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UB04 Update
NUBC Effective October 1, 2009 |
Patient Discharge Status 01: NEW DEFINITION
Discharged to Home or Self Care (Routine Discharge)
Usage Note: Includes discharge to home; home on oxygen if DME only; any other DME only; group home, foster care, independent living and other residential care arrangements; outpatient programs, such as partial hospitalization or outpatient chemical dependency programs.
Patient Discharge Status 04: NEW DEFINITION
Discharged/transferred to a Facility that Provides Custodial or Supportive Care
Usage Note: Includes intermediate care facilities (ICFs) if specifically designated at the state level. Also used to designate patients that are discharge/transferred to a nursing facility with neither Medicare nor Medicaid certification and for discharges/transfers to Assisted Living Facilities.
Patient Discharge Status 21: NEW DEFINITION
Discharged/transferred to Court/Law Enforcement
Usage Note: Includes transfer to incarceration facilities such as jail, prison or other detention facilities.
Learn more... UB04 Version 3.00 Update
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| United Healthcare
Important News
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Same Day Same Service Policy Billing Revision
Effective the fourth quarter of 2009, UHC will begin to generate a separate reimbursement when HCPC codes G0396-G0397, 92002-92014, 99202-99477 and 99401-99412 are used with an E/M code or service and that is appended with modifier 25.
UHC Awarded Tricare Managed Care Support Contract to Provide Serves for the Southern Region
July 13, 2009 UHC will be the Managed Care Support contractor serving Tricare beneficiaries in Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee, and portions of Texas. The first year of operations is anticipated to begin April 1, 2010.
Deployment of July 1, 2009 APC Updates
Ambulatory payment classification(APC) and fee schedule updates that support the UHC commercial APC payment methodology will be deployed in to the APC Grouper/Pricer on July 25, 2009. Claims with July 1 and later dates of service processed prior to this deployment date are reimbursed using the previous quarter's APC grouping and rate information. |
| Medicare Billing Update |
OBSERVATION: When an IP Admission may be changed to an OP Status-Use condition code 44 In cases where a hospital determines that an IP admission does not meet the hospital's IP criteria, the hospital may change the status from IP to OP and submit an OP(TOB 13X OR 85X) for medically necessary services as long as: 1. Change of status made prior to discharge or release; 2. No IP bill has been submitted to Medicare; 3. MD concurs with hospital determination AND 4. MD and hospital decision documented in medical record. CMS Transmittal 1745 CR 6492
More OBSERVATION
August 10, 2009 CMS implements description change to Revenue Code 76X, Chapter 25 of the IOM.
760 Specialty Services
762 OBSERVATION HOURS
769 Other Specialty Services
CMS Transmittal 1767 CR 6561
IP NDC codes accepted by CMS
CWF/DDE shall accept and pass on NDC codes, related unit, and quantity at the line level for IP claims using HCPC code C9399. MAC's must accept decimal values for quantity, although these may be rounded to a whole number for claims processing and pricing. CMS Transmittal 446 CR 6330
Clinical TrialsBeneficiaries enrolled in a managed care plan, institution providers must not bill OP clinical trial services and non-clinical trial services on the same claim. Claims submitted with either the modifier QV or Q1 shall be returned as unprocessable if the diagnosis code V70.7 is not submitted on the claim. CMS Transmittal 1743 CR 6431 CAHs TelehealthPermanent HCPCS codes assigned 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961 when submitted with a GT or GQ modifier that have elected Method II on TOB 85X. These codes replace G0308, G0309, G0311, G0312, G0314, G0315, G0317 and G0318 deleted from the 2009 HCPCS updated. CMS Transmittal 1716 CR 6458 NPI and Reference Lab
Reprint the NPI on claims for Reference Laboratory and Purchased Diagnostic Service performed outside the Billing Jurisdiction. MACs shall accept the billing provider's NPI in lieu of the performing providers' NPI. Any claim submitted without a NPI in Item 32a and the name, address and ZIP code of the performing provider in Item 32 of the CMS-1500 form will be returned to provider. CMS Transmittal 1690 CR 6362
SNF-Revised Billing Instructions
October 1, 2009 SNF's no longer need to use occurrence span code 74 in order for the bypass of TOB 210, no pay bills, to occur.
Appeals Revisions
CMS updated the amount that must remain in controversy to file a level 2 and level 5 appeal and clarified the requirements to overpayment cases that involve multiple beneficiaries. Additionally, CMS is providing instructions on how to handle misrouted requests for appeals, as well as paid claims.
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| What's the difference between a HAC or a Never Event?
Billing rules according to the Medicare program |
July 6, 2009
CMS introduced three national coverage decisions related to the NEVER EVENTS of wrong patient, wrong body part, wrong surgeries and invasive procedures. These three situations were deemed NOT COVERED. Bill Medicare to capture denial status and report charges. Never events must be billed as non covered services and charges split and placed on a separate and distinct bill from the covered services. IP Non covered services use TOB 110 (no-pay claim). All IP covered services use TOB 11X. FISS will create a bypass edit for IP overlapping dates of service.
Three new modifiers are to be used for this purpose:
PA: Surgery wrong body part
PB: Surgery wrong patient
PC: Wrong surgery on patient
Hospital Acquired Conditions (HACs) which are identified as hospital errors that were 'reasonably preventable' but not always avoidable or if proper practices were adopted. These services should be billed as a covered service. All covered services use TOB 11X. Many providers assumed that the HACs were non-covered conditions but the provisions of the DRA on required that the DRG assignment not be higher because of the HAC.
Interestingly enough the Oregon Association of Hospitals and Health Systems has adopted statewide guidelines for non-payment for serious adverse events. Policy states, 'hospitals will not seek payment from patients or payers for additional hospital charge directly resulting from the occurrence of an event if... more here |
| Tricare Billing and Reimbursement
May 1, 2009 |
TRICARE mandated by legislation to adopt Medicare's reimbursement rules when practical. Based on these statutory provisions, TRICARE will adopt Medicare's prospective payment system for reimbursement of hospital outpatient services.
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If you want the status quo then DO NOT READ any further. Cirius solutions are NOT THE STATUS QUO solution. CHANGE is evident immediately with INCREASED CASH and ENSURED COMPLIANCE with EASE OF USE. Every day extract value in solving billing, contractual or reimbursement issues with a business partner that SUPPORTS YOU! Find out more from our Regional LeadersNorthwest and Midwest: mark.ehnen@ciriusgroup.comSouthwest and East: dougs@ciriusgroup.com
Warm regards, Jayne Kronerjaynek@ciriusgroup.com Cirius Group, Inc.925.685-9300www.ciriusgroup.com | |
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Washington Healthcare Reform Update
July 16, 2009 |
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The House Committees on Education and Labor, Ways and Means, and Energy and Commerce introduced comprehensive health care reform legislation today that will reduce out of control cost, encourage competition among insurance plans to improve choices for patient and expand access to quality, affordable healthcare for all Americans.
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Key Metrics Managed Care |
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1. Net and Gross Revenue
2. Number of Days from Receipt of Claim to Payment
3 . Days in A/R
4. Underpayments & Overpayments as a Percent of Total A/R
5. Denials/Appeals as a Percent of Net Revenue
6.Bad Debt as a Percent of Overall Revenue
How does your hospital measure up? |
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| Case Study |
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Complimentary Webinar
Revenue Cycle
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Key Metrics Revenue Cycle Billing |
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1. DNFB Percent of Total A/R Charges
2 . DNFB A/R Days
3. Prebill Clean Claim Rate
4. First Pass Payment Rate
5.Manual Touch Rate
Learn More |
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ICD-10-CM and 5010 UPDATE
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CMS ICD-10-CM releases
Myths and Facts
5010 Timeline Effective Date of the regulation:
March 17, 2009
Level I Compliance by: December 31, 2010
Level II Compliance by: December 31, 2011
All covered entities have to be fully compliant on:
January 1, 2012
837P
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| HFMA ANI
The Seattle weather was perfect, but as our
leaders reminded us we are definitely in
the midst of "A Perfect Storm." Each of the
general speakers brought a unique perspective
to their presentation material that was
personal but yet fully drew us out into enormous difficulties we face in these turbulent political and economic times.
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