The UB-04 is made up of form locators (FL), or boxes to be completed. Some of the FLs are required, some are optional, and some are not used in the SNF setting. If any required pieces are missing, the claim will not pass the system edits when it is submitted to the MAC. Although most Medicare billing is done electronically and the UB-04 is completed largely by the billing software, it is important for Medicare billers to be familiar with the pieces of information required on the claim and how to complete the form.
Communication disconnects between the biller and other departments happen frequently. Billers do not always receive information that affects compliant billing. This may be due to fragmentization of departments, lack of meaningful Medicare utilization systems, differences in software (e.g., MDS vs. billing) that are not interoperable, or an unawareness from the interdisciplinary team (IDT) as to the importance of billers in the Medicare reimbursement process.
When the MAC denies a claim, the SNF has the option to appeal the decision through the appeals process and all requests at all levels must be made in writing. Download our infographic for help navigating the different levels and their instructions.
In our first edition of the AMBR Journal, we interviewed AMBR advisory board member Maureen McCarthy, RN, BS RAC-MT, QCP-MT, DNS-MT, about her experience working as a biller in long-term care. McCarthy is now a successful business woman, president a consulting company, and an expert in her field. Here’s what she had to say about billers who want to network more and communicate with their peers, but aren’t sure where to start.
When a Medicare Part A beneficiary is absent but not discharged, for reasons other than hospital or other SNF admission, a leave of absence (LOA) bill is required. The day of discharge, the day of death, or the day on which a beneficiary begins an LOA is not counted as a utilization day and is not billed. The exception to this rule is when the beneficiary is admitted to the SNF with the expectation that he or she will remain overnight but is discharged, dies, or is transferred to a nonparticipating provider before midnight of the same day.
The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed. In addition to billing Medicare, the 837I and Form CMS-1450 may be suitable for billing various government and some private insurers.
Your fellow billers want to hear from you on AMBR’s talk forum, Biller’s Talk. A member recently asked, “I have heard this both ways: For a skilled resident - g tube feeding and skilled care. For a new gtube, once the nutrition and tube is operationally stable, then can cut from skilled care to utilize remaining days at another date. OR, for a new gtube, when skilled, must exhaust 100 days if feedings remain at 26% and 501cc. Is there a specific reference for this?”
Therapy services under major category V are included in the SNF daily rate and accounted for on the consolidated bill for beneficiaries who are in the midst of a Part A stay. However, once a beneficiary who also has a Part B plan exhausts his or her Part A benefits, the SNF must begin billing therapy services to Part B.
We put together a proposal that you can use as is or adapt to earn support from program administrators to join the Association for Medicare Billing and Reimbursement for Long-Term Care. Download the proposal here.