Chapter 26 — Key Takeaways

The two forms, side by side

Professional Institutional
Form CMS-1500 UB-04 / CMS-1450
Electronic 837P 837I
Maintained by NUCC NUBC
Manual free subscription
Fields are items FORM LOCATORS

One facility encounter produces TWO claims and TWO patient balances — Ch. 16 §16.1.

Why institutions bill differently

A physician sells professional work. An institution sells a place with things in it, and its costs are organized by department.

Three consequences: the unit of billing is frequently the STAY (an inpatient claim can list forty charges and be paid one DRG amount) · charges are grouped by DEPARTMENT (hence revenue codes) · and much of what the payer needs to know is not a service at all (hence the circumstance codes).

The form locators, and three fields to know first

81 locators, six blocks: who and where · circumstances · charges · payers · diagnoses and procedures · providers.
FL 3a PATIENT CONTROL NUMBER — per encounter. The payer returns it on the remittance so the payment can be posted
FL 3b MEDICAL RECORD NUMBER — per person
FL 48 NON-COVERED CHARGES — the difference between FL 47 and FL 48 is what the payer is being asked for

Three fields hold diagnoses:

FL 67 PRINCIPAL — chiefly responsible, established after study · FL 69 ADMITTING — what was suspected · FL 70 REASON FOR VISIT — outpatient.

They frequently differ, and the disagreement is the story of the admission. A claim where 67 and 69 are always identical is one nobody is populating thoughtfully.

TYPE OF BILL — read it as three answers

   0   1   3   1
       │   │   └── FREQUENCY
       │   └────── BILL CLASSIFICATION
       └────────── FACILITY TYPE

   0131 = hospital · outpatient · admit through discharge
   0111 = hospital · inpatient Part A · admit through discharge

Facility: 1 hospital · 2 skilled nursing · 3 home health · 7 clinic · 8 special facility. Classification (hospital): 1 inpatient Part A · 3 outpatient. Frequency: 1 admit-through-discharge · 2/3/4 interim first/continuing/last · 7 REPLACEMENT · 8 VOID.

A corrected claim submitted with frequency 1 creates a DUPLICATE.

Same failure as Chapter 25's blank item 22. And interim claims must be in order and must not overlap.

Revenue codes

A REVENUE CODE SAYS WHERE. A HCPCS CODE SAYS WHAT.

0110–0219 room and board · 0250 pharmacy · 0270 supplies · 0300 laboratory · 0320 radiology · 0360 operating room · 0450 emergency · 0636 drugs requiring detail · 0001 the total line.

Room and board also encodes ACCOMMODATION and LEVEL OF CARE. A stay moving between units produces lines under more than one code. A patient-requested private room where semi-private sufficed is generally a non-covered differential — FL 48. And adding the accommodation units is the fastest sanity check on a facility claim.
INPATIENT (x1x) revenue codes required · HCPCS generally not — the DRG comes from FL 67 and FL 74
OUTPATIENT (x3x) revenue codes required · HCPCS required — OPPS pays per service

The reason is the payment system, not the form.

The revenue-code-to-HCPCS pairing lives in the CHARGEMASTER. A terminated HCPCS, an unaccepted revenue code, or a missing mapping all arrive as denials and are all maintenance problems wearing a claim's clothes. The revenue code follows the DEPARTMENT that performed the service, not the one the patient arrived in.

The four circumstance families

The professional claim has nothing like these, because a CMS-1500 describes services performed on a person and a UB-04 describes an EPISODE inside an institution — which started somewhere, lasted a period, was interrupted, ended in a disposition, and consumed benefit days.

   IS IT TRUE?          → CONDITION       a FACT    (Condition Code 44)
   WHEN DID IT HAPPEN?  → OCCURRENCE      a DATE
   HOW LONG?            → OCCURRENCE SPAN a RANGE   (the qualifying stay)
   HOW MUCH / MANY?     → VALUE           an AMOUNT (including COUNTS)

"Covered days" is a VALUE code, not a span — the families are distinguished by SHAPE, not by subject matter, and that is the item most people miss.

They drive payment more often than students expect, and they are populated by four different departments — registration, the unit, utilization review, and the business office.

Discharge status and the transfer rule

FL 17 — 01 home · 02 short-term general hospital · 03 skilled nursing · 06 home health · 07 left against medical advice · 20 expired · 30 still a patient · 62 inpatient rehabilitation.

THE TRANSFER RULE

A hospital that transfers rather than discharges may be paid a per diem rather than the full DRG — for defined DRGs, when the stay is below the geometric mean. A status of 01 on an actual transfer overstates the payment. Neither direction denies.

30 on a non-interim claim is a mismatch with FL 4's frequency digit — the two fields must agree.

Reviewers look for: 01 where the record documents a transfer · 30 on a non-interim claim · a facility whose distribution differs markedly from peers, which is computable from claims data with no chart.

Providers, authorization, and remarks

FL 76 ATTENDING — primary responsibility, required on virtually every claim · FL 77 OPERATING — conditionally required when FL 74 reports a procedure · FL 78/79 OTHER, with a qualifier. None is the billing provider.

FL 63 carries the treatment authorization code — and the number without its scope is a number, not a record (Ch. 24 §24.6), and the scope does not fit.

FL 80 — REMARKS — is the field where the truth frequently sits.

§26.10's example turns on a remark naming a receiving facility on a claim whose FL 17 says "discharged home." Somebody wrote down what happened in the one field nobody adjudicates.

Dates and the window

FL 6 statement covers period: every service date must fall inside it · interim claims must not overlap · and on a series claim the period covers a month of visits, correctly.

The three-day payment window bundles hospital outpatient services furnished within three days before an admission into the inpatient claim — one day for certain excluded facilities — with diagnostic and non-diagnostic services treated differently and an attestation mechanism for unrelated non-diagnostic services.

"The outpatient claim was correct" is not a defense. It was correct as a standalone claim, and the rule says it should not have been a standalone claim. Those are compatible.

Reading a UB-04

   1. FL 4   type of bill — is the FREQUENCY right?
   2. FL 6   statement period — do the dates fit? do interims overlap?
   3. FL 17  discharge status — does it match the record AND FL 4?
   4. FL 42  revenue codes — 0636 where a drug needs detail?
   5. FL 67  diagnoses — principal plausible? POA present?
   6. THE CODES — LAST. They are usually fine.

Wrong more often than the codes: the frequency digit · the discharge status (entered by someone who is not a coder) · a revenue code that does not match the charge.

Key terms

UB-04 / CMS-1450 · NUBC · form locator · 837I · type of bill · frequency digit · revenue code · condition / occurrence / occurrence span / value codes · patient discharge status · transfer rule · statement covers period · three-day payment window · principal / admitting diagnosis · patient control number · medical record number · non-covered charges · attending / operating provider · remarks

Monday morning

You should be able to:

  • Read a type of bill as three answers.
  • Say what a revenue code says that a HCPCS code does not.
  • Sort a fact, a date, a range, and an amount into the right family.
  • Reconcile accommodation units against the statement period.
  • Check FL 17 against the discharge summary — and read FL 80.
  • Say why "the outpatient claim was correct" is not a defense.
  • Read a facility claim in the right order, which does not start with the codes.

The Encounter, as a facility claim.

Same patient, same physician, same knee, same four services, same date — and the practice converted to a provider-based department:

                          INDEPENDENT     PROVIDER-BASED
   professional allowed     216.28          148.60
   facility allowed           0.00          212.40
                            ───────         ───────
   TOTAL                     216.28          361.00   ► 1.67×
   PATIENT                    47.58           84.52   ► 1.78×

Place of service becomes 22. The professional payment FALLS — the practice expense moved. The total RISES by two-thirds. The patient's share nearly doubles. A 0131 UB-04 appears with 0510 clinic · 0636 drug · 0300 laboratory, and M25.561 is the principal diagnosis.

The claim's shape is determined by WHO OWNS THE BUILDING, not by what happened to the patient.

Not an argument that the conversion is improper — hospital outpatient departments carry real costs. An argument that the patient cannot see any of it.