20071025 Understanding the UB04 clean claim process

1 1 HFMAHFMAO ctober 25,2007 october 25,2007 Understanding the Understanding the ub04 clean claim ub04 clean claim ProcessProcessUB04UB04 Presented byPresented byCarol D. EatonCarol D. EatonCitrus Valley Health PartnersCitrus Valley Health Partners2 Hospital Billing 101+ ub04 Hospital Billing 101+ ub04 AgendaAgendaRegistrationCharge Description Master(CDM)Coding/ claim CreationHIPAA Electronic Transaction ProcessUB04 Billing PreparationUB04 CMS-1450 Billing ProcessBilling InformationWebsitesQuality Improvements3 Revenue Cycle Revenue Cycle Perfect PicturePerfect Picture BillingProrationDocumentationCodingCharg e CaptureFollow-UpCollectionsPostingContra ct Recovery/AnalysisBad DebtSchedulingPreadmissionAdmittingFinan cial CounselingVerification4 Section:Section:Registration ProcessRegistration Process9 Scheduling: Target for improvement. Look at the number of departments and patients that can be scheduled or & registration: Improve your pre-registration to improve the time needed to create a clean registrations.

2 9 Eligibility & Authorization/Certification: Use electronic sources to obtain. Work with your area IPAs to communicate authorizations ahead of time. Assure services match certification / authorization9 Collecting Co-payments & deductibles: The more you collect and notify upfront, the better chance you have at collecting at all. Payment arrangements also can be made. Published messages or pre-registration & for Medical Necessity & Covered Services: Create the best system for obtaining LMRP/NCD information for Medicare patients. ABNs. Work with Utilization Review or Nursing departments to assure appropriate admissions5 Section:Section:Registration ProcessRegistration ProcessTraining must include: Corporate Compliance: Reporting, accuracy of admit/dischg coding, charity and discount guidelines Insurance eligibility, certification, authorization, matrix payer information Medicare: (ABN) Advanced beneficiary notice, (MSP) Medicare Secondary Payer, 3 day window rules, 1 day stay & re-admission rules, Observation requirements, Important Message for Medicare (letter), Condition of Admissions forms HIPAA:(Health Insurance Portability Accountability Act of 1996, Privacy vs Security.)

3 (Electronic/Passwords, verbal info, paper shredding). Never breach patient confidentiality. EMTALA: Emergency Medical Treatment Labor Act 1986 Clear patient friendly billing communication with patients. Smile and maintain eye contact. Sit & stand tall. Voice tone Job Description, manuals, departmental tour (timecard, vacation, attendance, dress code, name tag, HIPAA waste disposal, overtime, tardiness, switching, holidays)6 Section:Section:Registration ProcessRegistration ProcessHEALTH PLAN ADDRESSES(Use for NPI news)Sign up for Passwords and ID#s, make lists available to the staff involved:AETNA SHIELD ADMINISTRATOR HEALTH VALLEY MGMT-HLA ASSOC HORIZONS HEALTHCARE CARE :Section:Registration ProcessRegistration ProcessErrors to avoid.

4 Misspellings, ID#, Group# missing Incorrect search for correct Medical Record indexing ID Transposing numbers and Typos Invalid insurance mnemonics Incorrect insurance verification Missing authorizations (IPAs) Missing pre-certification /tracking#/ Referral#(Healthplan) Not collecting share-of-cost Medi-cal Missing ABN s(Advanced Beneficiary Notice) Medicare non-covered service Missing police booking sheets, blood alcohol forms, in-custody forms Medicare requires you to certify other care or treatment within 72 hour of admission & Medicare Secondary Payer Check for:legalguardian, parental & consentsAges included0-31 days31-1 years2-13 years14-17 year18-64 yearsOver 64 yearsAge CategoryNeonateInfantPediatricAdolescent AdultGeriatric8 Section:Section:Charge Master ProcessCharge Master process Conduct annual charge master reviews Updates should be quarterly or as often as changes are received Assure that computer order entry is connected to each charge in the specific departments matches the CDM.

5 Review charging tickets frequently Departmental involvement with charge protocols created includingCCI edits Develop departmental daily revenue master logs to review for accuracy and assure quality of systems Team approach to charge master changes should include accounting, HIM,IS, PFS, specific department management Periodic review of all coding on claims by third party to check your internal review processing Review ordering practices and assure documentation is present and accurate to match billing claims Education to all staff of changes, charge protocols, Federal payer documents as they arrive. System capture of requests, changes, audits and education Make sure the claim editor, billing staff or claim vendors are not changing your claim without you know exactly what s changed!9 Section:Section:Charge Master ProcessCharge Master ProcessNewborn Screening Facilities Department of Health Services program began dated July 11, 1, 2007 price increased from $ to $ the price changes occur in January & 16,2007 82261 & 83516 added,still the same final $costBilling will be as follows on your Inpatient claims (Newborn and NICU): Hydroxyprogestene 17-d(17-OHP) 83498 $ Tandem mass spectrometry(MS/MS) 83789 $ Galactose 1 phosphate uridyl transferase 82776 $ Hemagobin fract chromatography 83021 $ Thryoid stimulating hormone (TSH) 84443 $ Biotinidase (BD) 82261 $ Immunoreactive Trypsinogen(IRT) 83516 $ Genetic screening specimen collection DHS 36415 $ Genetic screening draw/handling DHS 99001 $ equal a total of $ +$ blood draw #510/412-150210 Section.

6 Charge Master ProcessRevenue Code Assignment Reminder CMS recommends the use of revenue codes that closely define where the procedures are performed. Revenue codes involved:036x Surgical,045x Emergency Room, 051x Clinic,075x GI Surgical Procedures10021-69990, 0008T, 0016T-0024T, 0027T 0033T-0040T, 0046T-0048T, 0050T-0056T, 0061T-0063T, 0071T, 0075T-0081T, 0084T, 0088T, 0090T-0100T, 0120T-0126T, 0133T, 0138T, 0141T-0143T Cardiovascular 92950-92961( ER can t both charge for the same encounter) Photodynamic therapy96567, 96570-96571 Other services & procedures99170, 99185-99186, G0127 Critical Care99291-99292 Therapeutic 90782-90799 Device Coding Effective April 1, 2005 OPPS require providers to code device HCPCS even if many of the are status indicator N . Devices are reported under RC 272,275,276,278, :Section:Charge Master ProcessCharge Master process Example: Charge Master line itemCharge# Description $ CPTHCPCSRev Code4540000 Dialysis Unch/ESRD/Emerg $ 90935 G0257 820 The coding comes from the Charge Master Example of charge on a claimGroupInsClaim (CPTcoding passes)820 Dialysis Unch/ESRD/Emerg070107 90935$ MedicareClaim (HCPCS coding passes)820 Dialysis Unch/ESRD/Emerg070107 G0257 $ Expired code: January 1, 2007 for Occult Blood (use 82270 only) See CR#5292 September 22,2006 R1062CP MM529212 Section:Section:Coding/ claim CreationCoding/ claim CreationICD-9-CM International Classification of Diseases 9thRevision Clinical ModificationVolume 1 Contains five appendices & Tabular list of codes including V codes ( , Other heart block):Appendix A: Morphology of Neoplasm'sAppendix B.

7 Deleted effective october 1 of each yearAppendix C: Classification of Drugs by AMA and their ICD9CM equivalentsAppendix D: Classification of Industrial Accidents according to agency ( , external causes: E828 Animal,riden)Appendix E: List of Three-Digit categoriesVolume 2 Diagnostic terms that are not in volume 1. Index to diseases includes most diagnostic terms in 3 Operations and procedures. 2 digits with one or two digits following the decimal point. ( , Incision. cerebral meninges)For information on ICD-9-CM and POA information:MM5499 CR5499 is scheduled for october 200813 Section:Section:Coding/ claim CreationCoding/ claim CreationCPT Level I- AMA s physicians Current Procedural Terminology Often referred to as HCPCS by the federal government payersEvaluation and Management (99201-99499)Anesthesiology (00100-01999, 99100-99140)Surgery (10021-69990)Radiology (including , radiation onc., diagnostic ultrasound)(70010-79999)Pathology & Laboratory (80048-89356)Medicine (90281-99602)HCPCS Level II-National-Healthcare Common Procedure Coding System.

8 Broad spectrum of services and supplies from patient transport to ostomy supplies, from chemotherapy drugs to durable medical equipment, and new technologies.( ,G0103,J7030,Q3001)Local Codes Level III-Specific State codes for Medicaid programs. CPT & HCPCS level II Modifiers -Provides communication with payers to indicate altered by some special circumstance(s) but the code description itself has not changed.**The existence of a procedure code does not imply coverage under any given insurance plan.** 14 Section:Section:Coding/Coding/ claim CreationClaim CreationModifier UsageModifier UsageMedicare Claims Processing Manual, Medicare Claims Processing Manual, Pub. 100 Pub. 100--04, chap 4, 04, chap 4, , , ( 01/21/05 & trans. 496,03/04/05)CPT Modifiers252750 525973747677 Medicaid: 50,51,80,99,P1,ZG,ZK,ZNHCPCS Level II ModifiersE1-E4 FAF1-F9 LCLDLTRCRTTAT1-T915 Section:Section:Coding/ claim CreationCoding/ claim CreationThe coding comes from the Medical Records AbstractingCoding -Diagnoses-ICD9 volume 1 ABS Status FINAL ADM LOCAL SUPERFICIAL SWELLNG 1 SEBACEOUS CYST 2 GANGLION OF TENDON 3 FAMILY HX-BREAST MALIG -Procedures-ICD9 volume 3 Date Physician Adm 1 EXC LES TEND SHEATH HAND 01/04/07 EDIE E 2 OTHER LOCAL DESTRUC SKIN 01/04/06 EDIE Y 3 (837I only)POA:Y,N,U,W,1 -CPT Codes-CPT volume IDate 1 11422 EXC H-F-NK-SP B9+MARG 01/04/07 2 25111 REMOVE WRIST TENDON LESION 01/04/07 3 00400 ANESTH, SKIN, EXT/PER/ATRUNK 01/04/0716 Section:Section.

9 Coding/ claim CreationCoding/ claim Creation Example of medical records abstracting coding on a Ins claim or Medicare claim360 Operating Room 010406 11422 $ 360 Operating Room 010406 25111 $.00370 Anesthesia 010406 00400 $ on the hospital system, coding from medical records will commonly be involved in some or all of these revenue codes. 360 Surgery, 361 Minor/Interventional Surgery, 369 Other OR,450 Emergency room proc, 750 Gastrointestinal your hospital s own charge master vs. medical record (HIM) coding system and how they flow to the claims you :Section:Coding/ claim CreationCoding/ claim CreationGROUP INS. FINAL claim CREATED252 DEMEROL 25MG AMP 010407 3 BACITRACIN OINT 15GM 010407 1 BANDAGE SURGICAL 010407 4 GROSS & MICROSCOPIC III 88304 010407 2 360 OR SERVICES 11422 010407 1 360 OR SERVICES 25111 010407 1 0 370 370 ANESTHESIA 00400 010407 1 VERSED 2MG/2ML INJ J2250 010407 1 REGLAN INJ 10MG J2765 010407 1 SUBLIMAZE 2ML AMP J3010 010407 1 710 RECOVERY ROOM 010407 1 Dialysis Unch/ESRD/Emerg 90935 010407 1 CHARGE $ 1 of 1 Creation date 010807 $ 1234567890 BLADEGRASS INSURANCE H23 Y Y

10 923459 TENDER,TEDDY 18 XDD333A66688 12444555777 FLY BY NIGHT U72742 WV163 970623895 010407 863 010407 1222444445 G2 A663334 HEALME GINA18 HIPAAHIPAAE lectronic Transaction ProcessElectronic Transaction ProcessClaim/Encounter (837)Status Inquiry (276)Status Response (277)Payment/Remittance (835)Eligibility Inquiry (270)Eligibility Response (271)UR Certification Request (278)UR Certification Response (278)19 HIPAAHIPAAE lectronic Transaction ProcessElectronic Transaction process 270/271 Inquire and Receive Response providing health care eligibility or benefit information associated with a subscriber or dependent. 278 Inquire and Receive a response for the following from Utilization Review units: Admission certification review Referral review Health care services certification Extend certification review 837 Institutional, Professional, Dental claim 276/277 claim Status Request/Response to obtain payer status (accepted/rejected, denied, approved and pending 835 claim Payment/Advice, Explanation of Benefits (EOB) submission to providers or other payers20 Section:Section.)