Change Request Detail
No.
1130
Date
1/28/2011
Submitter
Type of Request
Institutional Claim (UB-92)
Status
DSMO Process Completed
Business Reason
Payers need to know the dates that a patient received different levels of care for claims that include multiple inpatient room and board (R&B) revenue codes that distinguish the levels of care.  Examples of revenue codes that have different levels of care are: nursery levels 1-4; ICU; coronary care; rehab; and subacute care.  

An example of a claim with different levels of care and potentially different contracted rates by date of service follows:

A member has an inpatient claim for a stay from 12/21/2010 to 01/15/2011. 

The provider is contracted with different per diem rates based on the room and board revenue codes. 

The member cost share is based on the allowed amount for the room and board revenue codes

The member has a calendar year deductible. 

Member was in revenue code 121 from 12/21-12/27 for 7 days;

Then the member was in revenue code 214 from 12/28-01/01 for 5 days;

Then the member was in revenue code 202 from 01/02-01/10 for 9 days, and

Then the member was back to revenue code 121 for the remaining 4 days (no room and board charge for the discharge day). 

This is the order that the services on the claim are received because NUBC instructions indicate that the revenue codes should be sent in ascending numerical order:

Revenue code = 121   Units = 7 (121 would only be separated to 2 lines if there was a different daily rate, could get 121 with 11 units on one line if the daily rate was the same)

Revenue code = 121   Units = 4

Revenue code = 202   Units = 9

Revenue code = 214   Units = 5

The following impacts may result by not knowing the dates the patient received each service:

a)  The new calendar year deductible will not be taken on the per diem rates applicable to the days in the new calendar year based on actual incurred dates. 

b) The member's out of pocket limit for the previous calendar year will not accumulate based on the member cost share of the per diem rates applicable to the previous calendar year based on actual incurred dates.

c)  If a hospital contract has a provision that involves payment of room and board revenue code per diems up to a certain point during the confinement and days after fall under another type of reimbursement arrangement, we will not be able to determine the per diem rates because the actual incurred dates for the room an board revenue codes are not submitted.

d)  If utilization review results in days authorized at particular multiple levels of care (ICU vs. Medical/surgical, or NICU versus nursery level 2), comparison to room and board actual incurred dates is necessary.


From the above example you can see that the current method of submission does not definitively provide the dates that the patient received each level of care.  The claim level dates of service (statement from and through date) are included in the current NUBC instructions and indicate that the revenue codes should be sent in ascending numerical order.  The 837 institutional TR3 does not permit dates of service to be sent at the revenue code level for inpatient services. This makes it impossible to determine on which dates the patient was receiving each level of service. 


Suggestion
In order to rectify this we are requesting that the next version of the 837 Institutional format TR3 and the NUBC UB04 instructions be changed to require that line level service dates be sent when multiple R&B revenue codes that represent different levels of care are on a claim.   
DSMO Category
D
Recommendation
Disapprove. Including line item dates of service on inpatient claims would represent a major system change for providers that isn’t justified for a single payer/single scenario issue.  The DSMO recommends that the payer work it out with the provider on a case by case basis, rather than change the reporting methodology that is typically done today.
 
Payers could use one of the following methods to obtain the information they need:
•  Check the units that are billed on each line item revenue code
•  Use the information the payer already has in their system from authorization codes that payers require for inpatient admission or continued stay utilization management reviews
•  Request an itemized bill
•  Request a copy of the medical record

Appeal Recommendation