Medicare Exhaust Billing Procedure Manual Project Cynthia Gause Colorado Technical University Online ENGL205-1301 Technical Writing and Speaking Phase 4IP

Contents Contents 1 Phase 1 IP 2 Procedure Manual Outline 2 Phase 2 IP 3 Procedure Manual Proposal (Revised) 3 Brochure 4 Brochure Continued 5 Phase 3 IP 6 Medicare Exhaust Billing Checklist 6 Procedure Manual 7 Preparing Bill 3 Step I – Census 3 Step II – Bill Upload 4 Exhaust Billing Claim Coding 5 Step III- Xclaim 5 DDE Step IV 7 Secondary Claim Submission 8 How to submit Secondary Exhaust Claim 8 UB04 Claim examples 8 Billing Reference Tools 10 Type of Bills 11 Patient Status Codes 12 DDE Access/ Menu 13

Phase 1 IP
Procedure Manual Outline
Outline for Medicare Exhaust Billing Procedure Manual I. Introduction
This section will provide an overview of Medicare exhaust billing and the purpose of this manual. II. Bill Uploads
Upload bill and billing data in the Ram system to allow bills to be created. III. Claim Coding, and required remarks
Once bills have been uploaded and created, bills need to be coded correctly and remarks need to be added to the claim. IV. Submit Bill to Medicare thru Xclaim or DDE
Once coding and remarks have been added claim review to make sure all coding and remarks have been added correctly than submit the claim by using the Xclaim or DDE system. V. Verify Claim Submission In DDE
Log into the DDE system to verify that the claim was successfully accepted into the Medicare system and in a status of SB9000, verify this in DDE if claim was submitted by Xclaim or DDE. VI. Check Medicare Remit in 14 Days and Print for Secondary Billing.
The Medicare remit should be in the Xclaim system within 14 days showing claim status RB9997 with zero payment. Print Remit and attach to secondary claim.

Phase 2 IP
Procedure Manual Proposal (Revised)
To: Mrs. Hyatt (Finance Manager)
From: Cynthia Gause
Date: March 3, 2013
Re: Medicare Exhaust Billing Manual

I have been tracking the current outstanding receivable for the hospital Care Center. I have found that the outstanding insurance payments due on 90% of our claims are a direct result of Medicare
Exhaust claims that are unbilled. These unbilled exhaust claims are causing a delay of billing and payment from the secondary commercial insurance carriers. If the Medicare exhaust claims are billed promptly and correctly for an exhaust denial, the secondary insurance will pay the accounts in full once the claim is submitted with a copy of the Medicare exhaust of benefits denial. Having a procedure manual in place for Medicare exhaust billing will help to ensure that claims are submitted to Medicare and receive the proper benefits exhaust denial within 14 days of claim submission, so that the secondary insurance can be billed and remit payment within 30 days of the date of service. This will also benefit the organization because we currently have one Medicare biller, by creating this manual it will help to ensure that Medicare exhaust claims can continue to be billed by other staff on a regular basis to help keep the receivable clean or in the event that the current biller is out for an extended period of time. This will also help to reduce the amount of time balances remain outstanding on the accounts by 50% which is the ultimate goal of our department. Ms. Hyatt please take this proposal into consideration as it will help to improve the functions of the business as well as help us to exceed our current goals of maintain a controlled receivable which will only be beneficial to our business.
Brochure

Brochure Continued

Phase 3 IP
Medicare Exhaust Billing Checklist

Procedure Manual Preparation | Medicare Exhaust Billing Procedure Manual Checklist. | Yes | No | Not Required | Comments | The purpose and benefits of the procedure manual have been identified. | | | | | The objectives and goals been identified for the Medicare billing Procedure manual. | | | | | Outline clearly states topics that will covered by the manual, and rough draft of the manual has been completed. | | | | | Manual is appropriate for the intended audience, instructions are clear, and language is appropriate and directions are simple to follow. | | | | | Table of contents and reference tools are present. | | | | | Does the structure of the manual take into consideration the tools employees have provided to perform the functions of the job. | | | | | Manual is ready for preliminary review by management for approval. | | | | | Manual has proofread, alterations have been made finalized and approved my management. | | | | | Once approved manual is ready to be printed and distributed | | | | | Time frame has been set and approved for procedure manual updates due to ongoing changes with Medicare guidelines and procedures. | | | | |
Procedure Manual

JHH CARE CENTER
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Medicare Exhaust Billing Manual

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JHH Care Center
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Medicare Exhaust Billing Manual
JHH Care Canter
3910 Keswick Road Suite 4A
Baltimore, MD 21201
Phone 443.555.0125 • Fax 443.555.0145

Table of Contents
TABLE OF CONTENTS Introduction 1 Preparing Bill 3 Step I – Census 3 Step II – Bill Upload 4 Exhaust Billing Claim Coding 5 Step III- Xclaim 5 DDE Step IV 7 Secondary Claim Submission 8 How to submit Secondary Exhaust Claim 8 Billing Reference Tools 10 Type of Bills 11 Patient Status Codes 12 DDE Access/ Menu 13

Introduction

This Medicare exhaust billing procedure manual had been created for the JHH Care Center Medical billing staff. This manual has been created to provide the steps required to bill an exhaust claim to Medicare for denial in order to bill the secondary claim for payment. This manual will list the procedures step by step so that any biller who may need to step in to assist or take over Medicare exhaust billing will be able to perform the task by following the outlined procedures with minimal assistance or supervision while doing so.

Preparing Bill
Step I – Census

* At the end of each month review the 1189 census report which is emailed to all billers daily. * Identify any and all patients that have zero Medicare days remaining at the end of the month; this information can be identified on page 1 of the 1189 in the last row titled Available days. This will also tell you the date of the last Medicare covered day. * Proceed to page 2 of the 1189 and identify the secondary insurance listed for the patients who have been identified as exhausting their Medicare benefits. * Record the patient names, account numbers, and secondary insurance for the Medicare exhaust patients identified.

Step II – Bill Upload

* In order to upload bills enter the RAM system, go to the billing tab enter the patients name, medical record number, or account number, choose calculate charges. * Once you have calculated charges go back to the billing tab choose produce electronic bill if you are producing a bill that will be submitted electronically thru Xclaim, if you are billing a secondary claim you will need to choose produce a paper claim. * Once bill type paper or electronic has been chosen check box for insurance carrier, choose Medicare no pay for exhaust claims, if billing secondary or any other insurance as primary select the name of the insurance from the drop down menu. Click ok to produce bill. * Bill will generate and produce in Xclaim in your incomplete folder, electronic claim will be identified in red and paper claims will appear in blue. Double click on the bill to open it.

Exhaust Billing Claim Coding
Step III- Xclaim

* In Xclaim double click on bill to be submitted * In field #4 enter 110 as your bill type * On bill UB04 enter occurrence code A3 in fields 31-34 with the last covered day of service * Enter condition code 21 in field 18-28 * Enter Value code 81 in field 39-41 with the amount of non covered claim days. * In field 48 enter non covered charges which are shown under the total charge field #47 simply duplicate the charges in 47 by copying the charges into field 48. * Enter the following remarks in field labeled remarks “ Billing for full benefits exhaust denial”. * Click on the validate button to submit the claim to Medicare.
Note: Medicare only accepts electronic claims. Claims will transmit from Xclaim to the Medicare DDE system.

Note: See Exhaust Bill Example Below.

DDE Step IV

* Go to Novitassolutions .com * Request Medicare Log On * Medicare log on will be received in 7-10 days via email * Once logon is received click on the HIP Icon located on desktop * Next to session I place an in the blank field * Type FSSO on blank black screen that populates * You will be prompted to enter Medicare User ID * Enter User ID and create a password * Menu will populate * Claim status should be checked in DDE 14 days after submission thru Xclaim. * Choose option #1 named inquiry * Next to field HIC# enter the patients Medicare number and date of service. * Bills received for that span will populate * Place an S next to bill you want to review * If status is SB9000 claim has been received and is in process if status is RB9997 with a reason code of 39510 this means the claim has completed processing as a Medicare exhaust claim denial do a screen print. * Exit DDE system.
Secondary Claim Submission
How to submit Secondary Exhaust Claim

* Print Medicare Eob from Xclaim by going to the eob files enter patient name or account number select the eob and right click to print. * In field #4 correct make bill type 111,112,113, or 114 according to discharge status in field 17. * Select secondary claim in Xclaim by clicking on your incomplete folder. * In field 31 enter the occurrence code 24 and the date Medicare denied the claim which is the date indicated on the Medicare eob. * In field 54 enter $0.00 to show Medicare made no payment. * In field 55 enter the claim total amount ex:($55,000.00) * Print the claim , attach the printed Medicare Eob and the screen print from DDE that was retrieved during step IV. * Mail the claim to the secondary insurance carrier Secondary claims must be submitted hard copy, electronic submissions are not allowed. * Call Secondary Insurance 30 days after claim submission to verify claim status and note the account accordingly.
Note: If Medicare denied charges of $55,000.00 enter $0.00 in field 54 meaning no Medicare payment was made. And enter $55,000.00 in field 55 which is the amount that you would like to bill the secondary insurance for payment. See Secondary UB04 Claim example below.

Billing Reference Tools
DDE Claim Staus Location STATUS/LOCATION | CLAIM DISPOSITION | P B9996 | Claim waiting the payment floor hold | P B9997 | Paid claim– finalized location | P O9998 | Paid claim (offline)– finalized location | R B9997 | Rejected claim– finalized location | D B9997 | Denied claim– finalized location | T B9900 | Daily RTP location– claims cannot be worked when in this location | T B9997 | Finalized RTP location– claims can be worked when in this location | S B0100 | Claim is at the beginning of the system– all claims start here | S B2500 | Claim has been updated by the provider online– awaiting duplicate check | S B6000 | Claim waiting for additional development request (ADR) to becreated | S B6001 | Claim waiting for ADR response to be returned by the provider | S B9000 | Non-ESRD claim waiting to go to CWF– has cleared all FISSedits | S B9099 | Claim awaiting response from CWF |

Type of Bills
Note: 110 Type of bill is to uised for no pay/exhaust claims only.
Description
110 | Hospital, Inpatient (Including Medicare Part A), Non-Payment/Zero Claim | | 111 | Hospital, Inpatient (Including Medicare Part A), Admit thru Discharge Claim | 112 | Hospital, Inpatient (Including Medicare Part A), Interim - First Claim (Used by non-PPS acute | care facilities) | | 113 | Hospital, Inpatient (Including Medicare Part A), Interim - Continuing Claim (Used by non-PPS | acute care facilities) | Accept | 114 | Hospital, Inpatient (Including Medicare Part A), Interim - Last Claim (Used by non-PPS acute care facilities) | Deny | 115 | Hospital, Inpatient (Including Medicare Part A), Late Charge(s) Only Claim (Use for inpatient | Part A bill for ancillary services for non-PPS facilities) | Accept | 117 | Hospital, Inpatient (Including Medicare Part A), Replacement of Prior Claim | 118 | Hospital, Inpatient (Including Medicare Part A), Void, Cancel of Prior Claim | 11F | Hospital, Inpatient (Including Medicare Part A), Beneficiary Initiated Adjustment Claim | 11G | Hospital, Inpatient (Including Medicare Part A), Void, CWF Initiated Adjustment Claim | 11H | Hospital, Inpatient (Including Medicare Part A), HCFA Initiated Adjustment Claim | 11I | Hospital, Inpatient (Including Medicare Part A), Cancel of Prior Claim, Intermediary | Adjustment Claim | Accept | 11J | Hospital, Inpatient (Including Medicare Part A), Initiated Adjustment Claim | Hospital, Inpatient (Including Medicare Part A), OIG Initiated Adjustment Claim | 11M | Hospital, Inpatient (Including Medicare Part A), MSP Initiated Adjustment |

Patient Status Codes

CODE | DESCRIPTION | 01 | DISCHARGED TO HOME OR SELF CARE (ROUTINE DISCHARGE). | 02 | DISCHARGED/TRANSFERRED TO ANOTHER SHORT TERM HOSPITAL FOR INPATIENT CARE. | 03 | DISCHARGED/TRANSFERRED TO SKILLED NURSING FACILITY (SNF). | 04 | DISCHARGED/TRANSFERRED TO INTERMEDIATE CARE FACILITY (ICF). | 05 | DISCHARGED/TRANSFERRED TO A DESIGNATED CANCER CENTER OR CHILDREN’S HOSPITAL. | 06 | DISCHARGED/TRANSFERRED TO HOME UNDER CARE OR ORGANIZED HOME HEALTH SERVICE ORGANIZATION. | 07 | LEFT AGAINST MEDICAL ADVICE OR DISCONTINUED CARE. | 08 | DISCHARGED/TRANSFERRED TO HOME UNDER CARE OF A HOME IV PROVIDER. | 09** | ADMITTED AS AN INPATIENT TO THIS HOSPITAL (FOR USE ONLY ON MEDICARE OUTPATIENT CLAIMS). | 10 | DISCHARGED – NO LONGER COVERED BY MEDICAID. | 11 | DISCHARGED – TRANSFERRED TO ANOTHER CATEGORY OF SERVICE. | 12-19 | DISCHARGE TO BE DEFINED AT STATE LEVEL. | 20 | EXPIRED. | 21 | EXPIRED – NOT COVERED BY MEDICAID ON DATE OF DEATH. | 22-29 | EXPIRED – TO BE DEFINED AT STATE LEVEL. | 30 | STILL PATIENT OR EXPECTED TO RETURN FOR OUTPATIENT SERVICES. | | |

DDE Access/ Menu

MAIN MENU | 01 | INQUIRIES | 02 | CLAIMS/ATTACHMENTS | 03 | CLAIMS CORRECTIONS | 04 | ONLINE REPORTS VIEW |

01 – INQUIRIES | 10 | BENEFICIARY/CWF | 11 | DRG (PRICER/GROUPER) | 12 | CLAIMS | 13 | REVENUE CODES | 14 | HCPC CODES | 15 | DX/PROC CODES | 16 | ADJUSTMENT REASON CODES | 17 | REASON CODES | 19 | ZIP CODE FILE | 56 | CLAIM COUNT SUMMARY | 68 | ANSI REASON CODES | FI | CHECK HISTORY |

Sign & Sign Off Procedures
Signing On

Accessing DDE
From the sign-on screen, <ENTER> the following:

1. Type your User Identification (ID)
2. Tab to the PASSWORD field and type your password

New Password =========> Verify New Password ==>
PF 3=End
3. Press <ENTER>, the SIGN-ON IS COMPLETE screen will appear.

4. Type “FSS0” at the cursor.

5. Press <ENTER>. The FISS MAIN MENU will appear.

DDE MAIN MENU

01 INQUIRIES

02 CLAIMS/ATTACHMENTS

03 CLAIMS CORRECTION

04 ONLINE REPORTS

ENTER MENU SELECTION:

PLEASE ENTER DATA - OR PRESS PF3 TO EXIT

6. Press <ENTER>, the INQUIRY MENU will appear.

DDE INQUIRY MENU

BENEFICIARY/CWF | 10 | ZIP CODE FILE | 19 | DRG (PRICER/GROUPER) | 11 | OSC REPOSITORY INQUIRY | 1A | CLAIM SUMMARY | 12 | CLAIM COUNT SUMMARY | 56 | REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 | HCPC CODES | 14 | ANSI REASON CODES | 68 | DX/PROC CODES | 15 | CHECK HISTORY | FI | ADJUSTMENT REASON CODES | 16 | | | REASON CODES | 17 | | |
ENTER MENU SELECTION: F3 to Exit