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National Uniform Billing Committee Update
Effective: April 1, 2011 UB-04 Claim: Point of Origin-New Exception to Inpatient/Outpatient General Designation.
UB-04 Situational. Exempt from reporting point of origin for Type of Bill 014x (Hospital - Laboratory Services Provided to Non-patients).004010A1: Situational. Required for all inpatient admissions. Required on Medicare outpatient registrations for diagnostic testing services. 005010: Situational. Required for all inpatient and outpatient services except for Type of Bill 014x. Note: In addition, CMS agreed to drop the condition in its instructions that Code 9 is not appropriate for outpatient claims to be consistent with the UB-04; '9' will be a valid code on all claims. | |
Form Locator 06 Statement Covers Period (From-Through)
The Statement Covers Period "From Date" found within Form Locator 06 ("From Date") may be the same or a different date than the "Admission Date" found within Form Locator 12. The dates may coincide in some circumstances, but should not be confused.
Issue: When a patient receives outpatient services 3 calendar days prior to an inpatient admission, the outpatient charges may need to be included on the inpatient bill. On an initial bill the "From Date" would be prior to the "Admission Date" FL 12. Some payers will not accept a claim in this format.
Today, Medicare has edits prohibiting a PRIOR "Admission Date" to the Statement "From Date" and will reject claims for submission.
Resolution: Medicare will modify edits October 2011.
Billing Alert here
Condition Code 51-Attestation of Unrelated Outpatient Non-Diagnostic Services
Effective April 2011: the hospital attests that the outpatient diagnostic service provided within 3 calendar days (1 calendar day for non-subsection hospitals) prior to the admission is not related to the admission to the inpatient stay.
Reference Material from NUBC
UB-04 Mapping to 005010/005010A1 837 Claim Transaction
UB-04 Change Implementation Calendar
UB-04/837 Reporting Differences
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Payer Update | |
United Healthcare---UHC Administrative Manual Changes
UHC Administrative Manual here
UHC Network Bulletin
In the near future, United Healthcare is expected to reveal details of a pilot program to test a new bundled payment model for cancer treatment. They plan to make a one-time payment for a patient's complete course of treatment for common cancers. New York Times, Kaiser Health News. Full Article
Tricare Provider Manual Learn more |
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Medicare Quarterly News
CMS Awards Section 1011 contract to Highmark Medicare Services
Effective: November 29, 2010
Highmark will begin to generate ERA's for Q3 2010 payment on 02/25/2011.
Those claims paid will have a date of service range of April 1, 2010 through June 30, 2010. These ERAs will be available for download from the Highmark Data Center this February 28 through March 4, 2011.
Receiver ID's for ERA's were mailed to all receivers on December 30, 2010.
Transition News
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Clarification of "3-Day Payment Window" - Outpatient Services Treated as an inpatient
Effective: June 25, 2010 Implementation: April 4, 2011 Outpatient non-diagnostic services, other than ambulance and maintenance dialysis services, provided by hospital 3 days prior to admission must be billed with the inpatient stay, UNLESS the hospital attests to specific non-diagnostic services as being unrelated to the inpatient hospital claims by adding Condition Code '51' to the separately billed outpatient non-diagnostic services claim. CMS Transmittal 796 CR 7142
Repetitive Billing Requirements for Institutional Claims Effective: April 1, 2011 Implementation April 1, 2011 Repetitive Part B services furnished to a single individual by providers that bill institutional claims will be billed monthly (or at the conclusion of treatment). Repetitive services defined by revenue codes. CMS Transmittal 2092 CR 7163 Correct Reporting of Modifiers and Revenue Codes on Claims for Therapy ServicesEffective: April 1, 2011 Implementation: April 4, 2011 If any service line on an institutional claim contains more than one occurrence of the modifiers GN, GO, or GP they will be returned to the provider. Any institutional claim with a mismatched modifier and revenue code will be returned. CMS Transmittal 2091 CR 7170
NUBC Point of Origin Code Update
Effective: April 1, 2011
Points of origin codes are no longer required on 14x bill types. All bill types will now accept point of origin code - information not available.
CMS Transmittal 793 CR7144 MLN Matters MM7144
Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services Effective: January 1, 2011 Implementation: January 3, 2011 CMS is applying a MPPR to the practice expense payment when more than one unit or procedure is provided to the same patient on the same day. For therapy services furnished by a group practice or 'incident to' a physician's service the MPPR applies to all services furnished to a patient on the same, regardless of whether the serves are provided in one therapy discipline or multiple disciplines.
CMS Transmittal 826OTN CR 7050 MLN Matters MM7050 Additional ICD-9/POA production data (Institutional Claims Only)
Implementation Date: January 3, 2011
CMS is expanding the number of ICD-9/POA codes (diagnosis & procedures) processed on institutional claims.
CMS Transmittal 648 CR 6851
MLN Matters MM6851
5010 Requirement for Ambulance Suppliers Effective: January 1, 2011 Implementation: January 1, 2011 Effective for claims submitted in the version 5010 837P electronic format ambulance suppliers you must comply with the requirement to include a diagnosis code.
CMS established a new procedure for reporting fractional mileage amount on ambulance claims to improve reporting and payment accuracy.
Expansion of Medicare Telehealth Paid Services for 2011 Implementation: January 1, 2011
For Dates of service (DOS) on or after January 1, 2011, Medicare contractors will accept and pay the added codes according to the appropriate physician or practitioner fee schedule amount when submitted with a GQ or GT modifier.
CMS Transmittal 2032 CR7049
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| CMS RAC Update
Announcement January 29, 2011
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 Expanding FY 2010 RAC ADR limits to all Institutional Providers. Review for additional documentation limits for fiscal year 2010. The limits announced in December 2009 applied only to requests for DRG validation purposes; the same methodology will now be used for reviews for all institutional claim types. CMS will post the limits for physicians, non-physician practitioners and DMEPOS suppliers at a later date.
Institutional Providers tracking RAC audited claims may be interested in Sharp Healthcare provider's Charter and Workflow design. Gerilynn Sevenikar, VP of Revenue Cycle presented an extremely informative RAC education session last month and with her permission allowed us to share these documents.
CMS ADR Limitations
Sharp HealthCare Complex Audit Work Flow Design
Sharp HealthCare RAC Charter
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February is American Heart Month | | Click here and watch Betty White in her support of the American Heart Association |
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HIPAA 5010
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Version 5010 Implementation Changes to Present on Admission (POA) Indicator '1' and the K3 segment.
MLN Matters 7024
Current Medicare:
4010 to 5010 CROSSWALK837I
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Get Paid Sooner
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Mary Ackley, System Wide Revenue Cycle Director of Sutter Health
"Since our hospital affiliates implemented Cirius Prebill Claim Manager for all payer claim editing and direct payer submission, we are achieving a higher clean claim output and getting paid sooner. Our system wide Net days in A/R have dropped from 60 to 58.8 system wide. We get timely, great support from Cirius." | |
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Health Care Reform
PPACA
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Hospital Acquired Conditions
(Never Events)
Medicaid: No Medicaid payments for health care acquired conditions beginning July 1, 2011. Applies to hospitals and other facilities.
Medicare: Beginning in FY2015, hospitals in the top quartile of rates of hospital acquired conditions would be subject to a payment penalty under Medicare.
HHS Secretary is to report to Congress by January 1, 2012 whether this policy should apply to other Medicare providers.
Potential Financial Impact of Payment Penalties for Acquired Conditions ranges from $0.00 to $1.4 million.
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"You're denied coverage because of your pre-existing condition in having lousy health insurance."
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Beginners
Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT and RAC.
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