2010 UBO/UBU Conference Title: Bill Spawning – HIPAA 837I and 837P Session: T-6-1100.
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Transcript of 2010 UBO/UBU Conference Title: Bill Spawning – HIPAA 837I and 837P Session: T-6-1100.
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2010 UBO/UBU Conference
Title: Bill Spawning – HIPAA 837I and 837P
Session: T-6-1100
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Objectives
Have a high level awareness – of the HIPAA 837I standard transaction, to include
being able to understand the concept of a data segment and a data element
– of what will be available in the Central Billing Events Repository
– of those financial elements that will be available in the Service Enterprise Resource Planning System (such as General Fund Enterprise Business System, or GFEBS)
Understand that billing is much more than coding (and that getting a bill in the mail is less than half the work of getting the money in the “bank”)
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Pre-Test
Raise your hand as I read the statements if the statement applies to you.
1. I’ve written computer programs such as “Grand Theft Auto” – it was a piece of cake and only took 2 million hours of detailed programming
2. All programs I’ve ever used had the same password requirements; – no special characters; – with special characters but only the !&()+*-?= ;– with special characters but only @#$%<>…
3. When doing my taxes, I have ALWAYS had all the information they wanted. It has ALWAYS been called the same thing on the W2 as on the tax form.
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What You Need to Learn Prior to Falling Asleep
The MHS does not collect some data needed for certain types of billing, and never will. – It is not cost effective. – The data would not be used by anyone else.– Get over it.
There is a lot of power in the HIPAA 837 electronic bill capability to do coordination of benefits, enter co-pay/ deductibles, and other civilian things.
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Standard HIPAA 837 I
Think of submitting your individual taxes [HIPAA 837I]– Must be submitted with correct data in correct blanks– Taxpayer [Patient] name and demographic
information– Earnings by W2 [rates for each CPT]– Deductions [co-pay, deductible]– What if you don’t have the information?– Which sections can you just skip?
Farm subsidies [type of currency]– How much does the Federal government [insurance
company] owe you?
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HIPAA 837 I Transmission Control
Communications Transport Protocol– Address of the entity sending the transmission and
the address of the entity receiving the transmission– Example: Sent by central AF billing to a clearing
house– Addresses are those the two parties agree upon
Matched as second to end of entire transmission by a “Communications Transport Trailer”
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HIPAA 837I Transmission Control
Interchange Control Header– Provides the security information, such as a
password or other identifying information– Date and time of interchange– Which repetition separator will be used– Interchange version number– Interchange control number– If an interchange acknowledgement is needed– If this is a test or production data
Matched as second to end of entire transmission by a “Interface Control Trailer”
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Transmission Control
Functional Group Header and at the end Trailer– Says what kind of transaction, such as 837I, 837P,
HIPAA 837 - Health Care Claim (Professional, Institutional, Dental)
HIPAA 835 - Health Care Claim Payment/Advice Transaction HIPAA 834 - Benefit Enrollment and Maintenance HIPAA 270 - Health Care Eligibility/Benefit Inquiry HIPAA 271 - Health Care Eligibility/Benefit Response HIPAA 276 - Health Care Claim Status Request HIPAA 277 - Health Care Claim Status Notification HIPAA 278 - Health Care Review Information HIPAA NCPDP DO – Retail Pharmacy
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How Does The OUTSIDE Fit Together?
Detail Segment – 837P
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Communications Transport Trailer
Interchange Control Header
Functional Group Header
Detail Segment – 837I
Detail Segment – 276
Functional Group Trailer
Functional Group Header
Functional Group Trailer
Functional Group Header
Functional Group Trailer
Interchange Control Trailer
Communications Transport Protocol
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Detail Segments
HIPAA 837 - Health Care Claim – Institutional– Professional– Dental
HIPAA 835 - Health Care Claim Payment/Advice Transaction HIPAA 834 - Benefit Enrollment and Maintenance HIPAA 270 - Health Care Eligibility/Benefit Inquiry HIPAA 271 - Health Care Eligibility/Benefit Response HIPAA 276 - Health Care Claim Status Request HIPAA 277 - Health Care Claim Status Notification HIPAA 278 - Health Care Review Information HIPAA NCPDP DO – Retail Pharmacy
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Basic “Penmanship” Rules
BASIC A_Z (upper case) 0…9 (Arabic #s) – ! & () + * , - . / : ; ? = space
Extended a-z (lower case) – % ~ @ [ ] _ { } \ < > # $
Data element separator, asterisk (*) Sub-element separator, colon (:) Segment terminator, tilde (~) If transmitting in USA, usually extended set is fine –
could be problems with international partners, particularly with foreign languages
For the rest of this briefing, all the lower case letters should be upper case, but are lower so you can read them more easily
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1000 Header
HEADER
ST*837* 8675309*00510X223~ Begin hierarchical transaction –
BHT*0019*00*0123*20110309*0932*CH~– BHT – Beginning of hierarchical transaction– “0019” – Information Source, Subscriber, Dependent– “00” – original transmission (not sent to receiver before) – 0123 – submitter’s batch control number – 20110309 – date of transmission in CCYYMMDD– 0932 – time in HHMM, so 9:32 am– “CH” – chargeable
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1000A Submitter
1000A Submitter– NM1*41*2*AF Central Billing*****46*164.65.172.66~
NM1 – a name element “41” means submitter “2” means non-person entity Last name **** means I’m not using a bunch of fields, in this case
the first name, middle name, prefix, suffix “46” means Electronic Transmitter Identification Number “164.65.172.66” – our address
– PER*IC*Fred Darcy*TE*7036810000~ PER – submitter EDI contact information “IC” means Information Contact Fred Darcy is the free-form name “TE” means telephone and then the number
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1000B Receiver
1000B Receiver– NM1*40*2*AF Clearing House*****46*127.0.0.1~
NM1 – a name element “40” means RECEIVER “2” means non-person entity Last name **** means I’m not using a bunch of fields, in this case
the first name, middle name, prefix, suffix “46” means Electronic Transmitter Identification Number “127.0.0.1” – address for where we are sending the
package
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2000A Billing – Hierarchical and Billing Provider
HL – Billing Provider Hierarchical Level– HL*1**20*1~ notice this is the 1st “HL”
2000A Billing Provider Specialty– PRV*BI*PXC*261QM1100X~
PRV – Billing Provider Specialty Information segment “BI” means billing “PXC” means health care provider taxonomy code the HIPAA Health Care Provider Taxonomy
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2000A Foreign Currency Information
Situational– This will not be in the Central Billing Events
Repository and probably will not be used by the billing organization
Used to specify the currency (e.g., Euro, pounds UK, dollars Canadian) used in the transaction
CUR*85*CAD~– CUR means Currency – “85” means billing provider– “CAD” means Canada (CA is Canada, D is dollar)
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2010AA Billing Provider Name
NMI*85*2*56th Medical Group Luke*****XX*1194700971~– NM1 – segment name– “85” means billing– “2” means non-person entity– 56th Medical Group Luke – last name– ***** not used first name, middle name, prefix, suffix– “XX” National Provider Identifier– 1194700971 – NPI for Luke
N3*7219 North Litchfield Road~ N4*Luke AFB*AZ*85309~
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2010AA Billing Provider Name
REF*EI*as if I can even guess~– REF – billing provider tax ID– “EI” – employer tax number– Spot for the number
PER*IC*Dane I-forget*8008675309*ex*56~– PER – billing provider contact info segment,
situational, if different from submitting info– “IC” means information contact
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2010AA Billing, Pay-to Address
NM1*87*2~– “87” means “Pay-to provider” *
N3*5109 Leesburg Parkway*Suite 701*~– N3 is the address segment detail code * – Address line– Second address line
N4*Falls Church*VA*22041~– N4 is a city/state/zip segment detail– City– State– Zip
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2000B Subscriber Loops
2000B Subscriber HL Loop HL*2*1*22*0~
– notice this is the 2nd “HL” in the ST segment * – the HL loop to which this one is subordinate * – 22 means “subscriber” * – 0 means the subscriber is the patient and this is
the only claim
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Central Billing Events Repository Data Start HERE
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2000B Subscriber Loops
2010BA Subscriber– SBR*P*18*GRP01020102******CI~
2010BA Subscriber name– NM1*IL*1*Doe*John*T**Jr*MI*123456~– N3*123 Main Street~– N4*Phoenix*AZ*85309~– DMG*D8*19690815*M~– REF*SY*123456789~ (subscriber 2nd ID {SY is “SSAN
is next”}, situational, not required)
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2000B Subscriber Payer Loops
2010BB Payer Name NM1*PR*2*Health Inc Insurance*****PI*1234~
– PR is payer– PI is payer identification
N3*123 Main Street~ N4*Phoenix*AZ*85309~ REF*FY*1234~ (Reference – Payer 2nd ID, situational,
not required)– FY means “claim office number”
REF*G2*1234~ (Reference – Billing Provider 2nd ID, situational, not required)– G2 means provider commercial number
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2000C Patient Loops
2000C Patient HL Loop– HL*3*2*23*0~– PAT*01~
01 is a spouse– NM1*QC*1*Doe*Sally*J~
QC is that this person is the patient– N3*123 Main Street– N4*Phoenix*AZ*85309– DMG*D8*19700607*F~
In the patient demographic segment, the date is the birth date
F means female
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2300 Claim
2300 Claim– Diagnoses!
2310A Attending Provider 2310B Operating Physician 2310C Other Operating Physician 2310D Rendering Provider 2310E Service Facility Location 2320 Other Subscriber Information 2330A Other Subscriber Name
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2300 Claim Information
CLM*0009OUT201103010111*500***11:A:1*Y*A*Y*I~– 0009OUT201103010111 (DMIS ID 0009; outpatient;1
Mar 2010; 111th claim) is an example of a Claim Submitter’s identification of this claim, it is the patient control number, the number used to track this claim through the biller’s system
– 500 is an example of the total amount of all submitted charges of service segments for this claim; this number must match the sum of all the SV2 segments
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2300 Claim Information
CLM*0009OUT201103010111*500***11:A:1*Y*A*Y*I~– 11 is an example of a Facility Code Value (think Place of
Service, in this case 11 is the doctor’s office)– A is the facility code qualifier for the Uniform Billing Claim Form
Bill Type– 1 is the frequency of the claim (the only bill for the encounter, it
covers the entire encounter)– “Y” is there for entertainment value and to confuse people, the
guidance says “not used” but the example shows it– “A” the provider accepts assignment from the payer– “Y” means the patient has assigned benefits to the provider– “I” means federal law permits release of diagnosis info
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2300 Claim Information
DTP – Date or Time or Period– DTP*096*TM*1130~
DTP – Date or time or period “096” means “discharge” “TM” means the time will be expressed in Format HHMM 1130 is an example of 11:30 am
– DTP*434*RD8*20110301-20110305~ DTP – Date or time or period “434” means “statement” “RD8” means time will be CCYYMMDD-CCYYMMDD 20110301-20110305 means 1 Mar 11-5 Mar 11
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2300 Claim Information
DTP – Date or Time or Period– DTP*435*DT*201103011242~
DTP – Date or time or period “435” means “admission” “DT” means the time will be expressed in Format
CCYYMDDHHMM 201103011242 is an example of 1 Mar 2011 12:42 pm
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2300 Claim Information
CL1 – Institutional Claim Code CL1*1*7*30~
– CL1 – institutional claim code– 1 – an admission type code (1 = emergent; 2 = urgent;
3 = elective; 4 = newborn)– 7 – an admission source code (7 = ER; 2 = clinic;
1=nonhealthcare facility point of origin)– 30 – a patient status code (see list at end of briefing)
REF*LU*MD~– REF is a Reference identification qualifier– LU is location number for an auto accident state or province
code REF*EA*4444MN~
– EA is a medical record identification number
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2300 Claim Information
HI – Diagnosis information– HI*ABK:T8731*Y~
“ABK” is ICD-10-CM principal diagnosis “BK” is ICD-9-CM principal diagnosis T8731 is the diagnosis for neuroma of amputation stump,
right upper extremity Y” is “yes” in the Present on Admission Indicator
– HI*ABJ:T8741*Y~ “ABJ” is ICD-10-CM admitting diagnosis “BJ” is ICD-9-CM admitting diagnosis T8731 is the diagnosis for neuroma of amputation stump,
right upper extremity– HI*APR:R110~
“APR” is ICD-10-CM reason for outpatient visit
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2300 Claim Information
HI– HI*ABN*T560X1*Y*ABN*W3301*Y~
“ABN” is ICD-10-CM external cause of injury T560X1 is Toxic effect of lead and its compounds, accidental “Y” is yes for the Present on Admission Indicator “ABN” is for the additional ICD-10-CM external cause of
injury W3301 is Accidental discharge of shotgun “Y” is yes for the POA indicator
– HI*DR:123~ “DR” is diagnosis related group
– HI*ABF:J151*Y~ “ABF” is ICD-10-CM other diagnosis
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2300 Claim Information
HI*BBR:0B110F4:D8:20110302~– “BBR” is the ICD-10-PCS principal procedure– 0B110F4 is Tracheostomy device inserted to trachea,
open, to outside (cutaneous)– D8 is that a date in the CCYYMMDD format follows
HI*BBQ:02130KF:D8:20110304*BBQ:4A023N8:D8:20110304~– BBQ is other ICD-10-PCS procedures– D8 is that a date in the CCYYMMDD format follows
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2300 Claim Information NOT in CBER
Segments that are available but would not be in the Central Billing Events Repository
PWK – Claim supplemental information (paperwork) AMT – Patient estimated amount due REF – Service authorization exception code (for
example if it was an emergency which is why there was no pre-authorization
REF – Referral number (for example a payer provided a referral number for so many physical therapy encounters)
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2300 Claim Information NOT in CBER
Segments that are available but would not be in the Central Billing Events Repository
REF – Prior authorization (for example for major surgery) REF – Investigational device exemption number REF – Demonstration Project Identifier REF – Peer Review Organization Approval Number NTE – Claim note or a Billing Note (used when the
provider wants to indicate there is additional information needed to substantiate medical treatment)
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2300 Claim Information NOT in CBER
Segments that are available but would not be in the Central Billing Events Repository
HI*BI – Occurrence span information HI*BH – Occurrence information HI*BE – Value information HI*BG – Condition information HI*TC – Treatment code
condition (used for home health agencies)
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2310A Attending Provider Name
NM1*71*Jones*John****XX*1357986420~– “71” in this position is “attending physician”– XX is “the NPI is next”
PRV*AT*PXC*208D00000X~– PRV is attending provider specialty segment– “AT” is attending– “PXC” is “the HIPAA Health Care Provider Taxonomy
is next”
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2310 Additional Providers
2310B NM1*72*1*Meyers*Jane*****XX*1357986420~– “72” is operating physician– XX is “the NPI is next”– Is only used if there is a surgical procedure on the
claim 2310C NM1*ZZ*1*Doe*John*A***XX*1357986420~
– “ZZ” is mutually defined to indicate “other operating physician”
– Usually not needed, usually only one surgeon 2310D NM1*82*1*Doe*Jane*C***XX*1357986420~
– “82” is rendering provider
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2310E Service Facility
2310E NM1*77*2*Bolling Clinic*****XX*1468097532~
– “77” is Service Location (other than the doctor’s office)
– “2” is non-person entity N3*1300 Angell Street~ N4*Bolling AFB*DC*20032~
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2310F Referring Provider NOT in CBER
NOT in the Central Billing Event Repository, but could be for civilian sector
NM1*DN*1*Welby*Marcus*W**Jr*XX*1246809753~– “DN” is referring provider– “1” is a person – XX is “the NPI is next”
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2320 Other Subscriber Information
SBR*S*01*GR00786******13~– SBR is a subscriber information segment– “S” is secondary coverage– “01” is that the spouse is the one with the coverage– “GR00786” is an example of a insured group or policy
number– “13” is a claim filing indicator code representing “point
of service” – eventually this will go away when HIPAA National Plan IDs are fielded
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Claim Adjustments, Repricing…NOT in CBER
Claim adjustments, repricing, coordination of benefits (COB) payer paid amount, remaining patient liability, adjudication information, check remittance date, and other post bill generation activities will not appear in the Central Billing Events Repository (CBER).– These activities will be done by the Service
billing/collections activity.– Collections, adjustments, repricing, co-pays,
deductibles etc., will be tracked in the Service Enterprise Resource Planning (ERP) system.
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2330B Other Payer Name
NM1*PR*2*Another Insurance Group*****PI*1123344~– “PR” is payer– “2” is non-person entity– “PI” is payer identification
N3*100 N Broadway*Suite 10B~ N4*New York City*NY*10008~ Other payer information such as provider name,
operating physician and service facility will not be in the CBER as these data elements are not collected and stored centrally
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2400 Loops
2400 Service Line 2420C Rendering Provider 2420D Referring Provider
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2400 Services Provided
LX*1~– LX is a service line number segment
SV2*0300*HC:81099*73.42*UN*1~– SV2 is a institutional service line segment– 0300 is an example of a revenue code for the
laboratory– “HC” is a HCPCS code (includes CPT)– “81099” is a HCPCS lab unspecified code– “73.42” is the price billed– “UN” is “unit” – “1” is a quantity
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2400
DTP*472*D8*20110302~– DTP is date or time or period segment– “472” is a service– D8 indicates date format will be CCYYMMDD– 20110302 is 2 Mar 11
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Transaction Set Trailer NOT in CBER
Would not be in the CBER, this is done when the HIPAA transaction is sent to the clearing house
SE*1230*8675309~– SE is a transaction set trailer– 1230 is the number of segments included in the
transaction including ST and SE segments– 8675309 is the same transaction set control number
in the ST02 that began the transaction
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Transaction Set Trailer NOT in CBER
Again, this would not be in the Central Billing Events Repository – it is something used by the billing organization to make sure the “box of bills” are sent to the correct clearing house (e.g., FedEx)
Then the clearing house re-directs the data to the payer
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Business Usage
Coordination of Benefits– The CBER will list all the known possible payers
based on what is in the Other Health Insurance file and the PATCAT (patient category, such as Coast Guard)
– Billing entity needs to determine when there is a primary and secondary payer, will the bill go to
The first payer who enters what he paid, and the first payer send it directly to the second payer
The first payer send back his remittance, then you need to enter the 1st payer’s input and send to the second payer
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Capturing The Data
Encounter Data– Patient Registration
At the MTF entering the patient initially in the CHCS registration module will “bring down” the patient data (e.g., birthday, gender, EDI-PN) from DEERs
– Appointment Module To make an appointment there must be a “file and table
build” where the provider data (e.g., NPI and HIPAA taxonomy) are stored
Also will collect the date/time of the scheduled appointment and the DMIS ID
– Inpatient Module Assigns the medical record number, links the provider file
information
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Capturing The Data
Encounter Data– Ambulatory Data Module
Where outpatient coded data are collected– Can come from AHLTA or be entered directly in ADM
– Coding Compliance Editor Where all inpatient coded data are entered
Patient Demographics– DEERS
Insurance Information– DEERS Standard Insurance Tables/Other Health
Insurance– PATCAT – patient categories
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Capturing The Data
Rates– Insurance and Interagency
Inpatient – Diagnosis related group based Place of service 11 – outpatient doctor’s office professional Place of service 23 – hospital emergency room institutional Place of service 22 – outpatient hospital (same day surgery
institutional) Ambulance Laboratory Diagnostic Imaging Pharmaceutical Dental Anesthesia
– To Patient Cosmetic Family member inpatient rate
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MHS Limitations
Do not collect a separate institutional encounter for outpatient services done somewhere other than the doctor’s office– APVs, Observation, Emergency Department
Do not collect anesthesia minutes of service Do not collect the venipunctures (collection of specimen
in the laboratory) Do not collect ambulance mileage
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MHS Limitations
Do not have standardized dental encounter data information (each Service has own collection system which does not feed data centrally)
Not all laboratory services are collected in CHCS – CoPath
Do not collect the exact pharmaceutical dispensed Coding
– Do not collect if it is workers’ compensation and many other issues (condition, occurrence, and value codes)
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MHS Limitations
Poor understanding of assignment of PATCATs – BASED ON ELIGIBILITY OF THAT CARE ON THAT DATE
No “incident to” concept – encounters are collected based on the individual who did the service, not in the name of the physician– Otherwise, physician assistants and nurse
practitioners could not treat new problems – they could only see “follow-up” patients and do services already ordered by physicians
Possible suboptimal pursuit of Other Health Insurance In some cases, limited staffing to do accounts receivable
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MHS Limitations
Need to receive daily CHCS Provider File update – no central repository with every provider NPI type I
Do not have patient level cost accounting– Do not have standard Revenue Codes– MEPRS is non-standard and inconsistent (e.g., code
where work is done, but physical therapy is done on the wards)
– Cannot do DRG cost outliers
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Objectives
Have a high level awareness – of the HIPAA 837I standard transaction, to include
being able to understand the concept of a data segment and a data element
– of what will be available in the Central Billing Events Repository
– of those financial elements which will be available in the Service Enterprise Resource Planning System (such as General Fund Enterprise Business System, or GFEBS)
Understand that billing is much more than coding (and that getting a bill in the mail is less than half the work of getting the money in the “bank”)
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Questions
Is it time to wake up now? Yes. Where am I? The same place you were when you fell
asleep. Is this Kansas? Don’t you wish.
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Patient Status Examples:
Required. (For all Part A inpatient, SNF, hospice, home health agency (HHA) and outpatient hospital services.) This code indicates the patient’s status as of the “Through” date of the billing period (FL 6).
Code/Structure 01 Discharged to home or self care (routine discharge) 02 Discharged/transferred to a short-term general hospital for inpatient care. 03 Discharged/transferred to SNF with Medicare certification in anticipation of
covered skilled care (effective 2/23/05). See Code 61 below. 04 Discharged/transferred to an Intermediate Care Facility (ICF) 05 Discharged/transferred to another type of institution not defined elsewhere
in this code list (effective 2/23/05). Usage Note: Cancer hospitals excluded from Medicare PPS and children’s hospitals are examples of such other types of institutions.
Definition Change Effective 4/1/08: Discharged/Transferred to a Designated Cancer Center or Children’s Hospital.
06 Discharged/transferred to home under care of organized home health service organization in anticipation of covered skills care (effective 2/23/05).
07 Left against medical advice or discontinued care 08 Reserved for National Assignment *09 Admitted as an inpatient to this hospital
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Patient Status Examples:
10-19 Reserved for National Assignment 20 Expired (or did not recover - Religious Non Medical Health Care Patient) 21 Discharged/transferred to Court/Law Enforcement 22-29 Reserved for National Assignment 30 Still patient or expected to return for outpatient services 31-39 Reserved for National Assignment 40 Expired at home (Hospice claims only) 41 Expired in a medical facility, such as a hospital, SNF, ICF or freestanding
hospice (Hospice claims only) 42 Expired - place unknown (Hospice claims only) 43 Discharged/transferred to a federal health care facility. (effective 10/1/03) Usage note: Discharges and transfers to a government operated health care facility
such as a Department of Defense hospital, a Veteran’s Administration (VA) hospital or VA hospital or a VA nursing facility. To be used whenever the destination at discharge is a federal health care facility, whether the patient lives there or not.
44-49 Reserved for national assignment 50 Discharged/transferred to Hospice - home 51 Discharged/transferred to Hospice - medical facility 52-60 Reserved for national assignment
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Patient Status Examples:
61 Discharged/transferred within this institution to a hospital based Medicare approved swing bed.
62 Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital
63 Discharged/transferred to long term care hospitals 64 Discharged/transferred to a nursing facility certified under Medicaid but not
certified under Medicare 65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part
unit of a hospital. 66 Discharged/transferred to a Critical Access Hospital (CAH). (effective
1/1/06) 67-69 Reserved for national assignment 70 Discharge/transfer to another type of health care institution not defined
elsewhere in the code list. (effective 4/1/08) 71-99 Reserved for national assignment *In situations where a patient is admitted before midnight of the third day following the
day of an outpatient diagnostic service or service related to the reason for the admission, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services that began longer than 3 days earlier or were unrelated to the reason for admission, such as observation following outpatient surgery, which results in admission
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