Corporate Compliance

Note from the Instructor: ICD-10 and split billing claims

Medicare Insider, September 15, 2015

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This week’s note from the instructor is written by Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro.

While implementation of the long awaited and long overdue ICD-10 coding system is just around the corner, some questions still remain regarding “split billing” based on the October 1, 2015, date of service. Lately, I have been asked questions by billing staff from both PPS and critical access hospitals (CAH) so this may be a good time to clarify how and when to split bill.


Claims cannot contain both ICD-9 and ICD-10 diagnosis or procedure codes on and after the October 1 implementation date based on the actual dates of service. CMS has stated that dual coding—reporting both sets of codes—will not be permitted due to the significant resources and system changes that would be needed by Medicare and its trading partners. If this occurs, MACs will return any claims to providers for correction before resubmitting for the appropriate processing.

There may be instances when the services provided span the October 1 implementation date and providers will need to split the services into two separate claims. This requirement will apply to all hospitals, regardless of whether they are paid under the prospective payment system or cost-based methodology, such as a CAH.

When billing for services during an outpatient encounter or inpatient admission that cross midnight on October 1, 2015, be aware of the effect of the “from and through” dates on the claim and proper reporting of either ICD-9 or ICD-10 codes. According to the UB-04 Data Specifications Manual, the “from” date is the earliest date on the claim and the “through” date represents the last date on the claim.

Here are some common types of bills (TOB) that may cause problems if not split according to the date of service:

  • TOB 13X (outpatient PPS)–split bill using the “from” date on the claim
    • Caution: watch for emergency department and observation services and use the date when the care was appropriately initiated (i.e., start of care or date of order)
  • TOB 85X (outpatient CAH)–split bill using the “from” date on the claim
    • Caution: watch for emergency department and observation services and use the date when the care was appropriately initiated (i.e., start of care or date of order)
  • TOB 14X (non-patient outpatient lab)–split bill using the “from” date on the claim
    • Caution: watch for when the date of collection is different than the date of the test result and, in most cases, use the date of collection
      • Exception: when lab tests span a collection period, use the ending date as the date of service (i.e., 24-hour urine collection)
  • TOB 12X (Part B services during a Part A stay)–split bill using the “from” date on the claim
    • Caution: watch for when services fall within the three-day payment window and must be billed separately on TOB 13X
      • Excludes CAHs since outpatient services are already billed on TOB 85X
  • TOB 11X (inpatient PPS/CAH)–do not split bill if the claim has a discharge or “through” date on or after October 1, 2015
    • Caution: do not separately bill outpatient services that must be included on the inpatient claim under the three-day payment window, regardless if the services were provided prior to October 1, 2015
      • Excludes CAHs since outpatient services are already billed on TOB 85X
  • TOB 18X (CAH swing bed)–do not split bill if the claim has a discharge or “through” date on or after October 1, 2015

There are many other bill types that will be affected by split billing and I have mentioned only a few of the more obvious areas that hospitals should be aware of. Also, don’t forget about series accounts where outpatient services are provided over a period of time and may crossover into October 1, 2015.

CMS had previously published MLN Matters article SE1408 that remains pertinent and helpful today and should be reviewed by coders, billing staff, and anyone responsible for submitting charges on a claim. It doesn’t look like there will be any turning back now and hopefully all staff are ready for CMS to finally flip the switch.



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