Riverbend

Hospital FAQ

When is it appropriate to use the modifier "GY"?

As of January 1, 2004, the "GY" modifier should be used when billing for items or services statutorily excluded or that do not meet the definition of any Medicare benefit. Use of the GY modifier will result in a non-covered response from the edit module in all cases.
Laboratories should append the GY modifier to the CPT procedure codes for any service where the appropriate diagnosis for that service is on the list of diagnoses that are not covered. (7/5/2007)

Where do I find information on billing Outlier claims?

Billing for Outliers can be found in the Internet Based Manuals, Medicare Claims Processing Manual 100-4, Chapter 3 Section 20. http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf

Information on the background of Outlier Payments, along with examples are also availableon the CMS Web site, http://www.cms.hhs.gov/AcuteInpatientPPS/04_outlier.asp (7/5/2007)

What revenue code should be used when billing blood?

Units for revenue code (s) 381 and 382 should indicate the same number of units for value code 37 (blood amount furnished) on the claim. (4/1/2002)

Are subacute care facilities included in the transfer policy?

The Medicare program does not recognize subacute care as a distinct benefit. However, if a facility describing itself as providing subacute care is certified as a skilled nursing facility or nursing home and the services provided are covered and paid under the Medicare or Medicaid program, then the transfer policy would apply. (7/5/2007)

Why are our facility's claims being returned requesting a letter from the beneficiary indicating the beneficiary has elected to use LTR days?

RGBA does not require providers to submit a letter from the beneficiary indicating the election to use LTR days. If LTR days are indicated on the claim RGBA will accept the claim with the following conditions:

• Condition Code 68 on claims (beneficiary elects to use LTR days)
• Beneficiary is deceased
• Cost Outlier claim

If a claim has LTR days and does not meet the above conditions, RGBA will RTP (Return To Provider) RGBA will reject for 39507 - The coinsurance rate for lifetime reserve days exceeds your facility's average daily charge. Therefore, no Medicare payment can be made on this claim or only partial payment can be made since patient has been deemed not to use lifetime reserve days. (7/9/2007)

Providers need clarification on how to respond to reason code 70004.

Reason code 70004 occurs when the claim information indicates that a service is being billed on an inpatient claim that may be a possible exclusion from the Medicare program.

Your claim is being rejected because it contains statutorily excluded items and/or services. A letter will be sent to the QIO for review to determine if these services will be covered. Upon response from the QIO, your claim will be adjusted per the QIO'S instructions. .

If the QIO advises RGBA that the claim can be paid, we will adjust the claim accordingly. If you need to inquire about the status of the QIO's review, please contact the QIO directly. (7/6/2007)

How do I verify Psychiatric days available for the patient?

A facility can verify the days available for a beneficiary by accessing the Common Working File (CWF). You may access the CWF by entering HIon DDE, instead of FSS0 (zero). A screen will display prompting you to enter patient specific information into the appropriate fields. Once the fields are populated press enter. The patient eligibility information will be displayed. (7/5/2007)

What are the diagnostic testing requirements that must be met in order to separately bill for outpatient observation services?

For a diagnosis of chest pain the hospital must perform at least two sets of cardiac enzymes (either two CPK or two troponin) and two sequential electrocardiograms. For a diagnosis of asthma, a breathing capacity test or a pulse oximetry must be performed. The pulse oximetry codes are treated as packaged services under OPPS but must be reported if G0244 is billed. For a diagnosis of congestive heart failure, a chest x-ray, an electrocardiogram, and a pulse oximetry must all be performed as a part of the observation. Although no separate payment is made for packaged codes, hospitals must separately report the HCPCS code and a charge for pulse oximetry. This helps to establish whether the observation services for congestive heart failure or asthma diagnoses meet the criteria for separate payment. (7/5/2007)

Our inpatient hospital claims have been cancelled as a result of using an incorrect discharge status code. What should we do?

If the Common Working File (CWF) has canceled the claim you will need to resubmit the claim with the correct discharge status code.

If you discover the claim was filed with an incorrect discharge status code you may file an adjustment to the claim changing the discharge status code. Remember, you will need to add a condition code in field 24-30 on the UB 92. The appropriate condition codes are as follows:

• D0 Changes to service dates
• D1 Changes to charges
• D2 Changes in revenue codes/HCPCs
• D3 Second pr subsequent Interim PPS bill
• D4 Change in ICD-9 diagnosis and/or procedure codes
• D5 Cancel to correct HICN or provider identification number
• D6 Cancel only to repay a duplicate or OIG overpayment
• D7 Change to make Medicare the secondary payer
• D8 Change to make Medicare the primary payer
• D9 Any other change
• E0 Change in patient status

If you are using Direct Data Entry (DDE) you will add a condition code for the reason you are performing the adjustment.

Reminder: you will also need to add the adjustment reason code on page 3 of DDE. You may verify the correct adjustment code to use by accessing the adjustment reason code table in 01-Inquires and then 16-Adjustment Reason Codes. You will enter the claim type and press enter to access the adjustment reason code table. The adjustment reason code for discharge status code is SC. After entering the information press F9 to activate the claim in FISS. (7/5/2007)

Our facility has been instructed to add line item dates of service to our outpatient claims. Does this include all revenue codes?

You should add a line item date of service for every revenue code on the claim.

RGBA published Medi 1781-04 on June 21, 2004, which appended the CMS Medlearn Matters Article MM3337.

Effective for claims submitted on or after October 1, 2004, the Centers for Medicare & Medicaid Services (CMS) will require a single date in the LIDOS field on all outpatient claims and inpatient Part B claims. Medicare fiscal intermediaries will reject any such claims where the LIDOS field contains a range of dates.

Effective October 1, 2004, all claims submitted on bill types 12x, 13x, 14x, 22x, 23x, 24x, 32x, 33x, 34x, 71x, 72x, 73x, 74x, 75x, 76x, 81x, 82x, 83x, and 85x must contain a single date in the LIDOS field or the claim will be rejected as unprocessable. Effective for claims submitted on or after October 1, 2004, the Centers for Medicare & Medicaid Services (CMS) will require a single date in the LIDOS field on all outpatient claims and inpatient Part B claims. Medicare fiscal intermediaries will reject any such claims where the LIDOS field contains a range of dates.

Effective October 1, 2004, all claims submitted on bill types 12x, 13x, 14x, 22x, 23x, 24x, 32x, 33x, 34x, 71x, 72x, 73x, 74x, 75x, 76x, 81x, 82x, 83x, and 85x must contain a single date in the LIDOS field or the claim will be rejected as unprocessable. (7/5/2007)

Our facility would like clarification regarding the use of condition code 44.

RGBA published Medi 1740-04   on May 4, 2004.

Riverbend has not received any change in specific CMS' instructions regarding the assignment of patient status and has not received information to suggest that this code should be interpreted as implying a change in those instructions. The definition of condition code 44 should therefore be taken at face value and not extended to decisions for which it may not apply. (7/5/2007)

If a patient is in an inpatient stay and Medicare becomes effective during that stay how do we file the claim?

The primary insurance would be billed for the time the patient was covered. A facility would bill Medicare from the effective date until discharge.
Example: Patient admitted to "A" Hospital on October 15 and the patient was under a Large Group Health Plan (LGHP). Medicare became effective November 1 and the patient was discharged on November 30. "A" Hospital would file a claim to the LGHP for October 15 through October 31, assuming the employee insurance ended as of October 31. A claim should be filed to Medicare using the statement covers period November 1 through discharge. However, the admit date on the Medicare claim would be October 15 even though Medicare was not effective until November 1. (7/5/2007)

I am receiving rejected claims when billing multi-channel HCPCS for two separate visits on the same date. I am sending two claims with the condition code G0. Why are these rejected?

Not all multi-channeled HCPCS codes will be payable on the same date, regardless of modifiers or condition codes reported. If you have lab values from the first visit, there would have to be medical necessity for a second set. Services on the same date of service should be submitted on the same claim. The G0 condition code is to report multiple medical visits which occur on the same day in the same revenue center. The visits must be distinct and constitute independent visits. For example: a beneficiary going to the emergency room twice on the same day. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. Multiple visits on the same day with the same revenue code without condition code G0 will be rejected. (7/5/2007)

If a patient presents in the ER at 9:00 PM on 01/05/07 and the physician states/documents to admit the patient at 2:00 AM on 01/06/07, what would the admit date be for this inpatient admission?

The instructions for completing a claim form states the admission date is the day the patient was admitted. In your scenario, the patient is an outpatient (ED services) until admitted. Therefore, the admit date is the date the physician wrote the order and the admission took place. (7/5/2007)

There is a portion of the LCD L1352 that states 'ankle brachial index is not acceptable for reimbursement'. If a physician orders an Ankle Brachial Index (which codes to CPT 93922), is that a covered procedure at an acute care hospital?

If the physician is only ordering ankle brachial indices, it would not be reportable because this can be performed during the evaluation and management service provide by that physician.

The Riverbend LCD instructs that CPT code 93922 would include procedures such as doppler waveform analysis, volume plethysmography, and/or transcutaneous oxygen tension measurements. The ordering physician should make it clear that he is expecting more than ankle brachial indices before noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral are performed and reported. (7/5/2007)