During the pre-billing chart audit, review the following:
a. The 485, all pertinent verbal orders, and the F2F (if applicable), for the billing period, has been returned and signed by the Physician.
b. All visits/supplies have been entered and keyed using the correct job codes/HCPCS codes.
c. All charges are under the correct payer source, especially if the patient has more than one payer source listed.
d. The visits/frequency/supplies match what’s on the Plan of Care (or verify by using any supplemental orders).
e. Within the referral, especially with new admits, make sure you have the physician NPI Number and taxonomy code.
f. If the patient has Carolina Access, make sure the Carolina Access number has been entered in the referral. KB article: Carolina Access Number
g. If the patient’s Carolina Access Provider is different from the patient’s primary physician, follow steps to Cross-Reference NPI. KB article: Cross-Reference NC Access # to NPI
Medicaid Billing: If the patient is Medicaid primary, but patient also has Medicare, verify that the proper condition codes are listed in the referral. KB article: Condition Codes
Medicare Billing: If the patient was transferred from another HHA, directly prior to your admission, verify the appropriate condition code (47) is listed under Referral > Payers > Extra Billing Info. It is important that the Intake Dept provides this information to the billing staff. Depending on your agency roles, the Intake Dept or the Billing Staff will need to manually enter this code. If this code is required, but not provided on the NOA, the NOA will deny and this may cause payment penalties, due to late submission of the NOA.
Properly Discharging the Patient: It is always important to mark the patient as discharged, in a timely manner. Specifically for Medicare/PPS billing, if the patient is not marked as discharged, invalid episodes will continue to generate for the patient. If the patient is not properly discharged, it could also cause EOE claims to create with the incorrect end date.
Other Troubleshooting Tips for Claim Rejections
Check the Following:
a. View the Response/Rejection file. For tips, view the following article Reading 999 and 277 Response Files
b. Check the Referral for missing information. I.E. county code, sex, payer information. A very helpful report to track missing information in the referral is 07.02 Verify Sex/Race/DOB etc. Report 07.01 Verify Admit/Discharge Date will also pull up all patients who do not have a county code listed in the referral.
c. Zip Code: There needs to be a complete 9-digit ZIP code for the billing provider and service facility location.
d. Billing Provider Address: This needs to be a physical address. Version 5010 does not allow for use of a PO Box address for either professional or institutional claim formats.
e. Visits – Make sure all visits are at least 8 minutes or greater. Otherwise, the visit will show as 0 units on the electronic claim. A very helpful report to track visits under 8 minutes long is 02.34 Match Charges To Active Patients.