Saturday, June 25, 2016

How to bill Observation care on UB 04 - Locator 46

General Billing

• Report inpatient services with appropriate revenue and HCPCS codes
• Report the number of observation hours in Field Locator 46

Observation Following ER
Bill observation services that are a result of an emergency department visit on the same UB-04 form.

Observation Following SDC
Bill observation services that are a result of an outpatient surgical procedure (SDC) on the same UB-04 form.

Inpatient Following Observation

• Bill observation services that convert to an inpatient admission on the same UB-04 form as the inpatient admission.

• Enter the inpatient admission date in Form Locator 6 (statement covers period) as the beginning (from) date of the UB-04 form. Do not include the observation date within the statement covers period date range; this will cause the claim to deny as billed incorrectly because the number of admission days will not equal the number of days indicated by the statement covers period.

• Enter the date on which the patient was admitted for inpatient services or other start of care in Field Locator 12.

• Enter the time at which the patient was admitted for inpatient services or other start of care in Field Locator 13; hours are entered in two-digit military time (e.g., use 14 for 2:00 p.m.).

Per Diem Facilities
Bill observation services that convert to an inpatient admission after midnight of the observation day with the date of the observation service in Field Locator 45 and the number of hours in Field Locator 46.

Observation with Ancillary Services

Bill outpatient ancillary services received during an observation stay using appropriate revenue codes and HCPCS codes on the same UB-04 form as the observation services.

Observation with Radiological Procedures
Bill observation services used in conjunction with radiological procedures (i.e., CAT scan, MRI, ultrasound) on the same UB-04 form as the radiological procedure.


Observation with Diagnostic Procedures 

Bill observation services used in conjunction with diagnostic procedures on the same UB-04 form as the diagnostic services.

OI Denial Review Request
• Submit OI denial reviews as a Corrected Claim Appeal along with a completed Provider Claim Appeal Form.
• Submit as an outpatient claim and include only the observation room charges. All other outpatient charges that are submitted on the claim with the observation date of service will be denied.

Wednesday, June 22, 2016

How to bill Value and Revenue codes in UB 04

FLs 39, 40, and 41. Value Codes and Amounts.
a. Each code must be accompanied by an amount.
b. All codes are two alphanumeric digits.
c. Amounts may be up to ten numeric positions. (00000000.00)
d. If code 06 is entered, there must be an entry for code 37.
e. If codes 08 and/or 10 are entered, there must be an entry in FL 10.
f. If codes 09 and/or 11 are entered, there must be an entry in FL 9.
g. If codes 12, 13, 14, 15, 41, 43, or 47 are entered as zeros, occurrence codes 01, 02, 03, 04, or 24 must be present.
h. Entries for codes 37, 38, and 39 cannot exceed three numeric positions.
i. If the blood usage data is present, code 37 must be numeric and greater than zero.


FL 42. Revenue Codes.
a. Four numeric positions.
b. Must be listed in ascending numeric sequence except for the final entry, which must be “0001” for hardcopy claims only.
c. There must be a revenue code adjacent to each entry in FL 47.
d. For bill types 32X and 33X the following revenue codes require a 5-position HCPCS code:
0274, 029X, 042X, 043X, 044X, 055X, 056X, 057X, 0601, 0602, 0603, and 0604.
e. For bill type 34X, the following revenue codes require a 5-position HCPCS code:
0271-0274, 42X, 43X, 44X, and 0601-0604.
f. For bill type 21X, 32X, 33X, or 11X (IRF facilities) the following revenue codes require a 5-position HIPPS code:
0022 (SNF only), 0023 (HH only), 0024 (IRFs only).

Billing continuous visit on UB 04 form - FL 6 and FL 17

Submitting Bills In Sequence for a Continuous Inpatient Stay or Course of Treatment


When a patient remains an inpatient of a SNF, TEFRA hospital or unit, swing-bed, or hospice beyond the end of a calendar month, providers must submit a bill for each calendar month. (See §50.2.1 for frequency of billing for inpatient services.) Claims for the beneficiary are to be submitted in service date sequence. The shared system must edit to prevent acceptance of a continuing stay claim or course of treatment claim until the prior bill has been processed. If the prior bill is not in history, the incoming bill will be returned to the provider with the appropriate error message.

When an out-of-sequence claim for a continuous stay or outpatient course of treatment is received, FIs will search the claims history for the prior bill. They do not suspend the out-of-sequence bill for manual review, but perform a history search for an adjudicated claim. For bills other than hospice bills, if the prior bill is not in the finalized claims history, they return to the provider the incoming bill with an error message requesting the prior bill be submitted first, if not already submitted. The returned bill may only be resubmitted after the provider receives notice of the adjudication of the prior bill. A typical error message would be as follows:

Bills for a continuous stay or admission or for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. If you have not already done so, please submit the prior bill. Then, resubmit this bill after you receive the remittance advice for the prior bill.

For a partial hospitalization program claim to determine out-of-sequence claim submission for the outpatient course of treatment, providers must utilize the correct frequency digit in the type of bill as follows:

If the “from” and “through” (FL6) dates on the claim being submitted include the dates for all services of the course of treatment, then the frequency digit in the type of bill will be a “1” [Admit through Discharge Claim] (i.e., 131, 761, or 851). The final Patient Discharge Status code (FL 17) will be entered.

If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the start of the course of treatment (first of a series of bills) and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “2” [Interim – First Claim] (i.e., 132, 762, or 852). The Patient Discharge Status code (FL 17) will be a “30”.

If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the neither at the start or at the completion of the course of treatment and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “3” [Interim – Continuing Claim] (i.e., 133, 763, or 853). The Patient Discharge Status code (FL 17) will be a “30”
.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the completion of the course of treatment (last of a series of bills) and no additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “4” [Interim – Last Claim] (i.e., 134, 764, or 854). The final Patient Discharge Status code (FL 17) will be entered.

 Providers may submit Interim Bills daily, weekly, or monthly as long as the claims are submitted with the correct frequency code in the type of bill and sequentially.

For a hospice claim that is out of sequence, the FI searches their claims history. If the FI finds the prior claim has been received but has not been finalized (for instance, it has been suspended for additional development), they do not cause the out of sequence claim to be returned to the provider. Instead, they hold the out of sequence claim until the prior claim has been finalized and then process the out of sequence claim. If the prior hospice claim has not been received, the out of sequence hospice claim is returned to the provider with an error message as described above. FIs shall perform editing to ensure hospice claims are processed in sequence after any necessary medical review of the claims has been completed.

Since hospice claims received out of sequence do not pass all required edits, they do not meet the definition of “clean” claims defined in §80.2 below. As a result, they are not subject to the mandated claims processing timeliness standard and are not subject to interest payments. FIs will enter condition code 64 on the out of sequence claims they are holding when awaiting the processing of the prior claims to indicate that they are not “clean” claims.

Monday, June 20, 2016

BCBSNC CMS 1500 instruction on Signature on File and NDC number

Box 12. Have the patient or authorized person sign or indicate “SIGNATURE ON FILE” in lieu of an actual signature if you have the original signature of the patient or other authorized person on file authorizing the release of any medical or other information necessary to process this claim.


Box 13. Have the subscriber or authorized person sign or indicate “SIGNATURE ON FILE” in lieu of an actual signature if you have the original signature of the Member or other authorized person on file authorizing assignment of payment to you.


Box 14. Enter the date of injury or medical Emergency. For conditions of pregnancy enter the LMP. If other conditions of illness, enter the date of onset of first symptoms.

Box 24  The 6 service lines in section 24 have been divided horizontally to accommodate submission of both the NPI number and BCBSNC identifier during the NPI transition, and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. Use of the supplemental information fields should be limited to the reporting of NDC codes. If reporting NDC codes, report the NDC qualifier “N4” in supplemental field 24a followed by the NDC code and unit information (UN = unit; GR = Gram; ML = Milliliter; F2 = International Unit).




Wednesday, June 15, 2016

Drug Billing on CMS 1500 AND UB 04 -


• Drug Billing

o Providers are required to bill GHP with the applicable NDC and CPT/HCPCs codes for drugs.

** Reporting NDC on a CMS-1500 claim form

• Enter the NDC in the shaded sections of item 24A through 24G

o To enter the NDC information, enter the qualifier and then the 11 digit NDC information. Please enter the information without hyphenation.

o Providers are to bill each drug for a compound medication as a separate line item with the appropriate NDC.

• Enter the drug name and strength

• Enter the NDC quantity unit qualifier

• Enter the NDC quantity


** Reporting NDC on a UB-04 claims form

• Enter the NDC in the revenue description field (form locator 43)

o To enter the NDC information, enter the qualifier in the first two positions, left-justified, followed immediately by the 11 character NDC without hyphenation.

• Enter the NDC quantity unit qualifier

• Enter the NDC quantity

** Reporting NDC through EDI

• The NDC is to be billed in loop 2410 LIN3

o Reimbursement for specialty pharmaceuticals (i.e. hematology/oncology drugs), will follow Medicaid reimbursement guidelines.


Monday, June 13, 2016

Critical care during Global surgery CPT CODE 31500

 Global Surgery

Critical care services shall not be paid on the same calendar date the physician also reports a procedure code with a global surgical period unless the critical care is billed with CPT modifier -25 to indicate that the critical care is a significant, separately identifiable evaluation and management service that is above and beyond the usual pre and post operative care associated with the procedure that is performed.

Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled into the critical care codes. Therefore, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier -25. The time spent performing the pre, intra, and post procedure work of these unbundled services, e.g., endotracheal intubation, shall be excluded from the determination of the time spent providing critical care.

This policy applies to any procedure with a 0, 10 or 90 day global period including cardiopulmonary resuscitation (CPT code 92950). CPR has a global period of 0 days and is not bundled into critical care codes. Therefore, critical care may be billed in addition to CPR if critical care was a significant, separately identifiable service and it was reported with modifier -25. The time spent performing CPR shall be excluded from the determination of the time spent providing critical care. In this instance it must be the physician who performs the resuscitation who bills for this service. Members of a code team must not each bill Medicare Part B for this service.

When postoperative critical care services (for procedures with a global surgical period) are provided by a physician other than the surgeon, no modifier is required unless all surgical postoperative care has been officially transferred from the surgeon to the physician performing the critical care services. In this situation, CPT modifiers "-54" (surgical care only) and "-55"(postoperative management only) must be used by the surgeon and intensivist who are submitting claims. Medical record documentation by the surgeon and the physician who assumes a transfer (e.g., intensivist) is required to support claims for services when CPT modifiers -54 and -55 are used indicating the transfer of care from the surgeon to the intensivist. Critical care services must meet all the conditions previously described in this manual section.

Friday, June 10, 2016

Revised paper claim form CMS-1500 (version 02/12)


All paper claims are required to be submitted using the new CMS-1500 (02/12) form.
The National Uniform Claim Committee (NUCC) recently revised the CMS-1500 claim form to align the paper claim form with changes in the 5010 837P and accommodate ICD-10 reporting needs. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised paper claim form, CMS-1500 (version 02/12). The Centers for Medicare & Medicaid Services (CMS) adopted form CMS-1500 (02/12), which replaced the older CMS-1500 claim form (08/05), effective with claims received on and after April 1, 2014.

• Medicare began accepting claims on the revised form, (02/12), on January 6, 2014;
• As of April 1, 2014, Medicare only accepts paper claims on the revised CMS-1500 claim form, (02/12); and
When completing the claim form, ensure to use all capital typeface.
The revised form has a number of changes. The two most prevalent changes are new indicators to differentiate between ICD-9 and ICD-10 codes and new qualifiers to identify the role of the provider entered in item 17.
• The NUCC created a presentation that reviews the changes in detail. Click here external pdf file to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.

Item 17 qualifiers
The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
• DN -- referring provider
• DK -- ordering provider
• DQ -- supervising provider
Providers should enter the qualifier to the left of the dotted vertical line on item 17.
• Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).

Item 21 and 24E diagnosis changes
The revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.

Item 21
• For version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set), up to 12 diagnosis codes.
• Enter up to 12 diagnosis codes. Note: this information appears opposite lines with letters A-L. Relate lines A- L to lines of service in 24E by the letter of the line. Use the highest level of specificity.
• Do not provide narrative description in this field.
• Do not insert a period in the ICD-9-CM or ICD-10-CM code.
• The "ICD Indicator" identifies the ICD code set being reported. Enter the applicable ICD indicator as a single digit between the vertical, dotted lines.
• Indicator code set
• 0 -- ICD-10-CM diagnosis
• 9 -- ICD-9-CM diagnosis
Reminder: Providers cannot submit ICD-9 codes for claims with dates of service on and after October 1, 2015.


Item 24E
• For version 02/12, the reference will be a letter from A-L.
• When completing the claim form, ensure to use all capital typeface. This is especially important when indicating letter "I" and "L".
Additional changes
The following additional changes are also included in the revised form:

Item 8
• Form version 02/12: Leave blank.

Item 9b
• Form version 02/12: Leave blank.

Item 11b
• Form version 02/12: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Provide this information to the right of the vertical dotted line.

Item 14
• Form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in item 14.
ASCA reminder