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Form locators 66 to 75 (Figure 14.1) play an important role on the UB-04 claim form, as these fields are used to report the clinical information related to the claim, including diagnosis and procedure codes. Most of the computer reviews (edits) performed by Medicare with the Outpatient Code Editor (OCE) and the Medicare Code Editor (MCE) check the accuracy of the codes reported in these fields. A logical connection must exist between the reported diagnoses and the procedures used to treat the problems associated with the diagnoses. Without this connection, the claim will be rejected or singled out for closer examination and correction.
The procedures performed must also be considered medically necessary, given the diagnosis reported; if they are not, third-party payers will not pay for the charges. The present on admission (POA) indicator that is reported with diagnosis codes on the UB-04 also plays an important role in this section of the claim, as it can influence the final payment received for the inpatient admission. Patient account specialists must work closely with coders in the health information management (HIM) department to verify the accuracy and completeness of the diagnosis codes, POA indicators, and procedure codes contained in this section of the claim. Generally, the HIM staff members are responsible for assigning these codes based on the most up-to-date coding rules, the type of claim, and the patient's medical record and discharge summary. Learning ObjectivesUnderstand how to indicate in FL 66 (Diagnosis and Procedure Code Qualifier) which version of the ICD is being used on the current claim.Understand the importance of reporting an ICD-9-CM diagnosis code in FL 67 (Principal Diagnosis Code and Present on Admission Indicator) to describe the patient's principal diagnosis as well as whether the condition associated with it was present on admission (POA) or acquired during the hospital stay. Discuss the difference between the principal diagnosis, reported in FL 67, and secondary or other diagnoses, reported in FLs 67 A-Q (Other Diagnosis Codes and POA Indicators). Explain the use of FL 69 (Admitting Diagnosis Code) to describe the patient's diagnosis at the time of inpatient admission or the use of FL 70a-c (Patient's Reason for Visit) to describe the patient's reason for an unscheduled visit at the time of outpatient registration. Explain the use of FL 71 (Prospective Payment System Code) and FL 72 (External Cause of Injury Code). Understand when to report an ICD-9-CM code and corresponding date in FL 74 (Principal Procedure Code and Date) to describe the principal procedure performed during the period covered by the bill. Discuss the use of FLs 74a-e (Other Procedure Codes and Dates) in reporting other significant procedures performed during the period covered by the bill. |
