• To “V” or Not to “V”? Proper Use of “V” Codes
• Integrating UBWatch and CareWatch into your
triple-check
• Universal Billing Claims (TOB21X) and the MDS
Assessments
• Following the Medicare Claim Manual and RAI
Manual
• The CareWatch and UBWatch connection
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9-10:30 – UBWatch / CareWatch Connection
1
V-Codes
• LCD letter on Part B codes allows V-57.x to not be the principle diagnoses
› However, the V-code should be on the claim as a diagnosis/procedure.
• The code must be reported according to Official ICD-CM Guidelines for Coding
and Reporting, as required by the Health Insurance Portability and
Accountability Act (HIPAA), including any applicable guidelines regarding the
use of V codes. The code must be the full ICD-CM diagnosis code, including all
five digits where applicable.
• Other Diagnosis Codes Required – The SNF enters the full ICD-CM codes for
up to eight additional conditions in the appropriate form locator. Medicare does
not have any additional requirements regarding the reporting or sequence of
the codes beyond those contained in the ICD-CM guidelines.
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• Part A - March 28, 2011 CMS Transmittal 2183 effective 6/29/2011
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More on V Codes
• FL 67 - Principal Diagnosis Code
• Required.
› The principal diagnosis code will include the use of “V” codes. Where the proper code has fewer
than five digits, the hospital may not fill with zeros. The principal diagnosis is the condition
established after study to be chiefly responsible for this admission.
› When the purpose for the admission/encounter is rehabilitation, sequence the appropriate V code
from category V57, Care involving use of rehabilitation procedures, as the principal/first-listed
diagnosis. The code for the condition for which the service is being performed should be reported
as an additional diagnosis.
› Only one code from category V57 is required. Code V57.89, Other specified rehabilitation
procedures, should be assigned if more than one type of rehabilitation is performed during a single
encounter. A procedure code should be reported to identify each type of rehabilitation therapy
actually performed.
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• 15. Admissions/Encounters for Rehabilitation
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Triple Check
• UBWatch: Compares the Care Allowed with
the Care Provided with the Care Being Billed.
› The eHDS Electronic Triple Check brings three
processes together:
• Triple Check is checking the UB-04 complete
claim against
1. MDS – evidence based care for authorized benefit
2. Clinical documentation of care provided (MDS & Other sources)
3. Line Items from ancillary vendor bills (therapy CPT grids & sessions,
lab, pharmacy, x-ray bills, etc.) to ensure everything matches and
UBs is ok before billing.
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 MDS, Care & Therapy, and Billing
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Following the Medicare Claim Manual and RAI
Manual
›
›
›
›
›
Chapter 1
Chapter 6
Chapter 25
Chapter 26
Transmittals – esp. 2183 March 25, 2011
• RAI Manual May 2011 + Updates
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• Medicare Claims
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Advance Beneficiary Notice
• WHAT IS AN ABN?
• ABNs should only be provided to beneficiaries enrolled in Original (Fee-forService) Medicare. The ABN allows the beneficiary to make an informed
decision about whether to receive services that he/she may be financially
responsible for paying. The ABN serves as proof that the beneficiary had
knowledge prior to receiving the service that Medicare might not pay. If a
health care provider does not deliver a valid ABN to the beneficiary when
required, the beneficiary cannot be billed for the service.
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• An ABN is a written notice that a health care provider or his/her designee gives
to a Medicare beneficiary, before outpatient items or services are rendered,
when the health care provider believes Medicare will not pay for some or all of
the items or services.
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MDS / UB-04 Items that need to Match
Key Factors
MDS Assessments
Key Factor
Name
SSN
Medicare #
Medicaid #
Gender
Birthdate
MDS Field
A0500
A0600
A0600
A0700
A0800
A0900
UB-04 Locators
FL 8
FL 8
FL 60
??
FL 11
FL 10
Hospital qualiflying Stay
NA
FL 35 - Occurance Span
UB-04 Claim
FL 12
FL 31-34 Occurrence Code = 50
FL 45 Service Date
FL 31-34 - Occurrence Code = 16
Diagnoses Codes
Section I
FL 66-69 A-K + supplemented as needed
Therapies
Section O
FL 42 Revenue codes 42x, 43x & 44x
FL 46 - Service Units (Therapy Sessions)
Part A Days
RUG-HIPPS
RUG-HIPPS
FL 46
Therapy Sessions accurately reported
FL 44 - RUG HIPPs Code
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Admission Date
A1600
Discharge Date
A2000
Assessment Reference Date
ARD Date
Assessment Reference Date
ARD Date
Discharge Date
Discharge Date
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• The RAI is an assessment tool completed by facility clinical staff that is
transmitted electronically to state agencies and then transferred to
CMS, and is used to determine the RUG code.
• The 3-digit RUG code and the 2-digit AI make up the HIPPS code that
appears on the claim, and is used to determine the payment rate under
the SNF PPS.
• An adjustment request must be submitted if the RAI correction results
in a HIPPS code that is different from that already billed and paid,
except in those cases where the default HIPPS code was used.
• Claims that were filed with the HIPPS default code represent payment
in full and cannot be adjusted retroactively.
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Universal Billing Claims and the MDS
Assessments
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• Adjustment requests based on corrected assessments must be
submitted within 120 days of the service “through” date.
• The “through” date will be used to calculate the period during which
adjustment requests may be submitted based on corrected RAI
assessments.
• The “through” date indicates the last day of the billing period for which
the HIPPS code is billed.
• Adjustment requests based on corrected assessments must be
submitted within 120 days of the “through” date on the bill.
• For HIPPS changes resulting from an MDS correction, providers must
append a condition code D2 on their adjustment claim.
• An edit is in place to limit the time for submitting this type of adjustment
request to 120 days from the service “through” date.
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Why correct the logic flags and HIPPS code
using CareWatch?
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• Most skilled nursing facilities submit claims to the FI. However, a
nonparticipating skilled nursing facility (SNF) is considered a supplier
and its claims are submitted to the appropriate carrier under its own
Medicare supplier number.
• Section 1861(w)(1) of the Act permits a hospital, critical access
hospital, skilled nursing facility, home health agency, or hospice to
obtain under arrangement, services for which an individual is entitled to
under Medicare. Doing so discharges the liability of such individual or
any other person to pay for the services. This is required in specified
situations where the provider is paid under a PPS system.
• Where a patient is a SNF inpatient, the SNF must furnish all services
within the scope of the SNF benefit.
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UB-04 and SNFs
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Current CMS policy on these
benefits, and claims seeking
payment for them, can
also be found at:
TABLE 2:
BENEFIT
Inpatient Hospital
“
SNF. (Part A Paid)
“
INTERNET ON-LINE MANUAL
100-02, Benefit Policy, Chapter 1,
100-04, Claims Processing, Chapter 3;
100-02, Benefit Policy, Chapter 8,
100-04, Claims Processing, Chapter 6.
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Medicare Benefit Policy
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Medicare Claims
Inpatient
Part A
Inpatient
Part B*
In/Outpatient
Part A*
Outpatient*
Medicare FFS Bill Types
(All Types Listed)
11x – Hospital
18x – Swing Bed
21x – Skilled Nursing Facility (SNF)
41x – RNHCI – Religious Non-Medical
Health Care
Institution – inpatient
12x – Hospital
22x – SNF
81x, 82x – Hospice
Trust Fund
Payment
Part A only
13x, 14x – Hospital
23x – SNF
34x – Home Health (not prospective
payment (PPS))
43x – RNHCI outpatient
71x – RHC – Rural Health Clinic
72x – RDF – Renal Dialysis Facility
73x – FQHC – Federally Qualified Health
Center
74x – ORF – Outpatient Rehabilitation
Facility
75x – CORF – Comprehensive ORF
76x – CMHC – Community Mental Health
Center
83x – Hospital Outpatient Surgery1
85x – Critical Access Hospital (CAH)
=====================
32x, 33x – Home Health (PPS)
=====================
89x – NOE2 for Coordinated Care
Demonstration
Part B only
=======
Parts A and B
=======
No payment
Part B only
Part A only
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Category
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Chapter 170.2.3 - In Accordance with CMS Instructions (Rev. 2140,
Issued: 01-21-11, Effective: 01-01-10, Implementation: 02-22-11)
• The CMS instructions for submitting institutional claims to Medicare are contained in this
manual. General instructions that reflect guidance on the use of the paper UB-04, as
established by the National Uniform Billing Committee, are found in Chapter 25.
• These instructions apply to all institutional claim types. Additional chapters in this manual
supplement these general instructions. For example, see instructions for inpatient
hospital billing in Chapter 3, or inpatient skilled nursing billing in Chapter 6.
• In order to constitute a Medicare claim, services submitted for payment must be entered
in a claim format in accordance with these instructions.
• Services submitted for payment in a manner not complete and consistent according to
these instructions will not be accepted into Medicare’s electronic claims processing
system and will not be considered filed for purposes of determining timely filing.
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• For physician and supplier Part B claims, see Chapter 26 “Completing and Processing
Form CMS-1500 Data Set”.
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The FIs should take the following actions upon
receipt of incomplete or invalid submissions:
• If a required data element is not accurately entered in the appropriate field, RTP the submission to the
provider of service.
• If a not required data element is accurately or inaccurately entered in the appropriate field, but the
required data elements are entered accurately and appropriately, process the submission.
• If a submission is RTP for incomplete or invalid information, at a minimum, notify the provider of
service of the following information:
›
›
›
›
›
›
Beneficiary’s Name;
Health Insurance Claim (HIC) Number;
Statement Covers Period (From-Through);
Patient Control Number (only if submitted);
Medical Record Number (only if submitted); and
Explanation of Errors.
• NOTE: Some of the information listed above may in fact be the information missing from the
submission. If this occurs, the FI includes what is available.
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• If a conditional data element (a data element which is required when certain conditions exist) is not
accurately entered in the appropriate field, RTP the submission to the provider of service.
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80.3.3 - Timeliness Standards for Processing
Other-Than-Clean Claims “Suspended”
• Effective: 01-01-08, Implementation: 01-07-08)
• The Social Security Act, at §1869(a)(2), mandates that Medicare process all “other-thanclean” claims and notify the individual filing such claims of the determination within 45
days of receiving such claims.
• The contractor shall process all “other-than-clean” claims and notify the provider and
provider of the determination within 45 calendar days of receipt. (See Pub100-4, Chapter
1, §80.2.1 for the definition of “receipt date” and for timeliness standards for clean
claims.) However, when the contractor develops to the provider/supplier or beneficiary
for additional information, the contractor shall cease counting the 45 calendar days on
the day that the contractor sends the development letter. Upon receiving the materials
requested in the development letter from the provider/supplier and/or beneficiary, the
contractor shall resume counting the 45 calendar days.
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• Claims that do not meet the definition of “clean” claims are “other-than-clean” claims.
“Other-than-clean” claims require investigation or development external to the
contractor’s Medicare operation on a prepayment basis.
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• To remain on PIP, providers, (with the exception of HHAs
that do not receive PIP with the advent of PPS mandated
by law on October 1, 2000), must submit 85 percent of
their bills timely and accurately.
• Timely and accurately means that 85 percent of its bills
(excluding those listed below) are submitted within 30 days
of discharge and pass front-end edits for consistency and
completeness.
• Do not reinstate PIP for a provider until it meets all criteria
in PRM §§2405.1.B and 2407 and has met the
requirements in subsection A for timeliness and accuracy
for six consecutive months.
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How important is PIP?
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• Thus, for non-PPS hospitals and SNFs the evaluation process is
scheduled at 3-month intervals and PPS providers are evaluated every
4 months.
• The evaluation includes data from the entire 3- or 4-month period. In
determining whether a provider submitted its bills within 30 days of
discharge or through date on interim bills, count the date from Form
CMS-1450 FL6 (through date) to the date received by the FI. If the
provider does not meet the criteria, discontinue PIP immediately. The
periodic performance report that is provided in accordance with
subsection B will constitute advance notice before discontinuing PIP.
Strategy – prepare claims as soon as the validated MDS for Part A is done
And within every 2 weeks for Part B services
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How important is Cash Flow?
– 85% consistent and complete within 30 days….
17
• The provider (hospital, skilled nursing facility, and home health agency)
must retain medical records in their original or legally reproduced form
for a period of at least five years after it files with its FI the cost report
to which the records apply, unless State law stipulates a longer period
of time.
• Provider copies of Form CMS-1450 and any other supporting
documents, e.g., charge slips, daily patient census records, and other
business and accounting records referring to specific claims.
• The provider must retain copies of all other categories of health
insurance records in their original form. If it microfilms them, it should
store them in a low cost facility for the retention period described in
§110.3.
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Keeping Records – and what about HIPAA?
18
• When a patient remains an inpatient of a SNF, TEFRA
hospital or unit, swing-bed, or hospice for over 30 days,
these providers submit a bill every 30 days.
• (See §50.2.2 for Frequency of Billing.) Claims for the
beneficiary are to be submitted in service date sequence.
• The shared system must edit to prevent acceptance of a
continuing stay claim or course of treatment claim until the
prior bill has been processed. If the prior bill is not in
history, the incoming bill will be returned to the provider
with the appropriate error message.
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Billing Frequency
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Summarize
• Advanced Beneficiary Notice (ABN) – what does
this mean?
benefit – and Medicare feels the services are not
covered
• Who is caught in the Middle?
› Patient/Resident
› Provider?
› Congress?
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› When a service is not covered
› When a patient/resident feels Medicare is their
20
• Inpatient and outpatient providers are required to submit
demand bills using condition code 20 when requested by
beneficiaries.
• Billing with condition code 20 is ONLY in case when an
ABN is not given/not appropriate for billing related to
doubtful liability (for ABN instructions, see §60.4.1 below).
• Medicare contractors perform review of demand bills with
condition code 20, to assure compliance with codified
Medicare medical necessity, coverage and payment
liability policy.
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Demand Bill / Demand Benefit?
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•Questions / Discussion
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