Medical Billing Forum

Billing => Facility Billing => Topic started by: jc071172 on June 05, 2012, 11:28:14 AM

Title: Medicare UB04 MSDRG
Post by: jc071172 on June 05, 2012, 11:28:14 AM
When billing Medicare Inpatient TOB 111, doesn't Medicare require the DRG code on the UB-04 and if so, which FL should it fall into on a hardcopy UB-04 claim? Thanks.
Title: Re: Medicare UB04 MSDRG
Post by: snfcb on June 05, 2012, 01:10:14 PM
FL67 - Principal Diagnosis Code

FL67a-FL67Q Other Diagnosis
FL69 - Admitting Diagnosis Code

(from CMS Manual System - Pub 100-04 Medicare Claims Processing - Transmittal 1104)
FL 67 - Principal Diagnosis Code Required. The hospital enters the ICD code for the principal diagnosis. The code must be the full ICD diagnosis code, including all five digits where applicable. The reporting of the decimal between the third and fourth digit is unnecessary because it is implied. The principal diagnosis code will include the use of “V” codes. Where the proper code has fewer than five digits, the hospital may not fill with zeros. The principal diagnosis is the condition established after study to be chiefly responsible for this admission. Even though another diagnosis may be more severe than the principal diagnosis, the hospital enters the principal diagnosis. Entering any other diagnosis may result in incorrect assignment of a DRG and cause the hospital to be incorrectly paid under PPS. The hospital reports the full ICD code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67 of the bill. It reports the diagnosis to its highest degree of certainty. For instance, if the patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom must be reported (7862). If during the course of the outpatient evaluation and treatment a definitive diagnosis is made (e.g., acute bronchitis), the hospital must report the definitive diagnosis (4660). When a patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital should report an ICD code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82). Examples include: • Routine general medical examination (V700); • General medical examination without any working diagnosis or complaint, patient not sure if the examination is a routine checkup (V709); and • Examination of ears and hearing (V721). NOTE: Diagnosis codes are not required on nonpatient claims for laboratory services where the hospital functions as an independent laboratory.

FLs 67A-67Q - Other Diagnosis Codes Inpatient Required. The hospital enters the full ICD codes for up to eight additional conditions if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67 as an additional or secondary diagnosis. If the principal diagnosis is duplicated, the FI will remove the duplicate diagnosis before the record is processed by GROUPER for IPPS claims. The MCE identifies situations where the principal diagnosis is duplicated for IPPS claims. Outpatient - Required. The hospital enters the full ICD codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. NOTE: Medicare will ignore data submitted in 67I – 67Q.

FL 69 - Admitting Diagnosis Required. For inpatient hospital claims subject to QIO review, the admitting diagnosis is required. Admitting diagnosis is the condition identified by the physician at the time of the patient’s admission requiring hospitalization. This definition is not the same as that for SNF admissions.
Title: Re: Medicare UB04 MSDRG
Post by: snfcb on June 05, 2012, 01:20:11 PM
Claims Processing/Rejections -
Claims with certain Diagnosis Related Group Codes (DRGs) are rejecting inappropriately. If a provider’s claim fails for the DRG Code being invalid, the provider needs to remove the DRG code from the claim. Per the TR3 situational rule, DRGs are required only when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by
this implementation guide, do not send. CMS does not have DRG contracts with any of its providers so a claim containing a DRG submitted to CMS violates the TR3 situational usage rule.
Title: Re: Medicare UB04 MSDRG
Post by: jc071172 on June 05, 2012, 04:25:07 PM
So if CMS pays IP claims based on the IP PPS formula, which takes the relative weight of that DRG assigned to that patient, how does CMS know what the DRG is, if it is not displayed ont he claim? Do they take the ICD codes off the bill once they receive it hardcopy or electronically and calculate the DRG themselves?
Title: Re: Medicare UB04 MSDRG
Post by: snfcb on June 08, 2012, 01:06:23 PM
The system is designed to screen all cases and sort out those cases that require further review before classification into a DRG. Following this screening process, the fiscal intermediary, using an automated algorithm called “Grouper,” groups all discharge cases into one of 25 Major Diagnostic Categories (MDCs) before assigning it to 1 of the 499 DRGs. Most of the MDCs are based on the body system involved and disease types.

Calculating DRG payments involves a formula that accounts for the adjustments discussed in the (attached link). The DRG weight is multiplied by a “standardized amount,” a figure representing the average price per case for all Medicare cases during the year. The standardized amount is the sum of: (1) a labor component which represents labor cost variations among different areas of the country and (2) a non-labor component which represents a geographic calculation based on whether the hospital is located in a large urban, or other area. The labor component is then adjusted by a wage index. If applicable, cost outlier, disproportionate share, and indirect medical education payments are added to the payment.

Here is the link on DRG's: