Long Term Care Service Billing Requirements And Coding
Long Term Care ServiceBilling Requirements andCoding5/18/20161
To provide an overview of basicbilling rulesTo provide billing requirementsand claim coding specificationsfor each provider type sosubmitted claims can beaccepted and priced correctly.To provide coding examples forcommon billing scenarios.5/18/20162
The Department will accept claimsin an American National Standard(ANS) X12 837I Health Care Claim(5010) file format or as a directdata entered (DDE) claim.5/18/20163
To be eligible for payment consideration all Long Term Care (LTC) claims submitted on an837I must meet the same requirements as current Department generated LTC claims do.The Direct Billing of LTC services is strictly a billing process change. No changes are being made to provider or recipient eligibility policies related topayment of LTC services. Claims received for a provider or recipient that is ineligible for payment of thebilled services or billed service period submitted will be rejected. (Note: Recipientmust be Medicaid eligible and have an LTC admit on system to be eligible for LTCpayment.) No changes are being made to policies related to the requirements to bill other payersbefore submission of a claim for Medicaid reimbursement. Claims received for a recipient who has a TPL, such as Blue Cross Blue Shield or anyother commercial payer, and for which TPL is not reported on the submitted claimwill be rejected. Claims received for a recipient whose services are covered by a Managed CareOrganization will be rejected. Claims received for a recipient residing in a nursing facility (provider type 033) withMedicare Part A coverage that do not reflect a Medicare payment or do not showMedicare exhaust date or date active care coverage ended will be rejected. No changes are being made to the timely submittal requirements for paymentconsideration of LTC claims. Claims received, as an initial or resubmitted claim following prior rejection, morethan 180 days after the date of service or the date the admission transaction iscompleted by DHS caseworker will be rejected. Claims after disposition by Medicare or its fiscal intermediary must be received bythe Department no later than 24 months after the date of service.No changes are being made to the procedures for billing service periods prior to July 1,2016. Only claims for LTC service periods beginning July 1, 2016 and after can besubmitted electronically on the 837I. LTC service periods prior to July 1, 2016 will be rejected if submitted on the 837I. Paper UB-04 claims submitted for LTC services will not be accepted.5/18/20164
The combination of NPI, Taxonomy Codes and Type of Bill Facility Codes submitted ona claim provides critical information that allows the Department to properly price thereceived claim. Therefore, there will be strictly enforced edits to assure thatappropriate codes are received on the claim. If the NPI used to submit an LTC claim is not a registered NPI in the NPPESsystem, or cannot be cross-walked to a unique HFS PIN, the claim will berejected. If the Taxonomy Code used to submit an LTC claim is not an accepted Taxonomyfor billing provider type, the claim will be rejected.If the Type of Bill Facility Code used to submit an LTC claim is not an acceptedType of Bill Facility Code for provider, the claim will be rejected.Electronic claims submitted for LTC services must be for a single month of service. Claims that are submitted for more than one calendar month will be rejected. Claims received out of sequence will not be rejected but cannot be priced untilthe preceding month’s claim has been processed. Prior claim informationrelated to temporary absences and Medicare coverage will be reviewed for properpricing of current claim.Providers must bill services using the Revenue Codes, which identify specificaccommodations, ancillary or unique billing calculations or arrangements. A list of allavailable Revenue Codes can be found in the NUBC UB-04 Official Data SpecificationsManual. Most available revenue codes will be accepted on an LTC 837I claim but onlycertain codes will be used to price LTC claims. Claims received without Revenue Codes that can be priced will be rejected.Claims received with exceptional care Revenue Codes for which there is notapproval on the system will be rejected.Claims submitted without leave of absence Revenue Codes and Occurrence SpanCode, to cover the same days claimed as inpatient hospital stay, will be rejected.5/18/20165
The new LTC billing process has been designedutilizing the guidelines set forth by the WashingtonPublishing Company 837 InstitutionalImplementation Guidelines for the Health InsurancePortability and Accountability Act (HIPAA), version005010X223 and the National Uniform BillingCommittee’s (NUBC) data specifications, UB-04.However, in order for your submitted claims to beaccepted and priced appropriately there are somestate specific coding requirements.Some of the state required codes vary by providertype and services being billed. The next few slidesprovide pricing codes needed for each provider andservice type.5/18/20166
Type of BillMust be 89X – Special Facility Other - Outpatient ClaimType of Bill Frequency Code:1 - Admit Through Discharge2 – Interim – First Claim3 – Interim – Continuing Claim4 - Interim – Last Claim5 – Late Charge(s) OnlyTaxonomy Codes:311500000X - Dementia Special Care Legacy COS 086310400000X – Assisted Living Facility Legacy COS 087Revenue Codes:0240 – All Inclusive Ancillary, General Classification Legacy COS 086 or 087 basedon Taxonomy Code0180 - Leave of Absence days, General Classification Legacy BR codes 70 & 710182 – Leave of Absence Days, Patient Convenience Legacy BR codes 70 & 710183 – Leave of Absence Days, Therapeutic Legacy BR codes 70 & 710185 – Leave of Absence Days, Hospitalization Legacy BR codes 60 & 61Occurrence Span Codes and Dates:74 – Non-Covered Level of Care/Leave of Absence DatesValue Codes:80 – Covered Days81 – Non-Covered Days23 – Recurring Monthly Income (Patient Credit Amount)Leave of Absence Days (LOA) or Bed Reserve (BR) Days:LOA days will be reported with LOA Revenue Codes and must have a correspondingnon-covered occurrence span code 74 with the appropriate LOA dates even thoughsome bed reserve days may be payable. The total of “non-covered” days must also bereflected with a value code of 81.LOA days 1 – 30 in FY - Payable at 100% of facility daily Per Diem (Legacy BR codes 60and 70)LOA days 31 or over in FY – Non-payable (Legacy BR codes 61 and 71)The count of LOA days reported on prior claims will be utilized to determine if theLOA days reported on each submitted claim for services within the fiscal year arepayable or non payable.5/18/20167
Type of Bill065X Intermediate Care - Level I – Inpatient Claim066X Intermediate Care - Level II – Inpatient Claim079X Clinic - Other (Developmental Training) - Outpatient ClaimType of Bill Frequency Code:1 - Admit Through Discharge2 – Interim – First Claim3 – Interim – Continuing Claim4 - Interim – Last Claim5 – Late Charge(s) OnlyTaxonomy Codes:315P00000X – ICF Mentally Retarded with Bill Type 065X or 066XLegacy COS 073Legacy COS 038 - (Revenue code 0190 and approved Exceptional Care coverage)315P00000X – ICF Mentally Retarded with Bill Type 079Legacy COS 082 - (Revenue Code 0942 and approved DT enrollment)3140N1450X – Nursing Care- Pediatric with Bill Type 065X or 066XLegacy COS 074Legacy COS 038 – (Revenue code 0190 and approved Exceptional Care coverage)3140N1450X – Nursing Care- Pediatric with Bill Type 079XLegacy COS 082 – (Revenue Code 0942 and approved DT enrollment)320600000X – Residential Treatment Facility, Mental Retardation and/or Dev. Disabilities with Bill Type065X or 066XLegacy COS 076Legacy COS 038 – (Revenue code 0190 and approved Exceptional Care coverage)320600000X – Residential Treatment Facility, Mental Retardation and/or Dev. Disabilities with Bill Type079XLegacy COS 082 – (Revenue Code 0942 and approved DT enrollment)Revenue Codes:0110 - 0160 – Priced as General Room & Board Legacy COS 073, 074 or 076 based on Taxonomy code0180 - Leave of Absence Days, General Classification Legacy BR codes 21, 22 & 240182 – Leave of Absence Days, Patient Convenience Legacy BR codes 21, 22 & 240183 – Leave of Absence Days, Therapeutic Legacy BR codes 21, 22 & 240185 – Leave of Absence Days, Hospitalization Legacy BR codes 12, 13, 14 & 160190 – Sub acute Care – General Classification Legacy COS 0380942 – Education/Training Legacy COS 0825/18/20168
Occurrence Span Codes and Dates:74 – Non-Covered Level of Care/Leave of Absence DatesValue Codes:80 – Covered Days81 – Non-Covered DaysLeave of Absence Days (LOA) or Bed Reserve (BR) Days:LOA days will be reported with LOA Revenue Codes and must have a corresponding noncovered occurrence span code 74 with the appropriate LOA dates even though some bedreserve days may be payable. The total of “non-covered” days must also be reflectedwith value code 81.LOA reported as Revenue Codes 0180, 0182 and 0183 will be considered Therapeuticbed reserve days.Days 1 – 10 in FY - Payable at 100% of facility daily Per Diem (Legacy BR code 22)Days exceeding 10 in a FY – Payable at 75% of facility daily Per Diem (Legacy BR code 24)LOA reported as Revenue Code 0185 will be considered Hospitalization bed reservedays.For recipients under 21 years of ageDays 1 – 10 of a consecutive Hospital stay – Payable at 100% of facility daily Per Diem(Legacy BR code 12)Days 11 – 30 of a consecutive Hospital stay – Payable at 75% of facility daily Per Diem(Legacy BR code 14)Days 31 – 45 of a consecutive Hospital stay – Payable at 50% of facility daily Per Diem(Legacy BR code 16)Days 46 – on of a consecutive Hospital stay – Non-Payable (Legacy BR code 13)The count of LOA days reported on prior claims will be utilized to determine if the LOAdays reported on each submitted claim for services within the fiscal year are payable ornon payable.5/18/20169
Type of Bill011X Hospital Inpatient (Including Medicare Part A)021X Skilled Nursing Inpatient (Including Medicare Part A)022X Skilled Nursing Facilities (Including Medicare Part B)065X Intermediate Care - Level I – Inpatient Claim066X Intermediate Care - Level II – Inpatient Claim079X Clinic-Other (Developmental Training) - Outpatient ClaimType of Bill Frequency Code:1 - Admit Through Discharge2 – Interim – First Claim3 – Interim – Continuing Claim4 - Interim – Last Claim5 – Late Charge(s) OnlyRevenue Codes:0110 - 0160 – Priced as General Room & Board Legacy COS 065, 070, 071 or 072 based onTaxonomy Code & Bill Type0180 - Leave of Absence Days, General Classification Legacy BR code 210182 – Leave of Absence Days, Patient Convenience Legacy BR code 210183 – Leave of Absence Days, Therapeutic Legacy BR code 210185 – Leave of Absence Days, Hospitalization Legacy BR code 110191 – Sub acute Care Level I Legacy COS 038 (TBI I )0192 – Sub acute Care Level II Legacy COS 038 (TBI II)0193 – Sub acute Care Level III Legacy COS 038 (TBI III)0194 – Sub acute Care Level IV Legacy COS 038 (Vent )0942 – Education/Training Legacy COS 0820022 – Skilled Nursing Facility – PPS (RUG)NOTE: RUG Score is required to be reported as a Revenue Code 0022 with 5 digit RUG Score inProcedure Code feild. Revenue Code 0022 must report the total number of days and a zero charge. This is notto be treated as an accommodation revenue line and will have no bearing on the coveredday calculation.Revenue line 0022 can be repeated multiple times on the claim.5/18/201610
Taxonomy Codes:314000000X – Skilled Nursing Facility with Bill Types 021XLegacy COS 065 – Priced as zero when crossover shows full Medicare coverageLegacy COS 072 – Medicaid Payable over Medicare Payable amount314000000X – Skilled Nursing Facility with Bill Types 021X or 022X Showing Medicare BenefitExhaust/End/DeniedLegacy COS 070Legacy COS 038 – (Revenue code 0191 – 0194 and approved Exceptional Care coverage)314000000X – Skilled Nursing Facility with Bill Types 065X or 066XLegacy COS 071Legacy COS 038 – (Revenue code 0191 – 0194 and approved Exceptional Care coverage)314000000X – Skilled Nursing Facility with Bill Type 079XLegacy COS 083 – (Revenue Code 0942 and approved DT enrollment)313M00000X – Nursing Facility/Intermediate Care Facility with Bill Types 065X or 066XLegacy COS 071Legacy COS 038 – (Revenue code 0191 – 0194 and approved Exceptional Care coverage)313M00000X – Nursing Facility/Intermediate Care Facility with Bill Type 079XLegacy COS 083 – DT Agency Monthly Rate282N00000X – General Acute Care Hospital (LTC Wing) with Bill Types 21XLegacy COS 065 – Priced as zero when crossover shows full Medicare coverageLegacy COS 072 – Medicaid Payable over Medicare Payable amount282N00000X – General Acute Care Hospital (LTC Wing) with Bill Types 021X or 022X ShowingMedicare Benefit Exhaust/End/DeniedLegacy COS 070Legacy COS 038 – (Revenue code 0191 – 0194 and approved Exceptional Care coverage)282N00000X – General Acute Care Hospital (LTC Wing) with Bill Types 065X or 066XLegacy COS 071Legacy COS 038 – (Revenue code 0191 – 0194 and approved Exceptional Care coverage)5/18/201611
Occurrence CodeA3 – Benefits Exhausted22 – Date Active Care Ended24 – Insurance Denied50 – Assessment DateOccurrence Span Codes and Dates:70 – Qualifying Stay Dates for SNF74 – Non-Covered Level of Care/Leave of Absence DatesNOTE: MDS Assessment date is required when Revenue Code 0022 is reported. The MDS Assessment date will be submitted with an Occurrence Code of 50 alongwith an associated Occurrence Code date. Occurrence Code 50 can be reported multiple times with multiple assessmentdates.Value Codes:80 – Covered Days81 – Non-Covered Days82 – Coinsurance Days23 – Recurring Monthly Income (Patient Credit Amount)24 – Medicaid Rate Code (DT Agency Code)Leave of Absence Days (LOA) or Bed Reserve (BR) Days:LOA days will be reported with LOA Revenue Codes and must have a correspondingnon-covered occurrence span code 74 with the appropriate LOA dates. The total of“non-covered” days must also be reflected with value code 81.LOA reported as Revenue Codes 0180, 0182 and 0183 will be considered Therapeuticbed reserve days.All are non-payable (Legacy BR code 21)LOA reported as Revenue Code 0185 will be considered Hospitalization bed reservedays.All are non-payable (Legacy BR code 11)5/18/201612
Medicare Crossover ClaimsRecipients with Medicare Part A coverage must be billedto Medicare for any covered service prior to billingMedicaid. Claims submitted to Medicare will crossoverto Medicaid through a fiscal intermediary. To assureproper pricing of Medicare crossover claims, LTCproviders should submit LTC claims for a single calendarmonth of service to Medicare for dually eligiblerecipients.The Department’s policy regarding payment forMedicare coinsurance days for Medicaid eligible personsis not changing. Medicare coinsurance paid by theDepartment, if any, will still be based on the amountthat Medicare paid for the specific resident’s care.Medicare Coinsurance days payable by Medicaid will bederived from received crossover claims information byusing Value Codes and accommodation days.In the event that a Medicare claim does not successfullycrossover for Medicaid pricing the provider may submita claim with Medicare coverage directly to IllinoisMedicaid for payment consideration.5/18/201613
Claims With Medicare Coverage Submitted Directly to Illinois MedicaidClaims submitted to Medicare for reporting purposes only or for a benefit exhaust period are notsent to Medicaid through the fiscal intermediary. In addition claims sent to Medicare may notsuccessfully crossover. These claims will be rejected back to the provider. Some of the reasons acrossover claim may reject are: Medicaid system does not have a LTC admission for recipient, provider or date of service. Medicaid system does not have Medicaid eligibility for the recipient or the date of service. Medicare claim received has a statement period that crosses calendar months; i.e. 07/05/16 – 08/19/16Claims for Medicare covered service periods that do not crossover to Illinois Medicaid may be sentdirectly to Medicaid for payment consideration. Claims with Medicare coverage bill directly toMedicaid must show Medicare as primary payer and Medicare Coinsurance days as Value code 82with a TPL payment amount using the Medicare TPL code 909. The Medicare days payable byMedicaid will be derived from received claim information by using Value Codes and accommodationdays as follows: Calculation of accommodation days:The total accommodation days will be based on service from, service through dates andType of Bill Frequency. If Type of Bill Frequency Code is 2 or 3 will include service through date. If Type of Bill Frequency Code is 1 or 4 will not include the date of discharge unless thepatient discharge status is 20. Calculation of Medicaid Covered Days and Medicare Covered Days for Legacy COS Coding andPricing: Value Code 80 – Total Medicaid Covered days (Medicaid and Medicare Covered days) Value Code 81 – Non-covered Medicaid days (LOA days only) Value Code 82 Coinsurance Medicare Covered If Value Code 80 Value Code 82 an Occurrence Code and Occurrence Date showingwhen Medicare exhausted must be reported to show the date Medicare coverageended. The Statement From Date through the Medicare coverage end date will be identifiedas Medicare Covered Days. The Medicare Covered Day – Coinsurance Days (Value Code 82) Full CoveredMedicare Days (COS 065) starting from Statement From Date. The Days reported as Coinsurance (Value Code 82) (COS 072) will be appliedbeginning with the first date not determined to be Medicare Full Coverage. If there are Leave of Absence Days reported for date(s) within the Medicare Coveredperiod they should be included in Non-covered Days reported in Value Code 81 andwill be considered coded as non-payable bed reserves. Value Code 80 days – the Medicare Covered Days Medicaid Days (COS 070)beginning the day after the reported date Medicare coverage ended. If there are Leave of Absence Days reported for date(s) within the Medicaid coveredperiod they should be included in Non-covered Days reported in Value Code 81 andwill be considered coded as non-payable bed reserves.If Value Code 80 Value Code 82, then the days are all coinsurance days. AllCoinsurance days COS 072.See Claim Example #55/18/201614
Type of Bill065X Intermediate Care - Level I – In Patient Claim066X Intermediate Care - Level II – In Patient ClaimTaxonomy Code:310500000X – Intermediate Care Facility, Mental Illness with Bill Types 065X or 066XLegacy COS 071Type of Bill Frequency Code:1- Admit Through Discharge2 – Interim –First Claim3 – Interim – Continuing Claim4 - Interim – Last Claim5 – Late Charge(s) OnlyRevenue Codes:0110 -0160 – Priced as General Room & Board Legacy COS 0710180 - Leave of Absence days, General Classification Legacy BR codes 210182 – Leave of Absence Days, Patient Convenience Legacy BR codes 210183 – Leave of Absence Days Therapeutic Legacy BR codes 210185 – Leave of Absence Days Hospitalization Legacy BR codes 11Occurrence Span Codes and Dates:74 – Non Covered Level of Care/Leave of Absence DatesValue Codes:80 – Covered Days81 - Non Covered Days23 – Recurring Monthly Income (Patient Credit Amount)24 – Medicaid Rate Code (DT Agency Code)Leave of Absence Days (LOA) or Bed Reserve (BR) Days:LOA days will be reported with LOA Revenue Codes and must have a corresponding non-coveredoccurrence span code 74 with the appropriate LOA dates. The total of “Non-covered” days must also bereflected with a value code of 81.5/18/201615
Providers will continue to submit incomechanges and review patient credit amountselectronically through the EDI LTC links.The amount of patient credit applied to a claimwill be based on the amount of patient creditentered into the LTC patient credit segments bythe Dep
for each provider type so submitted claims can be . Manual. Most available revenue codes will be accepted on an LTC 837I claim but only certain codes will be used to price LTC claims. . Legacy COS 072 – Medicaid Payable over Medicare Payable amount . 314000000X – Skilled Nursing F
5. The batch will close and so will the OPIE Billing application. 6. To return to OPIE Billing, create a new batch. Get Started in Billing - Set up Global Settings in Billing Admin Rights in OPIE are required to access Billing Settings. 1. Log into OPIE Billing, go to the top left part of the Window to the menus: File, Windows, Help and click .
Consolidated Billing 3 Medicare Part B 3. SNF Billing Requirements 4. Billing Tips 5 Special Billing Situations 6 Readmission Within 30 Days 6 Benefits Exhaust 7 No Payment Billing 8 Expedited Review Results. 9 Noncovered Days 10 Other SNF Billing Situations 10. Resources 12. The American Hospital Association (the " AHA
Select Long-Term Care Occupations, Pooled 2003-2013. 27. UCSF Health Workforce Research Center on Long-Term Care Research Report 6 Entry and Exit of Workers in Long-Term Care Executive Summary In the past decade, the health care industry, and long-term care (LTC) in particular, saw substantial job growth. In anticipation of growing demand .
The process for an AIA billing in Foundation has a few basic steps: 1. Create an AIA billing record 2. Create a schedule of values for Application 1 3. Print and post the application 4. Repeat as needed 5. Release retainage Create an AIA Billing Record Setting up an overall billing record for your progress billing job in Foundation means two .
insurance called Qualified Long-Term Care Insurance. This regulation is intended to provide requirements for all long-term care insurance contracts, including qualified long-term care insurance contracts, as defined in the NAIC Long-Term Care Insurance Model Act and by Section 7702B(b) of the Internal Revenue Code of 1986, as amended.
Long Term Care and Personal Care Homes FINANCIAL SUBSIDY APPLICATION FOR: PERSONAL CARE HOME LONG TERM CARE . Financial Assessment Officer - Eastern Health Long Term Care 760 Topsail Road - Business Side, Mount Pearl, NL A1N 3J5 Tel: (709) 752-4361 Fax: (709) 752-4740 .
into long-term health care benefit plans. Conversely, Medicaid expenses on long-term health care services for residents may be offset by similar amounts (as aforementioned) annually. This is about 5.07-5.78 percent of the Medicaid long-term care appropriations for Nursing Home Careor 2.99-3.40 percent of the total Medicaid Long Term
COMPANY – Lee County Electric Cooperative, Inc. (LCEC) CONDUCTOR – A wire that carries electric energy. CONDULET – A conduit fitting such as the LL, LR, LB, etc. CONJUNCTIVE BILLING – Additive billing, plural meter billing, conjunctional metering and all like or similar billing practices which seek to combine, for billing purposes, the
