ubwatch process central control, llc. ubwatch process submits claim into ubwatch billing reviews...

UBWATCH PROCESS

CENTRAL CONTROL, LLC

UBWatch Process

Key Roles

Corporate Coding Specialist/Gatekeeper

Accounts Receivables/Billing

Corporate MDS Director

Corporate Coding Specialist/Gatekeeper

Approves all therapy diagnosis codesCreation of Diagnosis sheets

Primary sheets Therapy sheets

Coding Audits MCR A, MCR B, Medicaid, Private Pay, Outpatient, etc. Nurse Practitioner visits

Triple Check Medicare Cards, H&P, Benefit Day, Treatment Grids, Weekly

Therapy notes, 700/701Runs exceptionsCorrects coding issues for reloadingManages outstanding claims in UBWatch

Accounts Receivable

Reviews entries made into census line from PCC that feed UB04 Basic demographics; payer setup; qualifying stay entry; required

occurrence codes and span dates; leave days documented correctly; ancillary charges are present on claim

Reviews signed admission documents Assignment of benefits; Medicare Secondary Payer Questionnaire;

Covered/Non Covered Benefits for Skilled care; ABNResponsible for post review of any denied claims

Identify any denied claims and alert Triple Check team for further review

Works closely with MDS to assure COT RUGs transfer to claim correctly

Corporate MDS Director

Audit sample MDS’ monthly for coding accuracy and RUG support. Use MDS calendar to assist with capturing OBRA assessments that are due

Audit sample of certifications for skilled residents to assure completion and timely signature of MD

Audit skilled residents daily for setting ARDs of assessments in the system; to assure it is in timeframe which CMS allows to avoid default rates.

Review case mix weekly and at snapshot end Work closely with coder; monitoring diagnosis for skilled

residents upon admit, to assure the diagnosis relates to qualifying hospital stay.

Review preliminary Case mix for each facility and for any delinquent assessments noted on report, assist with correction as needed prior to final Case mix report

Triple Check

Performed monthly at a corporate level Corporate Coding Specialist Corporate MDS Director Accounts Receivable Corporate Quality Coordinator Chief Financial Officer

Performed on a select number of Medicare A residents

Triple Check

Admission Information Verify Medicare number Verify primary PCC diagnosis sheet Verify ICD-9 codes correspond to diagnosis Verify most current admission date Hospital qualifying stay dates (hospital

discharge/transfer summary related to 3 day qualifying stay requirements)

Verify that resident has benefit days available per the CWF

Triple Check

Physician’s Orders Physician order to admit to skilled service Initial orders for evaluation & treatment for therapy

or other skilled service Complete clarification order Physician orders signed/updated every 30 days Order to discharge off Medicare/skilled service

Triple Check

Physician Certifications/Re-certifications Initial certification within 72 hours of admit (Complete

information/sign/date/timely Re-certification on or before Day 14 Re-certification on or before Day 30 Additional recertification complete

Triple Check

Skilled Nursing Documentation Verify charting done at least once per 24 hours Related to skilled service being provided Related to skilled ICD-9 Charting supports therapy services Documentation supports late loss ADL’s in MDS

Section G

Triple Check

ADL’s ADL’s are accurate MDS accurately coded ADL’s are accurately coded Documentation support ADL’s ADL’s are support by medical record

Triple Check

Therapy Documentation Daily treatment and therapy notes are current Number of minutes, units, HCPCS, modifiers are

accurate for billing Therapy evaluation complete with MD sign/date Plan of care update or 701 complete with MD

signature Admission ICD-9 code matches 700 form

Triple Check

MDS ARD within window for MDS cycle Reason for assessment is correct Other RUG related MDS items are supported by

medical record, including accuracy of therapy minutes/days

MDS locked, transmitted, and accepted

Triple Check

ABN Proper notifications at the time of admission Proper notice of continued stay or discontinuation

of service Copy of signed notices readily available Most current version of form being used Form not altered as per CMS regulations

Triple Check

Payer Source Assignment of benefits form is signed Medicare secondary payer questionnaire completed

Triple Check

UB-04 Verify admission date Verify discharge/transfer date Verify discharge status code Confirm admission dx Confirm primary dx

Top 10 UBWatch Exceptions

1. Therapies on UB inconsistent with corresponding MDS

Correction: Review DOS; check therapy software to assure therapy was received compared to what is coded on MDS

Top 10 UBWatch Exceptions

2. Other diagnoses in the claim do not seem to be supported by the MDSs found

Correction: Review DOS, check physician orders, care plan, chart and if diagnosis is active, request MDS to review and code active diagnosis on MDS; if diagnosis is not active, will remove from diagnosis sheet

Top 10 UBWatch Exceptions

3. Admitting diagnosis in the claim do not seem to be supported by the corresponding MDSs found

Correction: Review admit diagnosis and if it relates to care. Suggest MDS review and if pertinent to care with documentation support, suggest adding to MDS.

Top 10 UBWatch Exceptions

4. Claim type and dates inconsistent with corresponding MDSs

Correction: Review DOS to assure MDS covers time frame

Top 10 UBWatch Exceptions

5. Admission date is greater than 30 days from qualifying hospital stay

Correction: Verify that we have code 78, on the occurrence span code, with correct dates on claim. Also, verify that we have condition code 57 on claim.

Top 10 UBWatch Exceptions

6. No corresponding MDSs for claim

Correction: Review DOS and assure MDS covers time frame in question. Sometimes this is noted when a discharge occurs right after an assessment was done. Validate that an assessment was done to cover DOS prior to discharge

Top 10 UBWatch Exceptions

7. Incorrect principal diagnosis coding for therapy claim

Correction: Add/Remove therapy codes from principal diagnosis OR add penny charges to the claim

Top 10 UBWatch Exceptions

8. Claim type and date inconsistent with other claims

Correction: Reload previous claims. Some claims are stopping in suspense and were never cleared; therefore, looking for original claim

Top 10 UBWatch Exceptions

9. Therapy services not justified by diagnosis on Part B claim

Correction: Check LCD for diagnosis codes that justify CPTs billed

Local Coverage Determination (LCD)

Medicare contractors can create guidelines for certain services to determine if they are reasonable and necessary, and covered as a Medicare benefit.

Top 10 UBWatch Exceptions

10.No qualifying hospital stay before admission

Correction: Add the qualifying stay which was omitted on Census line