Billing & Reimbursement fr Hspital Services Hspital Manual Table f Cntents Overview....1 Inpatient Services....1 Inpatient claims....1 Maternity admissins....4 Per case reimbursed admissins nly....4 Outpatient Services....5 Cardilgy....5 Diabetic educatin....5 Emergency services....6 Labratry services.... Observatin services.... Outpatient surgery.... Outpatient implantable devices....11 Radilgy services....12 Shrt-term rehabilitatin therapy services....13 Sleep study (neurlgy)....13 Additinal billing infrmatin....14 Revenue cdes requiring HCPCS/CPT cdes....14 Nt separately payable (NSP) prcedures....14 Cding discrepancies....14 Billing requirements fr prviders cntracted under Ambulatry Payment Classificatin (APC)....14 Billing fr physician and advanced practice nurse services....15 Prfessinal ffice-based services in an utpatient setting....15 Crdinatin f Benefits/Other Party Liability....15 9/1/2013.i
Billing & Reimbursement fr Hspital Services Hspital Manual Overview The purpse f this sectin is t describe the specific billing requirements fr services rendered in the hspital setting and t supplement the General Infrmatin sectin f this manual. Inpatient Services The purpse f this sectin is t cmmunicate specific billing requirements and reimbursement plicies fr inpatient hspital services. Hspitals will be reimbursed fr inpatient services accrding t the terms f their Agreement. T the extent that any f the requirements r plicies in this sectin cnflict with the Agreement, the terms f the Agreement shall gvern. Inpatient claims Preapprval Preapprval is required fr certain services prir t services being perfrmed, including elective inpatient admissins. Fr detailed infrmatin n Preapprval, please refer t the Care Management and Crdinatin sectin f this manual. Inpatient day An inpatient day is an admissin perid that begins at midnight n the day f admissin and ends 24 hurs later. The midnight-t-midnight methd is t be used in reprting inpatient days even if the hspital uses a different definitin fr ther purpses. Any part f an inpatient day, including the day f admissin, cunts as an inpatient day. The day f discharge is nt cunted as an inpatient day. Inpatient services Inpatient services are Cvered Services that are diagnstic, therapeutic, r surgical and pursuant t an admissin. Reimbursement fr inpatient services includes, but is nt limited t: ancillary services anesthesia care appliances and equipment diagnstic services medicatin and supplies nursing care radilgy recvery rm services rm and bard surgical prcedures (including implantable devices, bld, and bld prducts) therapeutic items (drugs and bilgicals) The reimbursement rates fr inpatient acute admissins are inclusive f all services prvided t the Member during the admissin. The rate f payment is determined by the effective date f a Member s inpatient admissin and applies fr the length f the admissin; therefre, any rate change under the cntract during the Member s stay will nt apply. 9/1/2013.1
Billing & Reimbursement fr Hspital Services Hspital Manual Outpatient services included in reimbursement fr inpatient services Outpatient services rendered during an inpatient admissin. IBC s hspital inpatient reimbursement includes payment fr all services prvided (1) during the inpatient stay, (2) n the day f the admissin, and (3) n the day f discharge. There is n additinal payment fr services billed n an utpatient basis. Charges fr utpatient services rendered t the Member during the inpatient stay, n the day f the admissin, and n the day f the discharge must be reprted n the inpatient claim. If a hspital submits a separate claim fr utpatient services that were, r shuld have been, reprted n the Member s inpatient claim, the utpatient claim is subject t retrspective review thrugh a prvider audit. Outpatient services rendered prir t an inpatient admissin (preadmissin). Outpatient prcedures, such as preadmissin services and ther services related t the admissin, can be befre the date f the inpatient admissin, but they are nt separately reimbursable. Charges fr utpatient services nt related t the admissin may be billed separately. Preadmissin services include: Preperative examinatins. Services billed with a diagnsis cde fr preperative examinatins are nt separately reimbursable. Preadmissin diagnstic services. IBC s acute care hspital inpatient reimbursement includes payment fr preadmissin diagnstic services, and charges fr preadmissin diagnstic services must be included n the inpatient claim. Diagnstic services prvided t a Member within three days prir t and including the date f the Member s admissin are deemed t be inpatient services and included in the inpatient payment. Fr example, if a Member is admitted n a Wednesday, utpatient services prvided by the hspital n Sunday, Mnday, Tuesday, r Wednesday are included in the inpatient reimbursement. Diagnstic services include the fllwing revenue/prcedure cdes*: 0254: Drugs incident t ther diagnstic services 0255: Drugs incident t radilgy 030X: Labratry 031X: Labratry pathlgical 032X: Radilgy diagnstic 0341, 0343: Nuclear medicine, diagnstic/diagnstic radipharmaceutical 035X: Cmputed tmgraphy (CT) scan 031: Anesthesia incident t radilgy 032: Anesthesia incident t ther diagnstic services 040X: Other imaging services 046X: Pulmnary functin 041: Audilgy diagnstic 0482: Cardilgy, stress test 0483: Cardilgy, echcardilgy 053X: Ostepathic services 061X: Magnetic resnance technlgy (MRT) 062X: Medical/surgical supplies, incident t radilgy r ther diagnstic services 03X: Electrcardigram (EKG/ECG) 04X: Electrencephalgram (EEG) 0918: Testing, behaviral health 092X: Other diagnstic services * The list f diagnstic services may be revised peridically t reflect current revenue and/r prcedure cdes. 9/1/2013.2
Billing & Reimbursement fr Hspital Services Hspital Manual Other preadmissin services. Nn-diagnstic utpatient services that are related t a Member s hspital admissin during the three days immediately preceding and including the date f the Member s admissin are deemed t be inpatient services and are included in the inpatient payment. Nn-diagnstic services are defined as being related t the admissin when there is a match between the principal diagnsis cdes (first three digits) assigned fr bth the preadmissin services and the inpatient stay. Inpatient hspice care Reimbursement is made directly t the cntracted hspice agency fr the prvisin f inpatient hspice care. The cntracted hspice agency is respnsible fr reimbursing the hspital fr the prvisin f general inpatient hspice care. Present n admissin (POA) indicatr All acute care hspitals are required t fllw instructins frm the Centers fr Medicare & Medicaid Services (CMS) regarding the identificatin f the POA indicatr fr all diagnsis cdes fr inpatient claims. Claims submitted withut a valid POA indicatr will be rejected. Cnsistent with the CMS requirements fr POA indicatrs, the fllwing facility types are exempt: critical access hspitals lng-term care hspitals cancer hspitals children s inpatient facilities inpatient rehabilitatin facilities psychiatric hspitals Member enrllment during an admissin IBC payment respnsibility varies depending n the Member s cverage, as summarized belw: Cmmercial HMO and PPO Members. IBC is required t cver the admissin frm the Member s enrllment date in an IBC plan. If a Member enrlls in a Cmmercial plan frm anther Cmmercial HMO plan, the previus plan shuld cver the Member s entire admissin. Medicare Advantage HMO and PPO Members. Original Medicare cvers the Member thrugh t the discharge date. If the Member s benefits plan r regulatins cnflict with these prvisins, actual payments may vary. Member terminatin during an admissin IBC payment respnsibility varies depending n Member cverage and prvider payment methdlgy, as summarized belw: Payment methdlgy Cmmercial HMO and Medicare Advantage HMO/PPO Line f business Cmmercial PPO Per diem Pays t the discharge date Pays t the last cvered day Per case Pays the entire case rate Pays the entire case rate Percent f charge Pays t the discharge date Pays t the last cvered day If the Member s benefits plan r regulatins cnflict with these prvisins, actual payments may vary. 9/1/2013.3
Billing & Reimbursement fr Hspital Services Hspital Manual Maternity admissins Reimbursement fr maternity admissins is inclusive f the mther and newbrn days while the mther is inpatient. Nenatal intensive care unit (NICU) and transitinal nursery days are paid separately regardless f mther s status as inpatient. Nrmal delivery claims. When billing newbrn baby charges (e.g., revenue cde 010, 011, 012, r 019) the maternity charges fr mther and baby must be cmbined n the same UB-04 frm. NICU charges shuld als be added t the mther s inpatient bill using revenue cde 013 r 014. Detained baby claims. If the baby remains hspitalized after the mther is discharged (i.e., detained baby), a new admissin with its wn Preapprval is required. The detained baby s admissin date is the same date as the mther s discharge date. A separate claim fr the detained baby s admissin is required. Fr Members with Federal Emplyee Prgram (FEP) cverage. In thse cases where the baby requires a higher level f care and is cnsidered sick while the mther is still hspitalized, a separate admissin fr the baby is needed. The baby s admissin requires its wn Preapprval. The baby s claim is t be billed using either revenue cde 013 r 014, and the admissin date is the same as the Preapprval date. Per case reimbursed admissins nly All inpatient days that are reimbursed under a diagnsis-related grup (DRG) and/r per-case payment rate are subject t Medical Necessity review, which may include cncurrent review and/r retrspective review. Admissins that have been preapprved will nt be retrspectively denied fr Medical Necessity unless the Preapprval was based n errneus infrmatin r misinfrmatin prvided by the hspital. Readmissins Readmissins are subject t the Inpatient Hspital Readmissin plicy, which applies t hspitals and health systems paid per case r per admissin fr inpatient hspital stays. Fr additinal infrmatin n readmissins, please refer t ur medical plicies at www.ibx.cm/medplicy. Ungrupable r invalid DRG Claims that are ungrupable r grup t an invalid DRG will be denied payment. Claims may be resubmitted by the hspital with crrected data. Versin DRG versus rate effective date Unless therwise specified in the cntract, the gruper versin used will be based n the cntracted versin in effect n the date f admissin. Fr all hspitals, the CMS Pricer adjustment factr applied t the DRG pricing will be based n the date f admissin. Per-diem reimbursed admissins nly All inpatient days that are reimbursed under a per diem payment rate are subject t a cncurrent review f Medical Necessity. In the event the hspital fails t prvide timely medical infrmatin necessary fr cncurrent review as requested by IBC, inpatient days nt reviewed cncurrently will be reviewed retrspectively fr Medical Necessity. Admissins that have been cncurrently reviewed will nt be retrspectively denied fr Medical Necessity unless the cncurrent review was based n errneus infrmatin r misinfrmatin prvided by the hspital. 9/1/2013.4
Billing & Reimbursement fr Hspital Services Hspital Manual Revenue cde grupings Per diem reimbursement shall be based n bed-type in accrdance with the fllwing crsswalk. T the extent that any f the fllwing revenue cdes cnflict with the Agreement, the terms f the Agreement shall gvern. Grup Medical/surgical Revenue cdes 0110, 0111, 0112, 011, 0120, 0121, 0122, 012, 0130-0132, 0134, 013, 0140-0142, 0150-0152, 015, 0206, 0214 Medical/surgical/pediatric 0113, 0123, 0133, 0143, 0153 Intensive care 0200-0203, 020-0213, 0219 Sub-acute 0159, 0190-0194, 0199 Maternity/NICU 010-014, 019 General rehab (nn-behaviral health) 0118, 0128, 0138, 0148, 0158 Behaviral health 0114, 0116, 0118, 0124, 0126, 0128, 0134, 0136, 0138, 0144, 0146, 0148, 0154, 0156, 0158, 0204 Outpatient Services The purpse f this sectin is t cmmunicate specific billing requirements and reimbursement plicies fr utpatient hspital services. All services are reimbursed in accrdance with IBC s medical plicies, which can be fund at www.ibx.cm/medplicy. Hspitals will be reimbursed fr utpatient services accrding t the terms f their Agreement. T the extent any f the belw requirements r plicies cnflict with the Agreement, the terms f the Agreement shall gvern. Please refer t the current Crrelatin Edits fr Outpatient Claims, which is updated and distributed each quarter, when determining which revenue cdes and HCPCS and/r CPT cdes t use fr billing. Cardilgy The technical cmpnents fr utpatient cardilgy services are paid at the hspital s cntracted utpatient rate, with the exceptin f the fllwing EKG prcedure cdes: 93000, 93005. These prcedure cdes are paid as a glbal reimbursement fr technical and prfessinal service cmpnents fr HMO Members, and the hspital is respnsible fr reimbursing the Physician fr their prfessinal services. Diabetic educatin Outpatient diabetic educatin is a cvered benefit fr eligible Members wh have been diagnsed as having diabetes mellitus and have a written Physician rder t attend an utpatient diabetic educatin prgram. In rder fr a participating hspital s prgram t be eligible as an apprved utpatient diabetic educatin prgram in the IBC netwrk, the prgram must be certified by the American Diabetes Assciatin (ADA) and specifically referenced in the Agreement. When billing fr diabetic educatin, use revenue cde 0942, include the HCPCS and/r CPT cde(s), the number f units, and a diabetic diagnsis n the UB-04 frm. Fr billing and reimbursement purpses, ne unit is equal t ne visit (individual r grup sessin). 9/1/2013.5
Billing & Reimbursement fr Hspital Services Hspital Manual Emergency services Reimbursement rates fr emergency services are inclusive f all services prvided t the Member during the visit, including the prfessinal cmpnent f labratry and radilgy fr all managed care Benefits Prgrams. Fee schedule payments fr Traditinal (Indemnity) Members apply nly fr facility services. Hw t bill fr emergency services Whenever ne f the revenue cdes in the 045X series is present, the UB-04 admitting diagnsis and the Member s reasn fr the visit are required fields fr utpatient claims. Please reprt ne diagnsis cde describing the Member s stated reasn fr seeking care. Emergency rm/department (ER) claims that d nt have the required infrmatin cmpleted will nt be prcessed. Critical care Critical care in the ER is t be billed with prcedure cde 99291 (i.e., critical care). Please nte that prcedure cde 99292 is nt separately reimbursable. When ER level-f-service prcedure cdes are billed with 99291, the claim will be paid at the lwer level f service. Fllw-up care Rutine (nn-emergent) fllw-up care prvided in the ER setting by a Participating Prvider is nt a cvered benefit and is nt eligible fr a separate ER visit payment. Claims billed fr rutine (nnemergent) fllw-up care prvided in the ER setting that cntain a rutine fllw-up diagnsis cde will be autmatically denied. When fllw-up care prvided in the ER setting is denied as a nncvered service, cmmercial Members may be billed fr such nncvered services. In rder t bill Members fr these services, yu must prvide the Member with prir written ntice indicating that fllw-up care in the ER setting is nt cvered and that they will be financially respnsible fr any fllw-up care given in the ER setting. Inpatient admissins If the ER visit results in an inpatient admissin, the date the Physician wrte the rder becmes the date f admissin. The ER charges shuld be included n the inpatient claim, and n separate ER claim shuld be filed. Surgical prcedures If an ER visit includes surgery perfrmed in a fully equipped and staffed perating rm, the facility will receive fee schedule reimbursement fr the ER and fr the surgery. Otherwise, the surgical services are included in the reimbursement fr the ER visit. The surgery shuld be billed using the apprpriate surgery revenue and HCPCS and/r CPT cdes. When surgical services are perfrmed in the ER and nt a fully equipped perating rm, thse surgical services shuld be reprted with the applicable ER revenue cdes. Reimbursement fr ER services when billed with surgical services Services billed tgether Services reimbursed* Revenue cde requirements Surgical services perfrmed in the perating rm and emergency services perfrmed in the ER Surgical services and emergency services perfrmed in the ER Bth ER services and surgical services are reimbursed ER services are reimbursed Surgical services reprted with 36x, 481, 49x, r 90; ER services reprted with 45x Surgical services reprted with 45x; ER services reprted with 45x *Fee schedule reimbursement fr these services includes all services prvided during the visit, including the prfessinal cmpnent f labratry and radilgy. 9/1/2013.6
Billing & Reimbursement fr Hspital Services Hspital Manual Observatin services If an ER visit includes bservatin services, bservatin services may be eligible fr separate reimbursement at the hspital s cntracted rate. Fr additinal infrmatin n bservatin services, please refer t ur medical plicies at www.ibx.cm/medplicy. Labratry services Members are required t btain a Physician rder fr labratry services. Reimbursement fr labratry services is a glbal (i.e., technical and prfessinal cmpnent) payment fr services rendered. Payment is made directly t the facility accrding t the hspital s cntracted rates (if there is n separate designated labratry agreement). Capitated labratry services Labratry services fr HMO/POS Members are generally prvided by the designated Prvider under the Capitated Labratry Prgram. A cmplete listing f the services included in this prgram can be fund at www.ibx.cm/medplicy. Labratry services that are excluded frm capitatin are paid at the hspital s cntracted rate. STAT labratry services fr HMO/POS Members If an HMO/POS Member receives STAT labratry services frm their capitated labratry Prvider, these services are included in the capitated labratry payment and are nt separately reimbursed. Hwever, if the HMO/POS Member is nt at their capitated site fr STAT labratry services, payment fr the STAT testing will be reimbursed accrding t the hspital cntracted rates. A Referral is nt required fr any STAT labratry services. Fr additinal infrmatin n STAT labratry services, please refer t ur medical plicies at www.ibx.cm/medplicy. Observatin services Observatin services are cnsidered an utpatient service, and invlve the use f a bed and peridic mnitring by the facility s nursing r ther ancillary staff in rder t evaluate and treat an individual s cnditin r determine the need fr a pssible inpatient admissin. Fr further details n bservatin services, including billing requirements and reimbursement, please refer t ur medical plicies at www.ibx.cm/medplicy. Outpatient surgery Outpatient surgery reimbursement represents an all-inclusive payment fr all facility Cvered Services prvided during and related t the surgical prcedure. The all-inclusive payment includes services/items prvided in cnjunctin with surgical prcedures but excludes certain implantable devices. Please refer t the Outpatient Implantable Devices sectin n page.11 fr mre infrmatin. All services related t the utpatient surgery shuld be billed n the same claim. Surgeries perfrmed n multiple dates shuld be billed n separate claims fr each surgical date f service and include all f the services related t each surgery. D nt bill multiple surgical dates f service n the same claim. Outpatient surgical prcedures are assigned a surgical categry, which determines the level f reimbursement. Surgical prcedures nt listed n the Outpatient Fee Schedule are individually reviewed fr payment cnsideratin when perfrmed in a hspital utpatient setting. Services included in reimbursement fr utpatient surgery Outpatient services rendered prir t an utpatient surgical prcedure. Outpatient prcedures, such as preadmissin diagnstic services and ther services related t the surgical prcedure, can ccur befre the date f the surgical prcedure but are nt separately reimbursable. 9/1/2013.
Billing & Reimbursement fr Hspital Services Hspital Manual Preperative examinatins. Services billed with a diagnsis cde fr preperative examinatins are nt separately reimbursable. Preadmissin diagnstic services. Reimbursement fr utpatient surgical prcedures includes payment fr preadmissin diagnstic services. Charges fr preadmissin diagnstic services must be included n the surgical claim. Diagnstic services prvided t a Member within 30 days prir t and including the date f the Member s surgery are included in the surgical prcedure payment. Diagnstic services include the fllwing revenue/prcedure cdes*: 0254: Drugs incident t ther diagnstic services 0255: Drugs incident t radilgy 030X: Labratry 031X: Labratry pathlgical 032X: Radilgy diagnstic 0341, 0343: Nuclear medicine, diagnstic/diagnstic radipharmaceutical 035X: Cmputed tpgraphy (CT) scan 031: Anesthesia incident t radilgy 032: Anesthesia incident t ther diagnstic services 040X: Other imaging services 046X: Pulmnary functin 041: Audilgy diagnstic 0482: Cardilgy, stress test 0483: Cardilgy, echcardilgy 053X: Ostepathic services 061X: Magnetic resnance technlgy (MRT) 062X: Medical/surgical supplies, incident t radilgy r ther diagnstic services 03X: Electrcardigram (EKG/ECG) 04X: Electrencephalgram (EEG) 0918: Testing, behaviral health 092X: Other diagnstic services *The list f diagnstic services may be revised peridically t reflect current revenue and/r prcedure cdes. Observatin services. When Outpatient surgical claims are paid accrding t the fee schedule, there is n additinal reimbursement fr bservatin rm services. Fr mre infrmatin regarding bservatin services, please refer t ur medical plicies at www.ibx.cm/medplicy. Multiple surgical prcedures When multiple utpatient surgical prcedures are perfrmed during the same date f service, Prviders may bill multiple utpatient surgical prcedures with multiple surgical revenue cdes. IBC will reimburse the primary prcedure at 100 percent f the cntracted rate and each eligible secndary prcedure at 50 percent f the cntracted rate. The primary service n each claim will be determined based n the highestallwable cntracted rate. When a claim has multiple prcedures with the same highest-allwable cntracted rate, the first listed prcedure with the highest allwable will be reimbursed as primary, all ther eligible prcedures will be reimbursed as secndary. 9/1/2013.8
Billing & Reimbursement fr Hspital Services Hspital Manual Example 1 Rev cde Prcedure cde Cntracted rate Status Reimbursement 0360 23130 $100 x 2.5 = $250 Primary (highest allwable) 100% f cntracted rate 0369 23156 $50 x 2.5 = $125 Secndary 50% f cntracted rate Example 2 Rev cde Prcedure cde Cntracted rate Status Reimbursement 0481 9293 $200 x 2.0 = $400 Primary (highest allwable) 100% f cntracted rate 0481 92938 $200 x 2.0 = $400 Secndary 50% f cntracted rate 0360 93505 $80 x 2.5 = $200 Secndary 50% f cntracted rate Incidental prcedures Services identified as incidental prcedures (IP) n the Outpatient Fee Schedule may r may nt be eligible fr reimbursement. When multiple surgical prcedures are perfrmed n the same date f service, prcedures identified as IP are cnsidered incidental t the primary prcedure and are nt eligible fr additinal reimbursement. Hwever, payment fr an IP is made when that prcedure is the nly surgical prcedure perfrmed r when it is the primary prcedure fr the episde f care. Example 1 (IP with additinal surgical prcedures) Revenue cde Prcedure cde IP Reimbursement 0361 24366 N/A 100% f cntracted rate 0361 24000 IP N reimbursement 0361 2846 N/A 50% f cntracted rate Example 2 (IP as primary surgical prcedure) Revenue cde Prcedure cde IP Reimbursement 0360 5862 IP 100% f cntracted rate Example 3 (IP as primary and secndary surgical prcedures) Revenue cde Prcedure cde IP Reimbursement 0360 29836 IP 100% f cntracted rate 0360 29830 IP N reimbursement Members may nt be balance-billed fr any incidental prcedure that is nt reimbursed by IBC. Surgical prcedures nt fund n the Outpatient Fee Schedule Surgical prcedures nt listed n the Outpatient Fee Schedule are individually reviewed fr payment cnsideratin when perfrmed in a hspital utpatient setting. IBC may als request medical recrds t help determine a reimbursement rate r t ensure that the prcedure cde reprted accurately represents the surgery perfrmed. If medical recrds are requested, IBC will make a determinatin regarding reimbursement nce the dcumentatin is received. 9/1/2013.9
Billing & Reimbursement fr Hspital Services Hspital Manual Variatins befre and after surgery Preapprval by IBC is based n the cde fr the prcedure planned, but the cde assigned fr billing after the prcedure may be different. Assuming the cdes are reasnably related, this is nt a barrier fr payment; hwever, an updated Preapprval/Precertificatin may be required. Cancelled surgeries Currently, three types f utpatient cancelled surgery scenaris are eligible fr reimbursement. In rder fr these claims t be prcessed crrectly, certain cding and billing criteria must be met. Claims submitted that d nt meet these criteria will be returned t the facility fr crrectin. Please nte the criteria fr each f the fllwing scenaris when cding and billing yur claims. Scenari 1: Patient receives preperative services, but surgery is cancelled. Example: The patient has preadmissin testing fr intended cataract surgery but subsequently develps a cld and the surgery is cancelled. Cding and billing requirements: Reprt the principal diagnsis cde, which is the reasn fr the surgery. Reprt the secndary diagnsis with the apprpriate diagnsis cde(s) indicating cancelled surgery. Reprt the HCPCS and/r CPT cde(s) fr the preperative services, indicating prcedures perfrmed and the date(s) f service. Submit the claim thrugh the standard channels n medical recrd review is required. Reimbursement: The hspital will be reimbursed fr preperative services accrding t its Agreement. Scenari 2: Planned surgery is stpped befre the entire prcedure is cmpleted. Example: The patient has planned a laparscpic adhesilysis. Surgery prceeds as far as the insertin f the laparscpe when the patient develps an arrhythmia and the surgery is stpped. Cding and billing requirements: Reprt the principal diagnsis cde, which is the reasn fr the surgery. There is n need t use a diagnsis cde indicating cancelled surgery. Cde the prcedure t the extent it was cmpleted. In this example, the diagnstic laparscpy cde wuld be used t describe the insertin f the scpe. Submit the claim thrugh the standard channels n medical recrd review is required. Reimbursement: The hspital will be reimbursed t the extent that the prcedure was perfrmed (e.g., diagnstic laparscpy) accrding t its Agreement. 9/1/2013.10
Billing & Reimbursement fr Hspital Services Hspital Manual Scenari 3: Patient was admitted t same day surgery/shrt prcedure unit, but surgery was cancelled befre it began. Example: Sme services related t the intended prcedure have been rendered. Fr example, the patient is in the perating rm. When anesthesia has been induced, the patient s bld pressure drps and the prcedure is cancelled. Cding and billing requirements: Reprt the principal diagnsis cde, which is the reasn fr the surgery. Reprt the secndary diagnsis with the apprpriate cde indicating cancelled surgery. Reprt the HCPCS and/r CPT cde fr the intended prcedure with the crrect revenue cde fr utpatient surgery. Submit the claim t yur Netwrk Crdinatr with medical recrds fr the encunter and the reasns fr the cancellatin. Claims submitted withut this required infrmatin will nt be cnsidered fr payment. Reimbursement: The hspital/facility may be reimbursed fr surgical prcedures cancelled fr reasns beynd the hspital s cntrl. The hspital will be reimbursed at the minr surgery rate (surgical categry M) fr fee schedule claims r accrding t their Agreement fr all ther claims. The prcedure will nt be reimbursed if the cancellatin is due t administrative reasns (e.g., equipment failure, staffing prblems). Outpatient implantable devices If the hspital is cntracted under the hspital Outpatient Surgery Fee Schedule, specific implantable devices are eligible fr additinal reimbursement. These select apprved implantable devices, listed and updated peridically thrugh Prvider bulletins, are reimbursed separately at the hspital s invice cst. Please refer t the Outpatient Implantable Device List. Hw t bill implantable devices Submit the claim electrnically thrugh standard channels. Bill the implant using revenue cde 025 r 028, as apprpriate. Charges must als be assigned t implants. These devices will be reimbursed separately at the Prvider s cst, as dcumented n the manufacturer s invice (shipping and sales tax excluded). The implant revenue cde and charges must be billed n the initial claim submissin. They will nt be added when the request fr implant reimbursement is submitted. After the base claim is paid, submit the fllwing dcumentatin via fax t Facility Payment at 215-238-088: perative reprt implant recrd implant manufacturer s invice (nt purchase rder) Nte: The purchase rder is nt acceptable in lieu f the manufacturer s invice. It may be submitted in additin t the manufacturer s invice t clarify a date discrepancy. Als, a manufacturer s invice received with handwritten amunts will nt be cnsidered acceptable dcumentatin. Generally, we will nt accept an invice with a date greater than the date f surgery as applicable dcumentatin. Hwever, it may be yur hspital s billing practice t request a device with a purchase rder, receive the device and use it during surgery, and then be billed by the manufacturer after the actual surgery date. If this is the case, include bth the invice and purchase rder fr dcumentatin, and specify that this is yur hspital s practice. 9/1/2013.11
Billing & Reimbursement fr Hspital Services Hspital Manual Fr certain implants that are purchased n cnsignment r rdered in bulk (e.g., drug-eluting stents), a representative cpy f the manufacturer s invice that reflects the cst per unit, units per rder (e.g., pack, case, bx), and mdel number and/r clear descriptin f the implantable device will be cnsidered acceptable dcumentatin. We will als require that the patient-specific serial number f the implantable device be recrded in the implant recrd. T facilitate prcessing, include a cver sheet that cntains a summary f the required infrmatin, including: Member name Member ID number Member claim number implant type invice amunt A sample frm is available fr yur use at www.ibx.cm/prviderfrms. Implant recrd The implant recrd is required t verify the mdel and serial number f the implantable device. This infrmatin can be fund n the implant labels that are attached t the implant recrd. The facility shuld place these labels n the perative reprt, purchase rder, r n ne f the fllwing: cardiac catheterizatin reprt implantable device registratin frm intra-perative nursing recrd medical device r issue tracking frm perative ntes prgress ntes Yu may submit ne f these frms in lieu f the implant recrd as lng as they include the implant label, indicating the implant s mdel and serial number, and a brief descriptin f the device. With the exceptin f radiactive seeds, implantable devices include implant labels frm the manufacturer. Implant requests received withut all required dcumentatin will nt be cnsidered fr reimbursement. Please nte that riginally submitted requests fr implant payments will be prcessed in accrdance with the timely filing prvisins f yur Agreement. Reimbursement exceptins The fllwing are examples f circumstances where implantable devices are nt eligible fr reimbursement: The base surgery claim has been denied r has nt yet been paid. The type f device is nt specified n apprved listing. There is insufficient dcumentatin. IBC is nt the primary payer. Radilgy services Radilgy services are reimbursed in accrdance with IBC s medical plicies, which are available at www.ibx.cm/medplicy. Members are required t btain a Physician rder and/r a Referral t receive radilgy services. Additinally, there are certain high-technlgy diagnstic services that require Preapprval, and IBC has delegated this respnsibility t AIM Specialty Health SM (AIM). 9/1/2013.12
Billing & Reimbursement fr Hspital Services Hspital Manual Fr additinal infrmatin n high technlgy diagnstic services, please refer t ur medical plicies at www.ibx.cm/medplicy. Payment will be made directly t the facility accrding t the hspital s cntracted rates. Reimbursement fr radilgy services is a glbal (i.e., technical and prfessinal cmpnent) payment. Please refer t the current Crrelatin Edits fr Outpatient Claims dcument, which is updated and distributed each quarter, when determining which revenue cdes and HCPCS and/r CPT cdes t use fr billing. Capitated services Radilgy services fr HMO/POS Members are generally prvided by the designated Participating Prvider under the Capitated Diagnstic Radilgy Prgram. A cmplete listing f the services included in this prgram can be fund at www.ibx.cm/medplicy. Radilgy services that are excluded frm capitatin are paid at the hspital s cntracted rate. Interventinal radilgy Interventinal radilgy (IR) invlves prcedures with bth a surgical and radilgical cmpnent. In additin t a surgical revenue cde and crrelated surgical prcedure cde, claims als shuld be submitted with a radilgy revenue cde and crrelated radilgy prcedure cde. The surgical prcedure cde is reimbursed and includes the radilgy services. Shrt-term rehabilitatin therapy services Shrt-term rehabilitatin therapy services are reimbursed in accrdance with IBC s medical plicies, which can be fund at www.ibx.cm/medplicy. Payment will be made directly t the facility accrding t the hspital s cntracted rates. Please refer t the current Crrelatin Edits fr Outpatient Claims dcument, which is updated and distributed each quarter, when determining which revenue cdes and HCPCS and/r CPT cdes t use fr billing. Capitated services Physical therapy and ccupatinal therapy services fr HMO/POS Members are generally prvided by the designated Participating Prvider under the Capitated Outpatient Shrt-Term Rehab Prgram. A cmplete listing f the services included in this prgram can be fund at www.ibx.cm/medplicy. Therapy services that are excluded frm capitatin are paid at the hspital s cntracted rate. Sleep study (neurlgy) In rder fr a participating hspital s sleep study prgram t be eligible as an apprved sleep study prgram fr IBC s netwrk, the prgram must be accredited by the Jint Cmmissin r the American Assciatin f Sleep Medicine, as specifically referred t in yur Agreement. Fr hspital billing, sleep study is part f the neurlgy fee schedule and shuld be billed using neurlgical revenue cdes. 9/1/2013.13
Billing & Reimbursement fr Hspital Services Hspital Manual Additinal billing infrmatin Revenue cdes requiring HCPCS/CPT cdes When billing ne f the revenue cdes listed belw, a crrespnding HCPCS/CPT cde must be reprted n the claim line. Revenue cde series Revenue cdes 02xx 0250-0256, 0258-0261, 0269, 024-025, 028, 0280, 0289-0294, 0299 03xx 04xx 0300-0312, 0314, 0319-0324, 0329-0333, 0335, 0339-0344, 0349-0352, 0359-0362, 036, 0369, 034, 0380-038, 0389-0381, 0399 0400-0404, 0409-0410, 0412-0413, 0419-0424, 0429-0434, 0439-0444, 0449-0452, 0456, 0459-0460, 0469-042, 049-0483, 0489-0490, 0499 05xx 0510-051, 0519, 0530-0531, 0539 06xx 0610-0612, 0614-0616, 0618-0619, 0621-0623, 0631-063 0xx 000, 020-023, 029-032, 039-040, 050, 060-062, 069, 01, 090 08xx 0820-0825, 0829-0835, 0839-0845, 0849-0855, 0859-0861, 0880-0881, 0889 09xx 0901, 0903, 0914-0918, 0920-0925, 0929, 0940-0949, 0951-0952 Nt separately payable (NSP) prcedures When multiple prcedures are billed, n additinal payment is made t hspitals fr prcedures identified as NSP n the Outpatient Fee Schedule. Services identified as NSP are an inherent part f anther prcedure and therefre are cnsidered packaged services/items fr which n separate payment is made. Members may nt be balance-billed fr any NSP prcedure that is nt reimbursed by IBC. Cding discrepancies Any cding discrepancies shuld be reprted using the NaviNet web prtal. In the Plan Transactins menu, select Claim Inquiry and Maintenance, then Claim INFO Adjustment Submissin. Billing requirements fr prviders cntracted under Ambulatry Payment Classificatin (APC) The billing requirements fr prducts reimbursed under APCs are as fllws: Crrelatin requirements. The Crrelatin Edits fr Outpatient Claims dcument will cntinue t be applied t all claims submitted, including claims submitted fr APC reimbursement. Please be sure t use the mst recently published crrelatins edits table. Integrated Outpatient Cde Editr (IOCE). The IOCE identifies billing errrs and indicates what actins t take t rectify a claim, as well as perfrms the calculatins t determine cmpsite rate payments where applicable. All claims submitted will be prcessed thrugh the IOCE, s any errrs will need t be addressed accrdingly t ensure that an acceptable claim is received and available fr adjudicatin. Mdifiers. All mdifiers required in accrdance with billing guidelines frm the CMS will be in effect. In rder t receive the crrect level f reimbursement, all claims submitted shuld cntain the apprpriate mdifiers fr the services rendered. Implantable items The Outpatient Implantable Device Reimbursement List des nt apply t APC reimbursement. The reimbursement fr implantable items is included in the apprpriate surgical prcedure and is nt paid separately. Please fllw CMS billing requirements fr mdifiers and cde cmbinatins fr implants. 9/1/2013.14
Billing & Reimbursement fr Hspital Services Hspital Manual Billing fr physician and advanced practice nurse services Physician and advanced practice nurse services may nt be billed by a facility using a UB-04 claim frm r 83I transactin. These services must be billed by the Physician r advanced practice nurse using his r her NPI n a CMS-1500 claim frm r thrugh an 83P transactin. Prfessinal ffice-based services in an utpatient setting When a prfessinal Participating Prvider perfrms a service that is cnsidered an ffice-based service (e.g., ffice visit, utpatient cnsultatin, prfessinal interpretatin and reprt) in an in a ffice-based setting (eg, clinic, treatment rm) lcated in a hspital facility, hspital affiliate wned site, etc., the facility is nt eligible t receive reimbursement fr these services r fr any services included in the payment t the prfessinal Participating Prvider. Hwever, accrding t their cntract, the facility is eligible t receive reimbursement fr any ancillary Cvered Services (e.g., labratry test, radilgic study) related t the ffice visit r cnsultatin. Fr additinal infrmatin abut these services, please refer t ur medical plicies at www.ibx.cm/medplicy. Crdinatin f Benefits/Other Party Liability All claims shuld clearly indicate if the claim is the result f an accident, such as a mtr vehicle accident, r related t emplyment. Refer t the General Infrmatin sectin f this manual fr mre details. The claim shuld be submitted t the apprpriate primary insurance carrier and shuld include all services rendered during the admissin r date f service. T ensure that timely filing standards are met, these types f claims shuld als be submitted t IBC with the apprpriate indicatr, in the event that the primary insurer denies respnsibility fr the claim. 9/1/2013.15