room Claims Eligibility (not checked/authorized) Coordination of Benefits (not reported correctly) Prior Authorization (not obtained) Pregnancy Only Services (not reported correctly) Duplicate Services Filing Time Limit (check with carrier for limits) Diagnosis/Procedure Inconsistent with Patient s Age/Gender Behavioral Health Claim (incorrectly reported )

36 Slide 35 Emergency Room Claim Denials ER Claims: ER claims should be billed appropriately based on the members /patients medical conditions. Emergency services (revenue code 450). Nonemergent services (revenue code 451). If ER claim denies (revenue code 450): Complete a claim follow up (i.e. letter, tele call etcc) Attach medical records for appeal or re-adjudication Attach a copy of the denial or EOB with the above info Submit the above information to the carrier within 30 days of the denial notice (best practice)

37 Slide 36 Coordination of Benefits Re-filing COB Claims: when you re-bill a COB claim. Attach another (duplicate) CMS-1450 (UB-04) claim form. Attach the primary carrier s Remittance Advice or letter explaining the denial or detail. Send the completed form along with all documents to the secondary/tertiary 3 rd party carrier

38 Slide 37 Prior Authorization Denials Normally the physician/provider is responsible for obtaining the preservice review for both professional and institutional services however, it is advisable for the facility to pre-authorize and not depend on the outside physician to provide this information to you. Hospital and ancillary providers should always contact the 3 rd party carrier to verify pre-service review status. (and obtain authorization if necessary) Verify with the 3 rd party payer if an authorization is required (and determine if the insurance is an in-network or an out-of-network provider/facility. If you have received a denial for non-prior authorization, inquire if a retro-auth can be requested.

39 Slide 38 Helpful Hints. Here are a few tips to keep in mind when filing claims: Verifying benefits can be helpful prior to submitting claims or appeals in order to have the most current policy information as well as any benefit exclusions that may be relevant to the services being rendered. Obtaining a copy of the member s current insurance card at all visits, as policies can often change. This will ensure that the claims are submitted with the most current policy information. Verifying the correct alpha prefix is on all claims this is extremely important. Many claims cannot be processed without the member s alpha prefix. If there are two insurance policies for a patient, please be sure to include both the primary and secondary policy information on the claims. If a corrected claim is needed, it must be marked as corrected claim, and indicate what is being corrected. If the corrected claim is not marked as such, it may be denied as duplicate or the issue may not be resolved appropriately. Be sure to include all current and complete provider information on the claims, including the current tax identification number and NPI numbers in the correct fields. If a response has not been received to a claim, contact the carrier s customer service (or their website) for claim status prior to resubmitting a claim. Do not re-submit a claim If the original claim is already on file but has not yet been processed, a resubmission will not expedite the processing of the original claim.

40 Slide 39 Thank you for sharing your time with me! I really appreciate you being such a GREAT audience!!!!!

41 Slide 40 Code definitions for FL17 01 Discharged to Home or Self-Care (Routine Discharge) 02 Discharged / Transferred to a Short-Term General Hospital for Inpatient Care 03 Discharged / Transferred to a SNF with Medicare Certification in Anticipation of Covered Skilled Care 04 Discharged / Transferred to a Facility That Provides Custodial or Supportive Care 05 Discharged / Transferred to a Designated Cancer Center or Children s Hospital 06 Discharged / Transferred to Home Under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care 07 Left Against Medical Advice or Discontinued Care 08 Reserved for National Assignment by the NUBC 09 Admitted as an Inpatient to This Hospital Reserved for National Assignment by the NUBC 20 Expired 21 Discharged / Transferred to Court / Law Enforcement Reserved for National Assignment 30 Still a Patient Reserved for National Assignment by the NUBC 40 Expired at Home 41 Expired in a Medical Facility such as a Hospital, SNF, ICF or Free-Standing Hospice 42 Expired, Place Unknown 43 Discharged / Transferred to a Federal Health Care Facility Reserved for National Assignment by the NUBC 50 Discharged to Hospice, Home 51 Discharged to Hospice, Medical Facility (Certified) Providing Hospice Level of Care Reserved for National Assignment by the NUBC 61 Discharged / Transferred Within This Institution to a Hospital-Based Medicare Approved Swing Bed 62 Discharged / Transferred to an Inpatient Rehabilitation Facility (IRF) Including Rehabilitation Distinct Part Units of a Hospital 63 Discharged / Transferred to a Medicare Certified Long Term Care Hospital (LTCH) 64 Discharged / Transferred to a Nursing Facility Certified Under Medicaid but Not Certified Under Medicare 65 Discharged / Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital 66 Discharges / Transfers to a Critical Access Hospital Reserved for National Assignment by the NUBC 70 Discharged / Transferred to Another Type of Healthcare Institution Not Defined Elsewhere in this Code List Reserved for National Assignment by the NUBC

42 Slide 41 References National Uniform Billing Committee: BlueCross BlueShield BluePlus of Minnesota: ssmn/documents/public/tost71a_ pdf Independence Blue Cross - ibx.com Downloadable CMS-1450/UB04 form: 06_B%20W%20PDF.pdf Type of bill codes: Two digit state abbreviations can be found at: