January 16, 2020
As of claim process dates February 2, 2020 and after, new facility correct coding claim “validation” edits will be introduced in the Claims Editor. Here are a few things for you to know:
- These edits are already used by CMS.
- We already apply these edits for outpatient services; starting in February they will also apply to inpatient services.
- Edits will confirm we have the information needed to process the claim.
- The claim will be denied if it’s determined to not meet the requirement. If appropriate, you may correct the claim and resubmit.
The new edits look at specific data elements that are/are not billed on an inpatient or outpatient hospital claim, depending on whether the data element is required or situational.
Required data elements are needed on a claim in order to provide specific and key information about the patient or the situation necessitating the services being billed to allow for the claim to be processed. Such required data elements include but are not limited to principle diagnosis, bill type and frequency, or from and to dates.
Situational data elements are data elements that may be needed depending on the situation or services being submitted for processing. Situational data elements include but are not limited to the patient account code, occurrence codes, or other procedure codes and dates.
If you bill for either Inpatient or Outpatient hospital services via electronic submission (837i) or via paper (UB-04/CMS-1450), review the data elements/UB-04 FIELDS called out below that will be edited as of process dates February 2, 2020 and after.
| EDIT | EDIT DESCRIPTION | UB-04 CLAIM FIELD LOCATION AND DESCRIPTION |
|---|---|---|
| Missing Account ID - Inpatient | The account ID is missing from the claim. | Field 3b - medical/health record number |
| Invalid Condition Code | The condition code <1> on the claim is invalid. | Fields 18-28 - condition codes |
| Patient DOB is Missing - Inpatient | Patient's date of birth is missing on the claim. | Field 10 - birthdate |
| Patient DOB is Invalid - Inpatient | Patient's date of birth <1>is invalid on the claim. | Field 10 - birthdate |
| Missing or Invalid Statement Covers Period From/Through Date - Inpatient | Missing admission date or invalid statement covers period from or through dates. | Field 6 - statement covers period: from-through |
| Inpatient Facility Discharge Date Missing | The discharge date is missing. | Field 6 - statement covers period: from-through |
| Inpatient Principal Procedure Required | A principal procedure code is required when a procedure code is found in the other procedure code field. | Field 74 - principle procedure: code and date |
| Facility Medicare ICD-10 Code Rule | Per CMS guidelines, ICD-10 codes can’t be billed for dates of service prior to October 1, 2015. | Fields 67: principal diagnosis code Field 67a through 6yq: other diagnosis codes |
| Facility Medicare ICD-9 Code Rule | ICD-9 code types can’t be billed for dates of service greater than September 30, 2015. | Fields 67: principal diagnosis code Field 67a through 6yq: other diagnosis codes |
| Invalid Occurrence Code | The occurrence code <1> on the claim is invalid. | Fields 31-34: code and date |
| Invalid Occurrence Span Code | The occurrence span code <1> on the claim is invalid. | Fields 35-36: occurrence span: code and from/through dates |
| Missing Patient ID - Inpatient | No patient ID was submitted on the claim. | Field 8a: patient Id |
| Interim Claims with Frequency Code 2 and 3 Requires Patient Discharge Status Code 30 - Inpatient | Per Medicare guidelines, the patient discharge status code must be 30 [still patient] when the frequency digit is the type of bill 2 [Interim- First Claim] or the frequency digit is the type of bill 3 [Interim- Continuing Claim]. | Field 4: type of bill Field 17: discharge status |
| Missing Provider ID - Inpatient | The provider ID is missing from the claim. | Field 76:attending Field 77: operating Fields 78-79: other |
| Point of Origin for Admission is Required on all Institutional Claims with the Exception of 014X | Point of origin for admission is missing or invalid. | Field 15: point of origin for admission/visit |
| Missing Type of Admission | This claim has a missing type of admission code. | Field 14: priority/type of admission |
| Invalid Type of Admission | This claim has an invalid type of admission code <1>. | Field 14: priority/type of admission |
| Type of Admission Frequency | Type of admission code 4 (newborn), can’t be billed more than once in a lifetime. | Field 14: priority/type of admission |
| Invalid Type of Bill - Inpatient | The type of bill code is invalid or missing. | Field 4: type of bill |
| Missing or Invalid Type of Bill - Inpatient | The type of bill code is invalid. | Field 4: type of bill |
| Invalid Value Code | This claim has an invalid value code <1>. | Fields 39-41: value codes and amounts |
Here are more resources for completing the UB-04/CMS1450 form or the ASC X12 837i electronic claim form:
- National Uniform Billing Committee (NUBC) at www.nubc.com via the NUBC Official UB-04 Data Specifications Manual
- CMS Claims Processing Manual, Publication 100-04, Chapter 25-Completing and Processing the Form SMC-1450 Data Set