6How Do I Bill Tribal Outpatient Hospital Services? Complete the UB-04 form for outpatient hospital services. Refer to How do I complete the UB-04? in the Billing Guidelines section for specific information on how to fill out the form as well as which fields are required. When billing on the UB-04, you will need to: Enter the billing provider's NPI in field 56. HCPCS codes should be used to describe outpatient diagnostic laboratory procedures (revenue codes 300 to 319). List services provided by using the Revenue Codes and descriptions listed later in this section (Rev. Cd. and Description, fields 42 and 43). Enter the Prior Authorization number if the claim includes an MRI or PET (Treatment Authorization Codes, field 63). Refer to How do I get a Prior Authorization for an outpatient MRI/PET? in the Prior Authorization section. Enter the ICD-9-CM diagnosis code for the primary discharge diagnosis (Prin. Diag. Cd., field 67). ICD-9-CM ICD-9-CM is the coding classification system used to describe diseases and operations. It serves an important function for physician reimbursement, hospital payments, quality review and benchmarking measurement (http://www.icd-9-cm.org). Enter an appropriate ICD-9-CM surgical procedure code if you list a charge for the operating room or for a surgical procedure (Principal Procedure Code, field 74). Include any needed attachments. Refer to What do I attach to a claim? in the Billing Guidelines section. Guidelines If you are billing for any of the following services, use the guidelines below. Anesthesia services must be billed using CPT procedure codes and their corresponding basic unit values found in the most current edition of the American Society of Anesthesiologists (ASA) Relative Value Guide. No physical status modifier or physical status procedure code is allowed. Because it takes more than one line in field 24 of the CMS-1500 claim form to bill for anesthesia services, follow the guidelines below. o On the first line, enter the procedure code, the billed charges, and the number of ASA basic unit values. o On the second line, enter "01999" (designated as "unlisted anesthesia procedure;" a procedure code being used for time), the billed charges, and the number of time units (1 IHS/Tribal Outpatient Hospital D-15
unit = 10 minutes). A time unit code is allowed only with corresponding anesthesia codes 00100-02010. Laboratory services. To bill the professional component of diagnostic lab services, use modifier - 26. You may be reimbursed for diagnostic laboratory services performed in your own laboratory, if you have the appropriate Clinical Laboratory Improvement Amendments (CLIA) certificate. Surgical Assistants. Physicians acting as surgical assistants must submit a separate CMS-1500 claim for their services, using a CPT modifier (-80, -81, or -82). If the claim is for a second surgical assistant, you must attach an explanation from the surgeon explaining the need for a second assistant. This is a covered service only for a tribal hospital selecting a reduced outpatient encounter rate in order to bill physician services. 7How are Tribal Outpatient Hospital Services Paid? Updated 07/09 Alaska Medical Assistance is the "payer of last resort," which means that you must bill all other people, companies, or organizations who might pay for the services before billing Alaska Medical Assistance. Tribal outpatient hospital services are reimbursed on an encounter rate, which is published in the Federal Register by the Indian Health Service. The encounter rate is payment for all outpatient-hospital services (including physician services) provided to one recipient on one day at one Tribal outpatient hospital (except as mentioned below). A laboratory or X-ray service will qualify for payment as an outpatient hospital service if it is the only service received by a patient, is rendered for a patient who is not present at the facility, or is rendered through telemedicine even if the hospital provides only the professional or technical component of the service. The encounter rate will be reduced by any other amount you have been paid for services, such as payments from other health insurance companies (third-party liability) or from recipients if they are not Alaskan Natives or American Indians. Refer to the Billing Third Party Liability section and Recipient Cost Sharing for Outpatient Hospital Services below. Exceptions Tribal clinics located within tribal hospitals. If you are performing outpatient surgical care services, you may choose to be reimbursed at the Medicare Ambulatory Surgical Center (ASC) facility rates if you enroll separately as an ASC provider. A tribal hospital does not need to meet any of the state regulatory requirements of an ambulatory surgical center in order to enroll as an ASC. If you bill outpatient surgical services as an ASC provider, the Medicare ASC rates will be considered payment in full for all professional and facility fees related to the outpatient surgery. Professional fees for a surgeon, assistant surgeon, or anesthesiologist are not separately reimbursable. In addition, if you bill as an ASC, you will not be separately reimbursed at the IHS/Tribal outpatient encounter rate for the same recipient on the same date of service. However, your facility may choose, by completing a written agreement with DHSS, to bill physician services separately from the outpatient hospital including outpatient surgery services. Under this agreement, you will be paid an outpatient encounter rate reduced by the average cost of physician services as determined from the Method E cost reports submitted by the hospitals in D-16 IHS/Tribal Outpatient Hospital Insert Revised 07/09
3Which inpatient hospital services are covered? A.Inpatient Hospital Services Inpatient hospital services are billed on a UB-04 form using revenue codes. The revenue codes listed in "Covered Revenue Codes for Inpatient Hospitals" later in this section are the only IHS/Tribal inpatient hospital services covered by Alaska Medical Assistance. B.Inpatient Professional Services Providing services in any inpatient hospital by a physician, physician assistant, advanced nurse practitioner, nurse midwife, or certified registered nurse anesthetist (CRNA) are billable services separate from the IP hospital. The services of a Physician, physician assistant, advanced nurse practitioner, nurse midwife or certified registered nurse anesthetist provided to an inpatient in a hospital must be billed separately. Refer to How do I enroll? in this section. Enroll each physician, advanced nurse practitioner, nurse midwife, physician assistant and certified registered nurse anesthetist individually and cross-reference him or her to the business practice group enrollment number. Mid-level providers, including physician assistants and certified registered nurse anesthetists must be enrolled with Alaska Medical Assistance, and can bill under their business practice group number. In addition, the following general guidelines apply to all inpatient hospital services. Services must be medically necessary Admission and treatment services at an inpatient hospital must be ordered in writing by an attending physician Admission for surgery must be on the date of surgery except for an emergency or when the recipient's physical or mental condition requires extensive preoperative preparation or therapy Private room accommodations are not covered unless justification of medical necessity is submitted with the claim. You can use the Certificate of Medical Necessity form in the Forms Section. Standard inpatient hospital services covered by Alaska Medical Assistance include: Routine daily hospital services (includes room, linen service, meals, special diets, general nursing service, medical records and admitting service, use of ordinary hospital equipment and instruments, routine treatments, routine drugs, and routine supplies) Drugs prescribed by the attending physician Central service supplies (includes the cost of preparing, handling, and storing supplies) IHS/Tribal Inpatient Hospital E-5 Insert Revised 07/09
Treatment trays, dressings, use of equipment ordered by the attending physician Operating room (includes most standard surgical supplies) Anesthesia Recovery room Normal and cesarean delivery (includes routine supplies) X-ray Laboratory Physical therapy Occupational therapy Speech-language pathology Hearing (audiology) services and evaluations Respiratory therapy Electrocardiography (EKG/ECG) Electroencephalography (EEG) Professional ancillary services Therapeutic abortions, if the procedure is necessary to save the life of the mother or if the procedure is to terminate a pregnancy that is the result of an act of rape or incest. You must attach a "Certificate to Request Federal (Medicaid) Funds for Abortion" to the claim. Refer to the Forms Section for a copy of this form. Other therapeutic abortions may be reimbursable in compliance with an Alaska court order. the department may make payment for organ transplants and requisite related medical care for: (A) kidney and corneal transplants; prior authorization is not required; (B) skin and bone transplants for which the department has given prior authorization; however, dental implants are not covered; (C) bone marrow transplants for which the department has given prior authorization; (D) liver transplants for which the department has given prior authorization, for persons with biliary atresia or other forms of end-stage liver disease; (E) heart, lung, and heart-lung transplants for which the department has given prior authorization. Updated 07/09 E-6 IHS/Tribal Inpatient Hospital
Guidelines If you are billing for any of the following services, use the guidelines below. Physician services are reimbursed under the Alaska Medicaid Physician fee schedule. Anesthesia Services must be billed using CPT procedure codes and their corresponding basic unit values found in the most current edition of the ASA Relative Value Guide. No physical status modifier or physical status procedure code is allowed. Because it takes more than one line in field 24 of the claim form to bill for anesthesia services, follow the guidelines below: o On the first line, enter the procedure code, the billed charges, and the number of ASA basic unit values. o On the second line, enter "01999" (unlisted anesthesia procedure), the billed charges, and the number of time units (1 unit = 10 minutes). A time unit code is allowed only with corresponding anesthesia codes 00100-02010. Laboratory Services. To bill the professional component of diagnostic lab services, use modifier - 26. You may be reimbursed for diagnostic laboratory services performed in your own laboratory, if you have the appropriate Clinical Laboratory Improvement Amendments (CLIA) certificate. Obstetrical Care. Routine global obstetrical care CPT procedure codes 59400 (vaginal delivery) and 59510 (cesarean delivery) are covered only when the patient has third-party insurance coverage. If the patient does not have third-party insurance, bill for routine obstetrical care with the procedure codes listed in the CPT manual. o If you provided antepartum care services - Bill the appropriate evaluation and management procedure code(s) o If you only performed the delivery - Bill procedure code 59409 (Vaginal Delivery Only) or 59514 (Cesarean Delivery Only) o If you performed the delivery and gave postpartum care - Bill procedure code 59410 (vaginal delivery only, including postpartum care) or 59515 (cesarean delivery only, including postpartum care) You must use one of these procedure codes if any time during the patient's postpartum period, you saw the patient and provided any postpartum service, whether in the hospital or the office. Surgical Assistants. Physicians, physician assistants and advanced nurse practitioners acting as surgical assistants must submit a separate claim for their services, using a CPT modifier (-80, -81, or -82). If you submit a claim for a second surgical assistant, you must attach an explanation from the surgeon explaining the need for a second assistant. Physicians, physician assistants or Certified Registered Nurse Anesthetists. o Bill a physician service under the group NPI (field 33a) with the qualifier ZZ and group practice taxonomy code in Field 33b. IHS/Tribal Inpatient Hospital E-15 Insert Revised 07/09
o Use the supervising physician's, the physician assistant's or certified registered nurse anesthetist's NPI in Field 24J. Advanced Nurse Practitioner or Nurse Midwife. ANP/NMWs are required to enroll with Alaska Medicaid and will be reimbursed based on that enrollment. Refer to the Advanced Nurse Practitioner/Nurse Midwife billing manual for specific billing guidelines, and to the appropriate provider billing manual when billing for other covered ANP/NMW services. Dispensing Advanced Nurse Practitioners, for instance, shall bill according to the covered services and billing guidelines found in the Pharmacy Services Provider Billing Manual. Updated 07/09 E-16 IHS/Tribal Inpatient Hospital
Figure L-2: Sample CMS-1500 Crossover Paper Claim Updated 07/09 Billing Third Party Liability L-13 Insert Revised 07/09
Sample MRN MEDICARE SERVICE CENTER MEDICARE 901 40 TH STREET S, SUITE 1 8 REMITTANCE FARGO, ND 581032146 NOTICE Note: Your EOMB may be formatted differently. ABC MEDICAL GROUP PROVIDER #: K0000BHXBK PO BOX 4444 DATE: 4/04/08 ANCHORAGE, AK 99507-1234 CHECK/EFT #: 183699999 PAGE #: 1 REND PROV SERVICE DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC-AMT PROV PD ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- NAME LIVINGSTON, JIM HIC 987654321A ACNT 11434-099999 ICN 1111987654321 ASG Y MOA MA01 MA15 1711111111 0320 032008 11 1 99213 180.00 77.20 0.00 15.44 102.80 61.75 PT RESP 15.44 CLAIM TOTALS 180.00 77.20 0.00 15.44 102.80 61.75 ADJ TO TOTALS: PREV PD INTEREST 0.00 LATE FILING CHARGE 0.00 NET 61.75 CLAIM INFORMATION FORWARDED TO: STATE OF ALASKA MEDICAID PROGRAM ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Updated 04/09 Billing Third Party Liability L-14
Completed Form Examples This section contains examples of completed forms, or mockups, to illustrate proper form completion. CMS-1500 Claim form - CHA/P TPL-Avoidance Request form Transportation Voucher Provider Enrollment form (Pages 1-4) Medicare Crossover Paper Claims Completed Form Examples R-1
Figure R-1: Completed CMS-1500 Claim Form - CHA/P Services Example Updated 07/09 R-2 Completed Form Examples Insert Revised 07/09