In my travels and contacts with various IRF providers across the USA (clients and non-clients alike while assisting with compliance audits or gap analysis to IRF conditions of participation), I have noticed something about the uniform bill and the fact that it’s completion in an IRF for Medicare Part A covered patients paid by the IRF PAI is not so “uniform.”
In particular I will discuss, field locator areas of the UB from 42 – 47 and the fact that I have seen various interpretations to the specific billing requirements defined in the Medicare Claims Processing Manual 100-04; Chapter 3, Section 140.3.
Because cost reports are ultimately created from provider statistical & reimbursement reports, the charge detail aggregate data influences Medicare allowable charges. That, in turn, is used to calculate outlier payments and facility specific adjustments (like market basket); it’s never too late to review your own facilities completion of the uniform bill if for nothing else but uniformity so that analysis across facilities is valid.
Type of bill, PPS designated revenue code, type of bed code and display of ‘ancillary’ therapy charges is where this discussion with real examples will concentrate.
For the Part A Medicare beneficiary – an IRF bill is tagged with a 0024 Revenue Code that symbolizes the patient will be paid by the IRF PPS designated Health Insurance Prospective Payment System (HIPPS) value. This is generally a five digit combination of the tier status (A-D) and the CMG derived by the IRF PAI grouper software. In some instances, this may be one of the five special CMGs (short stay or expired patient codes); this line item appears first in the list of detailed revenue codes.
- Room Type – Revenue Code – third and fourth digits in the room code designates the TYPE of room for the inpatient stay. A single bed is 011x; a double bed room is 012x; these two are used most often. Since 8 describes a rehabilitation accommodation; the last digit should be ’8‘. Also note that instructions state the field locators then must display the daily rate times the units. The unit would be the number of days in the patient’s stay. Avoid using general accommodation codes.
Last – although all other charges are to be itemized by revenue code and listed on the bill for cost report purposes, I will discuss the display of therapy services charges only within this post as this is generally the most varied item I see between bills. The claims processing manual describes this criteria for posting therapy services:
Even though a facility is not paid based on itemized charges, the details within the UB are significant to validate specificity of the care provided with the skills uniquely abundant in a rehabilitation level of care.
Display of therapy charges has varied interpretation from what I have seen. The leading code for therapy services are 04 with the third digit of ’2‘ symbolizing Physical Therapy; a ’3‘ Occupational Therapy and a third digit ’4‘ Speech Language Pathology. The ‘X’ symbolizes the Type of procedure where the AMA provided procedural codes are indicated. I believe the ‘or’ in the claims manual sentence is what makes the intended definition require additional clarification. Some facilities will leave all descriptions at the service only level while others define the procedure. In a world of cost reporting transparency the values behind the various services charges hold significant detail in what makes a rehabilitation service provider unique and deserving of a rehabilitation level of care. Many bills will not substantiate intensity of resources as a stand alone which begs review of the written chart on audit.
If you wonder why your cost to charge ratio may not symbolize the level of care you provide, you may find the key to improving the accuracy in the detail of this section of your bill. Each procedure code is validated by a ‘weight’ associated with providing that level of care and again, although not paid like outpatient, the charge master driven bill should incorporate the resources required to provide higher skilled services that demand comparable charge structures. Medically necessary interdisciplinary skill sets are portrayed more clearly in the level of service and care provided when the charge master maintains correlation to procedure code values on the detailed bill; this is despite cost reports rolling total charges to the first three characters for therapy services: 042, 043 and 044 for example. Why? Because the detail is available when transferred in cost reporting.
An IRF part A stay has been interpreted different ways although guided by the claims processing manual. Look at your detailed bill and see which example most closely resembles your reporting style. (Note – dollar signs are NOT utilized on real UB’s and are used for clarity only.)
EXAMPLES UB-04 IRF BILLS:
‘Procedure’ or ‘Service’ holds many different interpretations for display on the UB-04; I personally believe we need clarification and/or picture examples published as a MedLearn Matter to help everyone apply the same expectations on the uniform IRF bill. Before IRF’s are railroaded toward obscurity, providers of inpatient rehabilitation services need to understand the underlying charges that CMS attempts to compare. Most importantly, with value- based purchasing leading future payment reform, all bills should be uniform so that IRF cost to charge ratios do not, for the most part, remain mystery calculations.
How does your bill compare? Should these variances concern us?