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UBWATCH PROCESS CENTRAL CONTROL, LLC. UBWatch Process Submits claim into UBWatch Billing Reviews exceptions and fixes any coding issues Gatekeeper Allows.

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Presentation on theme: "UBWATCH PROCESS CENTRAL CONTROL, LLC. UBWatch Process Submits claim into UBWatch Billing Reviews exceptions and fixes any coding issues Gatekeeper Allows."— Presentation transcript:


2 UBWatch Process Submits claim into UBWatch Billing Reviews exceptions and fixes any coding issues Gatekeeper Allows exception -OR- Sends to facility for correction Corporate MDS Director Sends to reload claims Gatekeeper Reloads claim to clear exception (repeat) Billing

3 Key Roles Corporate Coding Specialist/Gatekeeper Accounts Receivables/Billing Corporate MDS Director

4 Corporate Coding Specialist/ Gatekeeper Approves all therapy diagnosis codes Creation of Diagnosis sheets  Primary sheets  Therapy sheets Coding Audits  MCR A, MCR B, Medicaid, Private Pay, Outpatient, etc.  Nurse Practitioner visits Triple Check  Medicare Cards, H&P, Benefit Day, Treatment Grids, Weekly Therapy notes, 700/701 Runs exceptions Corrects coding issues for reloading Manages outstanding claims in UBWatch

5 Accounts Receivable Reviews entries made into census line from PCC that feed UB04  Basic demographics; payer setup; qualifying stay entry; required occurrence codes and span dates; leave days documented correctly; ancillary charges are present on claim Reviews signed admission documents  Assignment of benefits; Medicare Secondary Payer Questionnaire; Covered/Non Covered Benefits for Skilled care; ABN Responsible for post review of any denied claims  Identify any denied claims and alert Triple Check team for further review Works closely with MDS to assure COT RUGs transfer to claim correctly

6 Corporate MDS Director Audit sample MDS’ monthly for coding accuracy and RUG support. Use MDS calendar to assist with capturing OBRA assessments that are due Audit sample of certifications for skilled residents to assure completion and timely signature of MD Audit skilled residents daily for setting ARDs of assessments in the system; to assure it is in timeframe which CMS allows to avoid default rates. Review case mix weekly and at snapshot end Work closely with coder; monitoring diagnosis for skilled residents upon admit, to assure the diagnosis relates to qualifying hospital stay. Review preliminary Case mix for each facility and for any delinquent assessments noted on report, assist with correction as needed prior to final Case mix report

7 Triple Check Performed monthly at a corporate level  Corporate Coding Specialist  Corporate MDS Director  Accounts Receivable  Corporate Quality Coordinator  Chief Financial Officer Performed on a select number of Medicare A residents

8 Triple Check Admission Information  Verify Medicare number  Verify primary PCC diagnosis sheet  Verify ICD-9 codes correspond to diagnosis  Verify most current admission date  Hospital qualifying stay dates (hospital discharge/transfer summary related to 3 day qualifying stay requirements)  Verify that resident has benefit days available per the CWF

9 Triple Check Physician’s Orders  Physician order to admit to skilled service  Initial orders for evaluation & treatment for therapy or other skilled service  Complete clarification order  Physician orders signed/updated every 30 days  Order to discharge off Medicare/skilled service

10 Triple Check Physician Certifications/Re-certifications  Initial certification within 72 hours of admit (Complete information/sign/date/timely  Re-certification on or before Day 14  Re-certification on or before Day 30  Additional recertification complete

11 Triple Check Skilled Nursing Documentation  Verify charting done at least once per 24 hours  Related to skilled service being provided  Related to skilled ICD-9  Charting supports therapy services  Documentation supports late loss ADL’s in MDS Section G

12 Triple Check ADL’s  ADL’s are accurate  MDS accurately coded  ADL’s are accurately coded  Documentation support ADL’s  ADL’s are support by medical record

13 Triple Check Therapy Documentation  Daily treatment and therapy notes are current  Number of minutes, units, HCPCS, modifiers are accurate for billing  Therapy evaluation complete with MD sign/date  Plan of care update or 701 complete with MD signature  Admission ICD-9 code matches 700 form

14 Triple Check MDS  ARD within window for MDS cycle  Reason for assessment is correct  Other RUG related MDS items are supported by medical record, including accuracy of therapy minutes/days  MDS locked, transmitted, and accepted

15 Triple Check ABN  Proper notifications at the time of admission  Proper notice of continued stay or discontinuation of service  Copy of signed notices readily available  Most current version of form being used  Form not altered as per CMS regulations

16 Triple Check Payer Source  Assignment of benefits form is signed  Medicare secondary payer questionnaire completed

17 Triple Check UB-04  Verify admission date  Verify discharge/transfer date  Verify discharge status code  Confirm admission dx  Confirm primary dx

18 Top 10 UBWatch Exceptions 1. Therapies on UB inconsistent with corresponding MDS Correction: Review DOS; check therapy software to assure therapy was received compared to what is coded on MDS

19 Top 10 UBWatch Exceptions 2. Other diagnoses in the claim do not seem to be supported by the MDSs found Correction: Review DOS, check physician orders, care plan, chart and if diagnosis is active, request MDS to review and code active diagnosis on MDS; if diagnosis is not active, will remove from diagnosis sheet

20 Top 10 UBWatch Exceptions 3. Admitting diagnosis in the claim do not seem to be supported by the corresponding MDSs found Correction: Review admit diagnosis and if it relates to care. Suggest MDS review and if pertinent to care with documentation support, suggest adding to MDS.

21 Top 10 UBWatch Exceptions 4. Claim type and dates inconsistent with corresponding MDSs Correction: Review DOS to assure MDS covers time frame

22 Top 10 UBWatch Exceptions 5. Admission date is greater than 30 days from qualifying hospital stay Correction: Verify that we have code 78, on the occurrence span code, with correct dates on claim. Also, verify that we have condition code 57 on claim.

23 Top 10 UBWatch Exceptions 6. No corresponding MDSs for claim Correction: Review DOS and assure MDS covers time frame in question. Sometimes this is noted when a discharge occurs right after an assessment was done. Validate that an assessment was done to cover DOS prior to discharge

24 Top 10 UBWatch Exceptions 7. Incorrect principal diagnosis coding for therapy claim Correction: Add/Remove therapy codes from principal diagnosis OR add penny charges to the claim

25 Top 10 UBWatch Exceptions 8. Claim type and date inconsistent with other claims Correction: Reload previous claims. Some claims are stopping in suspense and were never cleared; therefore, looking for original claim

26 Top 10 UBWatch Exceptions 9. Therapy services not justified by diagnosis on Part B claim Correction: Check LCD for diagnosis codes that justify CPTs billed

27 Local Coverage Determination (LCD) Medicare contractors can create guidelines for certain services to determine if they are reasonable and necessary, and covered as a Medicare benefit.

28 Top 10 UBWatch Exceptions 10. No qualifying hospital stay before admission Correction: Add the qualifying stay which was omitted on Census line

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