9-10:30 – UBWatch / CareWatch Connection 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

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. Part A - March 28, 2011 CMS Transmittal 2183 effective 6/29/2011 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.

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. 15. Admissions/Encounters for Rehabilitation 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.

Triple Check is checking the UB-04 complete claim against UBWatch: Compares the Care Allowed with the Care Provided with the Care Being Billed. The eHDS Electronic Triple Check brings three processes together: MDS, Care & Therapy, and Billing Triple Check is checking the UB-04 complete claim against MDS – evidence based care for authorized benefit Clinical documentation of care provided (MDS & Other sources) 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. 

Following the Medicare Claim Manual and RAI Manual Medicare Claims Chapter 1 Chapter 6 Chapter 25 Chapter 26 Transmittals – esp. 2183 March 25, 2011 RAI Manual May 2011 + Updates

Advance Beneficiary Notice WHAT IS AN ABN? 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. ABNs should only be provided to beneficiaries enrolled in Original (Fee-for- Service) 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.

Key Factors MDS Assessments UB-04 Claim

Universal Billing Claims and the MDS Assessments 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.

Why correct the logic flags and HIPPS code using CareWatch? 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.

UB-04 and SNFs 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.

Medicare Benefit Policy Current CMS policy on these benefits, and claims seeking payment for them, can   also be found at: TABLE 2: BENEFIT INTERNET ON-LINE MANUAL Inpatient Hospital 100-02, Benefit Policy, Chapter 1, “ 100-04, Claims Processing, Chapter 3; SNF. (Part A Paid) 100-02, Benefit Policy, Chapter 8, 100-04, Claims Processing, Chapter 6.

Medicare FFS Bill Types (All Types Listed) Medicare Claims Category Medicare FFS Bill Types (All Types Listed) Trust Fund Payment Inpatient Part A 11x – Hospital 18x – Swing Bed 21x – Skilled Nursing Facility (SNF) 41x – RNHCI – Religious Non-Medical Health Care Institution – inpatient Part A only Inpatient 12x – Hospital Part B only Part B* 22x – SNF   In/Outpatient Part A* 81x, 82x – Hospice Outpatient* 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

Chapter 170. 2. 3 - In Accordance with CMS Instructions (Rev 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. For physician and supplier Part B claims, see Chapter 26 “Completing and Processing Form CMS-1500 Data Set”. 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.

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 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. 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.

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-than- clean” claims and notify the individual filing such claims of the determination within 45 days of receiving such claims. 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. 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.

How important is PIP? 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.

How important is Cash Flow How important is Cash Flow? – 85% consistent and complete within 30 days…. 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

Keeping Records – and what about HIPAA? 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.

Billing Frequency 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.

Advanced Beneficiary Notice (ABN) – what does this mean? Summarize Advanced Beneficiary Notice (ABN) – what does this mean? When a service is not covered When a patient/resident feels Medicare is their benefit – and Medicare feels the services are not covered Who is caught in the Middle? Patient/Resident Provider? Congress?

Demand Bill / Demand Benefit? 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.

Questions / Discussion