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©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided.

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Presentation on theme: "©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided."— Presentation transcript:

1 ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care ® Arizona Medical Bill Reviewer Training Program Unit 2: Hospital Guidelines Module 1: Inpatient & Outpatient Hospital Services Module 2: Ambulatory Surgery Centers

2 2 Arizona Regulation Training – Inpat, Outpat, ASC Module 1 – Overview Hospital Guidelines… What are Inpatient & Outpatient Hospital and ASC Services? Reimbursement Billing Examples Hi, in this module you will learn about current hospital billing practices, reimbursement and how services are billed. Lets start by discussing Hospital services.

3 3 Arizona Regulation Training – Inpat, Outpat, ASC What are Inpatient Services? When in doubt, remember…if the patient occupied a bed at midnight, it is an inpatient stay! Inpatient services are when a patient is admitted to a hospital, skilled nursing facility or immediate care facility for bed occupancy. Services include, but are not limited to, diagnostic or therapeutic services and medical and surgical services.

4 4 Arizona Regulation Training – Inpat, Outpat, ASC Hospital Reimbursement In Arizona, there is no Hospital Fee Schedule so Usual and Customary Guidelines are used. Lets start with basic requirements for reviewing hospital bills, such as… UB-92/UB-04 Claim Form Revenue Codes Type of Bill Admission/Discharge Date Procedure Codes – Primary/Surgical Total Charge

5 5 Arizona Regulation Training – Inpat, Outpat, ASC Hospital Reimbursement Hospital claims are required to be submitted on the standard UB- 92/UB04 form. This form has the required fields for listing services rendered in a hospital setting and ensure proper reimbursement. Standard UB-92/UB-04 Claim Form

6 6 Arizona Regulation Training – Inpat, Outpat, ASC Hospital Reimbursement There are several codes required to allow proper reimbursement. Lets begin with Type of Bill. The three digit code identifies the type of services submitted for reimbursement InpatientOutpatient

7 7 Arizona Regulation Training – Inpat, Outpat, ASC Hospital Reimbursement Next, there are Revenue codes that identify accommodations, ancillary services or billing calculations rendered in the hospital. Here are examples of a few commonly used codes… 001NO NARRATIVE DEFINED152OB WARD 100ALL INCLUDE R&B/ANC153PEDS WARD 101ALL INCLUDE R&B154PSYCHSTAY WARD 110R&B PVT155HOSPICE WARD 111MED SUR GY PVT156DETOX WARD A complete list of codes is found in Appendix B in the U&C State Reference Guide (SRG).

8 8 Arizona Regulation Training – Inpat, Outpat, ASC Hospital Reimbursement Procedure codes identify types of services rendered to the patient. Inpatient and Outpatient services may be billed with one or two procedure types. These are Primary and Surgical Procedures. Although, the system is fully automated to recognize when one or the other or both procedures are required, here are examples in the event manual entry is needed. Primary Procedure : The primary procedure and procedure date must be keyed when included on the billing form. Surgical Procedure: The system requires an entry in this field when revenue codes 360 or 490 are present.

9 9 Arizona Regulation Training – Inpat, Outpat, ASC Hospital Reimbursement Additional factors in proper reimbursement are the Admission and Discharge dates of service. The Admission date starts the clock on the beginning of a patient stay or treatment. However, the date of admission is not always the date of service used on the detail lines. The Discharge date is an indicator of when the patient is released from a facility or treatment. When a date of admission is keyed on an Inpatient bill, the discharge date is also required. In the example below, Admission and Discharge fields are marked. Inpatient one Day Stay. Discharge field is populated, patient released after midnight. Outpatient treatment plan. Three consecutive days are regarded as one episode. Discharge indicator is not required.

10 10 Arizona Regulation Training – Inpat, Outpat, ASC Hospital Reimbursement Total Charge amount is the last important factor in receiving reimbursement of services. There are cases when there are two or more Total Charge amounts on the bill. At that time, a determination must be made as to which billed amount is correct. Examples of scenarios where more than one charge is on the bill: o The provider or payer applies a discount to the bill, the total billed charges are used, and no discount should be applied. o Non-Covered Services separated: All charges on the UB04 or UB92 should be included in the billed amount, even if they are separated and subtracted from the total as non-covered services. o Multiple bills under one Control Number: The total charge of all bills should be keyed.

11 11 Arizona Regulation Training – Inpat, Outpat, ASC Keying Inpatient Bills Keep in mind, when keying Inpatient bills in the Bill Review system, the data entry sequence is important. The sequence ensures billed details are properly entered on the line. Take the following steps: 1.Key Room and Board Charges 2.Key ancillary Revenue codes in the proper Billed Revenue field. 3.Key all CPT codes in the proper Billed Procedure fields

12 12 Arizona Regulation Training – Inpat, Outpat, ASC Trauma Reimbursement Trauma bills are recommended at 100% of billed charge. Bills are identified when TRAUMA is stamped on the bill. Also, Revenue code 208 should display on the bill.

13 13 Arizona Regulation Training – Inpat, Outpat, ASC Trauma Reimbursement In Bill Review, trauma bills are identified when the Trauma field indicator displays Yes. Qualifying Trauma Hospitals display 75 in the Action Reason Code field in the Provider Detail panel.

14 14 Arizona Regulation Training – Inpat, Outpat, ASC Implants Implants are tangible devises, hardware or instrumentations that are inserted into the patient during surgery. When this occurs, providers submit bills and documentation listing items used during the surgery. These services are considered separate from the surgical procedure, and generally allowed in addition to other facility fees. Implants are paid as billed and manufacture invoices are not required, when a Coventry Network contract does not dictate payment. With contracted rates, manufacture invoices may or may not be required for reimbursement.

15 15 Arizona Regulation Training – Inpat, Outpat, ASC Exclusions Exclusions are billed services the provider contract stipulates are reimbursed at designed rates, separate from and over and above per diem rates. Examples include: o Take Home Drugs o Prosthetics o Hospital based Physicians

16 16 Arizona Regulation Training – Inpat, Outpat, ASC Outpatient Services Outpatient Guidelines… How Bills are keyed Billing Examples Now, that weve discussed Inpatient services, lets move on to Outpatient hospital services.

17 17 Arizona Regulation Training – Inpat, Outpat, ASC What are Outpatient Services? An outpatient receives health care services without being admitted to a hospital. Instead, they are registered as an outpatient in hospital records. Examples of services injured workers might be treated for as an outpatient include: Broken bones Minor burns Wounds Outpatient services are rendered to patients for the purpose of administering medical treatment that does not require an overnight stay at a hospital.

18 18 Arizona Regulation Training – Inpat, Outpat, ASC Keying Outpatient Bills Outpatient Hospital bills require keying the same basic codes and procedures as Inpatient bills. However, there are a few differences, such as: Admission date can extend for three consecutive days, which is one episode. Room and Board Charges are not required. Lines are reviewed individually, based on CPT/Revenue codes. 1

19 19 Arizona Regulation Training – Inpat, Outpat, ASC Outpatient Hospital Outlier Outliers are Admissions with extraordinary cost warranting additional reimbursement beyond the maximum allowance.

20 ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care ® Arizona Medical Bill Reviewer Training Program Unit 2: Hospital Guidelines Module 2: Ambulatory Surgery Centers (ASC)

21 21 Arizona Regulation Training – Inpat, Outpat, ASC Ambulatory Surgery Center (ASC) ASC Guidelines… How Bills are keyed Billing Examples Youve learned about Outpatient Hospital services and next is another hospital service, Ambulatory Surgery Centers.

22 22 Arizona Regulation Training – Inpat, Outpat, ASC Ambulatory Surgery Centers (ASC) An ASC is any surgical clinic or ambulatory surgical center that is certified to participate in the Medicare program or any surgical clinic accredited by an approved accrediting agency.

23 23 Arizona Regulation Training – Inpat, Outpat, ASC Keying ASC Bills Ambulatory Surgery charges are submitted on UBs and CMS-1500 forms. UB charges are keyed the same as Outpatient Hospital bills, with exceptions. HCFA charges are keyed as billed. Examples of both are… Revenue codes 490 – 499 (ambulatory surgery) or 360 – 369 (operating room) required on the UB CPT codes required on the CMS-1500 (HCFA)

24 24 Arizona Regulation Training – Inpat, Outpat, ASC Non-Covered Charges Non-covered charges are services and circumstances that are not considered an integral part of the surgical or medical procedure, such as… Broken or missed appointments Stat fees Personnel items: Slippers, phone, toothbrush, toothpaste, lotion, powder, guest trays, shampoo, TV, admit kit (when more than one is billed) Any more than one office visit on the same day, without medical necessity After hours, call back and/or Sunday/Holiday Utilization review charges Nursing support or nursing increment charges Admission charges Universal precautions Room and board charges on date of discharge Private room: without medical necessity

25 25 Arizona Regulation Training – Inpat, Outpat, ASC Summary Inpatient services apply when a hospital patient occupies a bed at midnight. Outpatient services are rendered to patients for the purpose of administering medical treatment that does not require an overnight stay at a hospital Ambulatory Surgery Centers (ASC) is any surgical clinic or ambulatory surgical center that is certified to participate in the Medicare program or any surgical clinic accredited by an approved accrediting agency. Implants are paid at 100% of billed charges or contracted rate. Contract language determines if Invoices are required or not for reimbursement. Exclusions are billed services the provider contract stipulates are reimbursed at designed rates, separate from and over and above per diem rates. Non-Covered Charges are services and circumstances that are not considered an integral part of the surgical or medical procedure.


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