5010 Changes to CMS-1500 and UB-04 Billing Guides 12/22/2011 Table of Contents Introduction 1 CMS-1500 Changes 2 UB-04 Changes 4 Introduction The following changes have been made to the 5010 CMS-1500 and UB-04 billing guides. These guides are posted on the 5010 webpage www.mass.gov/masshealth/5010. The changes in this guide should be used in conjunction with the CMS-1500 and the UB-04 billing guides to ensure a complete set of instructions. Please Note: Effective January 1, 2012, MassHealth is moving toward an all-electronic claims submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the provider has received an approved electronic claim submission waiver. 90-day waiver requests and final deadline appeals may be submitted either electronically via the Provider Online Service Center (POSC) or on paper. Please see All Provider Bulletin 217, dated September 2011, for more information about MassHealth’s paper claims waiver policy. For information on how to submit 90-day waiver requests and final deadline appeals electronically, please also see All Provider Bulletin 220 and All Provider Bulletin 221, dated December 2011. CMS-1500 Changes Changes to the CMS-1500 Billing Guide Date Change Field No. Field Name Existing Description Change Description 10/20/11 Added Appendix A Pages 21-22 N/A N/A TPL Supplemental Instructions for submitting claims on the CMS-1500 for members with Medicare coverage were added as Appendix A. Earlier, these instructions were stand-alone documents on the 5010 Web page. 10/20/11 Added Appendix B Pages 23-24 N/A N/A TPL Supplemental Instructions for submitting claims on the CMS-1500 for members with Commercial Insurance were added as Appendix B. Earlier, these instructions were stand- alone documents on the 5010 Web page. 8/1/11 The ICD-9-CM diagnosis code is required for all provider types 21 Diagnosis or Nature of Illness or Injury (relate items 1, 2, 3, or 4 to 24E by line) If applicable, enter the ICD-9- CM diagnosis code. If there is a fourth or fifth digit, it is a required part of the code. Enter up to four ICD-9-CM codes. Relate lines 1, 2, 3, and 4 to the lines of service in Field 24E by line number. Use the highest level of specificity. Do not provide a narrative description in this field. When entering the number, include a space (accommodated by the period) between the two sets of numbers. If entering a code with more than three beginning digits (for example, E codes), enter the fourth digit over the period. Enter the ICD-9-CM diagnosis code. If there is a fourth or fifth digit, it is a required part of the code. Enter up to four ICD-9-CM codes. Relate lines 1, 2, 3, and 4 to the lines of service in Field 24E by line number. Use the highest level of specificity. Do not provide a narrative description in this field. When entering the number, include a space (accommodated by the period) between the two sets of numbers. If entering a code with more than three beginning digits (for example, E codes), enter the fourth digit over the period. 8/1/11 Billing change for Anesthesia 24G Days or Units For Anesthesia: Enter the total number of 15- minute periods, including as one unit any remaining fraction that equals or exceeds five minutes, that make up the beginning and ending clock time for the anesthesia service. See 130 CMR 433.000 for regulations about reporting anesthesia time. If no units are entered, the service is paid at the base rate. For Anesthesia: Enter the total number of minutes that make up the beginning and ending clock time for the anesthesia service. One minute equals one unit. See 130 CMR 433.000 for regulations about reporting anesthesia time. If no units are entered, the service is paid at the base rate. UB-04 Changes Changes to the UB-04 Billing Guide Date Change Field No. Field Name Existing Description Change Description 12/20/11 Billing Changes for Chronic Disease and Rehabilitation Outpatient Hospitals If required, enter the HCPCS code and modifier applicable to ancillary service and outpatient bills. Acute Outpatient Hospitals: If the revenue code entered in Field 42 requires a HCPCS code, refer to Ingenix Uniform Editor for accurate mapping of revenue codes and HCPCS codes. Chronic Disease and Rehabilitation Hospitals and Substance Abuse Treatment Outpatient Hospitals: Enter an applicable HCPCS code for each revenue code entered in Lines 1-22 in Field 42. Nursing Facilities, Acute Hospitals, Chronic Disease and Rehabilitation Hospitals, Substance Abuse Treatment Hospitals, and Psychiatric Inpatient Hospitals: Not required Home Health Agencies, Community Health Centers (for Home Health Services only), and Hospice Providers: Refer to Subchapter 6 of your MassHealth provider manual for the applicable HCPCS code. 340B Providers The UD modifier should be billed on the UB-04 claim form and associated with the applicable HCPCS code and NDC to properly identify 340B drugs. Chronic Disease and Rehabilitation Hospitals Outpatient Hospitals: Enter an applicable HCPCS code for each revenue code entered in Lines 1-22 in Field 42. Reference the Ingenix Uniform Editor for guidance in mapping revenue codes and HCPCS codes. Also enter the appropriate modifier as required. Please refer to Subchapter 6 of your MassHealth provider manual for the use of modifiers. 8/1/11 The diagnosis code describing the patient’s reason for visit is now required for certain provider types. 70 (a-c) Patient Reason DX Not required Acute Outpatient Hospitals, Hospital Licensed Health Centers, Chronic Disease and Rehabilitation Outpatient Hospitals, Substance Abuse Outpatient Treatment Hospitals, and Psychiatric Outpatient Hospitals: Enter the ICD-9-CM diagnosis code describing the patient’s reason for visit at the time of outpatient registration. Refer to the NUBC Instruction Manual for specific requirements. All Other Provider Types: Not required. 8/1/11 Description change 43 (Lines 1- 22) Description This does not apply to hospital claims that are paid as part of a bundled rate, such as the claims paid through the bundled hospital Payment Amount Per Episode (PAPE) at this time. This does not apply to vaccines, radiopharmaceuticals, or contrast media. This requirement does not apply to vaccines. It also does not apply to hospital claims that are paid as part of a bundled rate, such as the claims paid through the bundled hospital Payment Amount Per Episode (PAPE) at this time. Commonwealth of Massachusetts Executive Office of Health and Human Services 270/271 Companion Guide July 2008 DRAFT Version 9.1 -ii- -ii- Commonwealth of Massachusetts Executive Office of Health and Human Services Commonwealth of Massachusetts Executive Office of Health and Human Services 5010 Changes to CMS-1500 and UB-04 Billing Guides December 2011 -i- Commonwealth of Massachusetts Executive Office of Health and Human Services Changes to CMS-1500 & UB-04 Billing Guides December 2011 -5-