UB-92 Billing Instructions for Inpatient Chemical Dependency Services

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1 UB-92 Billing Instructions for Inpatient Chemical Dependency Services General Instructions The placing authority (county or tribe) authorizes Chemical Dependency services for eligible recipients. Bill for services after you receive an accurate notification letter from the county or tribe. If any of the information is inaccurate (units, rate, procedure codes, start or end dates, etc.), contact the county or tribe. Once the correction has been made, you will receive an updated notification letter. Use the information from the notification in conjunction with these UB-92 claim form instructions to submit your claims. Bill for services only after they have been provided. Do not bill for future dates. Inpatient Services include all residential chemical dependency treatment: Primary inpatient Halfway house Extended care Housing Use only the following revenue codes: 0100, 0240 & 0120, 0241 & 0110, 0243 & 0150 and Bill both treatment and room & board services for the same time span on separate claim forms. For example, bill the entire treatment authorization span on one claim and the room & board authorization span on another claim. You may also bill each authorization by a single or multiple calendar month(s). Note: Treatment and room & board services must be billed on separate claim forms. For example, bill revenue code 0240 (free standing & regional treatment centers: primary inpatient treatment services) on one claim form and revenue code 0120 (free standing & regional treatment centers: primary inpatient room & board) on another claim form). Paper claims must be typed. Use upper case lettering (capital letters). Use black ink. Use a 10 or 12 point font, preferably Times or Arial printface. Do not use bold or italics. Do not use punctuation marks. For example, omit the decimal point in the diagnosis codes. The forms used in these examples have been altered to fit your computer screen. They are not intended to be used for completing your claims. Use forms from your regular forms supplier. Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 1 of 11

2 Sample of UB-92 Claim Form This image has been reduced to fit on one page. Use forms from your forms supplier when completing actual claims. Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 2 of 11

3 Completing the UB-92 Claim Form for Inpatient Chemical Dependency Services FL1 - Provider Information: Enter the provider name, address and telephone number. FL3 Patient Control Number: Enter the alpha-numeric patient identifier assigned by the provider. FL4 - Type of Bill: Enter the 3-digit code that identifies the type of facility, bill classification, and frequency. The type of facility and bill classification (first and second digits) are used together for inpatient services as follows: 11x 81x 86x Hospital-based facilities, but not including Regional Treatment Centers (RTCs). Free standing inpatient, halfway house, extended care, housing and RTCs for dates of service prior to April 1, Free standing inpatient, halfway house, extended care, housing and RTCs for dates of services on or after April 1, Numerical values for frequency (third digit) are as follows: xx2 xx3 xx4 xx7 Indicates the first claim in a series of continuous claims or interim billing. When submitting the first claim, the date in the ADMISSION DATE field (FL17) must be the same as the date in the FROM DATE field (FL6). Indicates continuous claim or interim billing. Indicates the last claim or discharge claim. Indicates a replacement claim. FL5 Federal Tax Number: Enter the number assigned to the provider by the federal government for tax reporting purposes. (FEIN, EIN, TIN) FL6 - Dates of Service: Enter the dates of service in the FROM and THROUGH fields in MMDDYY format. Services must be provided before they can be billed. Note: The THROUGH DATE on the claim is the last night the client slept at the facility. FL7 - Number of Covered Days: Enter the number of days billed. The same number must be entered in FL46. FL12 - Recipient Name: Enter the recipient's last name, first name and middle initial as it appears on the notification letter. FL13 Patient Address: Enter the recipient s address. If the recipient does not have a permanent address, use the facility address. FL14 - Birth Date: Enter the recipient's birth date in MMDDYYYY format as it appears the notification letter. Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 3 of 11

4 Completing the UB-92 Form for Chemical Dependency Inpatient Services FL15 - Sex: Enter the recipient's gender. M for male F for female FL17 - Admission Date: Enter the date of admission in MMDDYY format. The date of admission must match the start date on the notification letter. FL18 - Admission Hour: Enter the hour code the recipient was admitted for inpatient services. Hour Code Time - AM Hour Code Time - PM 00 Midnight - 12:59 a.m. 12 Noon - 12: :00-01:59 a.m :00-01:59 p.m :00-02:59 a.m :00-02:59 p.m :00-03:59 a.m :00-03:59 p.m :00-04:59 a.m :00-04:59 p.m :00-05:59 a.m :00-05:59 p.m :00-06:59 a.m :00-06:59 p.m :00-07:59 a.m :00-07:59 p.m :00-08:59 a.m :00-08:59 p.m :00-09:59 a.m :00-09:59 p.m :00-10:59 a.m :00-10:59 p.m :00-11:59 a.m :00-11:59 p.m. FL19 - Type of Admission: Enter 3 in this field. FL20 - Source of Admission: Enter 8 in this field. FL21 - Discharge Hour: Effective 11/01/03, this field must be left blank. For through dates before 11/01/03, enter 99 in this field. FL22 - Status: Enter 30 in this field. FL37 - Replacement Claims Only: This field is only used when it becomes necessary to submit a replacement claim. The following information must be entered on Line A: The TCN of the most current incorrectly paid claim A space (using the spacebar) The 3-digit reason code of 406 Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 4 of 11

5 Completing the UB-92 Form for Chemical Dependency Inpatient Services FL42 - Revenue Codes: Enter the appropriate revenue code for the service provided. Treatment services and room & board must be billed separately on different claims. Bill one revenue code per claim in addition to the total line charges. All claims require a 0001 revenue code line item to indicate total charges billed. See table below for revenue codes and service descriptions. Revenue Code Service Description Type of Bill (1 st & 2nd digits) Prior to 04/01/04 Type of Bill (1 st & 2nd digits) On/After 04/01/ Hospital Based: Primary Inpatient 11x 11x 0240 Free Standing & Regional Treatment Centers: Primary Inpatient - Treatment Services 81x 86x 0120 Free Standing & Regional Treatment Centers: Primary Inpatient - Room & Board 81x 86x 0241 Halfway House - Treatment Services 81x 86x 0110 Halfway House - Room and Board 81x 86x 0243 Extended Care - Treatment Services 81x 86x 0150 Extended Care - Room and Board 81x 86x 0169 Housing Services - Room and Board 81x 86x FL44 - HCPCS/Rates: Enter the approved rate per unit as it appears on the notification letter. FL46 - Service Units: Enter the number of days. The same number must be entered in FL7. FL47 - Total Charges: Enter the total charges for each line item. Multiply the rate by the units to calculate the amount. Once all line item charges are entered, enter the total of all charges on a separate line using revenue code FL50 - Payer: Enter the payer name MEDICAID left justified. Enter the source of payment code D right justified. FL51 - Provider Number: Enter the 9-digit MHCP provider number from your notification letter. FL52 - Release of Information: This field indicates if the provider has a signed statement on file permitting the provider to release data to other organizations in order to adjudicate the claim. Enter one of the following codes: Y Yes N No R Refused Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 5 of 11

6 Completing the UB-92 Claim Form for Inpatient Chemical Dependency Services FL53 Assignment of Benefits: This field indicates if the provider has a signed form authorizing the third-party payer to pay the provider. Y Yes N -- No FL58 - Insured's Name: Enter the recipient's last name, first name and middle initial. FL59 - Relationship: Enter 18 in this field for through dates after 10/15/03. Enter 01 in this field for through dates before 10/16/03. Always enter 18 when using MN-ITS Interactive. FL60 - Recipient ID Number: Enter the recipient's 8-digit MHCP identification number as it appears on the notification letter. FL63 - Treatment Authorization: Enter the 11-digit service agreement number as it appears on the notification letter. FL67 - Principal Diagnosis Code & Subclassification: Enter the 5-digit Principal Diagnosis Code. Use the first four digits from below then add the appropriate fifth digit subclassification. The Principal Diagnosis Codes are listed below: ICD-9-CM Code 3030x 3039x 3040x 3041x 3042x 3043x 3044x 3045x 3046x 3047x 3048x 3049x 3050x 3052x 3053x 3054x 3055x 3056x 3057x 3058x 3059x Definition Acute alcoholic intoxication Other & unspecified alcohol dependence Opioid enter dependence Barbiturate & similarly acting sedative or hypnotic dependence Cocaine dependence Cannabis dependence Amphetamine & other psychostimulant dependence Hallucinogen dependence Other specified drug dependence Combination of opioid enter drug with any other Combination of drug dependence excluding opioid enter drug Unspecified drug dependence Alcohol abuse Cannabis abuse Hallucinogen abuse Barbiturate & similarly acting sedative or hypnotic abuse Opioid abuse Cocaine abuse Amphetamine or related acting sympathomimetic abuse Antidepressant enter abuse Other, mixed or unspecified drug abuse Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 6 of 11

7 Completing the UB-92 Claim Form for Inpatient Chemical Dependency Services The subclassification codes are: 0 - Unspecified 1 - Continuous 2 - Episodic 3 - In remission Note: ICD-9-CM Code 3051 is not valid for billing chemical dependency services FL76 Admitting Diagnosis Code: Enter the admitting diagnosis code from the ICD-9-CM manual. The same code must be entered in FL67. FL82 - Attending Physician Identification: Enter the 9-digit MHCP provider number as it appears on the notification letter. The same number must be entered in FL51. FL85 - Signature: The provider or an assigned representative must sign the claim. The signature may be typed, stamped or handwritten. FL86 - Date: Enter the date of claim submission in MMDDYY format. DHS Department of Human Services Glossary of Acronyms & Terms Discharge Claim A discharge claim refers to the last of a series of bills for the same course of treatment. HCPCS Heathcare Common Procedure Coding System. ICD-9-CM Manual International Classification of Diseases, 9th Revision, Clinical Modification Manual. Contains all diagnoses codes used for billing healthcare claims. Interim Billing Interim billing occurs when a bill for the same course of treatment has previously been submitted and further billings for the same course of treatment are expected. MHCP Minnesota Health Care Programs MMDDYY Month Day Year using two digits. For example, January 1, 2003 is coded as MMDDYYYY Month Date Year using two digits for the month and day and four digits for the year. For example, January 1, 2003 is coded as Notification Letter A document from MHCP listing the approved services, dates, rates, and other billing information for a recipient. Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 7 of 11

8 PCN Payer Claim Control Number. Formerly called the TCN or transaction control number. Replacement Claim A replacement claim is used to correct a previously submitted, incorrectly paid claim. An entire claim must be replaced, not just the incorrect information. RTC Regional Treatment Centers TCN Transaction Control Number UB Uniform Billing Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 8 of 11

9 Example: Inpatient Chemical Dependency Services Notification Letter Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 9 of 11

10 Example: Inpatient Chemical Dependency Services Treatment Services Claim This image has been reduced to fit on one page. Always use forms from your supplier when completing actual claims. Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 10 of 11

11 Example: Inpatient Chemical Dependency Services Room & Board Claim This image has been reduced to fit on one page. Always use forms from your supplier when completing actual claims. Tutorial: Completing UB-92 Claim Form for Inpatient Chemical Dependency Services 11 of 11

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