Inpatient and Outpatient Hospital Claim Edits

  • June 4, 2020

    This summer, Premera is implementing additional outpatient and inpatient UB-04 correct coding edits. Many of these edits are currently applied on professional claims.

    Starting with claims processed on or after July 6, 2020, the following outpatient and inpatient UB-04 correct coding edits will be implemented:

    Outpatient

    • Trauma response critical care code G0390 – Trauma response team associated with hospital critical care service
      • On a UB-04 claim form, this code is submitted with revenue code 068X-trauma response to indicate a trauma team was activated.
      • Code G0390 must be reported on the same date of service as a critical care visit, billed with CPT code 99291-critical care, evaluation and management of the critically ill or critically injured patient.
      • Code G0390 is only billed by trauma centers/hospitals licensed as designated trauma centers.
    • Add-on codes must be billed with an appropriate primary code
      • Add-on codes represent additional services rendered in conjunction with a primary service.
      • As identified in the CPT codebook, add-on codes, designated with a plus sign (+) must be billed with an appropriate primary code as noted in the parenthetical note listed after the add-on code.
    • Age of patient is not within the age band/age limits of the billed procedure code(s) or diagnosis code(s)
      • For example:
        • ICD-10-CM code Z00.111 – Health examination for newborn 8 to 28 days old and the patient age is 5 years old.
        • 99385 – Preventive medicine examination, 18-39 years and the patient age is 47 years old.
    • New patient E&M code (99201-99205, 99381-99387)
      • A new E&M office visit code is submitted within 3 years of a previously submitted established E&M office visit code submitted by the same facility within the past 3 years.
    • Occurrence span codes (fields 31-36)
      • Occurrence codes billed on the facility claim are invalid or exceed the “from-through” dates on the Outpatient facility claim (Field 6).

    Inpatient:

    • An admission diagnosis code is required (field 69)
    • Incomplete other diagnosis codes (fields 67, 67A-67Q)
      • All submitted diagnosis codes must represent the highest number of digits required for the diagnosis code per ICD-10 CM coding guidelines.
      • The highest level of specificity may be 4-7 digits total where applicable after the decimal point of the diagnosis code.
    • Invalid other ICD-10 PCS procedure code dates
      • Per ICD-10 PCS coding guidelines, all ICD-10 PCS procedure code must have 7 digits to be a valid code (fields 74.a through 74.e).
      • Dates for the PCS procedure codes must fall within the “from-through” dates in field 6.
    • Secondary diagnosis code is the same as the primary diagnosis code
      • When the secondary diagnosis is the same as the primary diagnosis, it will be considered a duplicate, which may impact the selection of a higher severity DRG.
    • Age of patient is not within the age band/age limits of the admitting diagnosis code
      • For example: ICD-10-CM code Z00.111. Health examination for newborn 8 to 28 days old and the age of the patient is 5 years old.
    • Delivery claim (vaginal or C-section) submitted without outcome of the delivery
      • Per ICD-10 CM coding guidelines, an additional Diagnosis code is required to indicate the outcome of the delivery (Newborn).
      • Outcome of delivery diagnosis codes are found in section Z37 of the ICD-10 CM codebook.
    • Invalid/incorrect discharge code (field 17)
      • An appropriate discharge status code is required to identify the status of the patient upon discharge (such as, discharged to home, patient died, discharged to SNF; patient transferred)
    • ICD-10 PCS procedure code 5A1955Z
      • This respiratory ventilator code is valid for an inpatient admit that is greater than 96 consecutive hours/4 days, per PCS coding criteria.
      • This procedure code impacts the selection of the DRG.

    These edits are all sourced to one or more of the following industry sources:

    • National Uniform Billing Committee (NUBC)
    • Official UB-04 Data Specification Manual
    • Medicare Claims Processing Manual, Publication 100-04, Chapters 25 and 26
    • CPT and HCPCS Coding Guidelines
    • ICD-10 CM and PCS Coding Guidelines

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