Government has a list of problems to be solved
Government has a list of problems to be solved
The Health Care Financing Administration (HCFA) can dream, can’t it? Administrators expected that some glitches found in standard systems and Outpatient Code Editor (OCE) for processing claims under the new outpatient prospective payment system (PPS) might be fixed in an October update.
Unfortunately, some problems surfaced too late for HCFA to include in the update. Those problems will be fixed on or before Jan. 1, 2001, HCFA administrators predict. If the fix is made prior to Jan. 1, HCFA will amend its posting to reflect the correction date. Claims for services that are incorrectly processed will be reprocessed as soon as an OCE fix can be installed.
Here are some OCE issues scheduled for resolution no later than January:
• Modifier 52 (reduced services): Claims containing modifier 52 with type T procedures are being inappropriately discounted in the OCE.
• Modifiers 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), 79 (unrelated procedure or service by the same physician during the postoperative period): Claims containing these modifiers are being inappropriately discounted in OCE.
Other reminders
In a notice addressing those glitches, HCFA also advised providers to keep these items in mind to assure compliance under PPS:
• Hospitals are responsible for proper reporting of units of service. Instructions were issued in Transmittal 747 of the Hospital Manual in December 1999 explaining the proper reporting of units.
• Hospital Manual Transmittal No. 747 also requires providers to report a line-item date of service on every line requiring an HCPCS (HCFA common procedure coding system) code, even if the dates-of-service span is the same day (such as 08/01/00 to 08/01/00). If the line-item date of service is not shown, the claim will be returned to the provider.
• As stated in PM A-00-36, dated June 2000, non-RHC (rural health clinic) services provided by hospital-based RHC facilities on or after Aug. 1, 2000, will be subject to payment under PPS. So hospital-based RHCs should discontinue billing non-RHC services on the RHC claim (bill type 71X). When a patient receives services from a hospital-based facility certified both as a hospital-based RHC and as part of the hospital outpatient department, the claim for non-RHC hospital outpatient services must be submitted using the hospital bill type (13X or 14X) along with the hospital’s provider number. This must be done since the services are not covered as RHC services, but may be covered hospital outpatient services that are paid under PPS or an existing fee schedule.
This change is needed to assure proper payment under PPS. RHC services remain subject to the encounter rate payment methodology and will continue to be billed using the RHC provider number, RHC bill type (71X) and revenue codes 52X and 91X. Failure to bill appropriately will result in the claim being returned to the provider.
• As stated in PM A-00-36, dated June 2000, payment for clinical diagnostic laboratory services furnished under the inpatient Part B benefit (bill type 12X), which were paid on cost prior to PPS, are now paid under PPS. These services must be billed with the appropriate HCPCS code to assure proper payment.
• When an implantable device, such as E0751 or L8600, is billed with revenue code 274, CWF will reject the claim. Since these devices are no longer subject to payment under the orthotic/prosthetic fee schedule, they should be reported under revenue code 278.
• The Electronic Remittance Advice (ERA) files contain the APC number assigned at the line. But when files are run through PC Print, the APC number does not print on the remits. At this time, PC Print is not designed to show this information, and there are no plans at this time to modify it. Providers may want to consider moving to an ERA format.
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