Friday, December 18, 2015

UB 04 - Form Locator - FL 67, 69 - POA indicator missing Denial

Form Locator 42

FL 42 - Revenue Code

Required. The provider enters the appropriate revenue codes from the following list to identify specific accommodation and/or ancillary charges. It must enter the appropriate numeric revenue code on the adjacent line in FL 42 to explain each charge in FL 47. Additionally, there is no fixed “Total” line in the charge area. The provider must enter revenue code 0001 instead in FL 42. Thus, the adjacent charges entry in FL 47 is the sum of charges billed. This is the same line on which non-covered charges, in FL 48, if any, are summed. To assist in bill review, the provider must list revenue codes in ascending numeric sequence and not repeat on the same bill to the extent possible. To limit the number of line items on each bill, it should sum revenue codes at the “zero” level to the extent possible.

Codes used for Medicare claims are available from Medicare contractors. Codes are also available from the NUBC ( via the NUBC’s Official UB-04 Data Specifications Manual.

Form Locators 43-65

FL 43 - Revenue Description/IDE Number/Medicaid Drug Rebate

Not Required. The provider enters a narrative description or standard abbreviation for each revenue code shown in FL 42 on the adjacent line in FL 43. The information assists clerical bill review. Descriptions or abbreviations correspond to the revenue codes. “Other” code categories are locally defined and individually described on each bill.

The investigational device exemption (IDE) or procedure identifies a specific device used only for billing under the specific revenue code 0624. The IDE will appear on the paper format of Form CMS-1450 as follows: FDA IDE # A123456 (17 spaces). HHAs identify the specific piece of durable medical equipment (DME) or non-routine supplies for which they are billing in this area on the line adjacent to the related revenue code. This description must be shown in Healthcare Common Procedure Coding System (HCPCS) coding.

When required to submit drug rebate data for Medicaid rebates, submit N4 followed by the 11 digit National Drug Code (NDC) in positions 01-13 (e.g., N499999999999). Report the NDC quantity qualifier followed by the quantity beginning in position 14.

The Description Field on Form CMS-1450 is 24 characters in length. An example of the methodology is illustrated below.

Form Locators 66-81

FL 66 – Diagnosis and Procedure code Qualifier (ICD Version Indicator) Required. The qualifier that denotes the version of International Classification of Diseases (ICD) reported. The following qualifier codes reflect the edition portion of the ICD: 9 - Ninth Revision, 0 - Tenth Revision.

FL 67 - Principal Diagnosis Code

Required. The hospital enters the ICD code for the principal diagnosis. The code must be the full ICD diagnosis code, including all five digits where applicable for ICD-9 or all seven digits for ICD-10. The reporting of the decimal between the third and fourth digit is unnecessary because it is implied.

The principal diagnosis code will include the use of “V” codes where ICD-9-CM is applicable. Where the proper code has fewer than five digits (ICD-9-CM) or seven digits (ICD-10-CM), the hospital may not fill with zeros. The principal diagnosis is the condition established after study to be chiefly responsible for this admission. Even though another diagnosis may be more severe than the principal diagnosis, the hospital enters the principal diagnosis. Entering any other diagnosis may result in incorrect assignment of a Diagnosis Related Group (DRG) and cause the hospital to be incorrectly paid under PPS. The hospital reports the full ICD code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67 of the bill. It reports the diagnosis to its highest degree of certainty. For instance, if the patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom must be reported. If during the course of the outpatient evaluation and treatment a definitive diagnosis is made (e.g., acute bronchitis), the hospital must report the definitive diagnosis. When a patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital should report an ICD code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations.

What steps can we take to avoid return to provider (RTP) reason code 34931?

A: One or more present on admission (POA) indicator(s) is/are missing, invalid or incorrectly submitted with the reported diagnosis code(s). It is recommended that you review each diagnosis code and POA indicator to ensure they are correct, prior to submitting your claim.

• POA is defined as being present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department and/or observation services, or outpatient surgery, are considered POA.

• Claims for inpatient admission to acute care inpatient prospective payment system (IPPS) hospitals must include the appropriate POA indicator for the principal and all secondary diagnoses, unless the code is exempt.

• It is important to review the POA exempt list to ensure you are submitting your claims correctly. Refer to downloads on the CMS website, at Hospital Acquired Conditions (Present on Admission) - Coding external link.

Note: The 2015 ICD-9-CM and ICD-10-CM POA exempt lists are identical to the 2014 ICD-9-CM and ICD-10-CM POA exempt lists. There were no changes.

• The CMS Hospital-acquired conditions (HAC) and present on admission (POA) indicator reporting provision external pdf file fact sheet provides background information, additional resources and general reporting requirements.
The following hospitals are exempt from this provision:
• Critical access hospitals
• Long term care hospitals
• Cancer hospitals
• Children’s inpatient facilities
• Religious non-medical health care institutions
• Inpatient psychiatric hospitals
• Inpatient rehabilitation facilities
• Veteran’s administration/department of defense hospitals

Valid values for POA indicators are:

Code Reason for code

Y Diagnosis was present at time of inpatient admission.
N Diagnosis was not present at time inpatient admission.
U Documentation insufficient to determine if the condition was present at the time of inpatient admission.
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

‘Blank’ Unreported/not used. Exempt for POA reporting.

Note: Blank is used on UB-04 claim form and the equivalent 5010 electronic claim version.

Hospital in patient claims form locator FL 67, 69

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