BILLING GUIDEBOOK

VETERANS HEALTH ADMINISTRATION

- CHIEF BUSINESS OFFICE -

FEBRUARY 28, 2013

CONSOLIDATED PATIENT ACCOUNT CENTERS (CPAC)

BILLING GUIDEBOOK

FRAMEWORK, PROCESSES, PROCEDURES, AND INTERNAL CONTROLS

VERSION 1.9

BILLING GUIDEBOOK

- TABLE OF CONTENTS -

EXECUTIVE SUMMARY..................................................................................................... 7

GUIDEBOOK NUMBERING CONVENTION ................................................................................ 8

1 - INTERNAL CONTROL STANDARDS .................................................................................. 9

2 - TYPES OF INTERNAL CONTROLS .................................................................................. 11

3 - RISKS AND INTERNAL CONTROLS KEY ............................................................................ 11

4 - ENTITY-LEVEL CONTROLS ........................................................................... 12

BILLING FRAMEWORK ................................................................................................... 20

1 - INPATIENT FUNCTION ................................................................................ 30

1.1 1.1.1 1.2 1.2.1 1.3 1.3.1 -

Inpatient Facility Charge Process ................................................................... 31 Submitting Inpatient UB-04 Claims ................................................................ 32 Inpatient Professional Fees Charge Process ................................................... 421 Submitting Inpatient CMS 1500 Claims ........................................................... 42 Skilled Nursing Facility Process ...................................................................... 48 Submitting Skilled Nursing Facility UB-04 Claims ............................................. 49

2 - OUTPATIENT FUNCTION.............................................................................. 55

2.1 2.1.1 2.2 2.2.1 -

Outpatient Facility Billing Process ................................................................... 58 Submitting Outpatient UB-04 Claims .............................................................. 59 Outpatient Professional Fees Billing Process..................................................... 64 Submitting Outpatient CMS 1500 Claims ......................................................... 65

3 - SPECIALTY BILLING FUNCTION .................................................................. 68

3.1 3.1.1 3.2 3.2.1 3.3 3.3.1 3.4 3.4.1 3.5 3.5.1 3.5.2 3.6 3.6.1 3.7 3.7.1 -

Ambulance Billing Process ............................................................................. 71 Submitting UB-04 Claims: Ambulance ............................................................ 72 Dental Ineligible Billing Process...................................................................... 78 Submitting UB-04 Claims: Dental Ineligible ..................................................... 79 DME and Prosthetics Process ......................................................................... 81 Submitting Outpatient UB-04 Claims: DME and Prosthetics ............................... 82 Inpatient Facility Fee Basis Claim Process ....................................................... 87 Submitting Inpatient UB-04 Claims: Fee Basis ................................................. 88 Outpatient Institutional and Professional Fee Basis Claim Process ...................... 97 Submitting Outpatient UB-04 Claims: Fee Basis ............................................... 98 Submitting Inpatient and Outpatient CMS 1500 Claims: Fee Basis.................... 103 Humanitarian Billing Process ....................................................................... 109 Submitting UB-04 Claims: Humanitarian ....................................................... 110 Tort Feasor and Worker's Compensation Cases .............................................. 113 Preparing Tort Feasor, Worker's Compensation and No-Fault Claims................. 114

4 - REPORTING FUNCTION ............................................................................. 120

4.1 - Claim Status Awaiting Resolution (CSA) and MRA Worklist (MRW) Reports ........ 121

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4.1.1 4.1.2 4.2 4.2.1 -

Managing the Claims Status Awaiting Resolution (CSA) Report ........................ 122 Managing the MRA Management Worklist (MRW) ........................................... 124 Processing Retrospective Coding Reviews...................................................... 125 Processing Retrospective Reviews from Coding .............................................. 127

5 - RECORDS MANAGEMENT ........................................................................... 136

5.1 5.1.1 -

Release of Information (ROI) Process ........................................................... 137 Processing Claims with Sensitive Diagnoses .................................................. 138

APPENDIX A: ACRONYM LIST ......................................................................................... 142

APPENDIX B: MANAGEMENT REPORTING ........................................................................... 144

APPENDIX C: LIST OF DIRECTIVES AND HANDBOOKS ............................................................... 147

APPENDIX D: LIST OF PROCEDURAL DOCUMENT EXAMPLES....................................................... 152

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- TABLE OF FIGURES -

Document Information 1: Version History .................................................................................5 Document Information 2: Document Authors .............................................................................5 Figure 1: Billing Framework ............................................................................................... 20 Figure 2: Inpatient Section Map .......................................................................................... 30 Figure 3: Inpatient Facility Charge Process .............................................................................. 32 Figure 4: Inpatient Professional Fees Charge Process ................................................................... 42 Figure 5: Skilled Nursing Facility Process ................................................................................. 48 Figure 6: Outpatient Section Map ........................................................................................ 55 Figure 7: Outpatient Facility Billing Process.............................................................................. 58 Figure 8: Outpatient Professional Fees Billing Process .................................................................. 64 Figure 9: Specialty Services Section Map ................................................................................ 69 Figure 10: Ambulance Billing Process.................................................................................... 71 Figure 11: Dental Ineligible Billing Process............................................................................... 78 Figure 12: DME and Prosthetics Process ................................................................................ 81 Figure 13: Inpatient Facility Fee Basis Claim Process .................................................................... 87 Figure 14: Outpatient Institutional and Professional Fee Basis Claim Process......................................... 96 Figure 15: Humanitarian Billing Process ............................................................................... 108 Figure 16: Tort Feasor and Worker's Compensation Cases ........................................................... 112 Figure 17: Reporting Section Map ...................................................................................... 119 Figure 18: CSA and MRA Worklist Reports ............................................................................. 120 Figure 19: Records Management Section map........................................................................ 135 Figure 20: Release of Information (ROI) Process ...................................................................... 136

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BILLING GUIDEBOOK

PROCEDURES 7.1 Cancel the claim: If provider information is missing, Billing Specialist will cancel the claim and assign a Reason Not Billable (RNB) in Claims Training. a. Assign cancellation code of XMC18 i. Add additional comments to assist FRM or designee in resolving this provider issue ii. The following day, FRM automatically receives notification via communication tool that claim has been canceled due to missing provider information & initiates steps to obtain required data b. Enter RNB and comment in Claims Tracking to specify the provider information that is missing (i.e. NPI, taxonomy code, PIN, Tax ID, etc.) b. If missing information has not been obtained after 30 days, FRM will notify Billing Specialist via communication tool that cancellation was appropriate i. END OF PROCEDURE c. If provider information is updated in VistA, FRM will notify Billing Specialist via communication tool to re-bill previously canceled claim i. PROCEED TO STEP 2 8 Send claim through scrubber: The Billing Specialist sends the claim through the Claims Scrubber. a. If valid insurance verification (VistA) edits appear: i. Forward error to Insurance Verification for correction. ii. After error is corrected and returned to Billing, send bill through the Claims Scrubber. b. After VistA edits, send claim to the Claims Scrubber. i. If valid non-coding edits exist, review and correct error ii. If valid coding edits exists return to coding for resolution via Recode/Reject process. i. If edits that appear are not valid, bypass scrubber. 9 Submit Claim: The Billing Specialist submits the claim through the appropriate process, depending on primary payer eligibility. a. If the patient has Medicare, payer sequencing is changed to secondary and claim is printed locally with Payer Exclusion letter.

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PROCEDURES 10 Print bill locally (If Necessary): If the bill cannot be submitted electronically, the Billing Specialist prints the bill locally: a. At Screen : i. Select Option [3] to force local print. ii. Authorize bill. iii. Send printed bill to Mail Room.

NOTE: Claims should be submitted electronically; however, Denial Management analyses, technical limitations or other special circumstances may warrant paper bills to be printed locally.

END OF PROCEDURE

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BILLING GUIDEBOOK

REFERENCE DOCUMENTS

RELATED HANDBOOKS AND OTHER REFERENCES

? Central Business Office Procedures Guide Series 1601C.03, Billing ? Ch. 1 Sec. G: General Billing Procedures ? Ch. 2 Sec. B: Ambulance Reasonable Charges and Billing Procedures ? Ch. 5 Sec. D: Fellow Services and Fee Basis (Purchased Care) Reasonable Charges and Billing Procedures

? Electronic Data Interchange (EDI) Billing Users Guide ? Integrated Billing (IB), Version 2.0 User Manual, March 1994 ? M-1, Part I, Chapter 21 Operations, Part I, Medical Administration Activities, Chapter 21, Authorized

Non-VA Hospitalization in the U.S. ? M-1, Part I, Chapter 22 Operations, Part I, Medical Administration Activities, Chapter 22,

Unauthorized Medical Services ? QuadraMed Encoder Suite Process Guide ? Reasonable Charges Desk Reference, Version 2.0 ? Uniform Billing Editor ? Bill Cancellation Review Request Procedure ? CPAC Facility Revenue Guidebook, SOP 5.1.1, Preparing Ambulance Services

On-line access to additional current guidance: ? CBO Intranet web site: ? ? Fee Program (Purchased Care for Veterans) web site: ? ? Ambulance reasonable charges and billing process ? Medicare Claims processing Manual ? Chapter 15 ? Ambulance ? Payer Exclusion Letter ? Complete the Ambulance UB-04 Form ? Medicare Benefit Policy Manual, Chapter 10 ? Ambulance Service ?

PROCEDURAL DOCUMENTATION EXAMPLES

CPAC Education Billing Level I/II ? Ambulance Services ? Billing Research Menu Options ? Billing Cancellation and Reasons Not Billable Codes

VERSION HISTORY VERSION DATE

1.9 1-24-13 1.8 12-28-12 1.6 6-11-2012 1.3 2-28-11 0.1 04-15-10

CHANGE DESCRIPTION Updated guidance Updated guidance Updated guidance Process change N/A (new draft version developed)

AFFECTED SECT. All All All Steps 5 & 5.1

APPROVED C. Hutchison C. Hutchison C. Hutchison C. Hutchison

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BILLING GUIDEBOOK

3.2 - Dental Ineligible Billing Process

Figure 11: Dental Ineligible Billing Process

3.2.1

3.2

Dental benefits are provided by the Department of Veterans Affairs according to very limited eligibility criteria, as established by law. There are only six dental categories or "benefit classes". Some allow extensive dental care, while other classes only proved for limited treatment. Most veterans do not meet the eligibility criteria to receive cost-free dental treatment at a VA facility. Those veterans who are ineligible for dental care may elect to pay for dental treatment at a VA facility according to the applicable cost-based rate for the type of care provided: emergent outpatient dental treatment or nonemergent outpatient dental treatment. On an ad hoc basis, Billing Specialists receive from facilities a list of dental ineligible encounters to be billed. Billing Specialists utilize the spreadsheet to establish billing records and generate bills on a UB-04 claim form for each encounter.

Billing staff perform the following procedures on an ad hoc basis: 1) Submitting UB-04 Claims: Dental Ineligible (BILL 3.2.1) ? Create and transmit bills to patients for

reimbursement for dental ineligible services.

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