From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing: New Billing Forms – The UB-04 and New CMS 1500 Date: 20 March 2007 Time:

2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives Understand the new requirements for the new UB-04 claim form, including new fields, modified fields, and NPI Review why field locators are filled in, and why the payer requires them Understand the new requirements for the CMS1500 claim form, including NPI Briefly address TPOCS changes for new billing form changes

2007 UBO/UBU Conference From Registration to Accounts Receivable 3 History of the Uniform Bill Between 1968 and1972, thirteen different form designs were developed and later discarded in an effort to develop a uniform bill for hospitals The 14th version was field tested in Georgia in 1973, modified again and introduced for a second trial in Wyoming HCFA (aka CMS) agreed to participate in a five-state pilot test of this latest version, known as UB A similar form was being used in NY State, known as UBF-1 South Carolina was using a form known as A-92-R In May of 1982, The National Uniform Billing Committee reviewed the various forms and developed/approved the UB-82 -Continued-

2007 UBO/UBU Conference From Registration to Accounts Receivable 4 History of the Uniform Bill The UB-92 was formed and fully implemented in 1994 The UB-04 was approved as the replacement for the UB-92 at the February 2005 meeting Health plans and clearinghouses need to be ready to receive the new UB-04 by March 1, Submitters can begin to use the UB-04 on March 1, 2007 There is a transitional period between March 1, 2007, and May 22, 2007, when both UB-92 and UB-04 can be used Starting May 23, 2007, all institutional paper claims must use the UB-04. The UB-92 will no longer be available for use after this date

2007 UBO/UBU Conference From Registration to Accounts Receivable 5 UB-04 Differences Standardization: All Form Locators (FL) will be nationally “controlled” All Code Ranges will be reserved for national assignment The UB-04 data specs will be the principal content used in the HIPAA electronic format The UB-04 is designed to accept the forthcoming ICD- 9-CM changes and support both National Payer and Provider ID #’s A national UB-04 manual is now available and published with hyperlinks to individual State Uniform Billing manuals

2007 UBO/UBU Conference From Registration to Accounts Receivable 6 FL 01: Provider Information Required The name and service location of the provider submitting the bill FL 01

2007 UBO/UBU Conference From Registration to Accounts Receivable 7 FL 02: Pay-to Information New Field - Situational Used when the pay-to name and address information is different from the Billing Provider in FL1. Can only identify a 5-digit zip code. Line 4 is not used, and is reserved for assignment by NUBC FL 02

2007 UBO/UBU Conference From Registration to Accounts Receivable 8 FL 03a-b: Patient Control Number and Medical Record Number Required Moved/New Field Previously in FL 23 FL 03

2007 UBO/UBU Conference From Registration to Accounts Receivable 9 FL 04: Type of Bill Required Expanded by 1 Digit. The first digit is a leading zero, the next 2 digits indicate the type of bill (i.e. 011 = Hospital Inpatient). The fourth digit defines frequency of the bill FL 05: Federal Tax Number Required Upper line is the federal sub-ID # assigned by the Provider. Lower line is entered as NN-NNNNNNN (w/ hyphen) FL 04-05

2007 UBO/UBU Conference From Registration to Accounts Receivable 10 FL 06: Statement Covers Period From/Through Required The From date should not be confused with the Admission Date (FL 12) FL 07: Unlabeled Not Used On the UB-92: FL07 used to be Covered Days, and FL08 was Non/Covered Days; FL09 used to be Co-insurance Days, and FL10 was L/T RSV Days. All have been eliminated from the UB-04 and substituted with new Value Codes FL 06-07

2007 UBO/UBU Conference From Registration to Accounts Receivable 11 FL 08a: Patient Identifier Required Report if number is different from the subscriber/insured’s ID (FL60) FL 08b: Patient Name Required On the paper form, use a comma or space to separate last and first names. Record hyphenated names with the hyphen as in Smith-Jones, Rebecca FL 08

2007 UBO/UBU Conference From Registration to Accounts Receivable 12 FL 09 a-e: Patient Address Required Previously in a single field Zip code is 9 positions Country Codes are available from: American National Standards Institute 11 West 42 nd St. 13 th Floor New York, NY FL 09

2007 UBO/UBU Conference From Registration to Accounts Receivable 13 FL 10: Birthdate Required If full birth date is unknown, use zeros for all eight digits, for paper claims. Enter: “MMDDYYYY” format FL 11: Sex Required The sex of the patient as recorded at admission, outpatient service, or start of care. FL 11 on the UB-92 used to be Unlabeled FL 10-11

2007 UBO/UBU Conference From Registration to Accounts Receivable 14 FL 12: Admission/Start of Care Date FL 13: Admission Hour FL 14: Priority (Type) of Visit FL 15: Source of Referral for Admission or Visit FL 16: Discharge Status (required on IP claims) FL 17: Patient Discharge Status All are required fields, except FL 13 and FL 16, which are situational fields. FL 16 on the UB-92 “Patient Martial Status” has been eliminated from the UB-04 FL 12-17

2007 UBO/UBU Conference From Registration to Accounts Receivable 15 FL 18-28: Condition Codes Situational 11 total Condition Codes. Codes are entered in alphanumeric sequence (numbered codes precede alphanumeric codes). No specific dates are associated with these codes. If all of the Condition Codes fields are filled, used FL 81 Code-Code Field with the appropriate qualifier (A1) to indicate that a Condition Code is being reported FL 23 on the UB-92 used to be Medical Record Number, which has now been moved to FL3b on the UB-04 FL 18-28

2007 UBO/UBU Conference From Registration to Accounts Receivable 16 FL 29: Accident State New Field - Situational Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code named in X12 code source 22 FL 30: Unlabeled Not used Reserved for assignment by NUBC FL 29-30

2007 UBO/UBU Conference From Registration to Accounts Receivable 17 FL 31-34: Occurrence Codes Situational 8 total Occurrence Codes. Codes should be entered in alphanumeric sequence (numbered codes precede alpha codes). Enter all dates as month, day and year: MMDDYYYY FL 31 on the UB-92 was an Unlabeled Field If all Occurrence Codes are filled, then use FL 81 (Code-Code field) using the appropriate qualifier (A2) to indicate than an Occurrence Code is being reported FL 31-34

2007 UBO/UBU Conference From Registration to Accounts Receivable 18 FL 35: Occurrence Span Code/From/Through Situational If all Occurrence Span Codes are filled, then use FL 81 (Code- Code field) using the appropriate qualifier (A3) to indicate than an Occurrence Span Code is being reported FL 36: Occurrence Span Code/From/Through Added Additional Occurrence Span Code FL 37: Unlabeled The ICN/DCN on the UB-92 (FL 37), has been Relocated to FL 64 on the UB-04 FL 35-37

2007 UBO/UBU Conference From Registration to Accounts Receivable 19 FL 38: Responsible Party Name/Address Situational Used to print the name and mailing address of the party responsible for the bill if a window envelope is utilized FL 38

2007 UBO/UBU Conference From Registration to Accounts Receivable 20 FL 39-41: Value Code / Amount Situational 12 total Value Codes. Value Codes are entered in alphanumeric sequence. Fields 39a through 41a must be completed before “b” line fields, etc. Negative numbers are not permitted except in FL 41. Report values in whole numbers, right justified to the left of the dollars/cents delimiter. The decimal is implied. If all of the Value Code Fields are filled, use FL 81 (Code-Code) with the appropriate qualifier code (A4) to indicate that a Value Code is being reported FL 39-41

2007 UBO/UBU Conference From Registration to Accounts Receivable 21 FL 42 (lines 1-23)Revenue Code: Required FL 43 (lines 1-22) Revenue Code Description: Required FL 43 (line 23) Page ___ of ___: Required. Previously inside the Charge Body of the UB-92 Form. Required on all pages. FL 44 (lines 1-22) HCPCS/Rates/HIPPS Rate Codes: Situational Expanded by 5 Digits – 1 HCPCS and 4 modifiers. FL (line 23) Creation Date: Required New Field FL 45 (lines 1-22) Service Date: Situational (Required on OP Claims) FL 42-45

2007 UBO/UBU Conference From Registration to Accounts Receivable 22 FL 46 (lines 1-22) Service Units: Required FL 47 (lines 1-23) Total Charges: Required. Removed Sign Field. Reduced 1 Digit. FL 48 (lines 1-23) Non-Covered Charges: Situational. Removed Sign Field. Reduced 1 Digit. Revenue Code 0001 is used on the final page to indicate total covered & non-covered charges. FL 49 (lines 1-23) Unlabeled: Not Used FL 46-49

2007 UBO/UBU Conference From Registration to Accounts Receivable 23 FL 50: a. Payer Name: Prime, b. Payer Name: Secondary, c. Payer Name: Tertiary Line A is required, Lines B & C are situational (FL 50 and FL 51) FL 51: Health Plan ID (a,b,c) Situational Report to HIPAA national health plan identifier when it becomes mandatory FL 32: Release of Information (a,b,c) Required. FL 50-52

2007 UBO/UBU Conference From Registration to Accounts Receivable 24 FL 53: Assignment of Benefits Required. Primary, Secondary and Tertiary. FL 52: Prior Payments Situational. Primary, Secondary and Tertiary. The “Patient Prior Payment Field” has been eliminated. FL 53-54

2007 UBO/UBU Conference From Registration to Accounts Receivable 25 FL 55: Estimated Amount Due Situational. Primary, Secondary and Tertiary. Eliminated the “Due From Patient Field” from the UB-04. FL 56: National Provider ID Situational. FL 57: Other Provider ID Situational. Primary, Secondary and Tertiary. Other Provider identifiers are assigned by the health plan. FL 55-57

2007 UBO/UBU Conference From Registration to Accounts Receivable 26 FL 58: Insured’s Name Required. Primary, Secondary and Tertiary. List last names first and use a comma or space to separate last and first names. FL 59: Patient’s Relationship Line A is a Required Field, Lines B & C are situational. Primary, Secondary and Tertiary. FL 58-59

2007 UBO/UBU Conference From Registration to Accounts Receivable 27 FL 60: Insured’s Unique ID Line A is a Required Field Lines b & C are situational. Primary, Secondary and Tertiary. FL 60

2007 UBO/UBU Conference From Registration to Accounts Receivable 28 FL 61: Insurance Group Name Situational. Primary, Secondary and Tertiary. FL 62: Insurance Group Number Situational. Primary, Secondary and Tertiary. FL 61-62

2007 UBO/UBU Conference From Registration to Accounts Receivable 29 FL 63: Treatment Authorization Code Situational. Primary, Secondary and Tertiary. FL 64: Document Control Number Situational. Primary, Secondary and Tertiary. FL 64 “Employment Status Code” on the UB-92 has been deleted from the UB-04 FL 63-64

2007 UBO/UBU Conference From Registration to Accounts Receivable 30 FL 65: Employer Name Situational Primary, Secondary and Tertiary. FL 65

2007 UBO/UBU Conference From Registration to Accounts Receivable 31 FL 66: DX Version Qualifier Required. Denotes ICD Version. FL 66 on the UB-92 “Employer Location” has been deleted from the UB-04. FL 67: Principal DX Code & Present on Admission Indicator Required. Positions 1-7 are for the DX code(s); Position 8 (shaded area) are for POA indicator’s) FL 67 A-Q: Other Diagnosis Required. 18 total DX’s (9 New) Note the Shadowed Fields. FL 68: Unlabeled Not used. FL 66-68

2007 UBO/UBU Conference From Registration to Accounts Receivable 32 FL 69: Admitting Diagnosis Code Situational. The ICD Diagnosis code describing the patient’s diagnosis at the time of admission. Required on IP Claims. FL 70: Patient’s Reason for Visit Code Required for all unscheduled OP visits FL 71: Prospective Payment System Code The PPS code assigned to the claim to ID the DRG based on the grouper software called for under contract with the primary payer. FL 69-71

2007 UBO/UBU Conference From Registration to Accounts Receivable 33 FL 72: External Cause of Injury Code Situational. The ICD DX codes of pertaining to external cause of injuries, poisoning, or adverse effects. 2 new FL’s (total of 3 E-Codes) on the UB-04. Positions 1-7 are for the DX code; position 8 (shaded area) is for the POA Indicator. FL 73: Reserved for Assignment by the NUBC Not used FL 72-73

2007 UBO/UBU Conference From Registration to Accounts Receivable 34 FL 74: Principal Procedure Code/Date Situational. Required for IP Claims (when a procedure was performed). Reporting the decimal between the 2nd and 3rd digits of the ICD is unnecessary because it is implied. Not used on OP Claims. FL 74 a-e: Other Procedure Code/Date Situational. Not used on OP claims. FL 75: Reserved for Assignment by the NUBC Not used FL 74-75

2007 UBO/UBU Conference From Registration to Accounts Receivable 35 FL 76: (1) Attending - NPI/QUAL/ID (2) Last/First Name All Situational FL 77: (1) Operating - NPI/QUAL/ID (2) Last/First Name FL 78 & 79: (1) Other ID - NPI/QUAL/ID (2) Last/First Name FL 76-79

2007 UBO/UBU Conference From Registration to Accounts Receivable 36 FL 80: Remarks Situational. Reduced Field Size. FL 81a-d: Code-Code QUAL/CODE/VALUE New Field. See Qualifiers on next page. FL 79 on the UB-92, “Procedural Coding Method Used”, has been eliminated from the UB-04. UB-92 Form Locators 85 “Provider Rep Signature” and Form Locator 86 “Date Bill Submitted” have been eliminated from the UB-04 –Continued– FL 80-81

2007 UBO/UBU Conference From Registration to Accounts Receivable 37 FL 81 Code Code Qualifiers A1NUBC Condition Codes (FL 18-28) A2NUBC Occurrence Codes (FL 31-34) A3 NUBC Occurrence Span Codes (FL 35-36) B1 Standards for the Classification of Federal Data on Race and Ethnicity (for public health data reporting only when required by state or federal law or regulations) B2 Marital Status (for public health data reporting only when required by state or federal law or regulations) B3Health Care Provider Taxonomy Code (code source: ASC X12 External Code Source 682) (National Uniform Claim Committee)

2007 UBO/UBU Conference From Registration to Accounts Receivable 38 Any Questions? Thank you for your Attention!

2007 UBO/UBU Conference From Registration to Accounts Receivable 39 Revised CMS-1500 Overview Although many providers now submit electronic claims, many of their software/hardware systems depend on the existing 1500 Claim Form in its current image. Minor changes have been made to the form to accommodate the National Provider Identifier (NPI), as well as current identifiers for a transition period until the NPI is implemented. In addition to modifying the 1500 form, the National Uniform Claim Committee drafted a reference instruction manual detailing how to complete the form. The updated 1500 manual, version 1.3 7/06 is currently available at

2007 UBO/UBU Conference From Registration to Accounts Receivable 40 CMS-1500 Billing Form Requirements CMS-1500 Billing Form CMS-1500 billing form has 33 items or data fields; 21 of which are required Required Data Elements are data elements that must be entered on the billing form Conditional Data Elements these are elements that depend on other data before required Blank data fields do not require data

2007 UBO/UBU Conference From Registration to Accounts Receivable 41 Claim Form Formats and Versions There are currently two versions of the Form CMS-1500 (12-90 and 08-05) The current CMS-1500 form has the numbers “(12-90) RRB -1500” in the lower right corner and four black alignment bars in the upper left corner The revised CMS-1500 form has the 1500 symbol and the approval date (08/05) in the upper left margin CMS-1500 (08-05) can be used as of 1 January 2007 but will not be mandatory until 2 April 2007 NOTE: There will be a period when both versions of the CMS-1500 will be accepted by payers

2007 UBO/UBU Conference From Registration to Accounts Receivable 42 CMS-1500 Implementation Timeline 2 January March 2007 Providers can use either the current Form CMS-1500 (12-90) or the revised Form CMS-1500 (08-05). Note: Health plans, clearinghouses, and other information support vendors should be able to handle and accept the revised Form CMS-1500 (08-05) by January 2, 2007 April 2, 2007 The version of CMS-1500 is discontinued. Only the CMS-1500 is to be used Note: All rebilling of claims should use the revised CMS (08-05) from this date forward, even though earlier submissions may have been on the current Form CMS (12-90)

2007 UBO/UBU Conference From Registration to Accounts Receivable 43 Four (4) bars OMB Approval date CMS Current Version (12-90)

2007 UBO/UBU Conference From Registration to Accounts Receivable 44 Revised CMS 1500 (08/05) 1500 symbol & OMB approval date

2007 UBO/UBU Conference From Registration to Accounts Receivable 45 Key Changes Referring Physician Information Items 17, 17a, & 17b

2007 UBO/UBU Conference From Registration to Accounts Receivable 46 Item 17 Item 17: Name of referring provider or other source who referred or ordered the service (Conditional Data Element) Revised - Title was changed from “Referring Physician” to “Referring Provider” Note:TPOCS will populate the referring provider information in Items 17, 17a and/or 17b

2007 UBO/UBU Conference From Registration to Accounts Receivable 47 Item 17a Item 17a: Other Id# / Qualifier (Conditional Data Element) The Other ID Number of referring or ordering provider, the provider taxonomy code of the referring or ordering provider should be reported in the shaded area The qualifier (PX- Provider Taxonomy) identifies the type of Other ID being reported in the shaded area and is entered in the qualifier field Qualifier field Revised - This area was shaded and a new field was added to hold the two-digit qualifier for other ID Number

2007 UBO/UBU Conference From Registration to Accounts Receivable 48 Item 17b Item 17b: Provider NPI # Required, if applicable (Required Data Element) NPI Type 1 of the referring or ordering provider will appear in this field, if available. If NPI is missing, then the Current Provider ID and/or Tax ID will be reported in Item 17a until the NPI is provided. New item – Additional field to accommodate the National Provider Identifier

2007 UBO/UBU Conference From Registration to Accounts Receivable 49 Key Changes – Service Line Section 24 Revised – To accommodate submission of both the NPI and other Provider Identifier during the NPI transition Key Changes Service Line Information Section 24

2007 UBO/UBU Conference From Registration to Accounts Receivable 50 Item 24B Note: TPOCS will provide users the option to determine if the encounter is related to ER services. When saving the bill TPOCS will assign the place of service code based on MEPRS code BIA* 23 If the MEPRS code is BIA*, then place of service code will be 23-Emergency Room Item 24B: Place of Service (Required Data Element) The place of service code identifies the location of where the service occurred. For DoD, the place of service code 26-Military Treatment Facility is hard coded in TPOCS for all 1500 claims with the exception of emergency room services.

2007 UBO/UBU Conference From Registration to Accounts Receivable 51 Item 24C Item Number 24C: EMG (Conditional Data Element) This item was originally labeled “Type of Service,” and is now the Emergency indicator “EMG.” The indicator states whether or not a service is related to an emergency Y For DoD, If MEPRS code is BIA* and services are emergency related, then Y for “Yes” will appear in the box; if “No,” the field will be left blank

2007 UBO/UBU Conference From Registration to Accounts Receivable 52 Item 24I Item 24I: ID Qualifier (Required Data Element) This field was originally titled “EMG,” which is now in Item 24c. This field is now titled “ID Qualifier.” The qualifier is used to identify the type of non-NPI number used to represent the provider For DoD, the non-NPI number used will be the HIPAA Taxonomy code; thus, the ID Qualifier-PX will be assigned. The Provider Taxonomy code of the rendering provider will be reported in the shaded area of Item 24J ID Qualifier = PX - Taxonomy code

2007 UBO/UBU Conference From Registration to Accounts Receivable 53 Item 24J Item 24J: Rendering Provider ID# (Required Data Element) This field was originally titled “COB.” The original fields 24J and 24k were combined and renumbered. They are now titled “Rendering Provider ID#” The Provider Taxonomy code of the rendering provider will be reported in the shaded area NPI Type 1 of the rendering provider will be reported in the unshaded area 207P00000X

2007 UBO/UBU Conference From Registration to Accounts Receivable 54 Item 24K Item 24K: Reserved for local use This field was deleted and combined with 24K

2007 UBO/UBU Conference From Registration to Accounts Receivable 55 Key Changes to Provider Information Key Changes Provider Information Items 32-33b

2007 UBO/UBU Conference From Registration to Accounts Receivable 56 Item 32 Item 32: Service Facility Location (Required Data Element) Address for the Treating/Service Facility will appear in this block. Block 32 will be limited to 78 characters with a three-line template, 26 characters each for address Note: On the print forms, there will now be a limitation of how small you can print on the forms (10 pitch) Items 32 and 33 will be restricted to three lines for the facility and provider address USAFA 10Th Medical Group/SGSBR 4102 PINION DR STE 100 USAF ACADEMY, CO 80840

2007 UBO/UBU Conference From Registration to Accounts Receivable 57 Item 32a Item 32a: NPI # (New Field) (Required Data Element) NPI Type 2 (treating MTF) will be reported in this field. This field allows for 10 characters

2007 UBO/UBU Conference From Registration to Accounts Receivable 58 Item 32b Item 32b: Other ID# (New Field) (Required Data Element) The non-NPI number will be either the Treating Facility Tax ID or HIPAA Taxonomy code preceded by the two-digit qualifier identifying the type of non-NPI number

2007 UBO/UBU Conference From Registration to Accounts Receivable 59 Items 33a-b Item 33a: NPI # (New Field) (Required Data Element) NPI Type 2 of the Billing facility will be reported in this field Item 33b: Other ID # (New Field) (Required Data Element) The qualifier followed by the HIPAA Taxonomy or Billing Facility Tax ID will be reported in this field

2007 UBO/UBU Conference From Registration to Accounts Receivable 60 UBO Functional Guidance In conjunction with the TPOCS CMS 1500/UB-04 implementation, the TRICARE Management Activity/ Uniform Business Office (TMA/UBO) will be responsible for providing functional guidance on business practices relating to data collection and billing procedures for the Military Treatment Facilities

2007 UBO/UBU Conference From Registration to Accounts Receivable 61 Summary Revised CMS-1500 overview CMS-1500 billing form requirements Claim form formats and versions CMS-1500 version implementation timeline CMS-1500 current version (12/90) Revised CMS-1500 (08/05) Revised CMS-1500 Key changes: Referring physician information Revised CMS-1500 Key changes: Service line Revised CMS-1500 Key changes: Provider information UBO functional guidance