NUBC UB04 Updates
Effective July 1, 2010 | Point of Origin (formerly Source of Admission)
FL 15 of the UB04 or in CL102/Loop ID 2300 of the 837I.
Three codes eliminated and will no longer be valid for use:
Code 7- Emergency Room
Code B- Transfer from Another Home Health Agency
(Replaced with new Condition Code 47)
Code C- Readmission to Same Home Health Agency
The recommendation is that in replacement of Code 7 use Code 1 and support this with FL 14 Priority Type of Visit 1 to further define patient's point of origin. Also, in effect is new Condition Code P7 but is to be used for "reporting purposes only" indicating that the patient was admitted directly from this facility's Emergency Room/Department.
Code E- Transfer from Ambulatory Surgical Center
Code F- Transfer from Hospice and is Under Hospice
Plan of Care or Enrolled in a Hospice Program.
FL 31-34: New Occurrence Code 50
for Assessment Date (for use with 5010 837 only).
Learn more...NUBC Billing Alert
CMS Transmittal 1929 CR 6801
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| United Healthcare
| Facility and Professional Reimbursement Policy: Wrong Surgical or Other Invasive Procedures
Effective July 1, 2010 dates of service
Pursuant to this new policy, which is consistent with that of CMS, United Healthcare will not reimburse for a surgical or other invasive procedure when the physician erroneously performs. Related services that will not be reimbursed include: all services in OR related to error, charges from physicians and other providers in the OR when the error occurs, and all related services provided during the same hospitalization. UHC members may not be billed for any amounts not paid due to the application of this policy.
NEW BILLING RULES- requires facilities and professionals to report wrong surgical or other invasive events in the following manner:
Hospitals will be required to submit a no-pay claim (TOB 0110) to report all charges associated with erroneous services. ICD-9-CM codes must be reported in positions 2-9 of E876.5, E876.6 or E876.7. Do not report these codes in the External Code of Injury fields. If there are also non-related services provided during the same stay, two claims will be required.
Hospital OP, ASC and 1500'smust report the erroneous services using the HCPCS modifiers PA, PB or PC per line item.
This billing rule applies to members enrolled in commercial plans, or administered by UHC, or one its affiliates, or other legal entities such as Oxford, Pacificare, M.D. IPA, Optimum Choice,Inc., MAMSI Life & Health, Neighborhood Health Partnership, River Valley and Sierra.
Overpayment Address:
Refunds of any credit balances existing on your records should be sent to:
United Health Group Recovery Services, P.O.Box 740804. Atlanta, CA 30374-0804
Provider Dispute Resolution Process Update Effective: April 1, 2010 The Claim Reconsideration stage of the dispute resolution process must be completed prior to submission of a Formal Appeal. All provider appeals request that did not previously go though the Claim Reconsideration process will be redirected to the Claim Reconsideration team for resolution. Claim Reconsideration Request Form here at the Formal Appeal Address: United Healthcare Provider Appeals P.O. Box 30559, Salt Lake City, Utah 84130-0575 External Readmission Reminder NoticeUHC has begun a process of reviewing inpatient re-admissions to acute care facilities recently expanded to the Medicare Advantage products offered by both UHC and Pacificare including Evercare, Secure Horizons, and AARP Medicare Complete following CMS guidelines. Full Network Bulletin 2010 here |
Medicare Billing Update-Effective: April 1, 2010
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Billing for Services Related to Voluntary Uses of ABN for Non-coverageModifier - GA has been redefined to mean "Waiver of Liability Statement Issued as Required by Payer Policy" and should be used to report when a required ABN was issued for a service. NEW Modifier - GX has been created with the definition "Notice of Liability Issued, Voluntary Under Payer Policy" and is to be used to report when a voluntary ABN was issued for a services. Note: GX modifier must be submitted with non-covered charges only, and you MAC will deny the claim as a beneficiary liability. CMS Transmittal 1921 CR 6563
Effective July 1, 2010
Correction to Processing of Non-Covered Revenue Codes
Medicare systems will be changed so that a revenue code line submitted with entirely non-covered charges and no indication that beneficiary liability may apply will not be returned to the providers. Such claims should be processed to completion with payment, assigning liability to the provider. CMS Transmittal 1928 CR 6774MLN6774
Expansion of Editing for Ordering/Referring Providers Medicare claim editing is being expanded to verify the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare. Both electronic and paper claims eligible and edits will apply to Carriers and Part B MAC's. Eligible providers are: doctor of medicine or osteopathy dental medicine dental surgery podiatrist medicine chiropractic medicine optometry physician assistant certified clinical nurse specialist nurse practitioner clinical psychologist certified nurse midwife clinical social worker CMS Transmittal 642 CR6417 005010 837 Institutional (837I) edits and 005010 837 Professional (837P) edits - July versionThe purpose is to provide the July 2010 updated edit spreadsheets to specific A&B MAC's which are, as of this time, in a position to implement 005010, specifically the following jurisdictions: J1, J3, J4, J5, J9, J10, J12, J13 and J14. CMS Transmittal 656 CR6849 Editing Guidance/Clarifications related to HIPAA 5010
Beneficiaries in State or Local Custody Under a Penal AuthorityFor the purposes of Medicare payment, individual who are in "custody" include, but are not limited to, individuals who are:
Under arrest
Incarcerated
Imprisoned
And more.....
CMS Transmittal 1944 CR6880
MLN6880
Medicare FAQ on "Charges for the Uninsured"
Q1 Can a hospital waive collection of charges to an indigent, uninsured individual?
Yes. Nothing in the CMS regulations Provider Reimbursement Manual or Program Instructions.
Read all
Timely Filing Requirements for Medicare Fee-For-Service Claims
President Obama signed into law the Patient Protection and Affordable Care Act (PPACA) which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste and abuse in the Medicare program.
Read full article here
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Hot Topic-Medicare 3 Day Billing Rule
MEDICARE LAW: Outpatient services
are included on the inpatient claim if
they are: "provided by the hospital (or by an
entity
wholly owned or operated by the
hospital) to the patient during the three days...immediately preceding the date of
the
patient's admission if such services
are diagnostic services...or are other
services related to the admission..."
42 U.S.C. §1395ww(a)(4).
| Learn more from a recent HFMA Webinar presentation here
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Editors Corner
"Trust & Verify"
| In the health care financial world these are words to live by. Given the looming complex changes facing our industry and the shifting of paradigms with bundled payments and capitation increasing quality of services and communication these words of wisdom ring truer today then they rang in yesteryears. And more than likely will ring most true in the near future. Possible outcomes are the acceleration of hospital mergers, shifting payer reimbursements and higher accountability rates.
Our answer is simple.
"Value Proposition of Access, Quality and Costs."
Keep our eyes on the horizon, who knows how the weather may change? Our objectives remain optimizing patient care and our patient's experience while fostering the financial health of our healthcare organizations.
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Imagine......Innovation that produced world-class revenue cycle and reimbursement results. With industry leading solutions for high-production, maximum-efficiency revenue cycle and reimbursement software solutions and services, you will streamline business operations and double staff efficiency. Cirius Group offers powerful, results-oriented financial software solutions and services. Regional Team:Northwest and Midwest: mark.ehnen@ciriusgroup.comSouthwest and East: dougs@ciriusgroup.com
Warm regards, Jayne KronerVP, Business Developmentjaynek@ciriusgroup.com Cirius Group, Inc.925.685-9300www.ciriusgroup.com |
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Washington
Health Care Reform
Financial Impact
Coverage Expansion
Medicaid
High Risk Pool
Children up to 26 years
Pre-existing conditions
Exchanges
Subsidies
Employers of 50 or more
Individuals
Payment Policies
Update reductions
Productivity Offsets
DSH reductions
Home Health changes
Rural provisions
Wage Index reform
Delivery system reforms
Learn more..... |
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Denial Prevention Industry studies report that 50% of denied claims are not filed, 90% of denials may be preventable, and up to 67% can be recovered if appealed.
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Design Basic Work Flow
Dedicated staff
Work Queues
Line vs Claim Level
Productivity Reports
Backlog Reports
# of denials per month $ of denials per month % of denials to Gross Remit Charges
% of denials to Gross Remit # % of direct denial write off's
# of accounts worked per day as % of 100%-establish target Departmental average Individual average
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 | CASE STUDY HERE
Clean Claims Improved
Alta Bates Summitt Medical Center, a Sutter Health Affiliate
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Welcome to
California Pacific Medical Group and Sacramento Sierra Hospital affiliates with Sutter Health new clients of Cirius Group, Inc.
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COMPLIANCE
ALPHABET AUDIT SOUP
| Some hospitals are using this information below when making selections for areas of focus for an audit. Medicare PEPPER Report Short-term and long-term acute care inpatient prospective payment system
hospitals that have My QualityNet accounts will receive PEPPERs via a My
QualityNet secure file exchange on or about January 25, March 24, May 24, August
24 and October 25, 2010.
For further information access website: www.pepperresources.org/Quality Net www.qualitynet.org/
AUDIT FOCUS: Evaluate high dollar ancillary charges, beginning with radiology services and compare each charge with the Medicare APC payment. If the single charge is priced lower than the APC payment rate this is an area of exposure for audit by the Medicare system.
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5010 Timeline
Level I Compliance by: December 31, 2010
Level II Compliance by: December 31, 2011
All covered entities have to be fully compliant on:
December 31, 2011
Update
837P and 837I 5010 guidelines
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| HFMA ANI
Destination is the beautiful Nashville, Tennessee countryside. Join us at the Cirius Group booth on the floor of the exhibit area for some special Cirius fun. Watch for future notices about this special fun event planned on the exhibit floor. You will not want to miss it.
Allow us the opportunity to share information about Cirius Group and what we can do for your facility to help you navigate through these turbulent economic times.
Early Bird Raffle
Register here
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