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Inpatient and Outpatient Facility Claims Filing
Please use the following guidelines for filing inpatient and outpatient claims:
- Inpatient Claims with both covered and non-covered days:
- When a claim has covered and non-covered days, facilities must report Value Code 80, Covered Days, and Value Code 81, Non-Covered Days.
- Value Code 31, Patient Liability Amount, should be used to report any charges for which the member is responsible. Room and board charges associated with a non-covered day should not be included in Value Code 31 without providing the member prior notice of the non-covered days.
- It is appropriate to bill ancillary charges as outpatient claims when the days are non-covered. These outpatient claims should be submitted as covered charges on a Type of Bill, 12x.
- All claims are subject to filing valid International Classification of Diseases, Ninth Revision,(ICD-9) diagnosis codes. Refer to www.icd9coding.com to verify if the diagnosis code is valid.
- Outpatient claims should be filed using the appropriate Physicians' Current Procedural Terminology/Healthcare Common Procedure Terminology Coding System (CPT/HCPCS) code in Form Locator (FL) 44 of the UB-04 claim form. For electronic transmissions, use the correct CPT/HCPCS code in the 2300 loop SV202 of the 837 claim transaction. If the facility is billing for outpatient surgery, a surgical CPT/HCPCS code is required in Form Locator (FL) 80 of the UB-04 claim form.
- Inpatient claims should continue to be filed with the appropriate ICD-9 procedure codes in Form Locator (FL) 80 of the UB-04 claim form. If an ICD-9 procedure code is not applicable, Form Locator (FL) 80 may be left blank. For electronic transmissions, use the correct ICD-9 procedure code in the 2400 loop HI01 of the 837 claim transaction. CPT/HCPCS codes are not required on inpatient claims and should not be filed for inpatient claims.
- Federal Employee Program (FEP) Member Observation Claims
New FEP member observation claims went into effect on April 14, 2012. This change applies to revenue codes 760 and 762. File the number of hours in observation as the number of services on the claim when one of these revenue codes is present. Make sure to bill a separate line for observation charges for each date of service along with the applicable hours/units.
Contact your Provider Network Services Representative if you have any questions.