All Entries in the "Access Q&A" Category
Priority type of visit: Required for all patient types?
Q: Regarding the “FL14″ field for “Priority Type of Visit” on the UB-04 form, is it needed on all patient types? Or is it needed just for inpatient and emergency room visits?
A: This field is required for all inpatient claims; it is optional for outpatient reporting.
Editor’s note: George Arges, senior director of the American Hospital Association, answered this question.
UB-04: Nine or 10 characters for the Secondary Identifier field?
Q: The UB-04 requirements are only for nine characters in fl76-fl79 line 1, Secondary Identifier field. But the Michigan state license, which is used for Blue Cross Blue Shield of Michigan (BCBSM) and all of our commercial payers, is 10 characters long. Can you explain why this is?
A: You are correct in noting that the secondary identifier field in FL76-79 has room for only nine characters. The NUBC sought to provide a secondary identifier such as the UPIN or SSN/TIN number. We felt that the NPI should be used as the primary identifier – including using the NPI as a reference to any state licensure number. If the BCBSM and the commercial payers need to have the state licensure number always reported, the NUBC would be willing to examine a request from these organizations to accommodate such reporting. One way would be to utilize the Code-Code field FL81 – establishing a qualifier to denote Attending, Operating, or Other caregiver’s State Licensure number.
Editor’s note: George Arges, senior director of the American Hospital Association, answered this question. .
Is ‘reason for visit’ a required field?
Q: I am curious about “FL70 a,b,c, reason for visit.” Is this a required field for all payers?
A: This is a situational use field. It would beneficial to capture this information on a routine basis – simply because it does convey the medical reason or symptom the patient indicated when he or she presented to your facility. This could be helpful with EMTALA requirements to explain the basis for the emergency department visit.
Editor’s note: George Arges, senior director of the American Hospital Association, answered this question. .
Is “covered days” only a Medicare requirement?
Q: “Covered days,” which is currently FL7 on the UB-92 form, will be identified as a value code 80 on the UB-04. Is this only a Medicare requirement? Will commercial and Medicaid payers require us to complete the value code?
A: The reporting of the UB-92 covered days, non-covered, etc., only changes in the way one reports this information on the paper UB-04-it is now reported as a value code. In the value code section code, “80″ indicates that for electronic reporting continues to handle it the way you had done this before. Generally, these codes were created primarily for the Medicare program to track benefit days. We are not changing the usage requirements; it is possible that another health plan may want similar information reported. Your experience with the health plan should determine whether you need to report this information for them.
Editor’s note: George Arges, senior director of the American Hospital Association, answered this question.
Is it OK to submit the standard three-digit bill type on a UB-04 form?
Q: “Type of Bill” FL4 has been expanded to four digits on the UB-04 form. Are payers going to expect four digits or is it OK to only submit the standard three-digit bill type?
A: Although the NUBC recommended that for the paper UB report the “Type of Bill” with the leading zero and for the electronic transaction standard do not include the leading zero, initially it might be best not to include the leading zero. However, we would ask that as you make the necessary system modifications to your information systems, that you expand this field size to four characters to anticipate future assignment of this added character.
Editor’s note: George Arges, senior director of the American Hospital Association, answered this question.
An effective strategy for avoiding these IP only denials?
Q: Is there an effective strategy for ensuring that the appropriate admission status is ordered for surgery patients to avoid IP only denials? Our facility is presently looking a variety of options to ensure that patients admitted through day surgery have appropriate orders to avoid denials, including physician education, case management, and developing a gatekeeper function within OR scheduling to alert doctors to an IP only-procedure status. None are proving to be completely effective.
A: The most effective method is to implement a peer-to-peer program using board certified, contracted physicians as review agents. This type of program seems to be accepted by local physicians, as long as the firm involved spends the time on-site in the beginning of the project to sell the local physicians on the benefits of the service.
Peer-to-peer programs also open the opportunity to improve physician documentation, thus making it easier for HIM codes to capture all necessary information during the coding process. This type of program works better than non-peer intervention and much better than the use of local physicians, who are service patients in the same market.
Editor’s note: Sandra Wolfskill, FHFMA, president of Wolfskill & Associates, answered this question.
Q&A: Delivering charts
Q: Is it a HIPAA violation to take files containing PHI out of the office to make preoperative/postoperative calls and deliver charts to an out-of-town physician’s office for signature?
A: You should remove patient records from the facility’s safekeeping under very limited circumstances, usually in response to a subpoena or court order. Ideally, an employee on duty at the time of the call (not working from home) should conduct preoperative/postoperative calls. If an employee must make these calls on his or her own time, it could be a violation of federal labor laws.
If a staff member is exempt from certain labor laws and must make follow-up calls from home, he or she should take only limited information (e.g., the patient’s name and telephone number) out of the facility and document the follow-up calls on a blank form to file in the patient’s medical record.
It can be difficult to get out-of-town physicians to come back to the facility to complete records, but most organizations have solved this without physically taking the records to the physician. For example, you could mail the original document to the physician for signature, along with a stamped, self-addressed return envelope (keep a copy of the report in the patient’s record, should the original be lost). Or, fax the document to the physician and ask him or her to sign it and mail or fax it back.
Editor’s note: Mary Brandt, president of Bellaire, TX-based Brandt & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.
Do we need two different NPI numbers?
Q: We are a nursing home that does our own DMERC billing, so we have both a Medicare provider number and a DMERC provider number. Are we required to have two NPI numbers?
A:You will need to obtain two NPI numbers. Medicare requires different entities (hospital, SNF, etc.) to have different provider numbers. In addition, if the entity provides different and distinct services, that entity also needs to obtain separate provider numbers for each service. In this case, you are providing both skilled nursing services, as well as DME services. Because Medicare has distinct reimbursement regulations for these types of services, each will need an NPI number.
It is also a good idea to always check with your local Medicare FI to clarify its rules.
Editor’s note: Steven Orvis, director of revenue cycle services for Sinaiko Healthcare Consulting, answered this question.
Observation: Are providers subject to penalties for overusing observation status?
Q: If hospitals place too many patients in observation status, are they penalized by CMS?
A: No. Patients are placed in observation because of the type of care they require. As long as the patients meet criteria for observation, the number of patients has no bearing on the use of observation. The Medicare fiscal intermediary is responsible for monitoring medical necessity of patients placed in outpatient observation.
Editor’s note: The Texas Medical Foundation answered this question.
If a physician determines that a patient is acute and is not responding to treatment after a stay in outpatient observation, can the patient then be admitted as an inpatient?
Q: If a physician determines that a patient is acute and is not responding to treatment after a stay in outpatient observation, can the patient then be admitted as an inpatient?
A: Yes. An outpatient observation stay can be converted or progressed from observation to inpatient admission if the patient has an acute condition that requires treatment in an inpatient setting. The physician should document the medical necessity of admission in the medical record and write an order for inpatient admission.
Editor’s note: The Texas Medical Foundation answered this question.