Health Information Management

Keep abreast of new UB-04 claim form changes

APCs Insider, September 15, 2006

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Keep abreast of new UB-04 claim form changes

QUESTION: We have heard about possible expansion of ICD-9-CM diagnosis codes for the new UB-04 claim form. Do you have any insights as to how this will affect outpatient coding and OPPS?

ANSWER: CMS institutional providers may use the UB-04 beginning March 1, 2007, however, they will have a transitional period between March 1, 2007 and May 22, 2007 where they can use the UB-04 or the UB-92. Starting May 23, 2007, all institutional paper claims must use the UB-04. The UB-92 will no longer be accepted after this date. See CMS Transmittal 1018, issued July 28, 2006, for more details:

The National Uniform Billing Committee made significant upgrades to the UB-04 form locator (FL) fields. The following ICD-9-CM diagnosis requirements are effective for outpatient reporting as listed below. Remember that although you must report ICD-9-CM procedure codes through your technology or encoder, per CMS, ICD-9-CM procedure codes are not part of the outpatient HIPAA data set, and the agency will not accept these codes.

FL 69: Admitting diagnosis-required. For inpatient hospital claims subject to QIO review, the admitting diagnosis is required. Admitting diagnosis is the condition requiring hospitalization that the physician identifies at the time of the patient's admission. This definition is not the same for SNF admissions.

FL 70A-70C: Patient's reason for visit-situational. The patient's reason for visit is required for all un-scheduled outpatient visits for outpatient bills. The hospital will have three ICD-9-CM diagnosis(es) to report, if applicable. This is a great addition and will certainly assist in the effort for supporting medical necessity of tests ordered in the ED.

FL 67: Principal diagnosis code-required. The hospital enters the ICD-9 code for the principal diagnosis. The code must be the full ICD-9 diagnosis code, including all five digits where applicable.

FL 67A-67Q: Other diagnosis codes outpatient-required. The hospital enters the full ICD-9 codes in FLs 67A-67Q for up eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. Note: Medicare will ignore data submitted in 67I - 67Q. This area has been upgraded to capture 17 secondary diagnoses, however CMS will only identify the first eight. It is important that you capture the ICD-9-CM diagnosis which supports medical necessity within these eight secondary diagnoses.

FL 72: External cause of injury (ECI)-codes not used. Any data entered here will be ignored. This area will hold one E code.

Review this information with your outpatient coding professionals to ensure capture of accurate ICD-9-CM diagnoses, which will strengthen your severity of illness and improve your case-mix now and in the future. Work with your facility and vendors to make sure they know the timeline and are prepared for implementation.

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