Part 4. Billing - Indian Health Service · PDF fileRevenue Operations Manual Part 4 Billing Version 1.0 July 2006 Department of Health & Human Services Indian Health Service Business

Revenue Operations Manual

Part 4

Billing

Version 1.0 July 2006

Department of Health & Human Services Indian Health Service

Business Office

Indian Health Service Revenue Operations Manual

Part 4. Billing Version 1.0 Table of Contents July 2006

Part 4 - ii

Part 4. Billing

Table of Contents

1. Overview of Billing 1.1 About the Revenue Operations Manual 1.2 About the Billing Process 1.3 General Billing Policy Statement 1.4 General Billing Guidelines 1.5 Capturing all Reportable and Billable Services 1.6 About the CMS-1450 / UB-92 Form 1.7 Modifiers and their Role in Billing 1.8 Place of Service 1.9 “Incident To” Services 1.10 Billing Form Review 1.11 Utilization Review 1.12 Roll-Over/Cross-Over for Secondary and Tertiary Billing

2. Hard Copy Versus Electronic Claims Processing 2.1 Hard-Copy Claims Processing 2.2 Monitoring Approved Claims 2.3 Electronic HIPAA compliant claims processing 2.4 Electronic Data Interchange Alternatives 2.5 Tips for Electronic Submission of Claims

3. Billing Medicare 3.1 About Medicare Billing 3.2 Common Working File (CWF) 3.3 Medicare Claim Change Condition Codes 3.4 Provider/Supplier Types 3.5 Procedure for Billing Medicare 3.6 Inpatient Medicare Part B 3.7 Ambulatory Surgery Center Billing – Medicare 3.8 Medicare Secondary Payer (MSP) 3.9 Medicare Secondary Payer (MSP) Claims Investigation 3.10 Medicare Timely Filing 3.11 Claims Resubmission Guidelines 3.12 Reimbursement for Clinical Nurse Specialist or Nurse

Practitioner



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3.13 Reimbursement for Physician Assistant

4. Billing Medicaid 4.1 About Medicaid Billing 4.2 Medicaid Approval and Export Process 4.3 Medicaid Timely Filing

5. Billing Private Insurance 5.1 Procedure for Billing Private Insurance 5.2 Private Insurance Timely Filing

6. Third Part Liability Billing 6.1 Third Party Liability Billing and Medicare Claims

7. Billing Private Dental Insurance 7.1 About Dental Insurance 7.2 Reporting Dental Services 7.3 Dental Billing Guidelines 7.4 Dental Timely Filing

8. Billing Pharmacy 8.1 About Point-of-Sale Pharmacy Billing 8.2 Guidelines for Submitting a Claim Form Manually 8.3 Reasons for Pharmacy Denials

9. Secondary Billing Process 9.1 Creating Secondary Claims 9.2 Printing the Rollback Detail (ROD) Report

Appendixes

A. IHS Reimbursement Methods

B. CMS 1450/UB-92 Form



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Version Control Version Date Notes

1.0 Beta February 2006 Initial version

1.0 July 2006 Published Version


Part 4. Billing Version 1.0 1. Overview of Billing July 2006

Part 4 - 1-1

1. Overview of Billing

Contents 1.1 About the Revenue Operations Manual ..................................................... 1-2

1.1.1 Revenue Operations Manual Objectives............................................. 1-2 1.1.2 Revenue Operations Manual Contents................................................ 1-2 1.1.3 Accessing the Revenue Operations Manual........................................ 1-3

1.2 About the Billing Process........................................................................... 1-3 1.3 General Billing Policy Statement............................................................... 1-4 1.4 General Billing Guidelines......................................................................... 1-4

1.4.1 Guidelines to Improve Reimbursement .............................................. 1-6 1.5 Capturing all Reportable and Billable Services ......................................... 1-7 1.6 About the CMS-1450 / UB-92 Form.......................................................... 1-8 1.7 Modifiers and their Role in Billing ............................................................ 1-8 1.8 Place of Service.......................................................................................... 1-9 1.9 “Incident To” Services ............................................................................. 1-10 1.10 Billing Form Review................................................................................ 1-11 1.11 Utilization Review.................................................................................... 1-11

1.11.1 Splitting Claims Process ................................................................... 1-11 1.12 Roll-Over/Cross-Over for Secondary and Tertiary Billing...................... 1-12



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1.1 About the Revenue Operations Manual The Indian Health Service Revenue Operations Manual provides a system-wide reference resource for all Indian, Tribal, and Urban (I/T/U) facilities across the United States, to assist any and all staff with any function related to business operation procedures and processes.

1.1.1 Revenue Operations Manual Objectives • Provide standardized policies, procedures, and guidelines for the Business

Office related functions of IHS facilities.

• Capture accurate coding for all procedures and services to maximize reimbursement for each facility.

• Provide on-line, via the IHS Intranet, reference material subdivided by department and function that is accessible to all facilities.

• Share innovative concepts and creative approaches to Business Office functions across all the Area offices and facilities.

• Promote a more collaborative internal working environment throughout all of IHS.

• Foster and promote continuous quality improvement standards, which when implemented and monitored on a day-to-day basis, will ensure the highest quality of service at each level of the Business Office operation.

1.1.2 Revenue Operations Manual Contents

The Revenue Operations Manual is divided into the following five (5) parts:

• Part 1 Administrative Roles and Responsibilities contains – Overview of revenue operations – Laws, acts, and regulations affecting health care – IHS laws, regulations, and policies – Health Insurance Portability and Accountability Act Privacy Rule – Business Office management and staff – Business Office Quality Process Improvement and Compliance

• Part 2 Patient Registration contains: – Overview of patient registration – Patient eligibility, rights, and grievances – Direct care and contract health services – Third-party coverage



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– Registration, discharge, and transfer – Scheduling appointments – Benefit coordinator

• Part 3Coding contains: – Overview of coding – Medical record documentation – Coding guidelines – Data entry

• Part 4 Billing contains: – Overview of billing – Hard copy vs. electronic claims processing – Billing Medicare, Medicaid, and private insurance – Third party liability billing – Billing private dental insurance and Pharmacy – Secondary billing process

• Part 5 Accounts Management contains: – Overview of accounts management – Electronic deposits and Remittance Advices – Processing zero pays, payments, and adjustments – Creating payment batches – Reconciliation of credit/negative balances – Collections and collection strategies – Rejections and appeals

Each part and chapter of the manual is designed to address a specific area, department, or function. A part may also contain one or more appendices of topic-related reference materials.

This manual also includes: • Acronym dictionary • Glossary

1.1.3 Accessing the Revenue Operations Manual

The Revenue Operations Manual is available for downloading, viewing, and printing at this website:

http://www.ihs.gov/NonMedicalPrograms/BusinessOffice/index.cfm?module=rom





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1.2 About the Billing Process Indian Health Care Improvement Act, P.1.94-437,authorizes the Business Office to bill and collect reimbursement from a patient’s health insurance and other third party resources. Title IV of the Indian Health Care Improvement Act, as amended, authorizes Indian Health Services facilities to bill and receive payment from Medicaid and Medicare patients. Public Law 100-713 of the Indian Health Care Improvement Act Amendments of 1998 allows IHS to bill and seek payments from private insurance companies and has ruled IHS has the statutory right of recovery.

For an overview of how IHS and Tribes are paid for services rendered to patients in IHS facilities, see Part 4, Appendix A. “IHS Reimbursement Methods.”

1.3 General Billing Policy Statement The third party billing policy for the Business Office is to optimize collections efficiently and effectively from Medicaid, Medicare, private insurance, and other alternate resources in compliance with the rules and regulations of the Centers for Medicare/Medicaid (CMS) and IHS and Third Party Accounts Management and Internal Controls policy.

To have a successful claims management process, everyone in the third-party billing process must perform their specific duties accurately, cooperatively and timely. All necessary steps will be taken to ensure that follow-up on every third party account is adequately and appropriately performed in a timely manner. All IHS facilities will be made aware that collecting third party revenue is a cooperative organizational effort.

1.4 General Billing Guidelines • All fee schedules need to be reviewed and updated yearly. The Custom

Fee Analyzer can be purchased and used as a guide for reviewing the outpatient fee schedule for the facility.

The Analyzer begins with a detailed process on how to review the facility’s fees. It is recommended that once a fee schedule is established by the facility that it is used for all payers. To review codes other than outpatient, use either the HCPCS or Dental Analyzer.



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• All diagnoses affecting the current treatment of the patient must be included on the claim forms.

Diagnosis codes (ICD-9) need to be selected with care. All coding must be accurate, precise, and meaningful to guarantee prompt and accurate payment.

• The health care providers will be responsible for providing either the narrative for the diagnosis or in selecting an accurate code that matches his/her written description.

• The coders will code the applicable code and enter all codes into the RPMS system.

• The provider will provide written documentation of the diagnosis and ICD9 code either on the PCC form or in the Electronic Health Record.

• Depending on the facility, the coder or biller will validate the provider’s coding.

• A coder or biller should never modify documentation by a provider. If a provider fills out a charge ticket and signs it or completes an EHR with an electronic digital signature, then that document is a legal record and should not be altered.

• If the diagnosis code listed by the provider differs from the coder/biller, the coder or biller must review the discrepancy with the provider. If the provider agrees with the coder/biller, the provider must change the code and initial the claim (either the PCC or as an amended claim in the Electronic Health Record).

• All Medicare, Medicaid, and private insurer claims require a linkage or a relationship between the CPT and ICD-9-CM codes.

• Current Physician Terminology (CPT) is required by most insurers. Procedure codes need to be routinely checked or validated against the diagnostic codes to assure reimbursement is made only for those procedures that are “medically necessary” for the treatment of the stated diagnosis. Either the coder or biller, depending on the facility, should validate the CPT codes for accuracy.

• Claims are processed to the insurer according to the terms set forth in the benefit plan. After receiving the claim, the plan may: – Verify the patient’s coverage type – Verify the services provided are covered – Verify services meet Plan requirements – Verify pre-certification was required and/or obtained.


• Billing must be familiar with the requirements, benefits, and exclusions for each insurer. AR must also follow-up on all rejected, unpaid, or denied claims within the stipulated timeframe for each insurer

1.4.1 Guidelines to Improve Reimbursement

The organizational flow of information and accurate documentation and coding is crucial to processing third party claims.

To prevent claims from being rejected, the business process needs to review such areas as:

• inaccurate or lack of coding • incomplete claims • lack of supporting documentation • poor communication with the payer • not billing for services rendered

The overall reimbursement process is a series of sequential or interconnected but independent steps, starting with the patient’s visit to the facility. The steps involve:

• Assuring that all patients are registered for scheduled or walk-in appointments.

• Obtaining accurate and detailed insurance and demographic information during the registration process.


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• Accurately documenting the service, examination, and patient care by all providers (physician, mid-level practitioner, nurse, or others).

• Capturing and coding correctly all reportable and billable services.

• Billing all billable services that are not only reimbursable by the insurance company but also supported by documentation.

• Reconciling claim payments to assure correct payment.

• Appealing all rejections that should have been paid.

1.5 Capturing all Reportable and Billable Services It is important to assure that providers document all services and procedures in the clinical record and enter the applicable codes into the EHR or the RPMS PCC application. To accomplish this, the Business Office should:

• Devote time each week to learn more about billing and coding for services, to acquire enough knowledge to identify all reportable services, procedures, and even supplies.

• Keep current with all the updates from the insurers, for example, MedLearn Matters, CMS newsletter, Medicaid Newsletters, and others.

• Conduct peer review and track the reasons of all rejections or denials. This would include registration, coding, data entry, provider, billing, and accounts receivable. This would determine if errors are identifiable and can be reduced or corrected in the future.

• Make sure the providers document all the services and procedures. This information should be entered into the EHR by the provider or thoroughly documented on the superbill, PCC or PCC+. Documentation should include the E&M level of service, diagnosis, date of services, procedure, patient name, location, and any other pertinent demographic information.

• Educate providers with current billing changes.

• Understand billing requirements for bundling and unbundling of services.

• Examine coding options such as whether to use CPT or HCPCS level II or Level III codes for procedures and services. Carriers or insurer payer policies may dictate what procedure codes or combination of codes to submit.

• For a date of service when multiple surgical procedures are involved, sequence each procedure. The first procedure should be the primary reason for the surgery, and other surgical procedures become secondary. After sequencing, then add the appropriate modifier.



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• Link all diagnosis codes or symptoms to the relevant procedures or services. Linking addresses the medical necessity question, supports the services provided, and relates the reason for each service.

• Understand or analyze reports associated with the billing process such as EOB, ERA, RPMS reports, CMS top-ten error reports, and RTP reports.

• Report all software issues promptly to the supervisor.

1.6 About the CMS-1450 / UB-92 Form The CMS-1450 form, more commonly known as UB-92, serves the needs of many payers. Not all of the data elements need to be completed for every payer.

Data elements in the CMS uniform electronic billing specifications are consistent with the CMS-1450 form data set to the extent that one processing system can handle both. Definitions are also identical. However, due to the space constraints on the form, the electronic record contains more characters for some items than the corresponding items on the form

The revenue coding system for both Form CMS-1450 and the electronic specifications are identical.

Effective June 5, 2000, CMS extended the claim size to 450 lines. For the hard copy UB-92 or Form CMS-1450, CMS will accept claims of up to 9 pages. In addition, effective October 16, 2003, all state fields will be discontinued and reclassified as reserved for national assignment.

For descriptions of the locator fields, see Part 4, Appendix B,” CMS 1450/UB-92 Form.”

1.7 Modifiers and their Role in Billing Modifiers are used to modify payment of a procedure code, assist in determining appropriate coverage, or otherwise identify the detail on the claim. The use of modifiers ensures the appropriate reimbursement by the insurer.

Modifiers are entered in box 24 D on the HCFA-1500 (CMS-1500) claim form or UB 92 (CMS 1450).

For the most current list of modifiers, refer to the current CPT or HCPCS Code book.



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Note: The modifiers are updated on a yearly basis, and the tables are supplied to each RPMS site by the IHS Office of Information Technology (OIT). It is the responsibility of each Area IT to install the updated tables.

1.8 Place of Service Place of Service is a two-digit indicator assigned by CMS to the various places where a medical service or procedure can be provided.

03 – School 04 – Homeless Shelter 05 – Indian Health Service Free-standing Facility 06 – Indian Health Service provider-based Facility 07 – Tribal 638 Free-standing Facility 08 – Tribal 638 Provider-based Facility 11 – Office 12 – Home 13 – Assisted Living Facility 14 – Group Home 15 – Mobile Unit 20 – Urgent Care Facility 21 – Inpatient Hospital 22 – Outpatient Hospital 23 – Emergency Room – Hospital 24 – Ambulatory Surgical Center 25 – Birthing Center 26 – Military Treatment 31 – Skilled Nursing Facility 32 – Nursing Facility 33 – Custodial Care Facility 34 – Hospice 41 – Ambulance – Land 42 – Ambulance – Air or Water 49 – Independent Clinic 50 – Federally Qualified Health Facility 51 – Inpatient Psychiatric Facility 52 – Psychiatric Facility Partial Hospitalization 53 – Community Mental Health Center 54 – Intermediate Care Facility/Mentally Retarded 55 – Residential Substance Abuse Treatment Facility 56 – Psychiatric Residential Treatment Center 57 – Non-residential Substance Abuse Treatment Facility 60 – Mass Immunization Center 61 – Comprehensive Inpatient Rehabilitation Facility 62 – Comprehensive Outpatient Rehabilitation Facility 65 – End-Stage Renal Disease Treatment Facility 71 – State or Local Public Health Clinic 72 – Rural Health Clinic



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81 – Independent Laboratory 99 – Other Unlisted Facility

The place where a service is rendered can determine the reimbursement and coding conventions applied to the service codes.

If services are rendered in two locations in a given day, such as the clinic and the emergency room, the reimbursement is reduced for the services provided or split into technical and professional components. For the latter, usually two separate bills are provided by the facility.

1.9 “Incident To” Services “Incident To” services are defined as services commonly furnished in a physician’s office, which are

• incident to the professional services of a physician or a non-physician provider’s employee

• limited to situations in which there is direct physician/non-physician personal supervision.

This applies to auxiliary personnel employed by the physician/non-physician, which includes but is not limited to, nurses, technicians, therapists, non-physician practitioners, and others.

“Incident To” rules apply to all insurers.

To have the same service covered as “incident to” the services of a physician, it must be performed under the direct personal supervision of the physician as an integral part of the physician’s personal in-clinic service. This does not mean that for each visit the patient must also see the physician. It does mean there must have been a direct, personal, professional service furnished by the physician/non-physician to initiate the course of treatment. There must also be subsequent services by the physician/non-physician of a frequency that reflects his/her continuing active participation in, and management of, the course of treatment.

There are four things that are required to qualify for “incident to”:

1) The physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist must be an employee of the physician or of the entity which also employs the physician.

2) The physician has to have initially seen the patient.



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3) The physician has to have direct supervision; the physician has to be within the facility, but not necessarily in the same room and must be available to render assistance and direction if necessary.

4) The physician must have an active participation in the on-going care of the patient.

1.10 Billing Form Review The forms you use to bill depend on payer requirements. Prior to submission, review your paper claim forms (e.g., CMS 1450, CMS 1500, ADA, NCPDP, etc.) to ensure that the form locators are completed, based on specific payer requirements.

For information on the CMS 1500 form, go to this website:

http://www.nucc.org

For information on the CMS 1450 (UB-92) form, go to this website:

http://www.nubc.org

1.11 Utilization Review Authorization numbers from insurers need to be obtained and are required on the bills when they are generated for billing. Utilization review needs to assure that all billable services have been captured to bill for acute care days and ambulatory care services. The purpose of the process is to assure each facility meets hospitalization and length of stay criteria.

Utilization staff, in this process, needs to work closely with Admitting, Billing, providers, and Coders.

1.11.1 Splitting Claims Process

Hospital billing is split with professional services on the HCFA-1500 form, and the hospital charges, (e.g., lab, pharmacy, radiology, anesthesia, emergency room provider, nurse) and supplies on the UB-92.

Splitting claims is payer specific. For example:

• Split lab for technical and professional

• DME and medical

http://www.nucc.org/

http://www.nubc.org/



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For more information, see the RPMS IHS Third Party Billing (ABM) User’s Manual, which is available at this website:

http://www.ihs.gov/cio/rpms/index.cfm?module=home&option=documents

1.12 Roll-Over/Cross-Over for Secondary and Tertiary Billing Medicare currently has contractual arrangements with supplemental insurers to automatically crossover claims payment information for their policyholders. An eligibility file furnished by the supplemental insurer is used to drive the process rather than information found on the claim. These eligibility files are matched, based on the Health Insurance Claim (HIC) number, against Medicare’s internal eligibility file. If a match occurs, the beneficiary’s record is flagged indicating to which company we will cross claim payment information.

The name of the crossover insurance company will appear on both the beneficiary Explanation of Medicare Benefits and the provider’s Remittance Notice.

Users need to ensure the crossover payment was forwarded to the correct secondary payer by reviewing the remittance advice.

Each supplemental insurer is given the opportunity to specify criteria related to the claims the insurer wants Medicare to crossover. Examples of claims most often excluded from the crossover process:

• Totally denied claims • Claims denied as a duplicate or for missing information • Adjustment claims • Claims reimbursed at 100% • Claims for dates of service outside of the supplemental policy’s effective

and end dates.

As part of the CMS process, it is required for each service furnished by the provider that the provider reports each service as a separate line item on the claim form.

As claims are processed, the beneficiary’s eligibility record is checked by the system to determine whether the claim should be considered for crossover. If the beneficiary’s eligibility record is flagged for crossover, the claim is then checked by the system to determine whether the claim meets the crossover criteria required by the insurer. If the claim is not excluded, at this point it is

http://www.ihs.gov/cio/rpms/index.cfm?module=home&option=documents



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marked for crossover to the appropriate company. An electronic claims payment record is then created and forwarded to the requesting insurer. This eliminates the need for the billing office to file claims for the patient’s supplemental benefits.

Upon receipt of the transmittal crossover file, the system will initially edit the file and return a flat file to the contractor indicating the number of claims received and accepted. The entire file that contains any transmission error will be returned with a request for retransmission.

In regard to crossovers, Medicare cannot add, change, or delete any eligibility information furnished by an insurer. In addition, the crossover process is totally automatic, and does not require or permit any clerical intervention.

The crossover insurance companies send an eligibility tape at least once a month to the primary insurer. The crossover company’s eligibility tape reads the internal eligibility record and looks for the HIC matches.

The Medicaid update process is the same as the automatic crossover process except the eligibility tape is sent to the primary insurer by each state


Part 4. Billing Version 1.0 2. Hard Copy vs. Electronic Claims Processing July 2006

Part 4 - 2-1

2. Hard Copy Versus Electronic Claims Processing

Contents 2.1 Hard-Copy Claims Processing ................................................................... 2-2

2.1.1 Procedure for hard copy claims processing: ....................................... 2-2 2.2 Monitoring Approved Claims .................................................................... 2-3 2.3 Electronic HIPAA compliant claims processing........................................ 2-3 2.4 Electronic Data Interchange Alternatives................................................... 2-5 2.5 Tips for Electronic Submission of Claims ................................................. 2-6



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2.1 Hard-Copy Claims Processing Hard-copy claims are printed on a paper form, such as UB92 (now called the CMS 1450), ADA, HCFA 1500 (now called CMS 1500), NCPDP, or other paper forms.

If you are unable to submit claims electronically, a paper form must be submitted. Prior to mailing the claim to the insurer,

• All corrections should be made.

• All forms should be reviewed by the biller for accuracy, based on payer requirements.

Examples of using a hard-copy claims process include payer requirements and resubmission.

Billing on a paper claim will delay your reimbursement. To be HIPAA compliant and to expedite payment, every effort should be made to submit claims electronically.

It is highly recommended that any high dollar claim (over $5000) be sent certified, either initially or through resubmission when the insurer has not received the original claim.

Always attach an EOB with the secondary or tertiary claim.

For private insurance, if there are two accounts on the same day, for example, a pre-operative visit and a surgery or admission, the two accounts should be merged together for billing.

Note: Insurers keep a record of errors on coding or documentation and may use this information as part of any future audits.

2.1.1 Procedure for hard copy claims processing:

All forms should be printed and mailed in a timely manner – within 72 hours. The biller completes the claim review, and then

– Sorts claims by payer – Addresses envelops with payer information – Delivers them to the mailroom



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2.2 Monitoring Approved Claims Sites should frequently monitor the Bills Awaiting Export report. This report is an RPMS Third Party Billing function and allows the user to see the number of bills approved and ready to be printed (exported).

To run this report, access the RPMS Third Party Billing system. From the main menu:

1. Type PRTP to access the Print Bills menu.

2. Type AWPR to select the Bills Awaiting Export report.

The system displays three options.

3. Choose Summarize Report by Insurer (2).

You will be listed as the default approving official.

4. At the prompt, type 4, to remove yourself as the approving official (this option allows you to view all approving officials).

5. Select your device.

The report will display a bill summary by insurer with an average number of days from approval date to present, plus a total billed amount

This report may also be provided to Billing staff as a reminder to print or export existing claims.

2.3 Electronic HIPAA compliant claims processing Electronic Data Interchange (EDI) is the process of transacting business electronically. It includes submitting claims electronically, or “paperless” claims processing, as well as electronic remittance, electronic funds transfer, and electronic inquiry for claim status and patient eligibility.

Health care service information is a detailed, itemized record of health care services performed that are provided to a health plan for reimbursement. The ASC X12N 837 electronic claim form format has been adopted by Health and Human Services and Indian Health Services and is used by professionals (providers), institutions (facilities), and dental.



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Some insurers may require an institutional guide versus a professional guide. It is important that you communicate with your health plans or payers to determine which of these guides will be used and what changes to the current claims submission process to expect.

In addition, the ASC-X12N 835 Health Care Claim Payment guide is used for the explanation of claim processing and/or payment sent by the health plan to a provider or facility.

HIPAA does not require providers to conduct any standard transactions electronically. You may process some transactions on paper and others may be submitted electronically. However, those HIPAA standard transactions you choose to conduct electronically must comply with the HIPAA format and content requirements

The transmission of claim files is done in packages which contain a specific amount of data. The size of the packets varies, based on the protocol selected.

Following the transmission of claims files, the system performs edits on the files and provides a report. Edits include:

• File level (structural, security and file requirements are validated). These edits normally provide a response to the user right away. Some payers use a 997 acknowledgement, 824 acknowledgement, or TA1 acknowledgement. Generally, these acknowledgements indicate missing or incorrect data or incorrect format. The user will have to make necessary corrections, re-create the batch, and re-submit.

• Batch level (structural, security and batch requirements are validated). These edits are provided to the user. Unlike the file level edits, not all claims records are rejected. The user is encouraged to make the necessary corrections once the bill is cancelled and re-approve.

• Claim level (claim field requirements are validated). During this level of edit, the payer is processing the claim, utilizing their system edits. Rejections are reported on the remittance advice or 835’s. The claim usually has to be researched and re-submitted for payment. After each system cycle, accepted facility forms pay, suspend, or deny. Claims suspended due to errors related to Federal or State guidelines, require a manual review.



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In preparation for submitting claims electronically, the following items need to be completed:

• Notify appropriate IT contacts. • Identify payer that can receive an electronic form. • Complete business associate agreement and/or trading partner agreement. • Complete EDI application. • Obtain companion document. • Contact insurer and set up test file. • Set up billing system to correctly populate electronic batch files. • Run test file and correct transmission errors. • Change, if necessary, testing status to production status.

The benefits of submitting claims electronically are:

• The claims will be processed faster, improving cash flow. • Mailing and administrative costs are significantly reduced. • The front-end editing system saves staff time and effort in that fewer

claims are returned. • The facility can also use Electronic Remittance Notice (ERN) and

Electronic Funds Transfer (EFT). • Online query allows access to claims status information and patient

eligibility in real time. • Records and tracks timely filing – supporting documentation and

submission dates to insurer. • Becomes HIPAA compliant.

2.4 Electronic Data Interchange Alternatives • A software vendor can be selected to enhance the software system

currently in place.

• Claims can be transmitted directly to the payer or use a separate clearinghouse.

• A billing agent can be used.

Each facility will need to use the requirements and processes established by the various payer alternatives.



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2.5 Tips for Electronic Submission of Claims • Enrollment forms will need to be completed and agreements must be

signed.

• FTP, web site connectivity, or a dedicated phone line is recommended to prevent interrupted transmissions.

• Make regular backups for all patient and claim data (Disaster-Recovery Procedures).

• Consider using Un-interruptible Power Supply (UPS) with a surge suppressor to protect your equipment if the facility is prone to power outages.

• Always read the response file from EDI to know what and when was received and whether transmission was accepted.

• Promptly make claim corrections and re-submit.

• When you dial into the insurance company to send claims or retrieve responses and remittances, you are connecting with their communication platform.

• Test a wide variety of claims – inpatient, outpatient, surgery, and such, based on batch limitations set by insurer.

• Reference EDI procedures under HIPAA privacy and security regulations.

• System issues that may cause payment delays should be reported to the supervisor.

• When transmitting claims, the biller needs to print a receipt from the insurer to determine that the transmission was successful.


Part 4. Billing Version 1.0 3. Billing Medicare July 2006

Part 4 - 3-1

3. Billing Medicare

Contents 3.1 About Medicare Billing.............................................................................. 3-3

3.1.1 RPMS Third Party Billing and Medicare Claims Creation................. 3-4 3.2 Common Working File (CWF) .................................................................. 3-5 3.3 Medicare Claim Change Condition Codes................................................. 3-5 3.4 Provider/Supplier Types............................................................................. 3-6

3.4.1 Medicare Part A Providers .................................................................. 3-6 3.4.2 Medicare Part B Suppliers/Practitioners ............................................. 3-7

3.5 Procedure for Billing Medicare.................................................................. 3-8 3.5.1 Outpatient Medicare Part A ................................................................ 3-8 3.5.2 Outpatient Medicare Part B................................................................. 3-9 3.5.3 Inpatient Medicare Part A ................................................................... 3-9 3.5.4 In/Outpatient Medicare Part A............................................................ 3-9

3.6 Inpatient Medicare Part B .......................................................................... 3-9 3.6.1 Billing Medicare Part B ...................................................................... 3-9 3.6.2 Inpatient Medicare Part B only ......................................................... 3-12

3.7 Ambulatory Surgery Center Billing – Medicare ...................................... 3-12 3.7.1 Editing a Claim for Facility Billing .................................................. 3-12 3.7.2 Billing for Professional Component ................................................. 3-12 3.7.3 Billing for Anesthesia Services......................................................... 3-16 3.7.4 Medicare Ambulatory Surgery Billing Procedure ............................ 3-19

3.8 Medicare Secondary Payer (MSP) ........................................................... 3-20 3.8.1 Working Aged................................................................................... 3-21 3.8.2 Disability ........................................................................................... 3-21 3.8.3 End Stage Renal Disease (ESRD)..................................................... 3-22 3.8.4 Liability/Automobile Medical or No-Fault/Personal Injury

Protection Insurance.......................................................................... 3-22 3.8.5 Veterans ............................................................................................ 3-22 3.8.6 Worker’s Compensation ................................................................... 3-23 3.8.7 Black Lung........................................................................................ 3-23 3.8.8 Provider Responsibilities under MSP ............................................... 3-24 3.8.9 Submitting Medicare Secondary Payer (MSP) Claims..................... 3-24

3.9 Medicare Secondary Payer (MSP) Claims Investigation......................... 3-25 3.10 Medicare Timely Filing............................................................................ 3-26

3.10.1 Part A Timely Filing ......................................................................... 3-26 3.10.2 Part B Timely Filing ......................................................................... 3-27



Part 4 - 3-2

3.11 Claims Resubmission Guidelines............................................................. 3-29 3.11.1 Steps for Approving a Secondary/Tertiary Claim in RPMS............. 3-29 3.11.2 Steps for Exporting a Claim:............................................................. 3-30 3.11.3 Steps for Reprinting a Claim for Resubmission................................ 3-30

3.12 Reimbursement for Clinical Nurse Specialist or Nurse Practitioner........ 3-31 3.13 Reimbursement for Physician Assistant................................................... 3-31



Part 4 - 3-3

3.1 About Medicare Billing The Centers for Medicare/Medicaid (CMS) is the regulatory agency for Medicare, Medicaid, and Managed Care Organizations. It is mandated that each facility submit electronically, Medicare and Medicaid claims in the HIPAA 837 format.

The IHS fiscal intermediary and carrier for Medicare is Trailblazer Health Enterprises, LLC. Tribes, Federally Qualified Health Center (FQHC), rural health centers, and other non-IHS entities may have other fiscal intermediaries or carriers. Most clinics have arranged with the intermediary/carrier to have claims transmitted electronically.

Reimbursement for covered inpatient ancillary services and outpatient services is based on all-inclusive rates negotiated annually by IHS and by the Center for Medicare/Medicaid (CMS). Services included in the IHS all-inclusive rates are:

• devices (other than dental) to replace all or part of an internal body organ, such as colostomy equipment and supplies

• certain ambulance services • laboratory; radiology; emergency room and outpatient facility services • other diagnostic services • physical therapy • speech pathology • occupational therapy • dialysis in the facility or home • other medical services such as injection of vaccines

For Ambulatory Surgical Centers (ASC), reimbursement is based on rates published in the Federal Register. A deductible and coinsurance applies to the outpatient services.

For the Medicare flat all inclusive rate, it is recommended that the correct E&M code be billed for Part A and Part B, even though some of the Federally Qualified facilities will have their RPMS system default to an agreed upon code by Medicare for billing purposes.

As with all insurers, the correct CPT codes should be coded at the facility, but the billing process should be done according to payer guidelines. All fees should be updated – CPT, HCPCS, Dental, ASC.



Part 4 - 3-4

Along with these updates your room rates need to be updated. Room rates can be updated by using the CHS claims your facility receives from the private facilities to which you send your patients. Complete a comparison and document as indicated in the following example.

Revenue Code Description Facility #1 Facility #2 Previous FY Proposed

RPMS transfer claims data from PCC into the Third Party Billing package. Some facilities are using a Commercial Off-the-Shelf (COTS) product for billing the insurer. If an IHS site is using other software, the data must interface with the RPMS Third Party Billing and Accounts Receivable applications.

3.1.1 RPMS Third Party Billing and Medicare Claims Creation

An option located on the RPMS Third Party Billing Site parameters menu allows a site to customize the claims creation process for Medicare. This option can also be accessed from the Location Edit module.

The prompt is labeled Medicare Part B? The user can choose one of the following:

• YES – Allows the system to generate Outpatient claims. These claims are generated with a Visit Type of 131 and are usually set up in the Insurer File as All-Inclusive. These are used mainly for FQHC sites that do not have the Part B authority, since the all-inclusive rate includes Part B.

• NO – Allows the system to generate two claims, an outpatient claim and a professional component claim: – Visit Type 131 – Outpatient – Visit Type 999 – Professional Component

131 – Outpatient Facilities that are hospital-based will generally set their prompts up for this.

• ONLY – Allows the system to generate professional claims. These claims are generated with a visit type of 000 – Professional Component. These claims are generated with the intention of billing a fee-for-service (itemized) claim for Medicare services. This type of claim is used primarily for Freestanding Health Centers.



Part 4 - 3-5

3.2 Common Working File (CWF) The Common Working File (CWF) reorganizes certain claims processing functions to simplify and improve overall Medicare claims processing, by creating localized databases containing total beneficiary histories. CWF was developed by the CMS Bureau of Program Operations and was designed to

• Create a beneficiary data set that contains all entitlement and utilization information in one location.

• Increase program savings by detecting additional duplicate and inappropriate payments.

• Enhance utilization review opportunities because all beneficiary history is in one file.

• Avoid costly adjustment processing and overpayment recovery activities with pre-payment edits, and perform pre-payment A/B data exchange edits within the claims process.

3.3 Medicare Claim Change Condition Codes

Note: These codes are specific to Medicare.

Claim Change Condition Codes

Valid Code Code Description D0 Change to Service Dates D1 Changes to Charges D2 Changes to Revenue Codes/HCPCS D3 Second or subsequent interim PPS bill D4 Change in Grouper input D5* Cancel only to correct a HICN or provider identification number D6* Cancel only to repay a duplicate payment or overpayment (includes

cancellation of an outpatient bill containing services required to be included on the inpatient bill)

D7 Change to make Medicare the Secondary Payer D8 Change to make Medicare the Primary Payer D9 Any other change E0 Change in Patient Status *D5 and D6 are for XX8 Type of Bill only.



Part 4 - 3-6

3.4 Provider/Supplier Types The following list of provider/supplier types is provided as an example for an Indian Health Services facility.

• Ambulance Service Supplier • Ambulatory Surgical Center • Audiologist • Certified Clinical Nurse Specialist • Certified Nurse Midwife • Certified Registered Nurse Anesthetist • Clinical/Group Practice • Clinical Psychologist • Community Mental health Center • Comprehensive Outpatient Rehabilitation Facility • Critical Access Hospital • Durable medical Equipment, Prosthetics, Orthotics, or Supplies • End Stage Renal Disease Facility • Federally Qualified Health Center - for guidelines, go to this website:

http://www.cms.hhs.gov/center/fqhc.asp

• Histocompatibility Lab • Home Health Agency • Hospice • Hospital • Hospital Department Billing for Part B Practitioner Services • Independent Clinical Laboratory • Independent Diagnostic Testing Facility • Indian Health Services Facility (See below instructions)

For information related to these and other Medicare provider/supplier types, go to this website:

http://www.trailblazerhealth.com/

Descriptions are available for the provider/supplier types, related to the application process for Medicare.

http://www.cms.hhs.gov/center/fqhc.asp




Part 4 - 3-7

3.4.1 Medicare Part A Providers

Contact the local CMS Regional Office, which will provide guidance and any initial forms required to begin the enrollment process.

3.4.2 Medicare Part B Suppliers/Practitioners

Contact: TrailBlazer Health Enterprises, LLC Provider Services P. O. Box 650544 Dallas, TX 75265-0544 Phone: (866) 528-1602

TrailBlazer will provide guidance and any initial forms required to begin the enrollment process.

• Licensed Clinical Social Worker • Mammography Screening Center • Managed Care Organization • Mass Immunization Roster Biller • Medical Faculty Practice Plan • Multi-Specialty facility or Group Practice • Nurse Practitioner • Occupational Therapist in Private Practice • Occupational Therapy (Group) • Organ procurement Organization • Other Medical Care Group • Outpatient Physical Therapy-Occupational Therapy/Speech Pathology

Services • Pharmacies • Physical therapist in Private practice • Physical Therapy (group) • Physiotherapy • Physician Assistant • Physician • Portable X-ray Facility • Psychiatric Unit (of hospital) • Public Health/Welfare Agency • Registered Dietitian/Nutrition Professional • Rehabilitation Agency • Rehabilitation Unit (of hospital) • Religious Non-medial

http://www.cms.hhs.gov/providers/enrollment/contacts/



Part 4 - 3-8

• Rural Health clinic • Rural Primary Care Hospital • Skilled Nursing Facility • Voluntary Health/Charitable Agency

3.5 Procedure for Billing Medicare TrailBlazers offers the online GPNet software for Medicare billing and follow-up. Other Fiscal Intermediaries (FI) may offer other types of software programs. However, it is strongly recommended that each facility that bills to TrailBlazers, use the GPNet software to do Medicare billing and follow-up.

A GPNet user manual is available at this website:

http://www.trailblazerhealth.com/parta/downloads/2003GPNet.pdf

There are multiple bill types. The three-digit alphanumeric code gives three specific pieces of information.

• The first digit identifies the type of facility.

• The second classifies the type of care.

• The third indicates the sequence of the bill in this particular episode of care. This is also known as the “frequency” code.

3.5.1 Outpatient Medicare Part A

Bill Types First digit Type of Facility 1 – Hospital

8 – Hospital ASC Surgery Second Digit Bill Classification 1 – Inpatient Part A

2 – Inpatient Part B Only 3 – Outpatient

Third Digit Frequency 0 – Nonpayment/Zero Claim 1 – Admit through Discharge Claim 2 – Interim – First Claim 3 – Interim – Continuing Claim 4 – Interim – Last5 – Late Charge Only Claim 6 – Adjustment of Prior Claim 7 – Replacement of Prior Claim 8 – Void /Cancel of a Prior Claim

http://www.trailblazerhealth.com/parta/downloads/2003GPNet.pdf



Part 4 - 3-9

3.5.2 Outpatient Medicare Part B

Bill Types Outpatient 13X, 14X – Hospital

23X – Skilled Nursing Facility 34X – Home Health (not PPS) 71X – Rural Health Clinic (RHC) 72X – Renal Dialysis Facility (RDF) 73X – Federally Qualified Health Center (FQHC) 74X – Outpatient Rehabilitation Facility (ORF) 75X – Comprehensive Outpatient Rehabilitation Facility (CORF) 76X – Community Mental Health Center (CMHC) 83X – Hospital Out surgery 85X – Critical Access Hospital (CAH)

Part B Only

Outpatient 32X, 33X – Home Health (PPS) Part A and B

3.5.3 Inpatient Medicare Part A

Bill Types Inpatient Part A

11X – Hospital 18X – Swing Bed 21X – Skilled Nursing Facility 41X – Religious non-medical Healthcare situation

Part A Only

3.5.4 In/Outpatient Medicare Part A

Bill Types In/outpatient Part A

81X, 82X - Hospice Part A Only

3.6 Inpatient Medicare Part B

3.6.1 Billing Medicare Part B

A. Assignment

Under the participating physician program, the physician agrees to accept payment from Medicare (80% of the allowable) plus from the patient, the remaining 20% of reasonable charges after the $100 deductible has been met.

The payment goes directly to the physician. Effective September 1, 1992, patients are not allowed to submit claims to Medicare (with five exceptions).



Part 4 - 3-10

Physicians, practitioners, and suppliers who fail to submit claims are subject to civil money penalties of up to $2,500 for each claim. Situations when a patient may file a claim are:

• Services covered by Medicare for which the patient has other insurance that should pay first;

• Services not covered by Medicare for which the patient wants a formal Part B coverage determination;

• Services provided by a physician who refuses to submit the claim;

• Services provided outside the United States; and

• When durable medical equipment is purchased from a private source.

Reasonable charges is the amount that Medicare lists on the Remittance Advice (RA) – formerly known as Explanation of Benefits (EOB) – which is the allowed (approved) charge for the procedure. This charge may be lower than the fee the physician lists on the claim.

When a physician accepts assignment, he or she may bill the non-beneficiary only 20% of what Medicare considers a reasonable (allowed) charge.

Interest fees cannot be assessed to Medicare patients. Do not collect the Medicare co-payment up front. However, it is permissible to collect the deductible up front for non-beneficiaries only.

B. Nonparticipating (non-par) Physician

A physician who does not participate has an option regarding assignment. The physician may not accept assignment for all services or may have the option of accepting assignment for some services and collecting from the patient for other services performed at the same time and place.

An exception to this policy is mandatory assignment for clinical laboratory tests and services by physician assistants.

Usually, a nonparticipating physician who is not accepting assignment collects the total fee from the patient but may bill no more than the Medicare limiting charge. Limiting charges is a percentage limit on fees, specified by legislation, that non-par physicians may bill Medicare beneficiaries above the fee schedule amount.

Medicare sends the payment check to the patient.



Part 4 - 3-11

C. Patient’s Signature Authorization

Signatures are required on all HCFA-1500 claims forms, except Medicare/Medicaid cases.

Sometimes it is not possible to obtain the signature of a Medicare patient because of confinement in a nursing facility or hospital or at home. In such cases, physicians can obtain a lifetime signature authorization from the patient. The lifetime beneficiary claim authorization and information release form is an example that can be used for assigned and non-assigned Medicare claims and kept in the patient’s medical records.

The HCFA-1500 form should be submitted with the notation in the patient’s signature block: “Patient’s payment authorization on file.” If the claim will be automatically crossed over and paid by a Medigap carrier, obtain a lifetime signature authorization for the Medigap carrier.

D. Time Limits

The time limit for sending in claims is the end of the year following the year in which services were used.

E. Required Form

The form that physicians use to submit their claims to Medicare is HCFA1500.

F. RA documents are received by the physician and the patient, with the Medicare check going to the Physician.

G. The following list shows the kinds of physicians’ services that Medicare Part B will help pay for.

• Medical and surgical services by a doctor of medicine (MD), doctor of osteopathy (DO or MD), or a doctor of dental medicine or dental surgery (DDS).

• Certain services by podiatrists (DPM)

• Limited services by chiropractors (DC), such as subluxation of the spine.



Part 4 - 3-12

3.6.2 Inpatient Medicare Part B only

Bill Types Inpatient Part B

12X – Hospital 22X – Skilled Nursing Facility

Part B Only

3.7 Ambulatory Surgery Center Billing – Medicare For the most up-to-date guidance for Ambulatory Surgery Center (ASC) services, got to this website:


3.7.1 Editing a Claim for Facility Billing

For instructions for editing a claim for facility billing, see the RPMS Third Party Billing User’s Manual, which is available at this website:

http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=documentschoice

3.7.2 Billing for Professional Component

The following screen output displays a sample walkthrough of billing for professional component.

Note: The information provided in this example is for demonstration purposes only.

Select Add/Edit Claim Menu Option:

Type ED and press Enter. EDITING A CLAIM (BILLING CATARACT EXTRACTION) Select CLAIM or PATIENT:

Enter the claim number (see the following claim example)

* is where the Billing Technician needs to review






Part 4 - 3-13

Claim Number: 12346 ............................... (CLAIM SUMMARY) .............................. _______ Pg-1 (Claim Identifiers) __________________ Pg-4 (Providers) ___________ Location..: GALLUP MED C | Attn: COX,JAMES Clinic....: DAY SURGERY | Oper: COX,JAMES Visit Type: PROFESSIONAL COMPONENT|__________ Pg-5A (Diagnosis) __________ Bill From: 11-29-2005 Thru: 11-29-2005 | 1) CATARACT LEFT EYE | ________ Pg-2 (Billing Entity) _________|________ Pg-8 (CPT Procedures) ________ MEDICARE ACTIVE | 1) CATARACT SURG W/IOL, 1 STAGE

Press Enter to go to the next page. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: 12346 ............................. (CLAIM IDENTIFIERS) ............................. [1] Clinic.............: DAY SURGERY * [2] Visit Type.........: PROFESSIONAL COMPONENT * [3] Bill Type..........: 999 [4] Billing From Date..: 10/19/2004 [5] Billing Thru Date..: 10/19/2004 [6] Super Bill #.......: [7] Mode of Export.....: 837 PROF (HCFA) [8] Visit Location.....: GALLUP MED C -------------------------------------------------------------------------------Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//

Press Enter to go to the next page. ~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: 12346 .................................. (INSURERS) ............................... To: MEDICARE PART A - TEXAS * Bill Type...: 999 12800 INDIAN SCHOOL RD, NE Proc. Code..: CPT4 ALBUQUERQUE, NM MEDIA-CARE Export Mode.: 837 PROF (HCFA) (888)763-9836 Flat Rate...: N/A ............................................................................... BILLING ENTITY STATUS POLICY HOLDER =============================================================== [1] MEDICARE ACTIVE Patient, Demo -------------------------------------------------------------------------------WARNING:072 - EMPLOYMENT STATUS CODE UNSPECIFIED WARNING:075 - EMPLOYER LOCATION UNSPECIFIED -------------------------------------------------------------------------------Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//

Press Enter to go to the next page.



Part 4 - 3-14

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 3 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: 12346 ................................. (QUESTIONS) ................................ * [1] Release of Information..: YES From: 04/04/2005 Thru: * [2] Assignment of Benefits..: YES From: 04/04/2005 Thru: [3] Accident Related........: NO [4] Employment Related......: NO [5] Emergency Room Required.: [6] Special Program.........: NO [7] Outside Lab Charges.....: [8] Date of First Symptom...: [9] Date of Similar Symptom.: [10] Date of 1st Consultation: [11] Referring Phys. (FL17) : [12] Case No. (External ID)..: [13] Medicaid Resubmission No: [14] PRO Approval Number.....: [15] HCFA-1500B Block 19.....: [16] Supervising Prov.(FL19): Date Last Seen: Enter RETURN to continue or '^' to exit:

Press Enter to go to the next page. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 4 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: 12346 ............................... (PROVIDER DATA) .............................. PROVIDER NUMBER DISCIPLINE ============================================================== (attending)PROVIDER, DR 8HZ343 OPHTHALMOLOGIST (rendering)PROVIDER, DR 8HZ343 OPHTHALMOLOGIST Desired ACTION (Add/Del/View/Next/Jump/Back/Quit): N// ~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 5A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: 12346 ................................. (DIAGNOSIS) ................................ BIL ICD9 SEQ CODE - Dx DESCRIPTION PROVIDER'S NARRATIVE =============================================================== 1 366.9 - UNSPECIFIED CATARACT CATARACT NOS Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//

Press Enter to go to the next page. ~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 8B ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: 12346 Mode of Export: 837 PROF (HCFA) ............................ (SURGICAL PROCEDURES) ............................ BIL SERV REVN CORR CPT SEQ DATE CODE DIAG CODE PROVIDER'S NARRATIVE UNITS CHARGE =============================================================== 1 CHARGE DATE: 10/19/2004 *** 1 66984 CATARACT SURG W/IOL, 1 STAGE 1 951.00 ========= $951.00 Desired ACTION (Add/Del/Edit/Seq/View/Next/Jump/Back/Quit/Mode): N//



Part 4 - 3-15

Keep pressing ENTER until you get to the LAST PAGE (8J)

Press ENTER, and the system prompts you back to PAGE 1. KEY ENTER (A) FOR APPROVAL ***** 837 PROF (HCFA) CHARGE SUMMARY ***** Corr Charge Date POS TOS Description Diag Charge Qty ------------------------------------------------------------------------------- 10-19-2004 22 2 66984 1 951.00 1 ---------- TOTAL CHARGE 951.00 Form Locator Override edits exist for POS/TOS ENTER SUMMARY =============================================================== Previous Bill Form Charges Payments Write-offs Non-cvd Amount ---------- ---------- ---------- ---------- ---------- ---------- 837 PROF (HCFA) 951.00 0.00 0.00 0.00 951.00 ========== ========== ========== ========== ========== 951.00 0.00 0.00 0.00 951.00 Do You Wish to APPROVE this Claim for Billing?

Enter (Y) YES



Part 4 - 3-16

3.7.3 Billing for Anesthesia Services

The following screen output displays a sample walkthrough of billing for anesthesia services.

Note: The information provided in this example is for demonstration purposes only.

Patient: 99999 Claim Number ............................... (CLAIM SUMMARY) .............................. _______ Pg-1 (Claim Identifiers) __________________ Pg-4 (Providers) ___________ Location..: GALLUP MED C | Attn: COX,JAMES E Clinic....: DAY SURGERY | Visit Type: PROFESSIONAL COMPONENT |__________ Pg-5A (Diagnosis) __________ Bill From: 10-19-2004 Thru: 10-19-2004 | 1) CATARACT NOS | ________ Pg-2 (Billing Entity) _________|________ Pg-8 (CPT Procedures) ________ MEDICARE ACTIVE | 1) CATARACT SURG W/IOL, 1 STAGE | ___________ Pg-3 (Questions) ___________| Release Info: YES Assign Benef: YES | | | ________________________________________|_______________________________ Desired ACTION (View/Appr/Next/Jump/Quit): N//

Press Enter to go to next page ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: ............................. (CLAIM IDENTIFIERS) ............................. [1] Clinic.............: DAY SURGERY * [2] Visit Type...... ..: PROFESSIONAL COMPONENT * [3] Bill Type........ : 999 [4] Billing From Date..: 10/19/2004 [5] Billing Thru Date..: 10/19/2004 [6] Super Bill #.......: * [7] Mode of Export... .: 837 PROF (HCFA) [8] Visit Location.....: GALLUP MED C ------------------------------------------------------------------------------ Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//

Press Enter to go to next page



Part 4 - 3-17

~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 5A Patient: 99999 Claim Number: ................................. (DIAGNOSIS) ................................ BIL ICD9 SEQ CODE - Dx DESCRIPTION PROVIDER'S NARRATIVE =============================================================== 1 366.9 - UNSPECIFIED CATARACT CATARACT NOS Desired ACTION (Add/Del/Edit/Seq/View/Next/Jump/Back/Quit): N//

Press Enter to go to next page. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 8G ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: Mode of Export: 837 PROF (HCFA) ............................ (ANESTHESIA SERVICES) ........................... REVN BASE TIME TOTAL CODE CPT - ANESTHESIA SERVICES CHARGE CHARGE CHARGE =============================================================== Desired ACTION (Add/Del/Edit/View/Next/Jump/Back/Quit/Mode): N// (A)

Type A (ADD) ============ ADD MODE - ANESTHESIA SERVICES =============== Select Anesthesia (CPT Code): 00142 ANESTH, LENS SURGERY ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY ...OK? Yes// (Yes) Anesthesia PROVIDER: MELO,FRANCISCO// FJM ANESTHESIOLOGIST Anesthesia BASE CHARGE: 183.7// Anesthesia PLACE OF SERVICE: 22// OUTPATIENT HOSPITAL * Anesthesia UNITS: 1// 60 * Anesthesia MODIFIER: AA Attempting FILEMAN lookup... ...OK? Yes// (Yes)

Press Enter for Yes. * Anesthesia START DATE/TIME: 101904@0900 (OCT 19, 2004@09:00) * Anesthesia STOP DATE/TIME: 101904@1000 (OCT 19, 2004@10:00) Anesthesia OBSTETRICAL?: * Anesthesia TIME CHARGE: 167// 60



Part 4 - 3-18

Enter how the anesthesia should look after all required entry. ~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 8G ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient: 99999 Claim Number: Mode of Export: 837 PROF (HCFA) ............................ (ANESTHESIA SERVICES) ........................... REVN BASE TIME TOTAL CODE CPT - ANESTHESIA SERVICES CHARGE CHARGE CHARGE =========================================================================== [1] 00142-AA ANESTHESIA FOR PROCEDURES ON EYE; 183.70 60.00 243.70 LENS SURGERY Start Date/Time: 19-OCT-2004 9:00 AM Stop Date/Time: 19-OCT-2004 10:00 AM ========== $243.70

Keep pressing ENTER until the system prompts you to return to the Main Menu.

Type A to approve the claim. ***** 837 PROF (HCFA) CHARGE SUMMARY ***** Corr Charge Date POS TOS Description Diag Charge Qty ------------------------------------------------------------------------------ * 10-19-2004 22 7 00142-AA 1 243.70 60 ---------- TOTAL CHARGE 243.70 Form Locator Override edits exist for POS/TOS

Press Enter to go to next page. Previous Bill Form Charges Payments Write-offs Non-cvd Amount ---------- ---------- ---------- ---------- ---------- ---------- 837 PROF (HCFA) 243.70 0.00 0.00 0.00 243.70 ========== ========== ========== ========== ========== 243.70 0.00 0.00 0.00 243.70 Do You Wish to APPROVE this Claim for Billing? (Y) YES

Type YES to approve the claim.



Part 4 - 3-19

3.7.4 Medicare Ambulatory Surgery Billing Procedure

The regulatory agency for Medicare program is the Centers for Medicare and Medicaid (CMS). Under the prospective payment system (PPS), Attachment C – for covered ambulatory surgery services, the reimbursable rate is based on the Ambulatory Surgery center (ASC) Group Rates published in the Federal Register. Medicare Part B deductibles and coinsurances apply to eligible covered services.

The coder completes the coding for all ambulatory surgery visits. The coding will be entered in the PCC menu.

The claims generator will convert and create a bill in the Third Party Billing appliation overnight.

The biller will print out a Flag-As Billable Brief Summary listing and will use this listing as a guide to what visits/claims to bill. The bill type for Ambulatory surgery is 831.

All edits need to be accomplished to complete a “clean” claim. Once all the edits have been made, the biller will determine the approval of the bill and will submit the bill on the appropriate claim form, which will be transmitted electronically.

• Review the Inpatient or Ambulatory Surgery abstracts from UR.

• Verify completeness and accuracy.

• Enter the claims data into the system for processing.

• Review data for completeness and accuracy.

Type of Bills (Locator 4 on the UB92) – Inpatient Claims 111

The total days in the hospital has been determined to be medically necessary based on the severity of the illness according to the utilization review criteria, or stated another way, the services to the patient have been labeled as “covered services.”

– Ambulatory Surgery 831

This bill type is used to bill for ambulatory surgeries done on an outpatient basis. Ambulatory surgery rates must be used.



Part 4 - 3-20

– No Pay Claims 110

During the utilization review, the severity of the illness did not warrant hospitalization. The utilization review will indicate “0 Bill”. Remarks should include why the services were not covered.

– Outpatient Claims 131 – Inpatient Part B Only 121

The severity of the illness has been determined not medically necessary based on the utilization review criteria. Room and board for the hospitalization are not covered nor are any provider visits.

– Other alternate resources 117

A claim was processed and paid; however, the patient had other alternate resources that should have been billed. Using “117” will instruct the system to “recoup” reimbursement.

3.8 Medicare Secondary Payer (MSP) Medicare Secondary Payer (MSP) is used by Medicare when Medicare is not responsible for paying first. It is important to check if Medicare or Medicaid has already been billed and take the appropriate action.

For accounts with two insurance companies, the RPMS Accounts Receivable application requires documentation of the primary billing company.

By Federal law, Medicare is secondary payer to a variety of government and private insurance benefit plans. Medicare should be viewed as the secondary payer when a beneficiary can reasonably be expected to receive medical benefits through one of more of the following means:

• An Employer Group Health plan for working aged beneficiaries • A Large Group Health Plan for disabled beneficiaries • Beneficiaries eligible for End State Renal Disease • Liability/Automobile medical or no-fault insurance/Personal Injury

Protection (PIP) • Veterans Administration (VA) • Workers’ Compensation Plan • Federal Black Lung Program



Part 4 - 3-21

Any conditional primary payment(s) made by Medicare for services related to an injury is subject to recovery. Conditional payments can be made on:

• Liability • Automobile medical or no-fault insurance • Workers’ Compensation

For more information on Medicare Secondary Payer, go to this website:

http://www.cms.hhs.gov/MedicareSecondPayerandYou/

3.8.1 Working Aged

Medicare is secondary for the Working Aged when the following conditions apply:

• Employer Group Health Plan of 20 or more employees, • Employer Group Plan covers the same services as Medicare, • Beneficiary is age 65 or older, • Beneficiary is entitled to Part A (hospital insurance of Medicare, and • Beneficiary or spouse of beneficiary is actively employed and covered by

an employer group plan by reason of his/her employment

3.8.2 Disability

Medicare is secondary for beneficiaries who are under age 65 and are entitled to Medicare due to a disability other than End State Renal Disease (ESRD) for the following criteria:

• The beneficiary has coverage under a Large Group Health Plan with 100 or more employees,

• The beneficiary is entitled to Medicare based solely on a disability (other than ESRD), and

• The beneficiary is actively employed or covered as a dependent of an actively employed person covered under a Large Group Health Plan with 100 or more employees.




Part 4 - 3-22

3.8.3 End Stage Renal Disease (ESRD)

The End Stage Renal Disease (ESRD) criteria applies to individuals, including dependent children who are entitled to Medicare on the basis of ESRD and who are covered under an Employer Group Plan, regardless of the size of the plan. The criteria are

• If an Employer Group Health Plan (EGHP) is offered through an employer because of his/her employment or employment of spouse or other family member’s active employment; then Medicare is secondary to an EGHP for individuals who have Medicare benefits based on ESRD. The beneficiary can be any age; and

• The period in which Medicare is secondary is called the coordination of benefit period. Secondary benefits are payable for a period up to 30 months.

3.8.4 Liability/Automobile Medical or No-Fault/Personal Injury Protection Insurance

Section 953 of the Omnibus Budget Reconciliation Act of 1980, amended by the Deficit Reduction Act of 1994, precludes Medicare payment for items or services to the extent that payment has been made or can reasonable be expected to be made under auto medical, Personal Injury Protection (PIP), no-fault, or any liability insurance plan or policy, including self-insurance plans.

Services that should be billed to these insurance plans are:

• Services payable under one of the above plans (except third-party liability) – that plan should be billed until all benefits are exhausted.

• Any payments made by Medicare for services payable under one of these policies constitute overpayments and are subject to recovery.

• Liability insurance plan is an exception to the above rule. The physician/supplier has the option to bill Medicare for conditional primary payment.

3.8.5 Veterans

Veterans who are also entitled to Medicare may choose which program will be responsible for payment for services that are covered by both programs. Claims for services for which the veteran elects Medicare coverage should be submitted to Medicare in the usual manner. A denial from the VA is not needed prior to submitting a claim for Medicare.



Part 4 - 3-23

Medicare will be primary to the VA in the following situations:

• VA denies the services and the services are covered under Medicare. • Correspondence is received indicating “No VA Coverage.”

Insurers frequently see the following situations with Medicare and VA:

• If the VA is unable to provide treatment for the services at one of its own facilities or by one of its own physicians, they may refer the beneficiary to an outside facility or physician.

• Pre-authorization is obtained from the VA to use an outside facility.

• The beneficiary has been issued a “fee basis” card. This card is an agreement by the VA to pay up to a specified dollar amount for treatment of a specific disability or for any condition specified on the face of the “fee basis” card.

3.8.6 Worker’s Compensation

Federal law precludes payment for services payable under a Worker’s Compensation policy. If services are work-related, the Worker’s Compensation policy should be billed until all benefits are exhausted.

Medicare remains primary payer for services not related to Worker’s Compensation.

With Worker’s Compensation:

• Medicare may make payments for Medicare covered services, if not payable under the Worker’s Compensation policy.

• Services payable under a Worker’s Compensation policy that have been paid by Medicare constitute overpayments and are subject to recovery.

• A beneficiary’s statement that an injury or illness is not work-related may be accepted in absence of reasonable doubt.

3.8.7 Black Lung

Medicare will pay secondary to an insurance company paying for Black Lung diagnosis with the exception of the United Mine Worker’s Association (UMWA). UMWA is their own government entity; therefore, Medicare Part B will deny charges.



Part 4 - 3-24

However, services rendered to these beneficiaries for conditions not related to black lung diagnoses should be billed directly to Medicare, such as cardiac failure brought on by renal failure. Medicare will pay primary for services not related to black lung disease.

3.8.8 Provider Responsibilities under MSP

Part A provider (hospitals):

• Obtain billing information prior to providing hospital services, using the recommended Centers for Medicare and Medicaid Services’ (CMS) questionnaire (or a questionnaire that asks similar types of questions).

• Submit any MSP information to the intermediary, using condition and occurrence codes on the claim

Part B provider (physicians and suppliers):

• Follow the proper claim rules to obtain MSP information, such as group health coverage through employment or non-group health coverage resulting from an injury or illness;

• Inquire at the time of the visit if the beneficiary is taking legal action in conjunction with the services performed.

• Submit an Explanation of Benefits (EOB) form to the designated carrier with all appropriate MSP information. If submitting an electronic claim, provide the necessary fields, loops, and segments to process an MSP claim.

For more information, go to the CMS website:


3.8.9 Submitting Medicare Secondary Payer (MSP) Claims

To ensure correct reimbursement when Medicare is secondary payer to another insurance company, use the following instructions:

• Screen Medicare beneficiaries for secondary coverage,

• Send claims to the primary insurance and then to Medicare,

and

• If you are filing a Medicare secondary claim on an HCFA-1500 claim form, list all services on the detail lines. Include a copy of the primary insurance company’s Explanation of Benefits




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• If you file electronically, you do not need to include a copy of the primary insurance company’s Explanation of Benefits. The claim does require the submission of three additional data elements: – Medicare secondary type codes; – Amount paid by primary payer; and – Amount allowed by primary payer

The physician or provider must file a Medicare secondary claim, if he/she receives the primary Explanation of Benefits directly from the beneficiary.

Item 11 of the HCFA-1500 must be completed. By completing this item, the physician or provider acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer.

• If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Items 11a-11c.

• If there is no insurance primary to Medicare, enter the word “NONE” and proceed to Item 12.

• If there has been a change in the insured’s insurance status, such as retired, enter the word “NONE” and proceed to 11b.

Item 11a is the insured’s birth date and sex; 11b is the employer’s name, if applicable; and 11c is the nine-digit payer ID identification number of the primary insurance plan or program.

3.9 Medicare Secondary Payer (MSP) Claims Investigation Effective January 8, 2001, the Coordination of Benefit (COB) contractor assumed responsibility for virtually all initial MSP development activities formerly performed by Medicare intermediaries and carriers. This means the COB contractor is charged with ensuring the accuracy and timely update of data populated on Medicare’s eligibility database regarding other health insurance that is primary to Medicare. The COB contractor also handles MSP-related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries.

The COB contractor is primarily an information gathering entity. A variety of methods and programs are used to identify situations in which Medicare beneficiaries have other health insurance this is primary to Medicare:



Part 4 - 3-26

Process Description Secondary Claim Development

When a claim is submitted with an explanation of benefits (EOB) attached from an insurer other than Medicare, a questionnaire is sent to the beneficiary to collect information on the existence of other insurance that may be primary to Medicare.

Self-Report Development A self-report covers the full spectrum of MSP situations. Any source that contacts the COB contractor initiates this type of development process in order to address these inquiries and to assure that the information provided is accurate.

Trauma Development When a diagnosis appears on a claim that information is received through correspondence or on a claim that indicates a traumatic accident, injury, or illness, which might form the basis of MSP, a questionnaire is sent to collect information on the existence of other insurance that may be primary to Medicare. This questionnaire may be sent to the beneficiary, provider, attorney, or insurer.

CFR 411.25 This process confirms MSP information received from a third party payer

3.10 Medicare Timely Filing

3.10.1 Part A Timely Filing

Under Medicare law, claims are accepted by the carrier for dates of service in the current year, the previous year, and the last three months (October, November, and December) of the year prior.

For purposes of the time limit, a hospital shall be deemed to have filed a claim for payment for inpatient hospital services on the date it submitted an admission notice for such services, provided the claim is submitted within 60 days after the intermediary or Social Security Administration, as appropriate, replied to the admission notice.

Where the hospital is establishing timely filing of the claim on this basis (i.e., the claim would not otherwise be timely filed), it should so note on the billing or an attachment to the billing, and indicate the date the admission notice was sent and the date the reply was received.



Part 4 - 3-27

Where there is a Social Security Administration (SSA) error (e.g., misrepresenting, delay, mistake, or other action of SSA or its intermediaries or carriers) that causes the failure of the hospital to file a claim for payment within the time limit, the time limit will be extended through the last day of the sixth calendar month following the month in which the error is rectified by notification to the hospital or beneficiary, but not beyond December 31 of the third calendar year after the year in which the services were furnished. (For services furnished during October -December of a year, the time limit may be extended no later than the end of the fourth year after that year.)

3.10.2 Part B Timely Filing

For Medicare payment to be made for a claim for physician and other Part B services reimbursable on a reasonable charge basis, the claim must be filed no later than the end of the calendar year following the year in which the service was furnished, except for services furnished in the last 3 months of a year, where the time limit is December 31 of the second year following the year in which the services were rendered. This time limit was effective with claims filed after March 1968. (See §§ 266.7 and 266.8 for effect of Federal non-workdays and rules applicable to claims received in the mail.)

For example: A patient received laboratory tests at a clinic in August 2004. The claim for reimbursement for such services must be billed on or before December 31, 2005. If the tests were performed in October 2004, the claim must be filed on or before December 31, 2006.

Where there is an administrative error (that is, misrepresentation, delay, mistake, or other action of SSA or its intermediaries or carriers) that causes the failure of the beneficiary or the hospital, physician, or supplier to file a claim for payment within the time limit specified in § 271, the time limit will be extended through the close of the sixth calendar month following the month in which the error is rectified.

Consideration of possible extension of the time limit on Part B reasonable charge claims will be initiated only if there is a basis for belief that the claimant (the enrollee or his representative or assignee) has been prevented from timely filing by an administrative error. For example, he states that official misinformation caused the late filing, or the social security office calls to the intermediary's attention a situation in which such error has caused late filing.



Part 4 - 3-28

In some cases, a hospital may have incorrectly billed for a Part B professional component as a hospital expense. For example, a physician's services were erroneously considered entirely administrative in nature and the error was not discovered until the final cost settlement.

Where the claim which included the physician services was filed within the time limit, it establishes protective filing for a subsequent perfection of a Part B claim. Such claims will be considered filed as of the date the incorrect billing was submitted to the intermediary provided the usual claims information (e.g., the SSA-1554 in the case of a hospital-filed claim) is submitted within 6 months after the month in which the notice was sent that payment for the patient care services was disallowed.

The perfected claim may be filed by the physician on the basis of assignment, or by the hospital (where the hospital has a contractual arrangement to bill and receive payment for the physician's services), or may be filed by the patient on the basis of an itemized bill.

A hospital claim filed within the Part B time limit will not establish a filing date for the related professional component where such component was recognized and not included in the provider bill (e.g., no claim was filed for the professional component as a non-provider expense because the physician and hospital could not agree on the exact amount of the component charge or who would bill for it).

Where the hospital bills for physician and hospital services under the combined billing procedure presume that the billing is timely filed as to the physician component if it is timely filed as to the hospital component, and that it is not timely as to the physician component if it is not timely filed as to the hospital component.

Where the time limit has expired on services reimbursable on a reasonable charge basis, there is no requirement that a bill be filed. However, where a person (or organization) accepts assignment within the time limit, but fails to submit a timely claim, he is barred by the terms of the assignment from collecting from the patient or other person amounts in excess of the deductible and coinsurance involved.

For claims submitted electronically to Medicare via GPNet, the following abbreviations may be returned for denied claims:

R status Rejected T status Return to Provider (RTP) D status Medically denied Type of Bill XXP (PRO adjustment) or XXI (Intermediary adjustment)



Part 4 - 3-29

The original bill can be resubmitted on both the status of T or R, if additional or corrected information is supplied. The original type of bill frequency codes should be used. The T status cannot be adjusted (XX7) or voided (XX8), since it is not considered an active bill.

3.11 Claims Resubmission Guidelines • In some instances, the claim may not be considered unless billing errors

are corrected. These Remittance Advices or Explanation of Benefits are routed back to the individual billing clerks for correction and then resubmitted to the respective insurer.

• Claim resubmission may be done via fax, mail, or electronically. – The filing limit for Medicaid varies by state, from as low as 120 days to

one year. Resubmission of claims is usually within 6 months from the date of the remittance advice.

• Medicare claims are accepted by the carrier for dates of service in: – The current year – The previous year – October, November, December of the year prior to that – Resubmission for denied claims must be appealed within 4 months

from the remittance date

• Most Private Insurance companies have a one year filing limit. Some private insurers are longer than one year. Resubmissions on denied claims must be completed by December 31 of the next calendar year

• The claim may then be rolled for further billing to secondary/tertiary insurer as applicable.

3.11.1 Steps for Approving a Secondary/Tertiary Claim in RPMS

1, Exit the Accounts Receivable (A/R) menu.

2. Go to the RPMS Third Party Billing application and select the Add/Edit Claim Menu.

3. At the prompt, type EDCL (Edit Claim Data) and press Enter..

a. Examine claim for accuracy and make corrections if necessary.



Part 4 - 3-30

b. On Page 1, check for visit type and mode of export.

• Visit type is set to Secondary or similar, based on site set up

• Mode of export allows you to bill the claim on a HCFA 1500 or UB-92 manually. Since Medicare/Medicaid claims are transmitted electronically by utilizing the HIPAA 837P and/or 837I, the mode of export needs to be changed to HCFA-1500 and/or UB-92 so claims can be resubmitted manually.

4. On Page 2, select the billing entity and insurer address.

5. On Page 3, review Assignment of Benefits and Release of Information.

6. On Page 4, check for provider name and credential.

Note: If corrections are needed on Pages 5A through 9F, claim is routed to Billing technician.

7. JO (Jump Zero) to claim summary.

8. Type A to approve the claims.

9. Verify the mode of export and correct dollar amount(s). Then type Y (Yes) to approve claim.

10. Exit EDCL.

3.11.2 Steps for Exporting a Claim:

1. Go to the Print Bills Menu, and select EXPR to export the approved claim.

2. Select form to be exported (HCFA-1500 or UB-92) and press Enter.

3. Select a print device for the HCFA-1500 or UB-92 form by entering the device for your printer, and press Enter.

3.11.3 Steps for Reprinting a Claim for Resubmission

1. Exit the Accounts Receivable (A/R) Menu.

2. Got to REPR or reprint bill.

3. At the prompt, type 1 for Selective Bill(s) and press Enter.



Part 4 - 3-31

4. Enter the claim number(s) and press Enter.

5. Enter the print device and enter the device for your printer for either the HCFA-1500 or UB-92 to reprint ADA.

6. Press Enter to start the print jobs.

For all resubmissions, attach a copy of the Remittance Advice, Explanation of Medicare Benefits, and Commercial insurance EOBs when appropriate

3.12 Reimbursement for Clinical Nurse Specialist or Nurse Practitioner For the Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP), payments are only under assignment. Direct payments can be made to either the NP or the facility, but only if no facility or other provider charges are paid in connection with the service. Reimbursement would be equal to 80 percent of the lesser of the actual charge or 85 percent of the physician fee.

3.13 Reimbursement for Physician Assistant For the Physician Assistant (PA), payments are made under an assigned basis. Since the PA services are performed under the direction of the provider, all payments would be made to the provider or facility, but only if no facility or other provider charges are paid in connection with the service. Reimbursement for eligible services would be equal to 80 percent of the lesser of the actual charge or 85 percent of the physician fee schedule.


Part 4. Billing Version 1.0 4. Billing Medicaid July 2006

Part 4 - 4-1

4. Billing Medicaid

Contents 4.1 About Medicaid Billing.............................................................................. 4-2 4.2 Medicaid Approval and Export Process..................................................... 4-2

4.2.1 Example of Electronic Claim Submission for Medicaid..................... 4-3 4.3 Medicaid Timely Filing.............................................................................. 4-3



Part 4 - 4-2

4.1 About Medicaid Billing The Centers for Medicare/Medicaid (CMS) is the regulatory agency for Medicare, Medicaid, and Managed Care Organizations. It is mandated that each facility submit electronically, Medicare and Medicaid claims in the HIPAA 837 format.

CMS has assigned each state to develop and operate its own Medicaid program.

Medicaid regulations are set forth I Title XIX of the Social Security Act. CMS has determined that IHS hospitals and clinics will bill Medicaid at current per diem rates according to the Federal Register for inpatient and outpatient visits (one visit per day). For hospitalizations, professional fees can be billed to Medicaid; however, each state determines the fee schedule that will be used.

Each state provides different benefits and eligibility packages for their population. Please contact your state for specific information. In addition, each Medicaid insurer provides a reference manual on setting up and submitting electronically.

4.2 Medicaid Approval and Export Process • Review the inpatient or ambulatory surgery abstracts received from

Utilization Review. Verify that abstract forms are complete and accurate.

• Review the RPMS Third Party Billing system “flagged as billable” report for inpatient, outpatient and ambulatory billing. This report is a review of claims automatically flagged by the nightly claims checker that are ready for billing.

• Bill according to the state’s billing format.

• Review claim data for accuracy and completeness.

• Any issues with coding, system problems, or missing information needs to be corrected before approval.

• Approve and export claim.

There are various ways of submitting claims electronically. Refer to your State Medicaid guidelines for batching and submitting claims electronically.



Part 4 - 4-3

4.2.1 Example of Electronic Claim Submission for Medicaid

This is a typical procedure for exporting batches of claims to Medicaid.

1. Review electronic claims menu, noting the number of claims submitted, number of claims eligible for submission, and claims referenced in the error report.

2. Review pre-bill listing prior to submission of claims electronically.

3. Transfer approved claims to the directory in the host file server (HFS).

4. Each type of bill (inpatient, outpatient, or ambulatory surgery) will be processed individually by selecting the appropriate listed option. A separate file will also be created by location.

5. Assign an appropriate file name to the selected type of bill.

6. Use File Transfer Protocol (FTP) software to transfer files to desktop or local PC, and then submit electronically in the correct transfer mode format.

4.3 Medicaid Timely Filing Most claims for services submitted to Medicaid must be submitted within the state required guidelines; for example, New Mexico Medicaid has a timely filing limit of within 120 days of the date the service. Some states require transmission as early as within 90 days.

Requests for adjustments to rejected or denied claims must be submitted within the State guidelines; for example, New Mexico Medicaid requires that providers submit claims within six (6) months of the date on the “remittance advice” form which accompanied the payment or denial of the claim.

Follow your State requirements for finalizing claims.

These are examples of exceptions to general time limitations for Medicaid submission:

• If claims are submitted more than 120 days after the date of service, the statement of benefits from the other insurance or the denial of benefits from the other insurance must be attached to the claim to verify that the other payment source has been pursued.



Part 4 - 4-4

• If a provider receives payment from the other insurance or liable third party after receiving payment from Medicaid, an amount equal to the lower of either the insurance payment or the amount paid by Medicaid must be immediately remitted to Medicaid.

• Claims for services furnished by out-of-state providers must be submitted within 120 days (or the timeframe authorized by the state Medicaid, if different) of the date of service. In the event the out-of-state provider does not have a Medicaid provider number for that state, the request for the provider number must also be submitted within the 120-day limit.

• Claims for services provided during a period for which retroactive eligibility has been established must be submitted within 120 days (or timeframe authorized by that state Medicaid) of the date the Medicaid claims processing area was notified of the retroactive eligibility.

• Corrected claims which are originally submitted within the timely filing limit and need corrections or additions must be completed and submitted to Medicaid or its claims processing area within 365 days of the date of service.

• Duplicate claims which are used to replace lost or unprocessed claims must be submitted within the same timeframe as an original date of service claim.


Part 4. Billing Version 1.0 5. Billing Private Insurance July 2006

Part 4 - 5-1

5. Billing Private Insurance

Contents 5.1 Procedure for Billing Private Insurance ..................................................... 5-2 5.2 Private Insurance Timely Filing................................................................. 5-8



Part 4 - 5-2

5.1 Procedure for Billing Private Insurance All admissions are identified through the RPMS system through the registration process for the patient.

1. Review source documents for completeness: – Patient chart documented and signed by provider – Diagnosis and procedures are coded with ICD-9 and CPT codes are

indicated – Progress notes are included in medical record from provider and nurses – Doctor’s orders are included – Authorizations for surgery or other procedures are included – Anesthesia records are included – Reports are in the medical record – lab, radiology, pathology, CT,

pharmacy, 24 hour intake and output flow sheets, operative report, IV solutions, and Intensive care daily reports (if applicable)

– Patient care record is complete – Re-check that insurance benefits have been revalidated within the past

30 days

2. logon to RPMS and the Main Menu.

3. Access the Third Party Billing System and press Enter.

4. Select Add/Edit Claims Menu.

5. Select Option ED - Edit Claim Data and Press Enter.

6. Select Bill or Patient.

Enter the Claim Number or the patient’s last name and first name, and social security number or health record number or date of birth.

Note: After the system checks for errors, checks eligibility file, checks for release of information, and assignment of benefits, it displays the claims summary.



Part 4 - 5-3

7. Review the Claim Summary.

Page 0 is the first screen to appear. This screen provides a high-level summary of the claim.

a. Check “Claims file error exists.”

This is the first place to review for any missing or inaccurate information. These errors must be corrected (by page).

b. Review those items that are required by the payer.

All errors must be corrected in order to approve the claim.

• Patient name • Health Record Number • Claim Number

Page 1 Claim Identifiers • Location • Clinic • Visit Type (drives property of claims

editor) • Bill From and Through Dates • Bill Type (edits in system) (Bill type

should not be changed to 999 • Mode of Export (claim form using to bill)

Page 2 Billing Entity • Name of insurance company • Status of claim

Page 3 Questions (both should be answered “yes”) • Release of information • Assign benefits

Page 4 Providers (list all providers on record) • Attending physician • Operating physician (if applicable)

Page 5A Diagnosis • List all coded diagnosis in words not codes

Page 5B ICD Procedures • List all coded ICD procedures in words not codes

Page 8 CPT Procedures • List all coded CPT procedures in words not codes



Part 4 - 5-4

8. At the Desired Action prompt, type N (Next) to move from page to page, and on each page, review the data for accuracy.

Page 1 - Claim Identifiers • Visit Location – Name of Clinic • Billing Location – Name of Clinic • Clinic – General, Day Surgery,

Outpatient, Walk-in, etc. • Visit Type – Inpatient, Ambulatory

Surgery, Outpatient • Bill Type – 111 (Inpatient), 831 (Day

Surgery), 131 (Outpatient) • Billing From Date – Admission or Visit

Date • Filling Through Date – Discharge or

Visit Date • Super Bill Number – Leave Blank

Page 2 - Insurers • Review the insurance companies for accuracy

• Confirm that the primary and secondary carriers are correct

• Confirm that the Export mode is UB-92 and HCFA-1500

Page 3 - Questions • 1 – Release of Information, • 2 – Assignment of Benefits, must

always be “yes” • 3 – Accident Related, • 4 – Employment Related, would be

“yes” if applicable • 5 – Emergency Room Required,

would be “yes” if the patient had an emergency room visit or was admitted from the emergency room

• 11 – Prior Authorization Number, enter if applicable

• 12 – HCFA-1500B Block 19, enter E codes and narrative descriptions of injury or accident

Page 3A - Ambulance Data • Indicate origin (location of patient pick-up)

• Destination (location where patient was transported)

• Medical necessity indicator must be answered

• Indicate covered/uncovered mileage • Indicate condition codes



Part 4 - 5-5

Page 4 - Provider Data • Verify all providers are listed – attending, operating, etc. that took care of the patient

• Verify the physician provider numbers are correct

• Verify the titles of the discipline of each physician

Page 5A - Diagnosis • The diagnosis codes should be listed in billing sequence order

• The ICD9 codes should be the providers written narrative

• Limit the use of V-codes – most insurers do not pay for V-codes

Page 5B - ICD Procedures • List all ICD procedures performed by provider

Page 7 - Inpatient/Day Surgery Data

• All inpatient services should be listed on this page

• Confirm data matches the Final A sheet

• Number 3 Admission Type and Number 4 Admission Source are often incorrect. Validate

• Number 11 Covered Days are often incorrect. Validate and if incorrect, enter the correct number of days. All Day Surgery accounts should be blank.

• Prior authorization, if applicable Page 8A - Medical Services • Multiple procedures and Evaluation

and Management (E&M) codes that begin with CPT code 9 are listed on this page

• Professional components for pathology with modifier 26 needs to be added

• EKG’s should be added on this page, if they are not list on Page 8H – Miscellaneous services

• Outpatient claims – Professional fee or Evaluation and Management codes should be added based on the superbill or Patient Care Service (PCS) form



Part 4 - 5-6

8B - Surgical Procedures • Surgical codes that begin with CPT codes 1 through 6 are listed on this page

• Surgical codes are submitted in the order coded

• Modifier 51 (Multiple Procedures) must be added manually to the claim once it is printed

• All procedures should be edited to match corresponding diagnosis codes

• Only one facility fee should be list. Delete all others.

Page 8C - Revenue Codes • The revenue codes include a charge for:

12X Room & Board 17X Nursery Room & Board 20X Intensive Care 21X Coronary Care 370 Anesthesia 710 Recovery Room 72X Labor room/Delivery (hourly charges) 272 Sterile Supply 278 Other Implants (also referenced on Page 3, Item 12) • Confirm data with file folder, correct

price and units • Outpatient – revenue codes not

applicable Page 8D - Medication • Pharmacy revenue codes include:

250 General Pharmacy 253 Take Home Drugs 257 Non Prescription Drugs 258 IV Solutions • For outpatient, view the medications in

the medication profile • Add any medications not listed, match

medications to corresponding diagnosis and ordering provider, and match dispense date with date of service



Part 4 - 5-7

Page 8E - Laboratory Services

• The laboratory services include all labs with revenue codes 30X and CPT codes that begin with “8”

• No pathology services (31X) should be listed on this page. The professional components should be listed on page 8A and the technical components listed on page 8H.

• For outpatient, check labs in the Lab Profile.

• Add any missing services and match the labs to the corresponding diagnosis

• A CLIA number may be entered for reference lab charges

Page 8F - Radiology Services

• The radiology services include all diagnostic radiology services with revenue codes 32X and CPT codes that begin with “7”. CT Scans are also entered on this page.

• For outpatient, check radiology reports to make sure the x-ray was completed.

• Match x-ray to the corresponding diagnosis

Page 8G - Anesthesia Services

• This page is only used for adding manual anesthesia charge. Anesthesia services are automatically interfaced by the system and are listed on Page 8C.

• Outpatient – this page is not applicable.

Page 8H - Misc. Services • This page is used to enter HCPCS codes for supplies. CPT codes are also entered on this page if required.

Page 8I - Inpatient Dental Services

• Payer specific.

Page 8K - Ambulance Services

• Attendant and mileage may be entered on this page.

Page 9A - Occurrence Codes

• Accident related codes and dates are used, if applicable.

• Medical condition codes and dates are used, if applicable

• Insurance related codes and dates are used, if applicable

• Service related codes and dates are used, if applicable



Part 4 - 5-8

Page 9B - Occurrence Span Codes

• Payer specific.

Page 9C - Condition Codes • Payer specific. Page 9D - Value Codes • Payer specific. Page 9E - Special Program Codes

• Payer specific.

Page 9F - Remarks • E codes and injury-related comments would appear on the UB92.

• Payer specific • This page can also be used to note

additional information

9. Approve, print, and mail claims to insurer.

5.2 Private Insurance Timely Filing Most private insurance companies allow claims to be filed within one year from the date of service and some even will allow reimbursement up to and including the end of the calendar year following the year in which the service was rendered. Insurers such as Workers’ Compensation may request that bills be submitted with 60-to-90 days from the date of service.

Check with insurance companies to determine specific filing limits.


Part 4. Billing Version 1.0 6. Third Party Liability Billing July 2006

Part 4 - 6-1

6. Third Party Liability Billing

Contents 6.1 Third Party Liability Billing and Medicare Claims.................................... 6-2


Part 4. Billing Version 1.0 6. Third Party Liability Billing July 2006

Part 4 - 6-2

6.1 Third Party Liability Billing and Medicare Claims The physician, who treats a Medicare beneficiary who has filed a liability claim, must bill the liability insurer as primary payer unless it is determined that the insurer will not pay promptly (i.e., within 120 days after the liability insurance claim is filed). In that instance, that physician may bill and accept payment of his full charges to the liability insurer and is not bound by Medicare’s limiting charge or the approved amount.

If the payment by the insurer is less than the physician’s full charge, the physician may file a claim for Medicare secondary payment. If 120 days have lapsed and the liability insurer has not made payment, a physician may file an assigned claim for conditional primary Medicare payment. If the physician does so, he/she must drop his/her claim against the liability insurer, except for applicable Medicare deductible and coinsurance amounts.

If a provider chooses not to bill Medicare during the Medicare filing period, they may not bill Medicare after this period has expired, even if they are unable to collect from the proceeds of the liability insurance settlement.

Special Circumstances:

• When a no-fault plan denies some or all of a claim on the basis of benefit exhaustion or specific no-fault policy coverage exclusion applicable to all policyholders, Medicare may pay for the services, subject to meeting normal Medicare guidelines. A copy of the denied Explanation of Benefits from the no-fault plan must accompany the claim to Medicare.

• Primary Medicare benefits may not be paid merely because the beneficiary wants to save his or her automobile insurance for future benefits.

For more information, see the Federal Medical Care Recovery Act (FMCRA) policy at this website:

http://www.ihs.gov/PublicInfo/Publications/IHSManual/Circulars/Circ06/Circ06_02/circ06_02.htm




Part 4. Billing Version 1.0 7. Billing Private Dental Insurance July 2006

Part 4 - 7-1

7. Billing Private Dental Insurance

Contents 7.1 About Dental Insurance.............................................................................. 7-2

7.1.1 X-Rays ................................................................................................ 7-2 7.2 Reporting Dental Services.......................................................................... 7-3 7.3 Dental Billing Guidelines........................................................................... 7-4 7.4 Dental Timely Filing .................................................................................. 7-6



Part 4 - 7-2

7.1 About Dental Insurance Medical insurance is designed primarily to cover the costs of diagnosing, treating, and curing serious illnesses. The process may involve a primary care physician and multiple specialists, a variety of tests performed by doctors and laboratories, multiple procedures, and masses of medications. Depending on the health, age, and attitudes of people in the medical coverage group, costs can fluctuate widely.

Dental insurance works differently. Most dental coverage is designed to ensure that the patient receives regular preventive care. High quality dental care rarely requires the complex, multiple resources often required by medical care. A thorough examination by the dentist and a set of x-rays are all it usually takes to diagnose a problem.

By and large, dental care is provided by a general practitioner, although some cases may require the services of a dental specialist. Because most dental disease is preventable, dental benefits plans are structured to encourage patients to get the regular, routine care vital to preventing the onset of serious disease.

Most dental benefits plans require patients to assume a greater portion of the costs for treatment of dental disease than for preventive procedures. By placing an emphasis on prevention, and by covering regular teeth cleaning and check-ups, Americans saved nearly $100 billion in dental care costs during the 1980s.

Dental billing is unique and requires different coding and supportive information to process the claims accurately. The following paragraphs provide information to assist the coder and biller in increasing reimbursement and preventing returns for clarification or additional information.

7.1.1 X-Rays

Many billers routinely send x-rays with the claim form, even though the x-rays may not be needed to process the claim. In addition, unnecessary submission of x-rays can be costly and time-consuming, and may potentially even delay the processing of the claim.



Part 4 - 7-3

Most of the dental insurers publish a list of procedures that require supporting x-ray information. Occasionally, a dental consultant at the insurer may also request an x-ray for review. If x-rays are required, the biller needs to list on a sticker attached to the x-ray package whether or not to return the x-ray copies to the facility.

7.2 Reporting Dental Services The CDT (Current Dental Terminology), also known as ADA (American Dental Association), has been designated as the national standard for reporting dental services by the Federal Government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is recognized by third-party payers nation wide.

IHS uses the ADA coding structure, which is four digits. However, RPMS has the capability of adding “D” or “0” as a prefix, if the payer requires this information.

Typical examples of procedures needing dental x-rays are:

Restorative •

•

• • •

Resin-four or more surfaces or involving incisal (anterior) Inlays/onlays-metallic; porcelain/ceramic; composite/resin Crowns-resin; cast Crown buildup (substructure), including any pins Labial veneers

Endodontics • Endodontic endosseous implant

Periodontics • Crown Lengthening-hard and soft tissue, by report

Prosthodontics, fixed

• • • • •

Implants Inlays/onlays Retainer for acid-etch retained bridge Bridge retainers-crown Retainer crown buildup (substructure) including any pins



Part 4 - 7-4

Oral Surgery • Root removal-exposed roots • Surgical removal of erupted/impacted tooth, tooth roots • Other surgical procedures • Removal of odontogenic/nonodontogenic cyst or tumor • Removal of foreign bodies-musculoskeletal system • Sequestrectomy for osteomyelitis • Maxillary sinusotomy • Simple fractures • Compound fractures • Osteoplastyosteotoomy/LeFort I, II and III • Saliolithotomy/excision of salivary gland • Endodontic endosseous implant • Implants

Procedure codes that require periodontal charting only

For these procedure codes, do not send x-rays unless specifically requested.

• Gingivectomy or gingivoplasty/gingival curettage • Gingival flap procedure, incl. root planning-quad • Osseous surgery-per quadrant • Periodontal root planning-per quadrant

Note: The list of procedures above is an example of a general listing. Insurance companies may require additional coding.

7.3 Dental Billing Guidelines • Many dental policies limit the number of examinations, consultations, or

office visits in a calendar year. Beyond this limit, the dental insurer may deny this claim and any additional visits may be the patient’s responsibility. The biller should understand the limitations, exclusions, and benefits of the major dental insurers before filing the claim.

• Usually procedure code (09430) is a visit associated with an observation and/or treatment of injuries and no other services are provided. For most dental insurers, it is not the code for a routine examination.

• X-rays must be dated, of diagnostic quality, and provide the ability to discern tooth structure, supporting structure, and the pathology.

• Many dental insurers limit the number of cleanings in a calendar year. The average is two per year. Any additional cleanings would be the responsibility of the patient.



Part 4 - 7-5

• For fluoride treatments in conjunction with prophylaxis, be sure to use procedure code 01205 for adults and 01201 for children. When fluoride and prophylaxis treatments are listed separately, with separate procedure codes, they may be counted separately toward the two prophylaxis and/or fluoride treatment limitation of most dental groups.

• Some of the insurers may require pre-authorization prior to the procedure. This needs to be verified with the insurance.

• Many of the dental insurers limit dental sealants to the occlusal surface of caries and restoration-free first molars to age 9. Usually, sealants applied to caries and restoration-free second molars are limited to age 14.

• For emergency palliative treatment, use procedure code 09110. These services are usually payable per visit, not per tooth, and the fee includes all treatment provided, except necessary x-rays. A description of the nature of the emergency and the treatment provided must be included. This visit and this procedure is primarily use to relieve the patient of discomfort and is not considered definitive treatment.

• Intraoral photographs are not a covered service. Cost of photographs are considered to be included in the cost of other services, except when they are taken in connection with orthodontia.

• For most dental insurers, when a periapical film is provided, the procedure should be submitted using procedure code 00220 for the first film and 002230 for each additional film.

• Narratives or explanations should be included with the claim submission to prevent delayed reimbursement or denied services.

For example, if the biller files a claim for a crown without any narrative but with an x-ray, the dental consultant might be unable to detect a fractured cusp that may have prompted the dentist to place a crown. The same is true of a crown provided for a tooth that appears on x-rays to have a satisfactory amalgam restoration. The rationale for the crown is only apparent when the dentist describes any recurrent decay that is only evident through a clinical examination.

• Questions related to policy need to be anticipated prior to claim submission.

For example, if you replace a crown that is less than five years old, anticipate the obvious question and explain what event or circumstance made the replacement necessary.



Part 4 - 7-6

• Remember, sometimes “A picture is worth a thousand words.” Wherever practical, a photograph may be more effective than words. Few, if any, dental carriers will reimburse you for intraoral photographs, but if it saves you time, photos will and can support your claim.

In summary, the biller needs to understand the difference between what is covered and what is not. Some necessary procedures won’t be payable, no matter what documentation is submitted. In such cases, it’s important to understand that a recommended treatment may be perfectly appropriate – it is just not a payable claim under the terms of the dental contract.

For example, if you provide treatment for erosion, there is a good chance the claim cannot be paid because erosion is a common exclusion under most dental programs. The same principle applies to treatments that address cosmetic needs rather than dental disease. Basically, if erosion or cosmetics is the reason for treatment, no amount of explanation will allow the consultant to approve the claim for payment.

7.4 Dental Timely Filing For most dental plans, there is a limitation for the number of procedures and/or dollar amounts in a given year. Dental plans request that reimbursement be made within a reasonable timeframe from the date of service.

Check with insurance companies to determine specific filing limits.


Part 4. Billing Version 1.0 8. Billing Pharmacy July 2006

Part 4 - 8-1

8. Billing Pharmacy

Contents 8.1 About Point-of-Sale Pharmacy Billing ...................................................... 8-2 8.2 Guidelines for Submitting a Claim Form Manually................................... 8-3 8.3 Reasons for Pharmacy Denials................................................................... 8-3



Part 4 - 8-2

8.1 About Point-of-Sale Pharmacy Billing The Point-of-Sale (POS) allows pharmacists to send claims to the Pharmacy Benefit Administrator (PBA) and subsequently to the insurer, via a telecommunications network as they are filling the prescriptions at the facility, and have those claims adjudicated online or in real time.

The following online functions are usually performed:

• Verify client eligibility. • Verify claim data validity. • Perform online duplicate services detection and drug caps. • Verify coverage of drug due to formulary restrictions, obsolete dates or

other reasons. • Price the claim and provide co-pay and reimbursement amounts. • Perform the detection of conflicts prior to filling the prescription. • Obtain PRIOR authorization.

With Point-of-Sale, drugs are entered into the Pharmacy package, which will be forwarded electronically to the insurer. If the claim is denied, an error report will be generated back to the pharmacy from the insurer. At this point, either a designated person in the pharmacy will research, correct, and re-submit electronically the corrected error for all rejections, or the same list will be sub-divided by area of responsibility between the Billing office and Pharmacy.

As example of the latter, the Billing office would work with Registration, if an incorrect pharmacy insurer number was listed or if the patient was not covered under the policy; whereas, the Pharmacy would be responsible for researching rejections related to NDC (National Drug Code) number errors, drug not covered under the formulary, or prescription was denied due to 30-day limitation.

Once the pharmacy is paid, the Billing and Accounts Receivable (AR) packages will be updated and reconciled. If the claim is denied, neither the Billing nor the AR system is updated.

As a precaution with Point-of-Sale, the biller should review all clinic bills to assure that none of the drugs billed electronically are also being submitted to the billing package with the clinic claim.

When the prescription is filled, the pharmacy enters the prescription data into the RPMS Pharmacy Point of Sale application.



Part 4 - 8-3

If an agreement is not in place to bill electronically with the pharmacy insurer or the facility has elected not to bill electronically via Point-of-Sale, a pharmacy charge will be entered into the Pharmacy package and forwarded to the Billing package. It will then be the responsibility of the Billing Office to generate a hard-copy claim using a Universal Claim form.

Many pharmacy insurers are requesting that billing for pharmacy services be done electronically versus manually and will defer or limit payment for those submitted manually. Therefore, all facilities are encouraged to move forward with electronic pharmacy billing.

8.2 Guidelines for Submitting a Claim Form Manually • The exact name and address of the pharmacy must be included on the

form.

• The National Association of Boards of Pharmacy Number (NABP) assigned to your specific pharmacy must be listed.

• The pharmacist must sign the form.

• The Rx number assigned to the pharmacy must be included.

• Use “N” for a new prescription; use “R” for a refill.

• Enter the number of tablets or capsules dispensed, the number of grams of ointments or powers, or “cc” or “ml” amounts of liquids. Use whole units only.

• Enter the number of days of medicine this prescription will supply.

• Enter the eleven-digit National Drug Code (NDC) number assigned to the product.

• Enter the prescriber’s DEA number.

• Enter the total charge for this prescription or product.

8.3 Reasons for Pharmacy Denials • Duplicate claim submission • Not a covered drug • Patient not covered under pharmacy insurance plan • Not provided or authorized by designated provider • Incomplete or invalid place of service listed • Did not complete or enter accurately the referring/order/supervising

physician’s name and/or their UPIN number • Did not complete or enter the correct NPI and/or billing name or address



Part 4 - 8-4

• Information required to make the payment was missing • Modifier was missing or inaccurate • Dispensing drugs for more than 30 days • Dispensing drugs before the 30 days • Max on Medicare drug program allowance ($600 cap) • Incorrect NDC number • Missing group number


Part 4. Billing Version 1.0 9. Secondary Billing Process July 2006

Part 4 - 9-1

9. Secondary Billing Process

Contents 9.1 Creating Secondary Claims........................................................................ 9-2 9.2 Printing the Rollback Detail (ROD) Report ............................................... 9-2



Part 4 - 9-2

9.1 Creating Secondary Claims This is the procedure for creating secondary claims. For this process to be successful, keep the following points in mind.

• Ensure that your Accounts Receivable staff are rolling back the payment/adjustment data.

• Have all supporting documentation (primary remittance advice) on hand during secondary billing.

• Never submit the original primary EOB to the secondary payer.

• If the primary EOB contains multiple claims for different patients, cross out patient data not related to the claim being submitted. Do not cross out on the original remittance.

9.2 Printing the Rollback Detail (ROD) Report Print the Rollback Detail (ROD) report to get a listing of claims with the status of “in edit” mode. This will assist the Biller to quickly identify potential secondary bills.

To access the ROD report:

1. In RPMS Accounts Receivable (AR), select the Reports menu.

a. In reports, select Roll Back Reports (RRM).

b. Select Roll Back Detail (ROD).

c. Type the begin date – this is usually the date you roll back the payment to third party.

d. Type the ending date.

e. Select the device.

The report will display the

• date roll back • roll over amount • bill number • bill status • claim status.



Part 4 - 9-3

Statuses in edit mode will need to be billed to secondary.

2. Press Enter until you reach the IHS Core Menu.

a. At the IHS Core Menu prompt, type TPB (Third Party Billing System) and press Enter.

b. At the Third Party Billing System prompt, type EDT (Add/Edit Claim) and press Enter.

c. In the Select Claim or Patient command line,” enter the claim number and press Enter.

d. Double-check the patient’s name and date of service. The system will ask “Correct Claim?” Respond YES.

e. If the following message appears, the claim is closed and needs to be opened for editing:

“All billing has been completed for this claim number. The claim is closed and uneditable.”

3. Press Enter until you reach the IHS Core Menu.

a. At the IHS Core Menu prompt, type TPB (Third Party Billing System) and press Enter.

b. At the Third Party Billing System prompt, type MGTP (Claim/Bill Management) and press Enter.

c. In the 3P Claim Data Patient command line, enter the claim number and press Enter.

d. The system will ask “Reopen Claim?” Respond with YES.

The claim is now in Edit mode.

e. Repeat steps a – e in step #2.



Part 4 - 9-4

4. The repeat process will bring you to the Claim Summary menu. Press Enter.

a. On Page 0, check section billing entity to make sure that insurer is active and press Enter. – If the patient’s insurance is not active, notify Patient Registration to

update information. – If date of service is more than 3 months old, the back billing limit may

affect the claim being billed. Table Maintenance would need to be adjusted to reflect the older dates. This process is usually done by the Supervisor or Designee.

b. On Page 1, Claim Identifiers, check line 2 and make sure the correct visit type has been entered to bill for Secondary. Follow local policy and procedures.

5. Type B to return to previous page and press Enter.

6. Type A to approve claim and press Enter twice.

7. When the message – “Do you wish to approve this claim for billing?” appears, enter YES to approve the claim.

If any non-covered or write-off adjustments have been indicated, the system will notify the user. Enter any additional adjustment amounts if needed.

8. If the amount billed is incorrect, enter NO and review the history of the claim.

9. Press Enter twice to return to the Third Party Billing System menu.

10. At the prompt type PRTP (Print Bills) and press Enter.

11. At the Print Bills menu prompt, type EXPR (Print Approved Bills).

12. Verify mode of export.

13. After the claim is exported (printed), attach the primary EOB and mail claim.


4. Billing 1.0 A. IHS Reimbursement Methods July 2006

Part 4 - A-1

A. IHS Reimbursement Methods IHS Reimbursement Methods provide an overview of how IHS and Tribes are paid for services rendered to patients in IHS facilities. These methods generally apply to Tribal programs, but should be adjusted as needed.

The Fiscal Intermediaries (FI) and/or carrier process and pay claims. Trailblazer is the sole Medicare FI for IHS. Tribes can use other FIs or carriers. In addition, other payers can pay direct or use other FIs to process and pay claims.

Indian Health Service Reimbursement Methods

Payer FI Provider Hospital CAH Hospital

Hospital Outpatient

Ambulatory Surgery

PharmacyDental Inpatient Outpatient

Medicare Trailblazers FFS Part B FFS Part B DRG (PPS) AIR AIR ASC rate FFS 2006 N/A*

Medicaid State FI FFS AIR AIR AIR AIR ASC rate AIR/FFS AIR/FFS

Private Insurance

PI FI FFS FFS FFS FFS FFS FFS FFS FFS

SCHIP PI1 FFS FFS FFS FFS FFS FFS FFS FFS Model

SCHIP2 FFS AIR AIR AIR AIR ASC rate & AIR & FFS AIR & FFSMedicaid FFS Model

FQHC3 Tribes only

AIR capped

AIR N/A N/A N/A N/A FFS/340B AIR

FMCRA FFS FFS FFS FFS FFS FFS FFS FFS

Military (Army, Navy etc)

AIR or TRICARE

AIR or TRICARE

AIR or TRICARE

AIR or TRICARE

AIR or TRICARE

AIR or TRICARE

AIR or TRICARE

AIR or TRICARE

Commission Corp4

TRICARE AIR

TRICARE AIR

TRICARE AIR

TRICARE AIR

TRICAREAIR

TRICARE AIR

TRICARE AIR

TRICARE AIR

TRICARE AIR

Notes: 1. PI rules apply 2. Medicaid rules apply 3. FQHC only pertains to Tribal outpatient clinics. HIS is not eligible for this provider

status. Their rates are capped by Medicare regardless of costs and for Medicaid some states pay based on average PPS. The reimbursement is paid to tribes, not IHS

4. Commissioned Officer and Dependents are eligible for services at remote facilities. TRICARE is the Plan which governs payments and provision of health services.

*Certain exceptions under Medicare


4. Billing 1.0 A. IHS Reimbursement Methods July 2006

Part 4 - A-2

AIR = All inclusive rate (per diem) The Medicare and Medicaid AIR is negotiated with CMS and published annually in the Federal Register. CAHs IP and OP Medicare rates are set based on cost reports sent directly to the FI for review. The basis of the AIR is derived from 47 hospital cost reports. IP and OP RPMS Workload is used to calculate the average AIR.

ASC = ASC = Ambulatory Surgery Center rate FFS = Fee-for-service FMCRA = Federal Medical Care Recovery Act FQHC = Federally Qualified Health Center SCHIP = State Children Health Insurance Program


4. Billing Version 1.0 B. CMS 1450/UB-92 Form July 2006 Part 4 - B-1

B. CMS 1450/UB-92 Form

Contents About the CMS-1450 / UB-92 Form.............................................................................B-3

Form Locator (FL) Fields .............................................................................................B-3 FL1 – (Untitled)........................................................................................................B-3 FL2 – (Untitled)........................................................................................................B-3 FL3 – Patient Control Number .................................................................................B-4 FL4 – Type of Bill ....................................................................................................B-4 FL5 – Federal Tax Number ......................................................................................B-7 FL6 – Statement Covers Period (From-Through) ....................................................B-7 FL7 – Covered Days.................................................................................................B-7 FL8 – Noncovered Days...........................................................................................B-8 FL9 – Coinsurance Days ..........................................................................................B-8 FL10 – Lifetime Reserve Days.................................................................................B-8 FL11 – (Untitled)......................................................................................................B-8 FL12 – Patient’s Name .............................................................................................B-8 FL13 – Patient’s Address..........................................................................................B-9 FL14 – Patient’s Birthdate........................................................................................B-9 FL15 – Patient Sex....................................................................................................B-9 FL16 – Patient’s Marital Status ................................................................................B-9 FL17 – Admission Date............................................................................................B-9 FL18 – Admission Hour ...........................................................................................B-9 FL19 – Type of Admission/Visit............................................................................B-10 FL20 – Source of Admission..................................................................................B-10 FL21 – Discharge Hour ..........................................................................................B-10 FL22 – Patient Status..............................................................................................B-11 FL23 – Medical Record Number............................................................................B-11 FL24 - FL30 – Condition Codes.............................................................................B-12 FL31 – (Untitled)....................................................................................................B-17 FL32 - FL35 – Occurrence Codes and Dates .........................................................B-17 FL36 – Occurrence Span Code and Dates..............................................................B-19 FL37 – Internal Control Number (ICN)/Document Control Number (DCN) ........B-20 FL38 – (Untitled Except on Patient Copy of the Bill)

Responsible Party Name and Address .....................................................B-21 FL39 - FL41 – Value Codes and Amounts.............................................................B-21 FL42 – Revenue Code ............................................................................................B-26 FL43 – Revenue Description ..................................................................................B-46 FL44 – HCPCS/Rates .............................................................................................B-46 FL45 – Service Date ...............................................................................................B-46



FL46 – Service Units ..............................................................................................B-47 FL47 – Total Charges .............................................................................................B-47 FL48 – Non-Covered Charges................................................................................B-48 FL49 – Untitled.......................................................................................................B-48 FL50A, B, C – Payer identification ........................................................................B-48 FL51A, B, C – Provider Number............................................................................B-48 FL52A, B, C – Release of Information...................................................................B-49 FL53A, B, C – Assignment of Benefits Certification Indicator .............................B-49 FL54A, B, C – Prior Payments...............................................................................B-49 FL55A, B, C – Estimated Amount Due..................................................................B-49 FL56 – (Untitled)....................................................................................................B-49 FL57 – (Untitled)....................................................................................................B-49 FL58A, B, C – Insured’s Name ..............................................................................B-50 FL59A, B, C – Patient’s Relationship to Insured ...................................................B-50 FL60A, B, C – Certificate/Social Security Number/HI Claim/

Identification Number ..............................................................................B-51 FL61A, B, C – Group Name...................................................................................B-51 FL62A, B, C – Insurance Group Number...............................................................B-51 FL63 – Treatment Authorization Code...................................................................B-51 FL64 – Employment Status Code...........................................................................B-52 FL65 – Employer Name .........................................................................................B-52 FL66 – Employer Location.....................................................................................B-52 FL67 – Principal Diagnosis Code...........................................................................B-52 FL68 - FL75 – Other Diagnoses Codes..................................................................B-53 FL76 – Admitting Diagnosis/Patient’s Reason for Visit........................................B-54 FL77 – E-Code .......................................................................................................B-54 FL78 – (Untitled)....................................................................................................B-54 FL79 – Procedure Coding Method .........................................................................B-54 FL80 – Principal Procedure Code and Date ...........................................................B-54 FL81 – Other Procedure Codes and Dates .............................................................B-55 FL82 – Attending/Referring Physician ID .............................................................B-55 FL83 – Other Physician ID.....................................................................................B-56 FL84 – Remarks .....................................................................................................B-57 FL85 – Provider Representative Signature.............................................................B-57 FL86 – Date ............................................................................................................B-57



About the CMS-1450 / UB-92 Form The CMS-1450 form, more commonly known as UB-92, serves the needs of many payers. Not all of the data elements need to be completed for every payer.

Data elements in the CMS uniform electronic billing specifications are consistent with the CMS-1450 form data set to the extent that one processing system can handle both. Definitions are also identical. However, due to the space constraints on the form, the electronic record contains more characters for some items than the corresponding items on the form

The revenue coding system for both Form CMS-1450 and the electronic specifications are identical.

Effective June 5, 2000, CMS extended the claim size to 450 lines. For the hard copy UB-92 or Form CMS-1450, CMS will accept claims of up to 9 pages. In addition, effective October 16, 2003, all state fields will be discontinued and reclassified as reserved for national assignment.

Form Locator (FL) Fields The following sections provide descriptions of the form locator (FL) fields and whether the information is required.

FL1 – (Untitled) Provider Name, Address, and Telephone Number

Required. The minimum entry is the provider’s name, city, State, and zip code. The post office box number or street name and number may be included. The State may be abbreviated using standard post office abbreviations. Five or nine digit zip codes are acceptable. Telephone and fax numbers are desirable.

FL2 – (Untitled) Not Required. This is one of the four fields which have not been assigned for national use.



FL3 – Patient Control Number Required. The patient’s unique alphanumeric number assigned by the provider to facilitate retrieval of individual financial records and posting of payments

FL4 – Type of Bill Required. This three-digit alphanumeric code gives three specific pieces of information:

• The first digit identifies the type of facility.

• The second digit classifies the type of care.

• The third digit indicates the sequence of this bill in this particular episode of care; also referred to as “Frequency” code.

First Digit – Type of Facility

1st Digit Type of Facility 1 Hospital 2 Skilled Nursing 3 Home Health 4 Religious Non-Medical (Hospital) 5 Religious Non-Medical (Extended Card) 6 Intermediate Care 7 Clinic or Hospital Based Renal Dialysis Facility 8 Special Facility of Hospital ASC Surgery 9 Reserved for National Assignment

Second Digit – Classification (Except Clinics and Special Facilities)

2nd Digit Classification Definition 1 Inpatient (Part A) 2 Hospital Based or Inpatient Includes Home Health Agency (HHA)

(Part B) visits under a Part B plan of treatment 3 Outpatient Includes HHA visits under a Part A plan

of treatment and use of HHA Durable Medical Equipment (DME) under Part A plan of treatment

4 Other (Part B) Includes HHA medical and other health services not under a plan of treatment, Skilled Nursing Facility (SNF) diagnostic clinical laboratory services to “nonpatients” and referred diagnostic services



2nd Digit Classification Definition 5 Intermediate Care – Level I 6 Intermediate Care – Level II 7 Subacute Inpatient Revenue code 19X required 8 Swing bed Used to indicate billing for SNF level of

care in a hospital with an approved swing bed agreement

9 Reserved for National Assignment

Second Digit – Classification (Clinics Only)

2nd Digit Classification (Clinics Only) 1 Rural Health Clinic (RHC) 2 Hospital Based or Independent Renal Dialysis Facility 3 Free-Standing provider-Based Federally Qualified Health Center

(FQHC) 4 Other (Part B) 5 Comprehensive outpatient Rehabilitation Facility (CORF) 6 Community Mental Health Center (CMHC) 7 Reserved for National Assignment 8 Reserved for National Assignment 9 Other

Second Digit – Classification (Special Facilities Only)

2nd Digit Classification (Special Facilities Only) 1 Hospice (Nonhospital based) 2 Hospice (Hospital based) 3 Ambulatory Surgical Center Services to Hospital Outpatients 4 Free Standing Birthing Centers 5 Critical Access Hospital 6 Residential Facility 7 Reserved for National Assignment 8 Reserved for National Assignment 9 Other



Third Digit – Frequency

The third digit, referred to as the Frequency code, indicates the sequence of this bill in this particular episode of care.

3rd Digit Frequency Definition A Admission/Election Notice Use when a hospice or religious non-medical health

care institution is submitting the Form CMS-1450 as an admission notice

B Hospice/Medicare Coordinated Care Demonstrations/Revocation Notice

Use when the UB-92 is used as a Termination/Revocation of a hospice, Medicare coordinated care demonstration or religious non-medical health care institution election.

C Hospice Change of Provider Use when the Form CMS-1450 is used as a Notice of Change to the hospice provider.

D Hospice/Medicare Coordinated Care Demonstration/Institution-Void/Cancel

Use when the UB-92 is used as a Notice of a Void/Cancel of a hospice, Medicare Coordinated Care Demonstration Entity, or Religious Non-medical Health Care Institution election

E Hospice Change of Ownership Use when the Form CMS-1450 is used for a Notice of Change in Ownership for the hospice.

F Beneficiary Initiated Adjustment Claim

Use to identify adjustments initiated by the beneficiary. For intermediary use only.

G Common Working File (CWF) Initiated Adjustment Claim

Use to identify adjustments initiated by CWF. For intermediary use only.

H CMS Initiated Adjustment Claim

Use to identify adjustments initiated by CMS. For intermediary use only.

I Internal Adjustment Claim (Other than provider or PRO)

This code is used to identify adjustments initiated by you. For intermediary use only.

J Initiated Adjustment Claim – Other

Use to identify adjustments initiated by other entities. For intermediary use only.

K Office of Inspector General (OIG) Initiated Adjustment Claim

Use to identify adjustments initiated by OIG. For intermediary use only.

M Medicare Secondary Payer (MSP) Initiated Adjustment Claim

Use to identify adjustments initiated by MSP. For intermediary use only. Note: MSP takes precedence over other adjustment sources.

P PRO Adjustment Claim Use to identify an adjustment initiated as a result of a PRO review. For intermediary use only.

0 Nonpayment/zero claims Use when the provider does not anticipate payment from the payer for the bill, but is informing the payer about a period of nonpayable confinement or termination of care. The “through” date is the date of discharge.



3rd Digit Frequency Definition 1 Admit Through Discharge

Claim Use for a bill encompassing an entire inpatient confinement or course of outpatient treatment for which the provider expects payments from the payer or which will update deductible for inpatient or Part B claims when Medicare is secondary to an EGHP.

2 Interim – First claim Use for the first of an expected series of bills for which utilization is chargeable or which will update inpatient deductible for the same confinement or course of treatment.

3 Interim – Continuing Claims (Not valid for PPS bills)

Use when a bill for which utilization is chargeable for the same confinement or course of treatment had already been submitted and further bills are expected to be submitted later.

4 Interim – Last Claim (Not valid for PPS bills)

Use for a bill for which utilization is chargeable and which is the last of a series for this confinement or course of treatment. The “through” date is the date of discharge.

5 Late Charge Only Use only for outpatient claims. Late charge bills are not accepted for Medicare inpatient or ASC claims.

7 Replacement of Prior Claim Used by the provider when provider wants to correct (other than late charges) a previously submitted bill.

8 Void/Cancel of a Prior Claim Use to indicate that this bill is an exact duplicate of an incorrect bill previously submitted.

9 Final Claim for Home Health PPS Episode

Use to indicate that the HH bill should be processed as a debit or credit adjustment to the request for anticipated payment.

FL5 – Federal Tax Number Not Required

FL6 – Statement Covers Period (From-Through) Required. The beginning and ending dates of the period include on this bill are shown in numeric fields (MMDDYY). Days before the entitlement are not shown. Use the “From” date to determine timely filing.

FL7 – Covered Days Required. The total number of covered days during the billing period applicable to the cost report including lifetime reserve days elected for which Medicare payment is requested, is entered. This should be the total of accommodation units reported in FL 46.



Covered days exclude any days classified as noncovered, as defined in FL 8, leave of absence days, and the day of discharge or death.

The provider does not deduct any days for payment made in the following instances:

• Workers’ Compensation • Automobile medical, no-fault, liability insurance • An EGHP for an ESRD beneficiary • Employed beneficiaries and spouses age 65 or over • An LGHP for disabled beneficiaries

FL8 – Noncovered Days Required. The total number of noncovered days during the billing period within the “From” and “Through” date that are no claimable as Medicare patient days on the cost report.

FL9 – Coinsurance Days Required. The number of covered inpatient hospitals days occurring after the 60th day and before the 91st day or the number of covered inpatient SNF days occurring after the 20th day and before the 101st day of the benefit period are shown for this billing period.

FL10 – Lifetime Reserve Days Required. The provider enters the number of lifetime reserve days applicable.

FL11 – (Untitled) Not Required. This is one of the seven fields which have not been assigned for national use.

FL12 – Patient’s Name Required. The patient’s name is shown with the surname first, first name, and middle initial, if any.



FL13 – Patient’s Address Required. This item shows the patients’ full mailing address including street number and name, post office box number or RFD, City, State, and Zip code.

FL14 – Patient’s Birthdate Required. The month, day, and year of birth is shown numerically as MMDDYYYY. If the date of birth was not obtained, the field will be zero filled.

FL15 – Patient Sex Required. An “M” for male and an “F” for female. This item is used in conjunction with FLs 67-81 to identify inconsistencies.

FL16 – Patient’s Marital Status Not Required.

FL17 – Admission Date Required. The month, day, and year of admission for inpatient care are shown numerically as MMDDYY.

FL18 – Admission Hour Not Required.



FL19 – Type of Admission/Visit Required on inpatient bills only. This code indicates the admission’s priority.

Code Structure

Code Admission/Visit Type

Definition

1 Emergency The patient required immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. Generally, the patient was admitted through the emergency room.

2 Urgent The patient required immediate attention for the care and treatment of a physical or mental disorder. Patient admitted to first available accommodation.

3 Elective The patient’s condition permitted adequate time to schedule the availability of a suitable accommodation.

4 Newborn Need to use a special source of admission codes. 5 Trauma Center Centers licensed by the state 9 Information not

available The hospital cannot classify the type of admission. (Rarely used)

FL20 – Source of Admission Required – Source of admission or outpatient registration

Code Source of Admission 1 Physician Referral 2 Clinic Referral 3 HMO referral 4 Transfer from a Hospital 5 Transfer from a SNF 6 Transfer from another Health Care Facility 7 Emergency Room 8 Court/Law Enforcement 9 Information Not Available A Transfer from a Critical Access Hospital B Transfer from another Home Health Agency C Readmission to Same Home Health Agency period

D-Z Reserved for national assignment

FL21 – Discharge Hour Not Required



FL22 – Patient Status Required – for inpatient, outpatient, HHA, and SNF.

Code Patient Status 01 Discharged to home or self care (routine discharge) 02 Discharged/transferred to another short-term general hospital for inpatient

care 03 Discharged/transferred to SNF. (for swing bed, use code 61) 04 Discharged/transferred to an Intermediate Care Facility 05 Discharged/transferred to another type of institution 06 Discharged/transferred to home under care of HH 07 Left against medical advice or discontinued care 08 Discharged/transferred to home under care of a home IV drug therapy

provider 09 Admitted as an inpatient to this hospital

Note: When a patient is admitted before midnight of the third day following the day of an outpatient service, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services that began longer than 3 days earlier, such as observation following outpatient surgery, which results in admission.

20 Expired or did not recover 30 Still patient 40 Expired at home (hospice only) 41 Expired in medical facility 42 Expired, place unknown (hospice only) 43 Discharge/transferred to a federal facility

44-49 Reserved for national assignment 50 Hospice – home

52-60 Reserved for national assignment 61 Discharged/transferred within this institution to a hospital-based Medicare

approved swing bed 62-70 Reserved for National Assignment 73-99 Reserved for National Assignment

FL23 – Medical Record Number Required. This is the number assigned to the patient’s medical/health record by the provider. If the provider enters a number, you must carry the number through your system and return it to the provider.



FL24 - FL30 – Condition Codes Required.

Code Condition Definition 02 Condition is employment

related Code indicates patient alleges that the medical condition in this episode of care is due to environments/events resulting from employment

04 Patient is HMO Enrollee Bill submitted for information only 05 Lien has been filed Provider has filed legal claim for recovery of funds

potentially due to a patient as a result of legal action initiated by or on behalf of a patient.

06 ESRD patient in first 30 months; covered by employer group health insurance

Code indicates that Medicare may be a secondary insurer.

07 Treatment of nonterminal condition for hospice

Code indicates patient has elected hospice but the provider is not treating the terminal condition.

08 Beneficiary would not provide information concerning other insurance coverage

Same

09 Neither patient nor spouse employed

Patient and spouse have denied employment.

10 Patient and/or spouse is employed but no EGHP coverage exists

There is no group health insurance from an EGHP or other health insurance that covers the patient,

11 Disabled beneficiary but no LGHP

There is no group health insurance from an LGHP or other health insurance that covers the patient.

12-14 Payer codes Reserved for internal use only by third party payer. 15 Clean claim delayed in

HCFA’s (CMS’s) processing system (payer code only)

CMS delayed claim processing. Interest is applicable.

16 SNF Transition Exemption (Medicare payer only code)

Code indicates an exemption from the post-hospital requirements applies for this SNF stay or the qualifying stay dates are more than 30 days prior to admission.

20 Beneficiary requested billing Provider realizes the services on this bill are not covered but the beneficiary has requested a formal determination.

21 Billing for denial notice Provider realizes the services on this bill are not covered, but requests a denial notice from Medicare in order to bill Medicaid or other insurer.

26 VA eligible patient chooses to receive services in a Medicare certified facility

Same

27 Patient referred to a sole community hospital for a diagnostic lab test

Sole community hospital only.



Code Condition Definition 28 Patient and/or spouse’s EGHP

is secondary to Medicare Code indicates that either the EGHP is a single employer plan and the employer has fewer than 20 full and part-time employees or the EGHP is multi-or multiple employers’ plan that elects to pay secondary to Medicare for employees and spouses aged 65 and older for those participating employers who have fewer than 20 employees.

29 Disabled beneficiary and/or family member’s LGHP is secondary to Medicare

Code indicates that either the EGHP is a single employer plan and the employer has few than 100 full and part-time employees or the LGHP is a multi- or multiple employer plans and that all employers participating in the plan have fewer than 100 full and part-time employees.

30 Qualifying clinical trials Non-research services provided to all patients enrolled in qualified clinical trials.

31 Patient is a full-time day student

Same

32 Patient is a cooperative work study student

Same

33 Patient is a full-time night student

Same

34 Patient is a part-time student Same 35 Reserved for national assignment 36 General Care Patient in a

special unit (Not used by hospitals under PPS) Patient placed in special unit in that no general beds were available.

37 Ward accommodation at patient’s request

(Not used by hospitals under PPS) Patient assigned to ward.

38 Semi-private room not available

(Not used by hospitals under PPS) Patient assigned to ward; no semi-private room available.

39 Private room medical necessary

(Not used by hospitals under PPS) Assignment to private room was medically necessary.

40 Same day transfer Patient transferred from one provider to another before midnight on the day of admission

41 Partial Hospitalization For partial hospitalization. For outpatient this includes a variety of psychiatric programs

42 Continuing care not related to inpatient admission

Continuing care plan is not related to condition or diagnosis

43 Continuing care not provided within prescribed post-discharge window

Continuing care plan was related to the inpatient admission but the prescribed care was not provided within the post-discharge window.

55 SNF bed not available SNF admission was delayed more than 30 days after hospital discharge because a SNF bed was not available.

56 Medical appropriateness SNF admission was delayed more than 30 days after hospital discharge because the patient’s condition made it inappropriate to begin active care within that period.



Code Condition Definition 57 SNF readmissions Patient previously received Medicare covered SNF

care within 30 days of the current SNF admission. 58 Terminated Medicare+Choice

Organization enrollee Code indicates that the patient is a terminated enrollee in a Medicare+Choice Organization plan whose three-day inpatient hospital stay was waived.

59 Reserved for national assignment 60 Operating cost day outlier Pricer indicates this bill is a length-of-stay outlier 61 Operating cost outlier Pricer indicates this bill is a cost 62 PIP bill Bill was paid under PIP 63 Payer only code Code reserved for internal use only. 64 Other than clean claim Claim is not “clean”. 65 Non-PPS bill Bill is not a PPS bill. 66 Provider does not wish cost

outlier payment Hospital paid under PPS and is not requesting additional payment as a cost outlier for this stay.

67 Beneficiary elects not to use Lifetime Reserve Days

Same

68 Beneficiary elects to use Lifetime Reserve Days

Same

69 IME/DGME/N&A payment only A request for supplemental payment from Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health

70 Self-administered EPO Code indicates the billing is for a dialysis patient who self-administers EPO.

71 Full Care in unit Patient who receives staff-assisted dialysis services 72 Self-Care in unit Patient who manages his/her own dialysis services

without staff assistance. 73 Self-Care training Billing is for special dialysis services where the

patient and his/her helper were learning to perform dialysis.

74 Home Billing for a patient who received dialysis services at home.

75 Home 100 percent payment Not to be used for services after April 16, 1990 76 Back-up facility dialysis Billing is for a home dialysis patient who received

back-up dialysis in a facility 77 Provider accepts or is

obligated/required due to a contractual arrangement by law to accept payment by a primary payer as payment in full.

No Medicare payment is due.

78 New coverage not implemented by HMO

Medicare newly covered service for which an HMO does not pay

79 CORF services provided off site

Occupational, physical, and speech therapy were provided off site.

A0 Special zip code reporting Five digit zip code of the location from which the beneficiary is initially placed on board the ambulance.



Code Condition Definition A3 Special Federal funding Code is designed for uniform use by State uniform

billing committee. A5 Disability Same as above A6 PPV/Medicare

Pneumonia/Influenza 100% Paid under a special Medicare program provision.

A7 Induced abortion-danger to life An abortion was performed to avoid danger to a women’s life.

A8 Induced abortion – victim of rape/incest

Discontinued October 1, 2002.

A9 Second opinion surgery Services requested to support second opinion in surgery. Part B deductible and coinsurance do not apply.

AA Abortion performed due to rape

Self-explanatory

AB Abortion performed due to incest

Self-explanatory

AC Abortion performed due to serious fetal genetic defect, deformity, or abnormality

Self-explanatory

AD Abortion performed due to a life endangering physical condition caused by, arising from or exacerbated by the pregnancy itself

Self-explanatory

AE Abortion performed due to physical health of mother that is not life endangering

Self-explanatory

AF Abortion performed due to emotional/psychological health of the mother

Self-explanatory

AG Abortion performed due to social economic reasons

Self-explanatory

AH Elective abortion Self-explanatory AI Sterilization Self-explanatory AJ Payer responsible for co-

payment Self-explanatory

AK Air ambulance required For ambulance claims AL Specialized treatment bed

unavailable For ambulance claims

AM Non-emergency medically necessary stretcher transport required

For ambulance claims

AN-AZ Reserved for national assignment



Code Condition Definition B0 Medicare Coordinate Care

Demonstration Program Self-explanatory

B1 Beneficiary is ineligible for Demonstration Program

Full definition pending

B2 Critical Access Hospital Ambulance Attestation

Attestation that CAH meets the criteria for exemption from the ambulance fee schedule.

B3 Pregnancy indicator Indicates patient is pregnant. B4-BZ Reserved for National

Assignment

M0 All-inclusive rate for outpatient Payer only code. Used by a CAH electing to be paid an all-inclusive rate for outpatient services

M1 Roster billed influenza virus vaccine or pneumonia vaccine

Payer only code. For providers that mass immunize.

M2 HHA payment significantly exceeds total charge

Payer only code. Charges in excess of covered billed charges.

C1 Approved as billed PRO review and fully approved all days and any outliers.

C3 Partial approval PRO review and some portion of stay denied C4 Admission denied PRO review and none of stay was medically

necessary. C5 Postpayment review PRO review after admission stay C6 Preadmission or preprocedure PRO authorized admission but has not reviewed the

services provided. C7 Extended authorization PRO authorized admission for an extended length of

time but has not reviewed the services provided. D0 Changes to service date Self-explanatory D1 Changes to charges Self-explanatory D2 Changes to revenue

codes/HCPCs/rate codes Changes in codes

D3 Second or subsequent interim PPS bill

Self-explanatory

D4 Change in ICD-9-CM diagnosis and/or procedure code

Change in codes

D5 Cancel to correct HICN or provider ID

Cancel only to correct an HICN or provider ID number

D6 Cancel only to repay a duplicate or OIG overpayment

Self-explanatory

D7 Change to make Medicare the secondary payer

Self-explanatory

D8 Change to make Medicare the primary payer

Self-explanatory

D9 Any other change Self-explanatory E0 Change in patient status Self-explanatory

E1-E9 Reserved for national assignment



Code Condition Definition G0 Distinct medical visit Report this code when multiple medical visits

occurred on the same day in the same revenue. Each visit was distinct.

G1-G9 Reserved for national assignment H0 Delayed filing, statement of Code indicates that Statement of Intent was

intent submitted specially submitted within the qualifying period to identify the existence of another third party liability situation.

FL31 – (Untitled) Not required.

FL32 - FL35 – Occurrence Codes and Dates Required. Event codes are two alphanumeric characters, and dates are shown as six numeric digits (MMDDYY).

Note: Occurrence and occurrence span codes are mutually exclusive. Occurrence codes values are 01 through 69 and A0 through L9.

Code Occurrence Definition 01 Accident/Medical coverage Available medical payment coverage. Include date of

accident/injury 02 No-fault insurance involved,

including auto accident/other State has applicable no-fault or liability laws (legal basis for settlement without admission or proof of guilt)

03 Accident/Tort Liability Third party’s action may involve a civil court process in an attempt to require payment by third party.

04 Accident/employment related Date of accident related to patient’s employment 05 Accident/No medical or liability

coverage There is no medical payment or third-party liability coverage. Include date of accident/injury

11 Onset of symptoms/illness When the patient first became aware of symptoms/illness

12 Date of onset for a chronically dependent individual

HHA claim only. This is the first month of the 3 month period immediately prior to eligibility under respite care benefit

16 Date of last therapy Last day of physical, occupational or speech therapy. 18 Date of retirement, patient

beneficiary Self-explanatory

19 Date of retirement ,spouse Self-explanatory 20 Guarantee of payment began Part A claim only. Date provider began claiming

payment under the guarantee of payment provision.



Code Occurrence Definition 21 UR notice received Part A SNF claims only. Admission or further stay was

not medically necessary. 22 Date active care ended Date covered level of care ended. Code is not

required if code “21” is used. 23 Date of cancellation of hospice

election period For intermediary use only

24 Date insurance denied Receipt date of denial of coverage by a higher priority payer

25 Date benefits terminated by primary payer

Date on which coverage no longer available to patient.

26 Date SNF bed available Date SNF bed available to hospital inpatient. 27 Date of hospice certification or

re-certification Date of certification for hospice benefit period.

28 Date CORF plan established or last reviewed

Date the plan of treatment was established or reviewed for CORF care.

29 Date OPT plan established or last reviewed

Date a plan was established or last reviewed for OPT.

30 Date outpatient speech pathology plan established or last reviewed

Data a plan was established or last reviewed for outpatient speech therapy.

31 Date beneficiary notified of intent to bill (accommodations)

Date of notice provided by the hospital to the patient that inpatient care is not longer required.

32 Date beneficiary notified of intent to bill (procedures or treatments)

Date of notice provided to the beneficiary that requested care may not be reasonable or necessary under Medicare.

33 First day of the Medicare coordination period for ESRD, beneficiaries covered by an EGHP

Required only for ESRD beneficiaries.

34 Date of election of extended care services

Date the guest elected to receive extended care services

35 Date treatment started for physical therapy

Self-explanatory

36 Date of inpatient hospital discharge for transplant procedure

Date of discharge for inpatient in which patient received a transplant procedure when the hospital is billing for immunosuppressive drugs.

37 Date of inpatient hospital discharge, non-covered transplant patient

Date of discharge for inpatient which the patient received a non-covered transplant procedure when the hospital is billing for immunosuppressive drugs.

41 Date of first test for pre-admission testing

Date on which the first outpatient diagnostic test was performed as part of a PAT program.

42 Date of discharge (hospice claims only) Date beneficiary terminated his/her election to receive benefits.

43 Schedule date of canceled surgery

Date for which ambulatory surgery was scheduled.

44 Date treatment started for occupational therapy

Self-explanatory



Code Occurrence Definition 45 Date treatment started for

speech therapy Self-explanatory

46 Date treatment started for cardiac rehabilitation

Self-explanatory

47 Date cost outlier status begins First day the inpatient cost outlier threshold is reached.

48-49 Payer codes A1 Birthdate – Insured A Birth date of insured in whose name the insurance is

carried. A2 Effective date – insured A

policy First date the insurance is in force.

A3 Benefits exhausted Last date for which benefits are available and after which no payment can be made.

A4 Split bill date Date patient became Medicaid eligible due to medically needy spend down. Also called “split bill date”.

B1 Birthdate – Insured B Birth date of individual in whose name the insurance is carried.

B2 Effective date – insured B policy

First date the insurance is in force.

B3 Benefits exhausted Last date for which benefits are available and after which no payment can be made.

C1 Birthdate – Insured C Birth date of insured in whose name the insurance is carried.

C2 Effective date – insured C policy

First date the insurance is in force.

C3 Benefits exhausted Last date for which benefits are available and after which no payment can be made.

C4-C9 Reserved for National Assignment

D0-D9 Reserved for National Assignment

FL36 – Occurrence Span Code and Dates Required. Event codes are two alphanumeric characters, and dates are shown numerically as MMDDYY.

Note: Occurrence and occurrence span codes are mutually exclusive. Occurrence span codes values are 70 through 99 and M0 through Z9.



Code Occurrence Span Definition 70 Qualifying stay dates Part A claims for SNF level care only

Hospital stay of at least 3 days which qualifies the patient for payment of SNF level of care

71 Nonutilization dates (for payer use on hospital bills only)

PPS inlier stays for which beneficiary had exhausted all regular days and/or coinsurance days.

72 Prior stay dates Part A claims only. Code indicates from/through dates given by the patient for any hospital stay that ended within 60 days of this hospital or SNF admission.

73 First/last visit Actual dates of the first and last visit occurring in this billing period where thee dates are different from those in FL6.

74 Noncovered level of care From/through dates for a period of at a noncovered level of care in an otherwise covered stay.

75 SNF level of care From/through dates for a period of SNF level of care during an inpatient hospital stay.

76 Patient liability From/through dates for a period of noncovered care for which the hospital is permitted to charge the beneficiary.

77 Provider liability – utilization charged

From/through dates for a period of noncovered care for which the provider is liable.

78 SNF prior stay dates Part A claims only. From/through dates given by the patient for a SNF stay that ended within 60 days of this hospital or SNF admission.

79 Payer code For payer use only. M0 PRO/UR stay dates If a code “C3” is in FLs 24-30, the from and through

dates of the approved billing period are here. M1 Provider liability – no

utilization From/through dates of a period of noncovered care that is denied due to lack of medical necessity or as custodial care for which the provider is liable.

M2 Dates of inpatient respite care From/through dates of a period of intermediate level of care

M4 Residential level of care From and through dates of a period of residential careM5-WZ Reserved for National

Assignment

FL37 – Internal Control Number (ICN)/Document Control Number (DCN)

Required. The control number assigned to the original bill needs to be documented in this field. All providers requesting an adjustment to a previously processed claim insert the ICN/DCN of the claim to be adjusted.



FL38 – (Untitled Except on Patient Copy of the Bill) Responsible Party Name and Address

Not Required.

FL39 - FL41 – Value Codes and Amounts Required. Code(s) and related dollar amount(s) identify data of a monetary nature that are necessary for the processing of this claim. The codes are two alphanumeric characters, and each value allows up to nine numeric digits.

Negative amounts are not allowed except in FL 41. Whole numbers or non-dollar amounts are right justified to the left of the dollars and cents delimiter. Some values are reported as cents.

If more than one value code is shown for a billing period, codes are shown in ascending alphanumeric sequence. There are four lines of data, line “A” through line “D”.

Code Title Definition 04 Inpatient professional component

charges which are combined billed

Code indicates the amount shown is the sum of the inpatient professional component charges which are combined billed. (Used only by some all-inclusive rate hospitals)

05 Professional component included in charges and also billed separately to Carrier

Code indicates the charges shown are included in billing charges (column 53) but a separate billing for them will also be made to the Carrier. For outpatient claims, these charges are excluded in determining the deductible and coinsurance due from the patient to avoid duplication when the bill for physician’s services is processed by the Carrier. These charges are also deducted when computing interim payment.

06 Medicare Part A and Part B blood deductible

Code indicates the amount shown is the product of the number of unreplaced deductible pints of blood supplied times the charge per pint.

08 Medicare lifetime reserve amount for first calendar year in billing period

Code indicates the amount shown is the product of the number of lifetime reserve days used in the first calendar year of the billing period times the applicable lifetime reserve coinsurance rate. These are days used in the year of admission.

09 Medicare coinsurance amount for first calendar year in billing period

On Part A bills, this code indicates the amount shown is the product of the number of coinsurance days used in the first calendar year of the billing period times the applicable coinsurance rate. This code is not used on Part B bills.



Code Title Definition 10 Medicare lifetime reserve amount

for second calendar year in the billing period.

Code indicates the amount shown is the product of the number of lifetime reserve days used in the 2nd calendar year of the billing period times the applicable lifetime reserve rate. The code is used only for stays spanning two calendar years when lifetime reserve days were used in the year of discharge.

11 Medicare Coinsurance Amount for second calendar year in billing period

On Part A bills, this code indicates the amount shown is the product of the number of coinsurance days used in the second calendar year of the billing period the applicable coinsurance rate. This code is used only for stays spanning two calendar years when coinsurance days were used in the year of discharge. This code is not used on Part B bills.

12 Working aged beneficiary/spouse with an EGHP

Code indicates the amount shown is that portion of a higher priority EGHP payment made on behalf of an aged beneficiary that the provider is applying to cover. If six zeros are entered in the amount field, the provider is claiming a conditional payment because the EGHP has denied coverage.

13 ESRD beneficiary in a Medicare coordination period with an EGHP

Code indicates the amount shown is that portion of a higher priority EGHP payment made on behalf of an ESRD beneficiary that the provider is applying to covered Medicare charges on the bill.

14 No-Fault, including auto/other insurance

Code indicates the amount shown is that portion of a higher priority no-fault including auto/other insurance payment made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges on this bill. If six zeros are entered in the amount field, the provider is claiming a conditional payment because the other insurance has denied coverage or there has been a substantial delay in its payment.

15 Worker’s Compensation Codes indicates the amount shown is that portion of a higher priority WC payment made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges. If six zeros are entered in the amount field, the provider is claiming a conditional payment because there has been a substantial delay in the other payer’s payment.

16 PHS, other Federal agency Code indicates the amount shown is that portion of a higher priority PHS or other Federal agency’s payment made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges.

17 Operating Outlier amount Codes indicates the amount shown is that portion of a higher priority PHS or other Federal agency’s payment made on behalf of a Medicare beneficiary that the provider is applying to covered Medicare charges.



Code Title Definition 18 Operating disproportionate share

amount (Not reported by providers). Report operating indirect medical education amount applicable with this code. Use the amount indicated in the pricer.

19 Operating indirect medical education amount

(Not reported by providers). Report operating indirect medical education amount applicable with this code. Use the amount indicated in the pricer.

31 Patient liability amount Code indicates the amount show is that which was approved by you or the PRO to charge the beneficiary for noncovered accommodations, diagnostic procedures or treatments.

32 Multiple patient ambulance transport

If more than one patient is transported in a single ambulance trip, report the total number of patients transported.

37 Pints of blood furnished Code indicates the total number of pints of whole blood or units of packed red cells furnished, whether or not they were replaced.

38 Blood deductible pints Code indicates the number of unreplaced deductible pints of blood supplied. If all deductible pints furnished have been replaced, no entry is made.

39 Pints of blood replaced Code indicates the total number of pints of blood which were donated on the patient’s behalf.

40 New coverage not implemented by HMO

(For inpatient services only). Code indicates the amount shown for inpatient charges covered by HMO.

41 Black lung Code indicates the amount shown is that portion of a higher priority BL payment made on behalf of a Medicare beneficiary that the provider is applying to Medicare charges on this bill. If six zeros are entered in the amount field, the provider is claiming a conditional payment because there has been a substantial delay in its payment.

42 Veterans Affairs Code indicates the amount shown is that portion of a higher priority VA payment made on behalf of a disabled beneficiary that the provider is applying to Medicare charges on this bill.

43 Disable beneficiary under age 65 with LGHP

Code indicates the amount shown is that portion of a higher priority LGHP payment made on behalf of a disabled beneficiary that the provider is applying to Medicare charges on this bill.

44 Amount provider agreed to accept from primary payer when this amount is less than charges but higher than payment received

Code indicates the amount shown is the amount the provider was obligated or required to accept from a primary payer as payment in full when that that amount is less than the charges but higher than amount actually received. A Medicare secondary payment is due.

46 Number of grace days A code “C3” or “C4” is in FL 24-30 (condition code) indicating that the PRO has denied all or a portion of the billing period.



Code Title Definition 47 Any liability insurance Code indicates amount shown is that portion from a

higher priority liability insurance made on behalf of a Medicare beneficiary that the provider is applying to Medicare covered services on this bill. If six zeros are entered in the amount field, the provider is claiming conditional payment because there has been substantial delay in the other payer’s payment.

48 Hemoglobin reading Code indicates the latest hemoglobin reading taken during this billing cycle. This is usually reported in three positions (a percentage) to the left of the dollar/cent delimiter. If the reading is provided with a decimal, use the position to the right of the delimiter for the third digit.

49 Hematocrit reading Code indicates the latest hematocrit reading taken during this billing cycle. This is usually reported in two positions (a percentage) to the left of the dollar/cent delimiter. If the reading is provided with a decimal, use the position to the right of the delimiter for the third digit.

50 Physical therapy visits Code indicates the number of physical therapy visits from onset through this billing period.

51 Occupational therapy visits Code indicates the number of occupational therapy visits from onset through this billing period.

52 Speech therapy visits Code indicates the number of speech therapy visits from onset through this billing period.

53 Cardiac rehabilitation visits Code indicates the number of cardiac rehabilitation visits from onset through this billing period.

54 Newborn birth weight in grams Actual birth weight or weight at time of admission for an extramural birth. Required on all claims with type of admission of 4 and on other claims as required by state law.

55 Eligibility threshold for charity care

Code identifies the corresponding value amount at which a health care facility determines the eligibility threshold for charity care.

56 Skilled nurse-home visit hours (HHA only)

Number of skilled hours during the billing period. Count only hours spent in the home. Exclude travel time. Report in hours.

57 Home health aide-home visit hours (HHA only)

Number of hours of home health aide services provided during the billing period. Count only hours spent in the home. Exclude travel time. Report in hours.

58 Arterial blood gas (PO2/PA2) Code indicates arterial blood gas value at the beginning of each reporting period for oxygen therapy.

59 Oxygen saturation (02 Sat/oximetry)

Code indicates oxygen saturation at the beginning of each reporting period for oxygen therapy.

60 HHA branch MSA Code indicates MSA in which HHS branch is located.



Code Title Definition 61 Location where service is

furnished (HHA and hospice) MSA number (or rural state code) of the location where the home health or hospice service is delivered.

62-65 Payer codes only 66 Medicaid spend down amount The dollar amount that was used to meet the

recipient’s spend down liability for this claim 67 Peritoneal dialysis The number of hours of peritoneal dialysis provided

during the billing period. 68 Number of units of EPO provided

during the billing period Self-explanatory. Reported in whole units.

69 State charity care percent Code indicates the percentage of charity care eligibility for the patient. Report the whole number.

70 Interest amount (For internal use by third party payers only) 71 Funding of ESRD networks (For internal use by third party payers only) 72 Flat rate surgery charge Code indicates the amount of the standard charge

for outpatient surgery where the hospital has such a charging structure.

75 Gramm/Rudman/Hollings (For internal use by third party payers only) 76 Provider’s interim rate (For internal use by third party payers only) Report

the provider’s percentage of billed charges interim rate during this period.

77-79 Payer codes A0 Special zip code reporting Five digit zip code of the location from which the

beneficiary is initially placed on board the ambulance.

A1 Deductible Payer A The amount assumed by the provider to be applied to the patient’s deductible amount involving the indicated payer.

A2 Coinsurance Payer A The amount assumed by the provider to be applied to the patient’s coinsurance amount involving the indicated payer.

A3 Estimated responsibility Payer A The amount estimated by the provider to be paid by the indicated payer.

A4 Covered self-administrable drugs-emergency

The amount included in covered charges for self-administrable drugs administered to the patient in an emergency situation.

A5 Covered self-administrable drugs – not self-administrable in form and situation furnished to patient

The amount included in covered charges for self-administrable drugs administered to the patient because the drug was not self-administrable in the form and situation in which it was furnished to the patient.

A6 Covered self-administrable drugs – diagnostic study and other

The amount included in covered charges for self-administrable drugs administered to the patient because the drug was necessary for diagnostic study or other reason.

A7 Co-payment A The amount assumed by the provider to be applied toward the patient’s coinsurance amount involving the indicated payer.



Code Title Definition A8-A9 Reserved for National Assignment

AA Regulatory surcharges, assessments, allowances or health care related taxes Payer A

Self-explanatory

AB Other assessments or allowances (e.g., Medical Education), Payer A

Self-explanatory

AC-AZ Reserved for National Assignment B1-C0 B1-C0 is the same as Payer A except for Payer B. C1-DZ C1-DZ is the same as Payer A except for Payer C E0-F0 E0-F0 is the same as Payer A except for Payer D F1-GB F1-GB is the same as Payer A except for Payer E GC-GZ Reserved for National Assignment H0-WZ Reserved for National Assignment X0-ZZ Reserved for National Assignment

FL42 – Revenue Code Required. For each cost center for which a separate charge is billed (type of accommodation or ancillary), a revenue code is assigned.

Additionally, there is no fixed “Total” line in the charge area. Instead, revenue code “0001” is always entered last in FL 42. Zero level billing is encouraged for all services which do not require HCPC codes.

Code Title/Definition 0001 Total Charge

For use on paper claims only. For electronic transactions, report the total charge in the appropriate data segment/field.

001X Reserved for internal payer use 002X Health Insurance Prospective Payment System

Subcatetory 0 – Reserved 1 – Reserved 2 – Skilled Nursing Facility PPS 3 – Home Health PPS 4 – Inpatient Rehabilitation Facility PPS 5-9 – Reserved

003X to 006X Reserved for national assignment 007X to 009X Reserved for state use.



Code Title/Definition 010X All Inclusive Rate

Flat fee charge incurred on either a daily basis or total stay basis for services rendered. Charge may cover room and board plus ancillary services or room and board only. Subcategory 0 – All-inclusive room and board plus ancillary 1 – All-inclusive room and board

011X Room & Board – Private (Medical or General) Routine service charges for single bed rooms. Most payers require private rooms to be separately identified. Subcategory 0 – General Classification 1 – Medical/Surgical/Gyn 2 – OB 3 – Pediatric 4 – Psychiatric 5 – Hospice 6 0 Detoxification 7 – Oncology 8 – Rehabilitation 9 – Other

012X Room & Board – Semi-private two bed (Medical or General) Routine service chares incurred for accommodations with two beds. Most payers require that semi-private rooms be identified. Subcategory 0 – General Classification 1 – Medical/Surgical/Gyn 2 – OB 3 – Pediatric 4 – Psychiatric 5 – Hospice 6 – Detoxification 7 – Oncology 8 – Rehabilitation 9 – Other

013X Semi-Private – Three and Four BedsSubcategory 0 – General Classification 1 – Medical/Surgical/Gyn 2 – OB 3 – Pediatric 4 – Psychiatric 5 – Hospice 6 – Detoxification 7 – Oncology 8 – Rehabilitation 9 – Other



Code Title/Definition 014X Private (Deluxe)

Deluxe rooms are accommodations with amenities substantially in excess of that provider to other patients... Subcategory 0 – General Classification 1 – Medical/Surgical/Gyn 2 – OB 3 – Pediatric 4 – Psychiatric 5 – Hospice 6 – Detoxification 7 – Oncology 8 – Rehabilitation 9 – Other

015X Room & Board Ward (Medical or General)Routine service charge for accommodations with five or more beds. Subcategory 0 – General Classification 1 – Medical/Surgical/Gyn 2 – OB 3 – Pediatric 4 – Psychiatric 5 – Hospice 6 – Detoxification 7 – Oncology 8 – Rehabilitation 9 – Other

016X Other Room & BoardAny routine service charges for accommodations that cannot be included in the more specific revenue codes. Subcategory 0 – General Classification 4 – Sterile Environment 7 – Self Care 9 - Other

017X NurseryCharges for nursing care to newborn and premature infants in nurseries. Subcategory 0 – General Classification 1 – Newborn, Level I – Routine care 2 – Newborn, Level II – Low-birth-weight neonates who are not sick but require frequent feeding and care 3 – Newborn , Level III – Sick neonates who do not require intensive care, but require 6-12 hours of nursing care 4 – Newborn, Level IV – Constant nursing and continuous cardiopulmonary and other support for severely ill infants 9 – Other



Code Title/Definition 018X Leave of Absence

Charges (including zero charges) for holding a room while the patient is temporarily away from the provider. Charges are billable for codes 2-5. Subcategory 0 – General Classification 1 – Reserved 2 – Patient Convenience 3 – Therapeutic Leave 4 – ICF Mentally Retarded – any reason 5 – Nursing Home (hospitalization) 9 – Other leave of absence

019X Subacute CareSubcategory 0 – General Classification 1 – Subacute Care, Level I – Skilled Care (minimal nursing intervention) 2 – Subacute Care, Level II – Comprehensive Care (Moderate to extensive nursing intervention) 3 – Subacute Care, Level III – Complex Care (Moderate to extensive nursing intervention) 4 – Subacute Care, Level IV – Intensive Care (Extensive nursing and technical intervention) 9 – Other Subacute Care

020X Intensive CareSubcategory 0 – General Classification 1 – Surgical 2 – Medical 3 – Pediatric 4 – Psychiatric 6 – Intermediate ICU 7- Burn Care 8 – Trauma 9 – Other Intensive Care

021X Coronary Care Subcategory 0 – General Classification 1 – Myocardial infarction 2 – Pulmonary Care 3 – Heart Transplant 4 – Intermediate CCU 9 – Other Coronary Care



Code Title/Definition 022X Special Charges

Some hospitals prefer to break out charges that are normally considered part of routine services. Subcategory 0 – General Classification 1 – Admission Charge 2 – Technical Support Charge 3 – U.R. Service Charge 4 – Late Discharge, medically necessary 9 – Other Special Charge

023X Incremental Nursing Charge RateCharge for nursing service assessed in addition to room and board Subcategory 0 – General Classification 1 – Nursery 2 – OB 3 – ICU (includes transitional care) 4 – CCU (includes transitional care) 5 – Hospice 9 – Other

024X All Inclusive AncillaryA flat rate charge incurred on either a daily basis or total stay basis for ancillary services only. Subcategory 0 – General Classification 1 – Basic 2 – Comprehensive 3 – Specialty 9 – Other All Inclusive Ancillary

025X Pharmacy Code indicates the charges for medication produced, manufactured, packaged, controlled, assayed, dispensed, and distributed under the direction of a licensed pharmacist. Subcategory 0 – General Classification 1 – Generic Drugs 2 – Nongeneric Drugs 3 – Take Home Drugs 4 – Drugs Incident to Other Diagnostic Services 5 – Drugs Incident to Radiology 6 – Experimental Drugs 7 – Nonprescription 8 – IV Solutions 9 – Other Pharmacy



Code Title/Definition 026X IV Therapy

Code indicates the administration of intravenous solution by specialty trained personnel to individuals requiring such treatment. Subcategory 0 – General Classification 1 – Infusion Pump 2 – IV Therapy/Pharmacy Services 3 – IV Therapy/Drug/Supply/Delivery 4 – IV Therapy/Supplies 9 – Other IV Therapy

027X Medical/Surgical SuppliesSubcategory 0 – General Classification 1 – Nonsterile Supply 2 – Sterile Supple 3 – Take Home Supplies 4 – Prosthetic/Orthotic Devices 5 – Pacemaker 6 – Intraocular Lens 7 – Oxygen-Take Home 8 – Other Implants

028X OncologySubcategory O – General Classification 9 – Other Oncology

029X Durable medical Equipment (DME) (Other than Rental) Equipment that can stand repeated use. Subcategory 0 – General Classification 1 – Rental 2 – Purchase of new DME 3 – Purchase of used DME 4 – Supplies/Drugs for DME Effectiveness (HHAs only) 9 – Other Equipment

030X LaboratorySubcategory 0 – General Classification 1 – Chemistry 2 – Immunology lab 3 – Renal patient (Home) 4 – Nonroutine Dialysis 5 – Hematology 6 – Bacteriology & Microbiology 7 – Urology 9 – Other Laboratory



Code Title/Definition 031X Laboratory Pathological

Tests on tissues and cultures. Subcategory 0 – General Classification 1 – cytology 2 – Histology 4 – Biopsy 9 - Other

032X Radiology – DiagnosticIncludes taking, processing, examining, and interpreting radiographs and fluorographs. Subcategory 0 – General Classification 1 – Angiocardiography 2 – Arthrography 3 – Arteriography 4 – Chest X-ray 9 – Other

033X Radiology – TherapeuticIncludes injection or ingestion of radioactive substances. Subcategory 0 – General Classification 1 – Chemotherapy – Injected 2 – Chemotherapy – oral 3 – Radiation Therapy 4 – Chemotherapy – IV 9 – Other

034X Nuclear MedicineSubcategory 0 – General Classification 1 – Diagnostic 2 – Therapeutic 9 – Other

035X CT ScanDue to coverage limitations, some insurers require that the specific test be identified. Subcategory 0 – General Classification 1 – Head Scan 2 – Body Scan 0 – Other CT Scan

036X Operating RoomSubcategory 0 – General Classification 1 – Minor Surgery 2 – Organ Transplant – other than kidney 7 – Kidney Transplant 9 – Other



Code Title/Definition 037X Anesthesia

Subcategory 0 – General Classification 1 – Anesthesia Incident to Radiology 2 – Anesthesia Incident to other Diagnostic Services 4 – Acupuncture 9 – Other Anesthesia

038X BloodCharges for blood must be separately identified. Subcategory 0 – General Classification 1 – Packed Red Cells 2 – Whole Blood 3 – Plasma 4 – Platelets 5 – leucocytes 6 – Other Components 7 – Other Derivatives (Cryopricipitates) 9 – Other

039X Blood Storage and processing Subcategory 0 – General Classification 1 – Blood Administration (transfusion) 9 – Other Processing & Storage

040X Other Imaging Services Subcategory 0 – General Classification 1 – Diagnostic mammography 2 – Ultrasound 3 – Screening Mammography 4 – Positron Emission Tomography 9 – Other Imaging Services

041X Respiratory ServicesSubcategory 0 – General Classification 1 – Inhalation Services 2 – Hyperbaric Oxygen Therapy 9 – Other Respiratory Services

042X Physical Therapy Charges for therapeutic exercises, massage, and utilization of effective properties of light, heat, cold, water, electricity, and assistive devices for diagnosis and rehabilitation of patients who have neuromuscular, orthopedic, and other disabilities. Subcategory 0 – General classification 1 – Visit Charge 2 – Hourly charge 3 – Group Rate 4 – Evaluation or Re-evaluation 9 – Other Physical Therapy



Code Title/Definition 043X Occupational Therapy

Services provided by a qualified occupational therapy practitioner for therapeutic interventions to improve, sustain, or restore an individual’s level of function in performance of activities of daily living and work, including, therapeutic activities, therapeutic exercises, sensorimotor processing, psychosocial skills training, cognitive retraining, fabrication and application of orthotic devices, and training in the use of orthotic and prosthetic devices, adaptation of environments, and application of physical agent modalities. Subcategory 0 – General Classification 1 – Visit Charge 2 – Hourly Charge 3 – Group Rate 4 – Evaluation or Re-evaluation 9 – Other

044X Speech-Language Pathology Subcategory 0 – General Classification 1 – Visit Charge 2 – Hourly Charge 3 – Group Rate 4 – Evaluation or Re-evaluation 9 – Other

045X Emergency Room Under the provisions of EMTALA (Emergency Medical Treatment and Active Labor Act), a hospital with an emergency department must provide upon request and within the capabilities of the hospital an appropriate medical screening examination and stabilizing treatment to any individual with an emergency medical condition and to any woman in active labor, regardless of the individual’s eligibility for Medicare. Observation or “hold beds” are not reported under this code. They are reported under revenue code 762. Subcategory 0 – General Classification 1 – EMTALA Emergency Medical screening services 2 – ER beyond EMTALA Screening 6 – Urgent Care 9 - Other

046X Pulmonary Function Charges for tests that measure inhaled and exhaled gases and analysis of blood and for tests that evaluate the patient’s ability to exchange oxygen and other gases. Subcategory 0 – General Classification 9 – Other



Code Title/Definition 047X Audiology

Charges for the detection and management of communication handicaps centering in whole or in part on the hearing function. Subcategory 0 – General Classification 1 – Diagnostic 2 – Treatment 9 – Other Audiology

048X Cardiology Subcategory 0 – General Classification 1 – Cardiac Cath Lab 2 – Stress Test 3 – Echocardiology 9 – Other

049X Ambulatory Surgical Care Subcategory 0 – General Classification 9 – Other

050X Outpatient Services Outpatient charges for services rendered to an outpatient who is admitted as an inpatient before midnight of the day following the date of service. This revenue code is no longer used for Medicare. Subcategory 0 – General 9 – Other

051X Clinic Clinic (non-emergency/scheduled outpatient visit) charges for providing diagnostic, preventive, curative, rehabilitative, and education services to ambulatory patients. Subcategory 0 – General Classification 1 – Chronic Pain Center

052X Free-Standing Clinic Subcategory 0 – General Classification 1 – Rural Health – Clinic 2 – Rural Health – Home 3 – Family Practice Clinic 6 – Urgent Care Clinic 9 - Other

053X Osteopathic Services Subcategory 0 – General Classification 1 – Osteopathic Therapy 9 – Other



Code Title/Definition 054X Ambulance

Subcategory 0 – General Classification 1 – Supplies 2 – Medical Transport 3 – Heart Mobile 4 – Oxygen 5 – Air Ambulance 6 – Neo-natal Ambulance 7 – Pharmacy 8 – Telephone Transmission EKG 9 – Other

056X Medical Social Services Charges for services such as counseling patients, interviewing patients, and interpreting problems of a social situation to patients on any basis. Subcategory 0 – General Classification 1 – Visit Charge 2 – Hourly Charge 9 – Other

057X Home Health Aide (Home Health) Subcategory 0 – General Classification 1 – Visit charge 2 – Hourly charge 9 – Other

058X Other Visits (Home Health) Code indicates the charges by an HHA for visits other than physical therapy, occupational therapy, or speech therapy, which must be specifically identified. Subcategory 0 – General Classification 1 – Visit Charge 2 – Hourly Charge 3 – Assessment 9 – Other

059X Units of Service (Home Health) This revenue code is used by an HHA that bills on the basis of units of service. Subcategory 0 – General Classification 9 – Home Health other

060X Oxygen (Home Health) Subcategory 0 – General Classification 1 – Oxygen – Stat/Equip/Suppl or Cont. 2 – Oxygen – Stat/Equip/Suppl under 1 LPM 3 – Oxygen – Stat/Equip/Over 4 LPM 4 – Oxygen – Portable Add-on



Code Title/Definition 061X Magnetic Resonance Technology (MRT)

Subcategory 0 – General Classification 1 – Brain 2 – Spinal Cord 3 – Reserved 4 – MRI – Other 5 – MRA Head and Neck 6 – MRA – Lower Extremities 7 – Reserved 8 – MRA – Other 9 – Other MRI

062X Medical/Surgical Supplies – Extension of 027X Subcategory 1 – Supplies Incident to Radiology 2 – Supplies Incident to Other Diagnostic Services 3 – Surgical Dressings 4 – Investigational Device

063X Pharmacy – Extension of 025X Subcategory 0 – Reserved 1 – Single Source Drug 2 – Multiple Source Drug 3 – Restrictive Prescription 4 – Erythroepoetin (EPO) less than 10,000 units 5 – Erythroepoetin (EPO) 10,000 or more units 6 – Drugs requiring detailed coding* 7 – Self-administrable Drugs *Revenue code 636 relates to HCPCS code, so HCPCS is the recommended code to be used in FL 44. The specified units of service to be reported are to be in hundreds rounded to the nearest hundred.

064X Home IV Therapy Services Subcategory 0 – General Classification 1 - Nonroutine Nursing Central Line 2 – IV Site Care, Central Line 3 – IV Start/Change Peripheral Line 4 – Nonroutine Nursing, Peripheral Line 5 – Training patient/Caregiver Central line 6 – Training Disabled Patient, Central line 7 – Training Patient/Caregiver, Peripheral Line 8 – Training, Disabled Patient, Peripheral Line 9 – Other



Code Title/Definition 065X Hospice Services

Subcategory 0 – General Classification 1 – Routine Home Care 2 – Continuous Home Care 3 – Reserved 4 – Reserved 5 – Inpatient Respite Care 6 – General Inpatient Care (non respite) 7 – Physician Services 8 – Hospice Room and Board 9 – Other

066X Respite Care (HHA only) Subcategory 0 – General Classification 1 – Hourly Charge/Nursing 2 - Hourly Charge/Aide/Homemaker/Companion 3 – Daily Respite Charge 9 - Other

067X Outpatient Special Residence Charges Subcategory 0 – General Classification 1 – Hospital Based 2 – Contracted 9 – Other

068X Trauma Response Subcategory 0 – Not used 1 – Level I 2 – Level II 3 – Level III 4 – Level IV 9 – Other

069X Not Assigned 070X Cast Room

Charges for services related to the application, maintenance, and removal of casts. Subcategory 0 – General Classification 9 – Other

071X Recovery Room Subcategory 0 – General Classification 9 – Other



Code Title/Definition 072X Labor Room/Delivery

Charges for labor and delivery room services are provided by specially trained nursing personnel to include prenatal, assistance during delivery and postnatal care. Subcategory 0 – General Classification 1 – Labor 2 – Delivery 3 – Circumcision 4 – Birthing Center 9 – Other

073X EKG/ECG (Electrocardiogram) Charges for operation of specialized equipment to record electromotive variations in actions of the heart muscle on an electrocardiograph for diagnosis of heart ailments. Subcategory 0 – General Classification 1 – Holter Monitor 2 – Telemetry 9 - Other

074X EEG Electroencephalogram Charges for operation of specialized equipment to measure impulse frequencies and differences in electrical potential in various areas of the brain to obtain data for use in diagnosing brain disorders. Subcategory 0 – General Classification 9 - Other

075X Gastro-Intestinal Services Procedure room charges for endoscopic procedures not performed in an operating room. Subcategory 0 – General Classification 9 – Other Gastro-Intestinal



Code Title/Definition 076X Treatment or Observation Room

Observation services are those services furnished by a hospital on the hospital’s premises, including use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital as an inpatient. Such services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. Most observation services do not exceed one day. Some patients, however, may require a second day of outpatient observation services. The reasons for observation must be stated in the orders for observation. Payers should establish written guidelines which identify coverage of observation services. Only 762 should be used for observation services. Subcategory 0 – General Classification 1 – Treatment Room 2 – Observation Room 9 – Other Treatment Room

077X Preventative Care Services Charges for the administration of vaccines. Subcategory 0 – General Classification 1 – Vaccine Administration 9 - Other

078X Telemedicine Future Medicare Demonstration project

079X Extra-Corporeal Shock Wave Therapy (formerly Lithotripsy) Subcategory 0 – General Classification 0 - Other

080X Inpatient Renal Dialysis Subcategory 0 – General Classification 1 – Inpatient Hemodialysis 2 – Inpatient Peritoneal (Non-CAPD) 3 – Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD) 4 – Inpatient Continuous Cycling Peritoneal Dialysis (CCPD) 9 – Other Inpatient Dialysis



Code Title/Definition 081X Organ Acquisition

The acquisition and storage costs of body tissue, bone marrow, organs and other body components not otherwise identified used for transplantation. Medicare requires detailed revenue coding. Therefore, codes for this series may not be summed at the zero level. Note: Revenue code 814 is used only when costs incurred for an organ search does not result in an eventual organ acquisition and transplantation. Subcategory 0 – General Classification 1 – Living Donor 2 – Cadaver Donor 3 – Unknown Donor 4 – Unsuccessful Organ Search Donor Bank Charge 9 – Other Organ Donor

082X Hemodialysis – Outpatient or Home Dialysis A waste removal process performed in an outpatient or home setting, necessary when the body’s own kidneys have failed. Waste is removed directly from the blood. Detailed revenue coding is required. Therefore, services may not be summed at the zero level. Subcategory 0 – General Classification 1 – Hemodialysis/Composite or other rate 2 – Home Supplies 3 – Home Equipment 4 – Maintenance 100% 5 – Support Services 9 – Other Hemodialysis Outpatient

083X Peritoneal Dialysis – Outpatient or Home A waste removal process performed in an outpatient or home setting, necessary when the body’s own kidneys have failed. Waste is removed indirectly by flushing a special solution between the abdominal covering and the tissue. Subcategory 0 – General Classification 1 – Peritoneal/Composite or other rate 2 – Home supplies 3 – Home Equipment 4 – Maintenance 100% 5 – Support Services 9 – Other Peritoneal Dialysis



Code Title/Definition 084X Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient

A continuous dialysis process performed in an outpatient or home setting, which uses the patient’s peritoneal membrane as a dialyzer. Subcategory 0 – General Classification 1 – CAPD/Composite or other rate 2 – Home Supplies 3 – Home Equipment 4 – Maintenance 100% 5 – Support Services 9 – Other CAPD Dialysis

085X Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient A continuous dialysis process performed in an outpatient or home setting, which uses the patient’s peritoneal membrane as a dialyzer. Subcategory 0 – General Classification 1 – CCPD/Composite or other rate 2 – Home Supplies 3 – Home Equipment 4 – Maintenance 100% 5 – Support Services 9 – Other CCPD Dialysis

086X Reserved for Dialysis (National Assignment) 087X Reserved for Dialysis (State Assignment) 088X Miscellaneous Dialysis

Charges for dialysis services not identified elsewhere. Subcategory 0 – General Classification 1 – Ultra Filtration 2 – Home Dialysis Aid Visit 9 – Miscellaneous Dialysis Other

089X Reserved for National Assignment 090X Behavior Health Treatments/Services

Subcategory 0 – General Classification 1 – Electroshock Treatment 2 – Milieu Therapy 3 – Play Therapy 4 – Activity Therapy 5 – Intensive Outpatient Services – Psychiatric 6 – Intensive Outpatient Services – Chemical Dependency 7 – Community Behavioral Health Program (Day Treatment) 8 – Reserved for National Use 9 – Reserved for National Use



Code Title/Definition 091X Behavioral Health Treatment/Services – Extension of 090X

Code indicates charges for providing nursing care and professional services for emotionally disturbed patient. This includes patients admitted for diagnosis and those admitted for treatment. Subcategories 0912 and 0913 are designed as zero-billed revenue codes (no dollars in the amount field) to be used as a vehicle to supply program information as defined in the provider/payer contract. Note: Medicare does not recognize codes 912 and 913 services under its partial hospitalization program. Subcategory 0 – Reserved for National Use 1 – Rehabilitation 2 – partial Hospitalization – Less Intensive 3 – Partial Hospitalization – Intensive 4 – Individual Therapy 5 – Group Therapy 6 – Family Therapy 7 – Bio Feedback 8 – Testing 9 – Other Behavior Health Treatments/Services

092X Other Diagnostic ServicesSubcategory 0 – General Classification 1 – Peripheral Vascular Lab 2 – Electromyelogram 3 – Pap Smear 4 – Allergy Test 5 – Pregnancy Test 9 – Other Diagnostic Service

093X Medical Rehabilitation Day Program Medical rehabilitation services as contracted with a payer and/or certified by the State. Services may include physical therapy, occupational therapy, and speech therapy. The subcategories of 93X are designed as zero-billed revenue codes (no dollars in the amount field) to be used as a vehicle to supply program information as defined in the provider/payer contract. Therefore, zero would be reported in FL 47 and the number of hours provided would be reported in FL 46. The specific rehabilitation services would be reported under the applicable therapy revenue codes as normal. Subcategory 1 – Half Day 2 – Full Day



Code Title/Definition 094X Other Therapeutic Services

Subcategory 0 – General Classification 1 – Recreational Therapy 2 – Education/Training (includes diabetes related dietary therapy) 3 – Cardiac Rehabilitation 4 – Drug Rehabilitation 5 – Alcohol Rehabilitation 6 – Complex Medical Equipment Routine 7 – Complex Medical Equipment Ancillary 9 – Other Therapeutic Services

095X Other Therapeutic Services (An extension of 94X) Subcategory 0 – Reserved 1 – Athletic Training 2 - Kinesiotherapy

096X Professional Fees Charges for medical professional that hospitals or third party payers require to be separately identified on the billing form. Services that were not identified separately prior to uniform billing implementation should not be separately identified on the uniform bill. Subcategory 0 – General Classification 1 – Psychiatric 2 – Ophthalmology 3 – Anesthesiologist (MD) 4 – Anesthetist (CRNA) 9 – Other Professional Fees

097X Professional Fees (Extension of 96X) Subcategory 1 – Laboratory 2 – Radiology – Diagnostic 3 – Radiology – Therapeutic 4 – Radiology – Nuclear Medicine 5 – Operating Room 6 – Respiratory Therapy 7 – Physical Therapy 8 – Occupational Therapy 9 – Speech Pathology



Code Title/Definition 099X Patient Convenience Items

Charges for items that are generally considered by the third party payers as strictly convenience items and are not covered. This code permits identification of particular services as necessary. Subcategory 0 – General Classification 1 – Cafeteria/Guest Tray 2 – Private Linen Service 3 – Telephone/Telegraph 4 – TV/Radio 5 – Nonpatient Room Rentals 6 – Late discharge Charge 7 – Admission Kits 8 – Beauty Shop/Barber 9 – Other Patient Convenience Items

100X Behavioral Health Accommodations Routine service charges incurred for accommodations at specified behavior health facilities Subcategory 0 – General Classification 1 – Residential Treatment – Psychiatric 2 – Residential Treatment – Chemical Dependency 3 – Supervised Living 4 – Halfway House 5 – Group Home

101X to 209X Reserved for National Assignment 210X Alternative Therapy Services

Alternative therapy is intended to enhance and improve standard medical treatment. The following revenue codes would be used to report services in a separately designated alternative inpatient/outpatient unit. Subcategory 0 – General Classification 1 – Acupuncture 2 – Accupressure 3 – Massage 4 – Reflexology 5 – Biofeedback 6 – Hypnosis 9 – Other Alternative Therapy Services

211X to 300X Reserved for National Assignment



Code Title/Definition 310X Adult Care

Charges for personal, medical, psycho-social, and/or therapeutic services in a special community setting for adults needing supervision and/or assistance with Activities of Daily Living (ADLs) Subcategory 0 – Not used 1 – Adult Day Care, Medical and Social – Hourly 2 – Adult Day Care, Social – Hourly 3 – Adult Day Care, Medical and Social – Day 4 – Adult Day Care, Social – Daily 5 – Adult Foster Care – Daily 9 – Other Adjult Care

311X to 899X Reserved for National Assignment 9000 to 9044 Reserved for Medicare Skill Nursing Facility Demonstration project 9045 to 9099 Reserved for National Assignment

FL43 – Revenue Description Not required. A narrative description or standard abbreviation for each revenue code in FL 42 is shown on the adjacent line in FL 43. The information assists clerical bill review. Descriptions or abbreviations correspond to the revenue codes. “Other” code categories descriptions are locally defined and individual described on each bill.

Home Health Agencies identify the specific piece of DME or nonroutine supplies for which they are billing in this area on the line adjacent to the related revenue code. This description must be shown in HCPCS coding.

FL44 – HCPCS/Rates Required. When coding HCPCS for outpatient services, the provider enters the HCPCS code describing the procedure here. On inpatient or SNF bills, the accommodation rate is shown here.

FL45 – Service Date Required. Except Indian Health Service hospitals and other hospitals located in American Samoa, Guam and Saipan, the line item dates of service is required with every HCPCS code.



FL46 – Service Units Required. Generally, the entries in this column quantify services by revenue category, for example, number of days in a particular type of accommodation, pints of blood. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed.

Providers have been instructed to provide the number of covered days, visits, treatments, procedures, tests, etc., as applicable for the following:

Service Type Units/Quantity Accommodations 100s – 150s, 200s, 210s (days) Blood 380s (pints) DME 290s (rental months) Emergency Room 450, 452, and 459 (HCPCS code definition for visit

or procedure) Clinic 510s and 520s (HCPCS code definition for visit or

procedure) Dialysis Treatments 800s (sessions or days) Orthotic/prosthetic devices) 264 (items Outpatient therapy visits 410, 420, 430, 440, 480, 910, and 943. Units are

equal to the number of times the procedure/service being reported was performed)

Outpatient clinical diagnostic laboratory tests

– 30X-31X (tests)

Radiology 32X, 34X, 35X, 40X, 61X, and 333 (HCPCS code definition of tests or services)

Oxygen 600s (rental months, feet or pounds) Hemophilia blood clotting factors

636

Up to seven (7) numeric digits may be entered. Charges for non-covered services are shown as noncovered or are omitted.

FL47 – Total Charges Required. The total charges for the billing period are summed by revenue code (FL 42) or in the case of revenue codes requiring HCPCS by procedure code entered on the adjacent line n FL 47. The last revenue code entered in FL 42 is “0001” which represents the grand total of all covered and non-covered charges billed. FL 47 totals on the adjacent line. Each line allows up to nine numeric digits.



CMS policy is for providers to bill Medicare on the same basis that they bill other payers. This policy provides consistency of bill data with the cost report so that bill data may be used to substantiate the cost report.

Medicare and non-Medicare charges for the same department must be reported consistently on the cost report. This means that the professional component is included on, or excluded from, the cost report for Medicare and non-Medicare charges. Where billing for the professional component is not consistent for all payers, i.e., where some payers require net billing and others require gross, the provider must adjust either net charges up to gross or gross charges down to net for cost report preparation. In such cases, adjust your provider statistical and reimbursement reports (PS&R) that you derive from the bill.

All revenue codes requiring HCPCS codes and paid under a fee schedule are billed as net.

FL48 – Non-Covered Charges Required. The total non-covered charges pertaining to the related revenue code in FL 42 are entered here.

FL49 – Untitled Not Required. This is one of the four fields which have not been assigned.

FL50A, B, C – Payer identification Required. If Medicare is the primary payer, “Medicare” is entered on line A. If Medicare is entered, the provider has developed for other insurance and has determined has determined that Medicare is the primary. All additional entries across line A (FLs 51-55) supply information needed by the payer named in FL 50A. If Medicare is the secondary or tertiary payer, the provider identifies the primary payer on Line A and enters Medicare information on lines B or C, as appropriate.

FL51A, B, C – Provider Number Required. This is the six-digit number assigned by Medicare. It must be entered on the same line as “Medicare” in FL 50.



FL52A, B, C – Release of Information Required. A “Y” code indicates the provider has on file a signed statement permitting the provider to release data to other organizations in order to adjudicate the claim. An “R” code indicates the release is limited or restricted. An “N” code indicates no release on file. Note: The back of Form HCFA-1450 contains a certification that all necessary release statements are on file.

FL53A, B, C – Assignment of Benefits Certification Indicator

Not Required.

FL54A, B, C – Prior Payments Required. For all services other than inpatient hospital and SNF services, the sum of any amount(s) collected by the provider from the patient toward deductibles (cash and blood) and/or coinsurance are entered on the patient (fourth/last) line of this column. Part A home health DME cost sharing amounts collected from the patient are also reported in this item.

FL55A, B, C – Estimated Amount Due Not Required.





FL58A, B, C – Insured’s Name Required. On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is shown in FLs 50-54, the provider enters the patient’s Name as shown on his Health Insurance card or other Medicare notice. All additional entries across that line (FLs 59-66) pertain to the person named in FL 58.

FL59A, B, C – Patient’s Relationship to Insured Required. If the provider is claiming a payment under any of the circumstances described in the second paragraph of FL 58 A, B or C, it may enter the code indicating the relationship of the patient to the identified insured, if this information is available.

Code Relationship Definition 01 Spouse 04 Grandfather or Grandmother 05 Grandson or Granddaughter 07 Nephew or Niece 10 Foster child 15 Ward Ward of the Court. This code indicates that the

patient is a ward of the insured as a result of a court order

17 Stepson or Stepdaughter 18 Self 19 Child 20 Employee 21 Unknown 22 Handicapped Dependent 23 Sponsored Dependent 24 Dependent of Minor

Dependent

29 Significant Other 32 Mother 33 Father 36 Emancipated Minor 39 Organ Donor 40 Cadaver Donor 41 Injured Plaintiff 43 Child Where Insured Has No

Financial Responsibility

53 Life Partner G8 Other Relationship



FL60A, B, C – Certificate/Social Security Number/HI Claim/Identification Number

Required. The provider enters the patients’ Medicare Health Insurance Claim Number as shown on the Health Insurance Card, Certificate of Award, Utilization Notice, EOMB, Temporary Eligibility Notice, Hospital Transfer Form, or as reported by the SSO. On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is shown in FLs 50-54, the provider enters the patient’s HICN, i.e., if Medicare is primary payer, in FL 60A.

FL61A, B, C – Group Name Required. Where the provider is claiming a payment under the circumstances described in the second paragraph of FLs 58 A, B or C, it enters the name of the insurance group or plan.

FL62A, B, C – Insurance Group Number Required. Where the provider is claiming a payment under the circumstances described in the second paragraph of FLs 58A, B, or C, it enters the identification number, control number, or code assigned by such health insurance carrier.

FL63 – Treatment Authorization Code Required. Whenever PRO review is performed for outpatient preadmission, pre-procedure, or inpatient preadmission, the authorization number is required for all approved admissions or services.



FL64 – Employment Status Code Required. Where the provider is claiming a payment under the circumstances described in the second paragraph of FL 58 A, B, or C, it enters the code which defines the employment status of the individual identified on the same line in FL 58, if the information is readily available.

Code Employment Status 1 Employed Full-Time 2 Employed Part Time 3 Not Employed, full or part time 4 Self-employed 5 Retired 6 On Active Military Duty

7-8 Reserved for National Assignment 9 Unknown

FL65 – Employer Name Required. Where the provider is claiming a payment under the circumstances described in the second paragraph of FL 58 A, B, or C and there is Workers’ Compensation, it enters the name of the employer that provides health care coverage for the individual identified on the same line in FL 58.

FL66 – Employer Location Required. Where the provider is claiming a payment under the circumstances described in the second paragraph of FL 58 A, B, or C, and there is Workers’ Compensation, it enters the specific location of the employer of the individual identified on the same line FL 58. A specific location is the city, plant, etc. in which the employer is located.

FL67 – Principal Diagnosis Code CMS only accepts ICD-9-CM diagnostic and procedural codes which use definitions contained in the Department of Health and Human Services Publication No. (PHS) 89-1260. CMS approves only changes issued by the Federal ICD-9-CM Coordination and Maintenance Committee. Diagnosis codes must be full ICD-9-CM diagnoses codes, including all five digits where applicable.



Inpatient

Required. The provider reports the principal diagnosis in this field. 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 principal diagnosis, as defined above, is entered. Entering any other diagnosis may result in incorrect assignment of a DRG and an overpayment to a hospital.

Outpatient

Required. Hospitals report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. Hospitals report the diagnosis to their highest degree of certainty. For instance, if the patient is seen on an outpatient basis for an evaluation of a symptom (such as cough), for which a definitive diagnosis is not made, the symptom is reported (786.2). If during, the course of the outpatient evaluation and treatment, a definitive diagnosis is made (such as acute bronchitis); the definitive diagnosis is reported (466.0).

If a patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital reports an ICD-9-CM code for “Persons without reported diagnosis encountered during examination and investigation of individuals and populations” (V70-V82). Examples include:

• Routine general medical examination (V70.0)

• General medical examination without any working diagnosis or complaint; patient unsure if the examination is a routine checkup (V79.9)

• Examination of ears and hearing (V72.1)

FL68 - FL75 – Other Diagnoses Codes Inpatient

Required. The provider reports the full ICD-9-CM codes for up to eight additional conditions if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or length of stay. The principal diagnosis entered in FL 67 should not under any circumstances be duplicated as an additional or secondary diagnosis. If it is duplicated, it should be eliminated by the GROUPER.



Outpatient

Required. Hospitals report the full ICD-9-CM codes in FLs 68-75 for up to eight other diagnoses that coexisted in addition to the diagnosis reported n FL 67. For instance, if the patient is referred to the hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported here.

FL76 – Admitting Diagnosis/Patient’s Reason for Visit Required. For inpatient hospital claims subject to PRO review, the admitting diagnosis is required. Admitting diagnosis is the condition identified by the physician at the time of the patient’s admission requiring hospitalization. FL 76 is a dual use field. Patient’s reason for visit is not required by Medicare but may be used by providers for non scheduled visits for outpatient bills.

FL77 – E-Code Not Required.

FL78 – (Untitled) Not Required. This is one of the four fields which have not been assigned for national use.

FL79 – Procedure Coding Method Not Required

FL80 – Principal Procedure Code and Date Required – Inpatient Only. The provider enters the ICD-9-CM code for the inpatient principal procedure. The principal procedure is the procedure performed for definitive treatment rather than for diagnostic or exploratory purposes or which was necessary to take care of a complication. It is also the procedure most closely related to the principal diagnosis (FL 67). For this item, surgery includes incision, excision, amputation, introduction, repair, destructions, endoscopy, suture, and manipulation.



The procedure code shown must be the full ICD-9-CM, Volume 3, procedure code, including all four digit codes where applicable. The date applicable to the principal procedure is shown numerically as MMDDYY in the “date” portion.

FL81 – Other Procedure Codes and Dates Required – Inpatient Only. The full ICD-9-CM, Volume 3, procedure codes, including all four digits where applicable, must be shown for up to five significant procedures other than the principal procedure (which is shown in FL80). The date of each procedure is shown in the date portion of Item 81, as applicable, numerically as MMDDYY.

FL82 – Attending/Referring Physician ID Required. Providers must enter the unique physician identification number (UPIN) and name of the attending/referring physician on inpatient bills or the physician that requested outpatient services. Paper bill specifications are listed below.

Inpatient Part A

Required. Hospitals and SNFs must enter the UPIN and name of the attending/referring physician. For hospital services, the Uniform Hospital Discharge Data Set definition for attending physicians is used. This is the clinician primarily responsible for the care of the patient from the beginning of the hospital episode. For SNF services, the attending physician is the practitioner who certifies the SNF plan of care. Enter the UPIN in the first six positions, followed by two spaces, the physician’s last name, one space, first name, one space, and middle initial.

Home Health and Hospice

Required. HHAs and hospices must enter the UPIN of the physician that signs the home health or hospice plan of care. Enter the UPIN in the first six positions followed by two spaces, the physician’s last name, one space, first name, one space, and middle initial.



Outpatient and Other Part B

Required. All providers must enter the UPIN of the physician that requested the surgery, therapy, diagnostic tests or other services in the first six positions followed by two spaces, the physician’s last name, one space, first name, one space, and middle initial. If the patient is self-referred (e.g., emergency room or clinic visit), SLF000 is entered in the first six positions and no name is shown.

Claims Where Physician Not Assigned a UPIN – Not all physicians are assigned UPINs. Where the physician is an intern or resident, the number assignment may not be complete.

Accept the SLF entry unless the revenue code or HCPCS code indicates the service can be provided only as a result of physician referral. If more than one referring physician is involved, the provider enters the UPIN of the physician requesting the service with the highest charge. If referrals originate from physician-directed facilities (e.g., rural health clinics) enter the UPIN of the physician responsible for supervising the practitioner that provided the medical care to the patient.

FL83 – Other Physician ID Inpatient Part A Hospital

Required if procedure is performed. Hospitals must enter the UPIN and name of the physician who performed the principal procedure. If there is no principal procedure, the hospital enters the UPIN and name of the physician who performed the surgical procedure most closely related to the principal diagnosis. If no procedure is performed, the hospital leaves this item blank.

Outpatient Hospital

Required where the HCPCS code reported is subject to the Ambulatory Surgical Center payment limitation or a reported HCPCS code is on the list of codes the PRO furnishes that require approval.

Other Bills

Not Required.



FL84 – Remarks Required. For DME billings by HHAs, the renal rate, cost and anticipated months of usage are shown so that you may determine whether to approve the rental or purchase of equipment. In addition, special annotations may be entered where Medicare is not the primary payer because Workers’ Compensation, an automobile medical or no-fault insurer, any liability insurer or an EGHP/LGHP is primary to Medicare.

This space is also available to report overflow from other items.

FL85 – Provider Representative Signature Not Required. No signature is required for a general care hospital unless a certification is required. A provider representative’s signature or facsimile is required on the bill of a psychiatric or tuberculosis hospital.

FL86 – Date Not Required. This is the date of the provider representative’s signature.

Documents

Part 4. Billing - Indian Health Service · PDF fileRevenue Operations Manual Part 4 Billing Version 1.0 July 2006 Department of Health & Human Services Indian Health Service Business