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Are you UB-04 savvy?
Editor’s note: This article was written by Glenda Hynes, RN, RAC-CT, a senior clinical consultant at Landview Therapy Resources in Massachusetts. For more information about Glenda Hynes, please see our ‘About’ page.
Clinical staff members often do not understand the relationship between the census and billing data they provide to the business office and the facility’s liability for reimbursement denials. CMS and managed care organizations are increasing their efforts to indentify billing errors and potential coverage concerns. Medicare Part A and Part B claims may be delayed or denied based on identified errors through the UB-04. Improving rehabilitation and clinical staff knowledge of revenue cycle processes and the claim form may reduce the number of claims reviewed, payment delays, and perhaps even reimbursement denials.
Prepare for RACs
Medical review programs focused on identification of improper payments have taken a giant step forward in recent years. Fiscal intermediaries and Medicare administrative contractors are being supported by systems and auditors, such as the Recovery Audit Contractors (RAC), who utilize sophisticated software to identify potential errors in facility data generated from the UB-04 and MDS.
RACs were developed to identify overpayments, duplication of services, improper payments, and services that don’t meet Medicare’s medical necessity criteria. A 2007 pilot project in three states identified over 992 million dollars in overpayments to be returned to the Medicare Trust Fund. As a result, CMS is in the process of expanding the RAC program to all states. These auditors are paid on a contingency basis which means they receive no salaries or fees, but are paid a percentage of the dollars recovered for CMS.
Probe audits – often the first step
CMS medical reviews follow a similar process. Contractors will initially examine a random number of claims (usually 20-40) seeking provider-related concerns. However, they may also choose a larger sample of claims and records if a spike in billing for a specific procedure or category is identified.
When auditors determine that a problem exists, the next step will often depend on the severity of the errors identified, which is determined by calculating a provider-specific error rate (number of claims in error: number of claims reviewed). Regardless of the error rate, providers are responsible for payment of the claims identified in error and education in billing and coding procedures. If auditors determine that a provider’s error rate is significant, additional reviews, including pre-payment reviews, may be conducted.
In addition to random audits, some facilities may experienced more focused audits of 100 records or more if past billing practices demonstrated a high error rate.
Unavoidable reviews
Ultimately, audits are unavoidable and, at one point or another, all providers will be reviewed. Because of this, pristine revenue cycle processes are more important than ever and facilities should conduct regular self-audits and correct any errors identified. Auditors will look for billing trends, potential duplication of services, and claims that do not appear to have supporting diagnoses for the services provided or RUG category assigned.
Pre-billing prevention strategies
Understanding the connection between the clinical and rehabilitation documentation and billing is essential to preventing an audit. Software edits and high volume medical reviews may be reduced by ensuring the information on the UB-04 is accurate and supports the RUG classification. For example, assessment reference dates and service dates must match, HIPPS modifiers must be accurate, and Medicare Part A bills must be submitted sequentially. Claims that indicate potential duplication of services, diagnostic codes that do not support the length of stay or scope of services, or service units that do not to support the RUG classification may be pulled for further review.
Key areas of oversight include, but are not limited to, the following items and field locators (FL) on the UB-04 claim form:
- Bill type is accurate, sequential, FL-2
- Admission dates and type support claim, FL-14 and FL-15
- Three-day qualifying hospital stay occurrence, FL-35
- Rehabilitation service codes support RUG category, FL-42
- HIPPS modifiers match MDS type, FL-45
- Accurate coverage dates for MDS, FL-45
- Service units support claim and RUG, FL-46
- Covered condition related to hospital stay or subsequent SNF stay (ICD-9-CM codes), FL-69 through FL-74
Facilities should ensure rehabilitation, nursing, and MDS staff members communicate clearly with billing staff. Educating clinical staff about the UB-04 and regular reconciliation of MDS, rehabilitation, and clinical data prior to billing are strategic elements in a facility’s audit prevention program.
CMS provides a sneak peek of RAI User’s Manual chapter
The Centers for Medicare & Medicaid Services (CMS) released an example of what Chapter 4: Care Area Triggers (CATs) and Care Planning of the Resident Assessment Instrument (RAI) User’s Manual, Version 3.0 will look like. CATs are replacing the MDS 2.0 Resident Assessment Protocols (RAPs). This is only an example and the final version will be included when CMS releases the RAI User’s Manual for the MDS 3.0 available later in the year.
To view Chapter 4: Care Area Triggers (CATs) and Care Planning, visit the Resources page on MDSCentral.
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