UB-04 New and Improved

Vol. 17 •Issue 10 • Page 14
UB-04 New and Improved

The updated UB-04 form is set to prepare for NPI, ICD-10 and better data reporting.

Although the upcoming May 23 deadline requiring use of the new UB-04 form only affects the 2 percent of claims submitted on paper, the same changes will affect electronic claims sooner or later.

With fields available to report national provider identifier (NPI), present on admission (POA) conditions and ICD-CM-10 codes, the UB-04 “is paving the way for the future of coding and quality reporting,” said Lou Ann Wiedemann, MS, RHIA, director of clinical coding and reimbursement at the American Health Information Management Association (AHIMA).

The National Uniform Billing Committee (NUBC) “did a good job listening to the different groups about how the UB form should be updated,” said Linda Corley, MBA, CPC, compliance officer for the revenue cycle solutions division of Perot Systems. One advantage of the new form is that it makes the paper claims form similar to the 827I, the electronic claims form hospitals use. That will better align information required by payers, she explained.

Why Now?

The timing of this new form is strategic, said Seana N. Long, RHIA, CCS, director of coding services for Precyse Solutions. The Centers for Medicare and Medicaid Services (CMS) has been talking about one claim form for both providers and professionals and the UB-04 seems to be going toward that, she said. When you add in the HCFA 1500, there was a lot of crossover work being done in claims analysis. Eliminating the HCFA 1500 may be part of the administrative simplification regulations of HIPAA and the Deficit Reduction Act, she noted.

The old UB-92 had no place for the DRG, but the new form captures both CPT codes and DRGs. This is very telling, Long said, and may indicate plans to eliminate the HCFA 1500 and/or move to one claim form. “CMS put a lot of thought into the new UB,” she said.

The time span between the UB-92 and UB-04 was a good amount of time, stated Corley. The NUBC has said it will be another 10 years before they would actively work to update the UB-04. Besides, she said, providers were busy implementing HIPAA regulations in 2002 and 2003.

Is ICD-10 On the Way?

The NUBC said that the main reason for revising the UB-92 was to provide specific form locators that would accommodate the lengthier ICD-10 codes, noted Corley.

AHIMA leaders and other industry movers and shakers have been pushing CMS to plan for ICD-10 implementation for years now. “There is more talk about ICD-10. There is a much greater industry understanding of ICD-10 and why we need it,” Wiedemann indicated.

The UB-04 provides for both nine- and 10-digit codes. The fields for admitting diagnosis, procedure codes and more have been increased to allow for electronic capture of ICD-10 codes, explained Laurie Johnson, RHIA, CCS, senior HIM consultant for Ingenix. “We’re all anxious to move to 10. HIM professionals can start to think that 10 is almost here when they start seeing changes to the billing format being provided.”

Why the Confusion?

A simple scan of online HIM discussion boards indicates that many are confused about the UB-04, with questions about the NPI and POA indicators topping the list. At this point, facilities do not have to report POA conditions. At press time, the industry was waiting for CMS to release guidelines on reporting POA conditions—due any day.

Some states, however, currently require POA reporting. “Anybody who is reporting POA is doing so because it is part of their state reporting requirements,” explained Wiedemann. Some states have been collecting a version for some time but they are fairly different from the national guidelines expected from CMS, said Corley. For example, California requires condition POA reporting, regulations that were developed in 1996.

The goal is to identify what conditions are present on admission. That will allow for more thorough reviews of patients’ medical conditions, said Corley.

With inconsistencies among different providers’ documentation, it can be difficult to determine which conditions were in fact present on admission, Wiedemann said. Preparing for POA reporting will require a focus on documentation and ensuring that there is adequate documentation to establish which conditions were POA.

People are alarmed because of the current state of documentation, Wiedemann expressed. “There are some facilities that do very well with documentation and some that do not. If a coder is at one of the facilities that doesn’t do very well, it’s easy to see why it would be a cause for concern.” Coders are under pressure to maintain productivity and get bills out the door. “Requesting additional clarifying documentation will only prolong the process,” she noted.

Another cause for concern is that POA reporting was identified in the inpatient prospective payment system proposed rule posted in early April as being implemented on Oct. 1 of this year. Currently, there is nowhere to capture that information, said Johnson. And, that doesn’t allow much time to educate coders and medical staff on proper documentation and other changes that need to occur for accurate POA reporting.

Aside from POA reporting, the new UB has fields for up to three reasons for an outpatient visit. “Many times an outpatient has three different points of service for three different disease processes,” explained Johnson. “In the past, there was no easy way to identify that other than with secondary diagnoses.” These new fields will help with the medical necessity, she said.

The UB-04 also allows for reporting of the NPI for those who requested a consultation. This will probably be a big change for a lot of providers, noted Long, because “never before did facilities have the responsibility or obligation to put down the referring physician for a consultation.” Providers will have to determine how to best collect that information.

No Crackdown on NPI

Just last month, CMS announced a contingency plan for those who will not be able to meet the NPI deadline. The move indicates that the agency “recognizes that there’s a lot of confusion,” said Johnson.

Corley believes that CMS has provided very clear instructions regarding NPIs and the contingency plan “indicates that a vocal segment has found the process to take longer than they initially thought it would.” The process of obtaining an NPI has gone smoothly for everyone she’s heard about.

But confusion exists for enough people, apparently. Not everyone will meet the deadline because “there is a lack of overall education and a lack of understanding on the industry’s part about who actually needs [an NPI] and who doesn’t,” Wiedemann stressed. Health care organizations and covered entities under the HIPAA regulations require an NPI, but there are subparts that also should be assigned an NPI. CMS has maintained the open-door policy it introduced several years ago, Wiedemann said, and has been encouraging e-mails and phone calls so they can address questions.

CMS is saying not to stop the process of getting an NPI, but that it will not penalize those who don’t have one by the May 23 deadline, explained Johnson. An NPI is “a good thing to have,” she said, because it will allow for better data tracking by each individual provider.

Prepare and Plan

Hospitals have been diligently getting ready for NPI and the UB-04, said Corley. In creating a matrix of state preparedness, she found that about 65 percent to 70 percent of Medicaid fiscal intermediaries will be ready for the May 23 deadline. The rest of the states will still be updating their systems.

Corley recommends that you ensure that your payers are ready. Ask them directly if they are ready or what they are doing to get ready. “If you don’t see indication that your vendor has created a POA flag or field, you might want to ask about that,” encouraged Johnson. If the fields for diagnostic and procedure codes haven’t been enlarged, ask about plans to accommodate that. Assessing how your vendors are doing with this round of changes will give you a better idea of what you’ll face when changes to electronic claims are implemented, she said.

In house, consider any interfaces your facility uses, said Johnson. Any that might use information from the UB-92 need to be updated.

Work with your clearinghouse and in-house IT department to ensure that information as entered is going to process through to the proper form locator, Corley recommended. Long suggested that you simulate populating the UB-04 and see what processes you need to tweak.

Understand the paper changes and make sure coders are coding for all of the reasons for the visit, stressed Johnson.

For the POA guidelines, “know that it’s coming,” said Wiedemann. “You need to have this on your radar so it doesn’t catch anybody by surprise. Discussions with your coding and medical staff need to begin.” Once Medicare issues the guidance and requirements, a lot more education and information will be available.

Beth Walsh is a writer/editor focusing on HIT issues.

UB-04 Fact Sheet Now Available

The “Implementation of the UB-04” fact sheet is now available in downloadable format from the Medicare Learning Network (MLN). This fact sheet reviews the new UB-04 paper claim form, which is only accepted from institutional providers excluded from the mandatory electronic claims submission. It includes background information, the transition period and a crosswalk. To read, download or print, select the title of the fact sheet from www.cms.hhs.gov/MLNProducts/MPUB/list.asp on the MLN Publications Web page.