Billing - Forms, Timeframes, and Claims Edits/Processing Flashcards
Describe Locum Tenens and conditions for payment
Locum Tenens and Reciprocal Agreements apply in situations like weekends and when the provider is on vacation or absent. Under Locum Tenens and Reciprocal Agreements, a substitute physician can be paid for services provided to a Medicare patient as long as:
* The regular physician is unable to provide the services.
* The patient had a previously-scheduled appointment or treatment with the regular physician.
* The substitute physician does not provide services to the patient for more than 60 days.
What is UB-O4
The UB-04 (Uniform Bill) refers to the hardcopy version of the hospital claim form (for institutional providers). Also known as CMS 1450.
What is 837I
refers to the dataset associated with UB-04 that is utilized to electronically submit claims to the payer (for hospital claims - institutional providers).
Who governs the UB-04 and 837I
The claims form (in both formats - i.e. UB-04 and 837I) is governed by the National Uniform Billing Committee (NUBC).
Describe the format and differences between UB-04 and 837I
The paper format is divided into boxes called field locators (FL), while the electronic version is divided into loops and segments. Certain data is required in each form locator / data segment depending on the circumstances of the claim.
There are several differences between the paper UB formats and the 837I electronic format:
* The UB formats have distinct FL numbers and names assigned to each data element reported.
* The UB-04 form contains 81 data elements and reports important information about the treatment and condition of the patient.
* The UB formats do not distinctly differentiate between patient data and subscriber data.
What is UB-04 also known as
CMS-1450
Describe the Type of Bill (TOB) Code
Type of Bill Code within UB-04/837I. It is a three-digit (excluding the leading zero) code in field locator 4 that describes the type of bill the hospital is submitting to the payer.
* 1st Digit – Type of Facility
* 2nd Digit – Bill Classification
* 3rd Digit – Frequency
Describe the Superbill
The superbill, or encounter form, is the sheet used to record certain data related to the patient encounter. Superbills have the most common E&M codes, procedures, and diagnosis codes preprinted on them, along with common tests if the office performs lab work and the like. There is space to record other items as well. The items the practitioner marks on the sheet are then entered in the patient account for billing purposes.
Each superbill is generally uniquely numbered so it can be tracked and accounted for. Each day’s sheets should be gathered at the end of the day and placed in order. If any are missing, they should be found. No superbills should ever be thrown away.
Describe the CMS-1500 and 837P forms
For non-institutional physician and professional service claims. CMS-1500 is the paper form and 837P is the data set for submitting electronically
What does the acronym “MSN” stand for?
Medicare Summary Notice (MSN)
What is another name for the Medicare Summary Notice
The MSN is also known as a remittance advice and was formerly known as the Medicare Explanation of Benefits.
Describe the Medicare Summary Notice (MSN)
The MSN is a quarterly statement to the payee/beneficiary reflecting services received, charges submitted, charges allowed, amount for which the beneficiary is responsible, and the amount that was paid to the provider or beneficiary. MSNs may specify deductible and coinsurance amounts.
The federal Medicare program has recognized that MSNs are a powerful fraud and abuse detection tool by actively enlisting beneficiaries to report suspected fraud and abuse. Recent changes in the format of MSNs are designed to make them more easily understood by people who are not fluent in the language of medical coding or HIPAA-standard adjudication codes. New MSNs contain plain language, and the CMS has undertaken an extensive public information campaign directing patients to compare their MSN to services actually received by healthcare providers.
Descibe EOB and RA
Explanation of Benefits (EOB) or Remittance Advice (RA) and 835
An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments/services were paid for on their behalf. A remittance advice (RA) reports the same information. The terms EOB and RA are often used interchangeably; the only distinct difference in the two terms is:
* An EOB may or may not have a check attached for payment of services.
* An RA should have a check attached or a voucher for an electronic payment which was made directly to the provider’s bank.
Electronic EOBs are called EDI 835 files.
Describe Mandatory Filing
When covered services are furnished to a Medicare beneficiary, healthcare providers and suppliers are required to submit claims for the services provided. The provider cannot charge the beneficiary for the labor of completing or filing the claims with Medicare. Failure to comply with this regulation can result in a Civil Monetary Penalty being imposed of up to $10,000 per violation that occurs.
What are the exceptions to the mandatoy filing rule?
There are exceptions to the mandatory filing rule. Providers are not required to file claims for services when:
* Medicare is listed as the secondary payer.
* The payment from the primary insurance is sent directly to the beneficiary.
* The beneficiary did not provide the primary insurance information to submit the information for MSP.
* The claim is for services that were provided outside of the United States.
* The claim is for services that are excluded from Medicare.
* The beneficiary signed an ABN for the services and indicated that he or she did not wish for the claim to be filed.
* The provider opts out of the Medicare program and enters into a private contract with the beneficiary.
* The provider has been debarred or excluded from the Medicare program.
Describe the importance of timely filing for medicare
All Medicare providers must submit claims for services within 12 months from the date of service. If claims are received past the one-year deadline, the claim will be denied for timely filing.
According to the new timely-filing regulations, claims which are submitted with line items date of service will use the line item dates to determine timely filing for outpatient claims.
Inpatient institutional claims should include span dates of service. the “Through” date on the claim will be used to determine the date of service for filing claims timely.
For professional claims submitted by physicians or other suppliers, the “From” date will be used to determine the date of service for filing claims timely.
Describe the 3-day and 1-day payment window rule
That requires all diagnostic and clinically related non-diagnostic outpatient services provided within three days of an inpatient admission to be combined to the inpatient claim when they are provided by an entity wholly owned or operated by the inpatient hospital (or by another entity under arrangements with the admitting hospital). Outpatient services on the same day as date of admit should always be combined.
Certain hospitals must comply with a similar rule that has a 1-day payment window. These include inpatient psychiatric hospitals, inpatient rehabilitation facilities, long term care facilities, children’s hospitals, and cancer hospitals.
This provision does not apply to ambulance services and non-diagnostic outpatient services not related to the primary diagnosis provided within three days of the admission. For these, the services are not bundled.
This rule is a Medicare requirement; it does not apply to Critical Access Hospitals and does not apply to all commercial payers.
What does acronym “NCCI” stand for
National Correct Coding Initiative (NCCI)
Describe the National Correct Coding Initiative (NCCI)
NCCI promotes correct coding methodologies and strives to eliminate improper coding. The NCCI identifies mutually-exclusive CPT-4 and HCPCS codes or those that should not be billed together.
NCCI was introduced to:
* Establish standards of medical billing
* Identify codes that may be a potential for fraud and abuse
* Identify codes that are components of another code and should not be unbundled and billed on the same encounter by the same provider
When and how do NCCI reviews take place?
NCCI edits apply to physician services under the Medicare Physician Fee Schedule
NCCI reviews occur before claims are paid. The processing system tests every pair of codes reported for the same date of service, for the same beneficiary, and for the same provider. If a pair of codes hits against an NCCI edit, the edited pair will be denied unless it is submitted with an appropriate modifier, and then only if the edit will allow the modifier(s).
What does the acronym “OCE” stand for
Outpatient Code Editor (OCE) Edits
Describe Outpatient Code Editor (OCE) Edits
OCE edits apply to hospital outpatient services under the hospital OPPS.
The end result of these edits is that some pairs of codes cannot be billed together, and some pairs can be billed only with modifiers to indicate unusual circumstances.
In addition, the edits look for things that are highly unusual, such as a hysterectomy on a claim for a male patient or removal of two appendixes.
OCE edits:
* Determine whether a specific code is payable under the hospital OPPS
* Include many of the CCI edits
* Determine if the ASC limit applies to each bill
What does the acronym “MCE” stand for
The Medicare Code Editor (MCE)
Describe the Medicare Code Editor (MCE)
The Medicare Code Editor (MCE) software edits claims to detect incorrect billing data that is being submitted. The MCE addresses three basic types of edits to support the assignment of an MS-DRG.
They are:
* Code edits – examine a record for the correct use of ICD-10 codes
* Coverage edits – examine the type of patient and the procedures performed to determine if the services were covered
* Clinical edits – examine the clinical consistency of procedural and diagnostic information to determine if it is clinically reasonable
What does the acronym “MUE”
Medically Unlikely Edits (MUE)
Describe Medically Unlikely Edits (MUE)
Just like the NCCI edits, the MUE edit is an automated prepayment edit that helps to prevent inappropriate payments. The MUE is a unit of service edit for HCPCS/CPT codes for services rendered by a provider to a single beneficiary on the same date of service. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations. (For example, this program would detect a claim for a person having “ten legs amputated.”)
Adding an appropriate modifier (for example, 76 for repeat procedure by the same physician or 91 for repeat clinical diagnostic laboratory test) may allow the claim to be processed appropriately.
In many cases, an MUE cannot be appealed. A provider who disagrees with an MUE should contact Correct Coding Solutions, the contractor who developed the program.
Describe RTP
Claim submissions that are found to be incomplete or invalid are returned to the provider (RTP). The term RTP is used to refer to the many processes utilized for notifying the provider that a claim cannot be processed (i.e. “return as unprocessible”) and must be corrected or resubmitted.
What is the timeline for correcting incomplete or invalid claims
Medicare allows 45 days to correct incomplete or invalid claims.
What are the 7 elements of compliance plan?
- Written policies and procedures
- Designated Compliance Officer (CO) and compliance committee
- Effective training and education
- Effective lines of communication
- Enforced standards and well-publicized disciplinary procedures
- Auditing and monitoring
- Responding to offenses and developing corrective action plans
When submitting paper claims using CMS-1500, what are the standards to support optimal processing?
- Position claim information centered within each box.
- Report no more than six lines of service per claim. (Use a new form for additional services).
- Report diagnosis codes with the appropriate ICD-10 code.
- Avoid special characters (such as hyphens, periods, parentheses, dollar signs, and ditto marks).
- Use correction fluid and retype the information if an error is made when keying information on the form. Do not hand-print the information over the correction or cross out the data.
