Healthcare Information Technology

Series 2 : Healthcare Claim Pricing : What is Type of Bill ( TOB) and why it matters ?

2015-10-25T17:53:00.003-05:00

http://urtesting.blogspot.com/

As we discussed Place of Service(POS) is required for all Professional claims similarly Type of Bill ( TOB) is required for all Institutional claims ( 837I).

TOB means what types of facility and what care was provided to the patient.

All claims need to billed with correct Types of bill otherwise claims will be denied.

Based on Types of bill we can say claim is Inpatient or Outpatient.

Claims Pricing is hugely varied between inpatient and outpatient setting so Types of Bill has many implication for reimbursement. Some of the services can only be performed in Inpatient facility but if claimed is billed with outpatient facility then it will be denied and vice versa.

e.g Ambulatory surgical center ( ASC) claims are outpatient is nature and must be billed with correct Type of bill.(083) means they need to bill 83X series TOB.

e.g SNF( skilled nursing facility ) claims are inpatient in nature and must be billed with correct type of bill.(02X-02X) where X anything between 1 to 9 . Means they need to bill 2X series TOB.( anything between 021-029) *

* Please see below how Types of Bill is defined and its structure( logic ).

Example :

Bill Types	Description
011X	Hospital Inpatient (Part A)
012X	Hospital Inpatient Part B
013X	Hospital Outpatient
014X	Hospital Other Part B
018X	Hospital Swing Bed
021X	SNF Inpatient
022X	SNF Inpatient Part B
023X	SNF Outpatient
028X	SNF Swing Bed
032X	Home Health
033X	Home Health
034X	Home Health (Part B Only)
041X	Religious Nonmedical Health Care Institutions
071X	Clinical Rural Health
072X	Clinic ESRD
073X	Federally Qualified Health Centers
074X	Clinic OPT
075X	Clinic CORF
076X	Community Mental Health Centers
081X	Nonhospital based hospice
082X	Hospital based hospice
083X	Hospital Outpatient (ASC)
085X	Critical Access Hospital

Structure of TOB :

Type of bill is a 4 character starting with leading Zero like 011X ( Inpatient hospital care.)

First character - leading Zero - 0 ( claims processing engine will ignore this)

Second Character - Facility Type

Third Character - Type of Care

Fourth Claims - Claims frequency

Description and Values of Second Character - Facility Type

Second Character	Description
1	Hospital
2	Skilled Nursing
3	Home Health (Includes Home Health PPS claims, for which CMS determines whether the services are paid from the Part A Trust Fund or the Part B Trust Fund.)
4	Religious Nonmedical (Hospital)
5	Reserved for national assignment (discontinued effective 10/1/05).
6	Intermediate Care
7	Clinic or Hospital Based Renal Dialysis Facility (requires special information in second digit below).
8	Special facility or hospital ASC surgery (requires special information in second digit below).
9	Reserved for national assignment (discontinued effective 10/1/05).

Description and Values of Third Character - Type of Care

-->

Third Character	All Facility except Clinic and other special facility	For Clinic	For Special Facility
1	Inpatient (Part A)	Rural Health Clinic (RHC)	Hospice (Nonhospital Based)
2	Inpatient (Part B) - (For HHA non PPS claims, Includes HHA visits under a Part B plan of treatment, for HHA PPS claims, indicates a Request for Anticipated Payment - RAP.) Note: For HHA PPS claims, CMS determines from which Trust Fund payment is made. Therefore, there is no need to indicate Part A or Part B on the bill.	Hospital Based or Independent Renal Dialysis Facility	Hospice (Hospital Based)
3	Outpatient (For non-PPS HHAs, includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment). For home health agencies paid under PPS, CMS determines from which Trust Fund, Part A or Part B. Therefore, there is no need to indicate Part A or Part B on the bill.	Free Standing Provider-Based Federally Qualified Health Center (FQHC)	Ambulatory Surgical Center Services to Hospital Outpatients
4	Other (Part B) - Includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for “nonpatients,” and referenced diagnostic services. For HHAs under PPS, indicates an osteoporosis claim. NOTE: 24X is discontinued effective 10/1/05.	Other Rehabilitation Facility (ORF)	Free Standing Birthing Center
5	Intermediate Care - Level I	Comprehensive Outpatient Rehabilitation Facility (CORF)	Critical Access Hospital
6	Intermediate Care - Level II	Community Mental Health Center (CMHC)	Reserved for National Assignment
7	Reserved for national assignment (discontinued effective 10/1/05).	Reserved for National Assignment	Reserved for National Assignment
8	Swing Bed (may be used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement).	Reserved for National Assignment	Reserved for National Assignment
9	Reserved for National Assignment	OTHER	OTHER

Fourth Character : Claims Frequency

Frequency Code	Description
0	Non-payment/zero claims
1	Admit thru discharge claim
2	Interim - first claim
3	Interim - continuing claim (not valid for PPS claims)
4	Interim - last claim (not valid for PPS claims)
5	Late charge(s) only claim
6	Adjustment of prior claim
7	Replacement of prior claim (eff 10/93) provider debit
8	Void/cancel prior claim (eff 10/93) provider cancel
9	Final claim -- used in an HH PPS episode to indicate the claim should be processed like debit/credit adjustment to RAP (initial claim) (eff. 10/00)
A	Admission election notice - used when hospice or Religious Nonmedical Health Care Institution is submitting the HCFA-1450 as an admission notice - hospice NOE only
B	Hospice/Medicare Coordinated Care Demonstration/RNCHI - Termination/Revocation Notice - hospice NOE only (eff 9/93)
C	Hospice change of provider notice - hospice NOE only (eff 9/93)
D	Hospice/Medicare Coordinated Care Demonstration/RNHCI - void/cancel - hospice NOE only (eff 9/93)
E	Hospice change of ownership - hospice NOE only (eff 1/97)
F	Beneficiary initiated adjustment claim (eff 10/93)
G	CWF generated adjustment claim (eff 10/93)
H	CMS generated adjustment claim (eff 10/93)
I	Misc adjustment claim (other than PRO or provider) - used to identify a debit adjustment initiated by CMS or an intermediary (other than QIO or Provider) - eff 10/93, used to identify intermediary initiated adjustment only
J	Other adjustment request (eff 10/93)
K	OIG initiated adjustment (eff 10/93)
M	MSP adjustment (eff 10/93)
P	Adjustment required by Quality Improvement Organization (QIO) -- formerly Peer Review Organization (PRO)
X	Special adjustment processing - used for QA editing (eff 8/92)
Z	Hospital Encounter Data alternate submission (TOB '11Z') used for MCO enrollee hospital discharges 7/1/97-12/31/98; not stored in NCH. Exception: Problem in startup months may have resulted in this abbreviated UB-92 being erroneously stored in NCH.

Please see the complete list with all the 4 character together.

Bill Types	Description
011X	Hospital Inpatient (Part A)
012X	Hospital Inpatient Part B
013X	Hospital Outpatient
014X	Hospital Other Part B
018X	Hospital Swing Bed
021X	SNF Inpatient
022X	SNF Inpatient Part B
023X	SNF Outpatient
028X	SNF Swing Bed
032X	Home Health
033X	Home Health
034X	Home Health (Part B Only)
041X	Religious Nonmedical Health Care Institutions
071X	Clinical Rural Health
072X	Clinic ESRD
073X	Federally Qualified Health Centers
074X	Clinic OPT
075X	Clinic CORF
076X	Community Mental Health Centers
081X	Nonhospital based hospice
082X	Hospital based hospice
083X	Hospital Outpatient (ASC)
085X	Critical Access Hospital

Advance Concept : Above tables can be loaded in database and validate the claims based on facility types for billing . e.g Hospice provider must submit a claims with TOB of 81 or 82 .If they submit other TOB .. that claims should be denied by the system .

Also based on the TOB payment may be different e.g TOB of 81 means Hospice care when patient is getting taken care at home .. so member home will derive the payment ( per diem rate) than 82 means member is getting taken care in facility so per diem is defined based on provider location.

Also based on outpatient and inpatient care reimbursement amount may vary .. provider should read provider contract carefully what they need to bill and how much they will get based on TOB.

Also clinical editing software will deny the claims if they submit a claims with TOB that is not suppose to bill for a specific type of service .. like TOB and Revenue codes combination or TOB and Procedure code condition.

Source :
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1775CP.pdf
http://www.resdac.org/cms-data/variables/Claim-Frequency-Code

Series 1 :Healthcare Claim Pricing : What is Place of Service (POS) and why it matters ?

2015-10-04T14:40:00.000-05:00

http://urtesting.blogspot.com/

Place of Service is one of the most important concepts to understand for claims as well as benefit configuration.

Place of Service : Where the service was rendered by healthcare provider. e.g. in Provider office, Patient Home, Home healthcare facility , Hospice center, Nursing Facility etc.

Please note that this healthcare provider is Professional Providers like physician , Nurse Practioner, specialists etc. and submitting CMS-1500 forms for reimbursement and not the Facility Providers.

e.g. 1. we went to doctor office for treatment then doctor will submit the claims with Place of service -11( Office)

e.g. 2. doctor come to patient home then doctor will submit claims with place of service -12( Home)

e.g.3. Patient is admitted to the hospital for treatment in a facility and physician who is not employed by Facility also called to see the patient then Facility will submit the UB-04 claims but this Physician will submit CMS-1500 forms for re-imbursement with correct place of service i.e. 21 - Hospital Inpatient.

Place of service is applicable to both Inpatient and Outpatient setting e.g. Place of service -21 means Inpatient Hospital , Place of Service 22 means Outpatient Hospital. So when Physician see a patient that is admitted in hospital i.e. patient is hospitalized ( Inpatient setting) , Physician will file the claim with Place of service - 21 however if physician see the patient in outpatient department ( Outpatient setting) then he will file the claim with place of service 22 ( Hospital Outpatient)

Place of Service is applicable to both Facility and Non-Facility.

Keeping everything simple, Place of service apply for Facility , for Non -Facility, for Inpatient , for Outpatient.

It is required by the law to report correct Place of Service.

Why it is important : Claims can be denied if provider is not submitting correct place of service. If provider has a contract to treat patient in Outpatient setting but he submits a claims with Inpatient place of service (21) that claim will be denied.

Based on place of service provider can get more or less payments e.g Place of service 23( Emergency visit) may get more re-imbursement then office visit.

provider may get less re-imbursement for all Facility place of service than Non- Facility place of service.( Because provider will be getting all the infrastructure from facility like office rent, equipment's, tools, electricity etc so his re-imbursement will be less)

Same service performed on different place of service will get different re-imbursement. CM Physician fee schedules are based on Facility and non-Facility setting.

If provider is not suppose to treat Urgent care or emergency visit and if submits such claims will be denied.

Also some of the services can not be rendered in all the place of services and that claims will be denied. eg. Pregnancy can not be delivered in Office ( POS-11) setting and that claims will be denied by the system edits.

Also some of the service will have the limitation ( like 2 or 3 units in a year for office visits ) and that limitation is reached then its patient responsibility to pay the amount .

If provider is suppose to treat only in Office then he can submit only the claims with Place of service 11 and all others claims will be denied.

Who Maintain POS : CMS

Please see all the POS with description and where it is applied ( Facility or Non-Facility) . This has been taken from CMS website. see that link below

https://www1d.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
01 Pharmacy (October 1, 2005) A facility or location where drugs and other medically related items and
02 Unassigned	--
03 School (January 1, 2003) A facility whose primary purpose is education.	NF
04 Homeless Shelter (January 1, 2003) A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). (See instructions below.)	NF
05 Indian Health Service Free-standing Facility (January 1, 2003) A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization. (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
06 Indian Health Service Provider-based Facility (January 1, 2003) A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
07 Tribal 638 Free-Standing Facility (January 1, 2003) A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization. (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF

08 Tribal 638 Provider-Based Facility (January 1, 2003) A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
09 Prison/Correctional Facility (July 1, 2006) A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders. (See instructions below.)	NF
10 Unassigned
11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.	NF
12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence.	NF
13 Assisted Living Facility (October 1, 2003) Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.	NF
14 Group Home (Code effective, October 1, 2003; description revised, effective April 1, 2004) A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).	NF

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF

15 Mobile Unit (January 1, 2003) A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.	NF
16 Temporary Lodging (April 1, 2008) A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code.	NF
17 Walk-in Retail Health Clinic (No later than May 1, 2010) A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services.	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
18 Place of Employment/Worksite (No later than May 1, 2013) A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual.	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
20 Urgent Care Facility (January 1, 2003) Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.	NF
21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.	F
22 Outpatient Hospital A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.	F

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
23 Emergency Room-Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.	F
24 Ambulatory Surgical Center A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.	F
25 Birthing Center A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of newborn infants.	NF
27-30 Unassigned	--
31 Skilled Nursing Facility A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.	F
32 Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.	NF
33 Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a longterm basis, and which does not include a medical component.	NF
34 Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.	F
35-40 Unassigned	--

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
41 Ambulance—Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.	F
42 Ambulance—Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.	F
43-48/Unassigned	--
49 Independent Clinic (October 1, 2003) A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.	NF
50 Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.	NF
51 Inpatient Psychiatric Facility A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.	F
52 Psychiatric Facility-Partial Hospitalization A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.	F
53 Community Mental Health Center A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a	F

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.
54 Intermediate Care Facility/Mentally Retarded A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.	NF
55 Residential Substance Abuse Treatment Facility A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.	NF
56 Psychiatric Residential Treatment Center A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.	F
57 Non-residential Substance Abuse Treatment Facility (October 1, 2003) A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.	NF
58-59 Unassigned	--
60 Mass Immunization Center A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.	NF
61 Comprehensive Inpatient Rehabilitation Facility	F

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
62 Comprehensive Outpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.	NF
63-64 Unassigned	--
65 End-Stage Renal Disease Treatment Facility A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.	NF
66-70 Unassigned	--
71 State or Local Public Health Clinic A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.	NF
72 Rural Health Clinic A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.	NF
73-80 Unassigned
81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.	NF
82-98 Unassigned
99 Other Place of Service Other place of service not identified above.	NF

Healthcare claims pricing : How to identify claim is Professional( Medical) claim or Institutional ( Facility or Hospital) claim

2015-09-26T20:05:00.000-05:00

http://urtesting.blogspot.com/

Healthcare claims pricing is very complex concept and ever evolving based on the healthcare rules and regulation and very hard to explain .. I am venturing to explains this .

There are 2 types of claims forms provider submits to healthcare payers for reimbursement ( Either paper or Electronic - 837 EDI file)

1. CMS -1500 form - Professional claims or medical claims or 837-P EDI

2. UB-04 form- Institutional claims or facility claims or hospitals claims or 837 -I EDI

How to identify claim is professional or Institutional : There are many way we can identify claim is professional or Institutional like professional claims will be claimed on CMS-1500 form Institutional claims will be on UB-04 form or 837 EDI will have identification ( ASC X12N 837 (005010X222A1) for professional and ASC X12N 837 (005010X223A2) for institutional or SV1 segment for Professional and SV2 segment for institutional claims or Revenue codes will not be there in professional claims and will be there in institutional claims but below one is the most important that I use for claims identification.

Professional claims :

Professional claims will have Place of service(POS)

Institutional claims :

Institutional claims will have Type of Bill( TOB)

Place of service and Types of Bill are 2 important concepts of claims pricing and I will explain this in details.Also claims will be Inpatient and Outpatient also depends on Place of service( some place of service are inpatient and some are outpatient) and Types of bill ( again some are inpatient and some are outpatient). Emergency or urgent care visit will have different place of service than office visit and so we have different price . In next post I will explain in details about Place of service and why it is important to understand.

As always thanks for reading my blog. You like it or dislike it please give the comments.

HMO Vs PPO

2015-02-07T19:25:00.002-06:00

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HMO vs PPO

BASIC Concepts

HMO – Health Maintenance Organization

PPO – Preferred Provider Organization

First of all HMO or PPO are Payer like Blue Cross Blue shield , United Healthcare, Anthem , Aetna, Humana, Cigna etc. that sells HMO and OR PPO plans. Plan is nothing but health Insurance Policy.
HMO or PPO has type of health insurance policy or plan.

HMO is restricted health plan where every member must has to go first the Primary Care Physician (PCP) for treatment. Patient does not go directly to any other provider other than PCP. PCP must refer to see any other physician or other Hospital.Referral are necessary for HMO plans. Every member has to select the Primary Care Physician. That PCP may be Individual Practitioner or group of physician (provider group). HMO plans are cheaper than PPO plans as it has lots of restrictions.

PPO is most flexible plan where member need NOT to go to primary care physician (PCP) for treatment. Member can visit to any specialist or hospital without any referral. PPO are costlier than HMO plans.

Advance Concepts:

HMO: Although by definition for HMO patient first need to see by PCP but there are some situation where it is not needed like Emergency services. Some other service like Gynecologist or obstetrician services it need not be PCP, any other providers in the network patient can go without the referral. HMO Plans does not cover out of networks treatments and patient is liable for payment.

HMO plans has its own set of HMO providers network having less providers or hospitals than PPO networks.

PPO: Members can visit in-network and out of network providers. Unlike HMO, when PPO member visit out of network cost of treatment will be higher but it would not be denied but in case of HMO it will be denied. PPO plans has PPO providers networks providers

POS -Place or Service - Hybrid plan of HMO and PPO – Does not require referral for specialist visit

EPO – Exclusive Provider Organization – Hybrid plan of HMO and PPO – Out of network visit is covered with higher cost share.

POS and EPO varies a lot from payer to payer, please read payer specific service to their website for what service are covered or not and what are the conditions.

POS and EPO plan are not sold very much.

Like or Dislike – Please comment.

ICD-10 Testing : Operational Neutrality,Financial Neutrality and Benefit Neutrality

2014-10-19T19:15:00.000-05:00

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ICD-10 Testing : As a part of overall ICD-10 testing , don't ignore Operational Neutrality, Financial Neutrality and Benefits Neutrality testing.

Operational Neutrality Testing : ICD-9 claims and its equivalent ICD-10 claims have to operate same way means if ICD-9 claims were denied then its equivalent ICD-10 claims also has to be denied,if ICD-9 claim were processed successfully then its ICD-10 claims have to be processed successfully.

Results of this testing will let you know if ICD-9 claims were processed successfully then why the ICD-10 is not processing successfully. This testing is must for ICD-10 test strategy.

Pull out thousand or ten thousand of ICD-9 claims that was processed successfully or was denied/error out . Convert that claims to ICD-10 claims ( use some automation to convert ICD-9 claims to ICD-10 claims or manually covert it using the X-walk) and process that and see how these ICD-10 claims are working in your ICD-10 adjudication system and see where is a problem , there may be payer specific edits that is not updated for ICD-10 claims or your clinical editing software is not working correctly or may be some other issues.

This testing will help you post production issues in advance and save your organization for ICD-10 disaster.

Financial Neutrality Testing : This testing will help you to know if ICD-9 adjudication system were paying $ X, are you also paying $ X for ICD-10 claims for the same ICD-9 claims or there are minus or plus in pricing. This testing is must for Financial neutrality of ICD-9 claims and ICD-10 claims.

ICD-9 and ICD-10 coding systems are Financial Neutral means there should not be any payment variation, if you find investigate the cause of variation.

Claims are paid either at claim level like DRG or Case rate or line level like outpatient visits like professional claims. Make sure that each line is priced equivalent to ICD-9 claims. Get the allowable amount of each line and compare with ICD-9 and ICD-10 claims. Make sure to compare the allowable amounts and not the benefits amounts( like copay, deductible and co-insurance as this varies for every visits).

Ensure providers contracts that uses ICD-9 diagnosis and procedure codes for pricing get re-mediated for ICD-10 codes otherwise these claims will never be priced. Not all contracts uses Diagnosis codes/Procedure codes but some providers use Diagnosis codes/Procedure codes as a part of provider contracts and that need to be re-mediated specially check all your networx contracts.

Create some automation script to pull out ICD-9 and ICD-10 claims and compare each service line and see the difference in dollar amount in spread sheet. If there is any variation investigate the issues. May be provider contract has been changed, Fee schedule has been changed , your contract terms has been changed from per Diem to Case rate or DRG pricing has changed orany other issues.

Benefits Neutrality : ICD-10 system has nothing to do with benefits of health plans so cost sharing between Patient and Health plans has to be 100 % neutral. Copay, deductible , co-insurance , out of pocket maximum has to be neutral.

This is going to be neutral unless your health plans have any components bases on ICD-9 Diagnosis codes and Procedure codes.Generally this is least important out of there neutrality testing.

Please leave comments if you have any.

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ICD-10 Testing of ICD-9 E codes ( E codes can not be a Primary Diagnosis Code)

2014-10-18T14:42:00.002-05:00

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ICD-9 E codes are external cause of injury codes and in ICD-9 claims processing system these codes can not be used as Primary Codes. If submitted as E codes then this has to be denied. Therefor corresponding X-walk of all this ICD-9 E codes to ICD-10 codes has to be testing as a part of ICD-10 testing.

There are so many ICD-9 E codes and here are first 20 of the X-walk based on Gems tool.

ICD-9 Codes	ICD-10 Codes
E0000	Y990
E0001	Y991
E0002	Y992
E0008	Y998
E0009	Y999
E0010	Y9301
E0011	Y9302
E0020	Y9311
E0021	Y9312
E0022	Y9313
E0023	Y9314
E0024	Y9315
E0025	Y9316
E0026	Y9317
E0027	Y9318
E0028	Y9319
E0029	Y9319
E0030	Y9321
E0031	Y9322
E0032	Y9323

Test your ICD-10 system to ensure that all ICD-10 external cause of entry claims denied when used as Primary Diagnosis codes.

There are also significant number of E-codes that are no longer valid in ICD-10 world( orphan codes), see my previous post for such codes and its impact.

Are ICD-9 and ICD-10 going to be Financial Neutral? Must test your DRG grouper.

2014-06-15T20:24:00.002-05:00

ICD-10 has yet to be implemented in USA and yet to see the real financial impact of ICD-9 to ICD-10.But in theory both ICD-9 and ICD-10 should not to have any financial impact and variation.The way ICD-9 and ICD-10 has been designed has nothing to take with the claim pricing in claims as claims pricing depends on HCPCS codes or revenue codes ( used in Provider agreements/networks for pricing ) that are not going to change by ICD-10 implementation.But one thing that is most important to understand the inpatient claims pricing that uses DRG codes. ICD-9 and ICD-10 has the same DRG but the DRG grouper that uses Diagnosis code has a impact and hence the DRG might changes in claims based on the DRG grouper / or the X-walk that built the DRG codes and then there would be absolutely price variation in ICD-10 claims.Make sure to test enough inpatients claims to make sure that ICD-9 and ICD-10 claims are financial neutral.

ICD-10 Delay : CMS has not yet not declared the new implementation date, should we ready for any surprise ?

2014-04-10T09:51:00.001-05:00

http://urtesting.blogspot.com/

Its been a week ICD-10 has been delayed but CMS has yet not come up with the new implementation.Are CMS thinking something different than us and may come up with something that will surprise everyone may be implementation of ICD-11, I am just think .. dont get me wrong. If CMS come with ICD-11 dont know what will happen to future.My finger is crossed and waiting to hear from CMS.

urtesting.blogspot.com

ICD-10 delay,is this the beginning of ICD-11

2014-04-02T22:24:00.000-05:00

http://urtesting.blogspot.com/
I have a apprehension that as ICD-10 has delayed to the earliest as of now is 1 oct 2015, WHO will be ready for ICD-11 code set by 2017 so should we not wait for another 2 year and implement ICD-11 code set directly rather than going through ICD-10 and then down the line new code set is coming.If industry has waited for than 20 years to implement ICD 10 then what's the harm in waiting 2 years and implement directly ICD-11.I am not saying this but our politician will say that and again pass the bill that will stop the ICD implementation for ever and that will be sub set for ICD-10 code set.

ICD-10 delay - bad bad for all

2014-03-31T22:24:00.001-05:00

http://urtesting.blogspot.com/
ICD-10 is delayed by at least an year is bad bad for healthcare space ,it is good for nothing and again a good reason to procrastinate beneath the delay.If you are not prepared on last 3 years how you are hoping that you will be ready in another year ? These guys will just chilled down and again say we are not ready.it was time to take the tough decision that was good for industry. Think about the college graduate who started preparing for ICD-10 from last 2 year hoping they will get the job this year , they are under water now.Think about the payers who has invested so much in training their staffs for ICD-10 , year delay will just kill all the training skill they have , they again need to be trained.think about the providers who hired the ICD-10 staffs for billing and EHR softwares ,they are not going to use for another 1 more year ,this is crazy and insane and overhead for industry.
I am not able to understand by extending an year who is going to benefited, is this patient no way.But it time to bite the bullet and move on with the same spirit for the good and quality healthcare. Sooner or later it's need to be fixed but sooner the better.

CMS form 1500 has been released for ICD-10 testing

2014-02-16T10:44:00.001-06:00

http://urtesting.blogspot.com/

CMS has released form 1500 for the professional claim for providers using a paper claims. This new form has a ICD indicator for ICD-9 and ICD-10 claims.

The timeline is:

January 6, 2014: Payers begin receiving and processing paper claims submitted on the revised 1500 Claim Form (version 02/12).
January 6 through March 31, 2014: Dual use period during which payers continue to receive and process paper claims submitted on the old 1500 Claim Form (version 08/05).
April 1, 2014: Payers receive and process paper claims submitted only on the revised 1500 Claim Form (version 02/12).

Please use the below URL to download the form and sample example.

http://www.nucc.org/%5Cimages%5Cstories%5CPDF%5C1500_claim_form_2012_02.pdf

visit - NUCC site for more deatils.http://nucc.org/

http://urtesting.blogspot.com/

Automation tool- converts ICD-9 edi claim file to ICD-10 edi claim file.

2013-10-25T17:50:00.001-05:00

http://urtesting.blogspot.com/

One of my friend has developed a automation tool that takes the icd9 claims as input and generates icd-10 brand new claims.The tool does the GEMs X-walk for icd 9 to icd 10 codes and also changes the date of service to service to a void the duplicate claim. I tested this and worked perfect for my testing.He is soon going to checkin the code in girth hub as open source.
Any one is interested please let me know.
This is a fantastic tool that also has the x-walk ability .
Urtesting.blogspot.com

HIPAA Transaction impacted by ICD-10 codes

2013-10-10T07:46:00.000-05:00

http://urtesting.blogspot.com/

There are many transaction that are going to be impacted by ICD-10 diagnosis and procedure codes. Offcousre the 837 insutional and professional claims has a huge impact but almost all the most used HIPAA transaction has impact except the 835 transaction.
834 has a impactd when enrolling a member for pre-existing condition where Diagnosis code comes in 834 edi files.There is an impact on 270 and 271 transaction for claims status and also for 278 for referral when provider is referring for a condtion that has a diagnosis code.

837 - Profession - has a impact
837 - Instuitional - has a impact
837 - Dental - has a impact

270 - has a impact
271- has a impact

278 - has a impact.

835 - No impact .. but there need to a testing of 835 for the ICD-10 claims for making sure that 835 generates as expected for ICD-10 837 edi files.

Please feel free to comments ..and ask any question if you have..

ICD-10 Testing for No Maps codes( orphan codes)

2013-10-05T10:35:00.000-05:00

http://urtesting.blogspot.com/

Interesting aspect for ICD-10 testing to test the ICD-9 codes that are no longer valid and test the ICD-10 codes that are brand new.In gems file there are total 424 codes ( mainly E codes, external cause of injury) that are no more mapped to any ICD-10 codes and there are total 669 ICD-10 codes that are brand new and not mapped to any ICD-9 codes. These ICD-10 codes are mainly R codes(realted to Coma) and T codes(related to overdosing).Testing is important to know how claim adjudication happens for these codes as these codes need to be configured and or mapped to any existing codes and see the finincail impcat on reimbursment.Here is attached the codes that are orphan in forward mapping ( no more mapped to ICD-10 codes)
36570
36571
36572
36573
36574
70720
70721
70722
70723
70724
70725
76409
76419
76529
7796
E8500
E8501
E8502
E8503
E8504
E8505
E8506
E8507
E8508
E8509
E851
E8520
E8521
E8522
E8523
E8524
E8525
E8528
E8529
E8530
E8531
E8532
E8538
E8539
E8540
E8541
E8542
E8543
E8548
E8550
E8551
E8552
E8553
E8554
E8555
E8556
E8558
E8559
E856
E857
E8580
E8581
E8582
E8583
E8584
E8585
E8586
E8587
E8588
E8589
E8600
E8601
E8602
E8603
E8604
E8608
E8609
E8610
E8611
E8612
E8613
E8614
E8615
E8616
E8619
E8620
E8621
E8622
E8623
E8624
E8629
E8630
E8631
E8632
E8633
E8634
E8635
E8636
E8637
E8638
E8639
E8640
E8641
E8642
E8643
E8644
E8650
E8651
E8652
E8653
E8654
E8655
E8658
E8659
E8660
E8661
E8662
E8663
E8664
E8665
E8666
E8667
E8668
E8669
E867
E8680
E8681
E8682
E8683
E8688
E8689
E8690
E8691
E8692
E8693
E8694
E8698
E8699
E8700
E8701
E8702
E8703
E8704
E8705
E8706
E8707
E8708
E8709
E8710
E8711
E8712
E8713
E8714
E8715
E8716
E8717
E8718
E8719
E8740
E8741
E8742
E8743
E8744
E8745
E8748
E8749
E903
E9040
E9041
E9042
E9043
E9049
E9050
E9051
E9052
E9053
E9054
E9055
E9056
E9057
E9058
E9059
E911
E912
E9130
E9131
E9132
E9133
E9138
E9139
E914
E915
E9241
E9270
E9271
E9272
E9273
E9274
E9278
E9279
E9286
E9292
E9294
E9300
E9301
E9302
E9303
E9304
E9305
E9306
E9307
E9308
E9309
E9310
E9311
E9312
E9313
E9314
E9315
E9316
E9317
E9318
E9319
E9320
E9321
E9322
E9323
E9324
E9325
E9326
E9327
E9328
E9329
E9330
E9331
E9332
E9333
E9334
E9335
E9336
E9337
E9338
E9339
E9340
E9341
E9342
E9343
E9344
E9345
E9346
E9347
E9348
E9349
E9350
E9351
E9352
E9353
E9354
E9355
E9356
E9357
E9358
E9359
E9360
E9361
E9362
E9363
E9364
E9370
E9371
E9372
E9373
E9374
E9375
E9376
E9378
E9379
E9380
E9381
E9382
E9383
E9384
E9385
E9386
E9387
E9389
E9390
E9391
E9392
E9393
E9394
E9395
E9396
E9397
E9398
E9399
E9400
E9401
E9408
E9409
E9410
E9411
E9412
E9413
E9419
E9420
E9421
E9422
E9423
E9424
E9425
E9426
E9427
E9428
E9429
E9430
E9431
E9432
E9433
E9434
E9435
E9436
E9438
E9439
E9440
E9441
E9442
E9443
E9444
E9445
E9446
E9447
E9450
E9451
E9452
E9453
E9454
E9455
E9456
E9457
E9458
E9460
E9461
E9462
E9463
E9464
E9465
E9466
E9467
E9468
E9469
E9470
E9471
E9472
E9473
E9474
E9478
E9479
E9480
E9481
E9482
E9483
E9484
E9485
E9486
E9488
E9489
E9490
E9491
E9492
E9493
E9494
E9495
E9496
E9497
E9499
E9500
E9501
E9502
E9503
E9504
E9505
E9506
E9507
E9508
E9509
E9510
E9511
E9518
E9520
E9521
E9528
E9529
E9530
E9531
E9538
E9539
E961
E9620
E9621
E9622
E9629
E963
E978
E9800
E9801
E9802
E9803
E9804
E9805
E9806
E9807
E9808
E9809
E9810
E9811
E9818
E9820
E9821
E9828
E9829
E9830
E9831
E9838
E9839
E984
E989
V6441
V6442
V6443

Here are the ICD-10 codes that are brand new and no map to any ICD-9 codes
R402130
R402131
R402132
R402133
R402134
R402140
R402141
R402142
R402143
R402144
R402230
R402231
R402232
R402233
R402234
R402240
R402241
R402242
R402243
R402244
R402250
R402251
R402252
R402253
R402254
R402330
R402331
R402332
R402333
R402334
R402350
R402351
R402352
R402353
R402354
R402360
R402361
R402362
R402363
R402364
R40241
R40242
R40243
R40244
T360X6A
T360X6D
T360X6S
T361X6A
T361X6D
T361X6S
T362X6A
T362X6D
T362X6S
T363X6A
T363X6D
T363X6S
T364X6A
T364X6D
T364X6S
T365X6A
T365X6D
T365X6S
T366X6A
T366X6D
T366X6S
T367X6A
T367X6D
T367X6S
T368X6A
T368X6D
T368X6S
T3696XA
T3696XD
T3696XS
T370X6A
T370X6D
T370X6S
T371X6A
T371X6D
T371X6S
T372X6A
T372X6D
T372X6S
T373X6A
T373X6D
T373X6S
T374X6A
T374X6D
T374X6S
T375X6A
T375X6D
T375X6S
T378X6A
T378X6D
T378X6S
T3796XA
T3796XD
T3796XS
T380X6A
T380X6D
T380X6S
T381X6A
T381X6D
T381X6S
T382X6A
T382X6D
T382X6S
T383X6A
T383X6D
T383X6S
T384X6A
T384X6D
T384X6S
T385X6A
T385X6D
T385X6S
T386X6A
T386X6D
T386X6S
T387X6A
T387X6D
T387X6S
T38806A
T38806D
T38806S
T38816A
T38816D
T38816S
T38896A
T38896D
T38896S
T38906A
T38906D
T38906S
T38996A
T38996D
T38996S
T39016A
T39016D
T39016S
T39096A
T39096D
T39096S
T391X6A
T391X6D
T391X6S
T392X6A
T392X6D
T392X6S
T39316A
T39316D
T39316S
T39396A
T39396D
T39396S
T394X6A
T394X6D
T394X6S
T398X6A
T398X6D
T398X6S
T3996XA
T3996XD
T3996XS
T400X6A
T400X6D
T400X6S
T402X6A
T402X6D
T402X6S
T403X6A
T403X6D
T403X6S
T404X6A
T404X6D
T404X6S
T405X6A
T405X6D
T405X6S
T40606A
T40606D
T40606S
T40696A
T40696D
T40696S
T407X6A
T407X6D
T407X6S
T40906A
T40906D
T40906S
T40996A
T40996D
T40996S
T410X6A
T410X6D
T410X6S
T411X6A
T411X6D
T411X6S
T41206A
T41206D
T41206S
T41296A
T41296D
T41296S
T413X6A
T413X6D
T413X6S
T4146XA
T4146XD
T4146XS
T415X6A
T415X6D
T415X6S
T420X6A
T420X6D
T420X6S
T421X6A
T421X6D
T421X6S
T422X6A
T422X6D
T422X6S
T423X6A
T423X6D
T423X6S
T424X6A
T424X6D
T424X6S
T425X6A
T425X6D
T425X6S
T426X6A
T426X6D
T426X6S
T4276XA
T4276XD
T4276XS
T428X6A
T428X6D
T428X6S
T43016A
T43016D
T43016S
T43026A
T43026D
T43026S
T431X6A
T431X6D
T431X6S
T43206A
T43206D
T43206S
T43216A
T43216D
T43216S
T43226A
T43226D
T43226S
T43296A
T43296D
T43296S
T433X6A
T433X6D
T433X6S
T434X6A
T434X6D
T434X6S
T43506A
T43506D
T43506S
T43596A
T43596D
T43596S
T43606A
T43606D
T43606S
T43616A
T43616D
T43616S
T43626A
T43626D
T43626S
T43636A
T43636D
T43636S
T43696A
T43696D
T43696S
T438X6A
T438X6D
T438X6S
T4396XA
T4396XD
T4396XS
T440X6A
T440X6D
T440X6S
T441X6A
T441X6D
T441X6S
T442X6A
T442X6D
T442X6S
T443X6A
T443X6D
T443X6S
T444X6A
T444X6D
T444X6S
T445X6A
T445X6D
T445X6S
T446X6A
T446X6D
T446X6S
T447X6A
T447X6D
T447X6S
T448X6A
T448X6D
T448X6S
T44906A
T44906D
T44906S
T44996A
T44996D
T44996S
T450X6A
T450X6D
T450X6S
T451X6A
T451X6D
T451X6S
T452X6A
T452X6D
T452X6S
T453X6A
T453X6D
T453X6S
T454X6A
T454X6D
T454X6S
T45516A
T45516D
T45516S
T45526A
T45526D
T45526S
T45606A
T45606D
T45606S
T45616A
T45616D
T45616S
T45626A
T45626D
T45626S
T45696A
T45696D
T45696S
T457X6A
T457X6D
T457X6S
T458X6A
T458X6D
T458X6S
T4596XA
T4596XD
T4596XS
T460X6A
T460X6D
T460X6S
T461X6A
T461X6D
T461X6S
T462X6A
T462X6D
T462X6S
T463X6A
T463X6D
T463X6S
T464X6A
T464X6D
T464X6S
T465X6A
T465X6D
T465X6S
T466X6A
T466X6D
T466X6S
T467X6A
T467X6D
T467X6S
T468X6A
T468X6D
T468X6S
T46906A
T46906D
T46906S
T46996A
T46996D
T46996S
T470X6A
T470X6D
T470X6S
T471X6A
T471X6D
T471X6S
T472X6A
T472X6D
T472X6S
T473X6A
T473X6D
T473X6S
T474X6A
T474X6D
T474X6S
T475X6A
T475X6D
T475X6S
T476X6A
T476X6D
T476X6S
T477X6A
T477X6D
T477X6S
T478X6A
T478X6D
T478X6S
T4796XA
T4796XD
T4796XS
T480X6A
T480X6D
T480X6S
T481X6A
T481X6D
T481X6S
T48206A
T48206D
T48206S
T48296A
T48296D
T48296S
T483X6A
T483X6D
T483X6S
T484X6A
T484X6D
T484X6S
T485X6A
T485X6D
T485X6S
T486X6A
T486X6D
T486X6S
T48906A
T48906D
T48906S
T48996A
T48996D
T48996S
T490X6A
T490X6D
T490X6S
T491X6A
T491X6D
T491X6S
T492X6A
T492X6D
T492X6S
T493X6A
T493X6D
T493X6S
T494X6A
T494X6D
T494X6S
T495X6A
T495X6D
T495X6S
T496X6A
T496X6D
T496X6S
T497X6A
T497X6D
T497X6S
T498X6A
T498X6D
T498X6S
T4996XA
T4996XD
T4996XS
T500X6A
T500X6D
T500X6S
T501X6A
T501X6D
T501X6S
T502X6A
T502X6D
T502X6S
T503X6A
T503X6D
T503X6S
T504X6A
T504X6D
T504X6S
T505X6A
T505X6D
T505X6S
T506X6A
T506X6D
T506X6S
T507X6A
T507X6D
T507X6S
T508X6A
T508X6D
T508X6S
T50906A
T50906D
T50906S
T50996A
T50996D
T50996S
T50A16A
T50A16D
T50A16S
T50A26A
T50A26D
T50A26S
T50A96A
T50A96D
T50A96S
T50B16A
T50B16D
T50B16S
T50B96A
T50B96D
T50B96S
T50Z16A
T50Z16D
T50Z16S
T50Z96A
T50Z96D
T50Z96S
Y700
Y701
Y702
Y703
Y708
Y710
Y711
Y712
Y713
Y718
Y720
Y721
Y722
Y723
Y728
Y730
Y731
Y732
Y733
Y738
Y740
Y741
Y742
Y743
Y748
Y750
Y751
Y752
Y753
Y758
Y760
Y761
Y762
Y763
Y768
Y770
Y771
Y772
Y773
Y778
Y780
Y781
Y782
Y783
Y788
Y790
Y791
Y792
Y793
Y798
Y800
Y801
Y802
Y803
Y808
Y810
Y811
Y812
Y813
Y818
Y828
Y829
Y900
Y901
Y902
Y903
Y904
Y905
Y906
Y907
Y908
Y909
Y95
Z3A00
Z3A01
Z3A08
Z3A09
Z3A10
Z3A11
Z3A12
Z3A13
Z3A14
Z3A15
Z3A16
Z3A17
Z3A18
Z3A19
Z3A20
Z3A21
Z3A22
Z3A23
Z3A24
Z3A25
Z3A26
Z3A27
Z3A28
Z3A29
Z3A30
Z3A31
Z3A32
Z3A33
Z3A34
Z3A35
Z3A36
Z3A37
Z3A38
Z3A39
Z3A40
Z3A41
Z3A42
Z3A49
Z6710
Z6711
Z6720
Z6721
Z6730
Z6731
Z6740
Z6741
Z6790
Z6791

Please feel fee to post the comment!

ICD-10 and Workers' Compensation

2013-10-02T17:22:00.001-05:00

http://urtesting.blogspot.com/

Do you know Workers’ Compensation has no impact on ICD-10 and they are not liable for any ICD-10 Implementation.Do you know why ? This is because Workers’ Compensation is not comes under HIPAA covered entity.

More information is available in CMS website.

Duplicate Diagnosis codes in ICD-9 and ICD-10

2013-09-22T14:57:00.003-05:00

http://urtesting.blogspot.com/

if your system is not storing ICD-9 and ICD-10 codes in your database with its type code then you are going to be in trouble. There are E codes ( External cause of Injury codes) that are both in ICD-9 and ICD-10 codes .
I queried the GEMS X-walk and found that there are total 34 E-codes that are same in ICD-9 and ICD-10.

here is a list based on Gems files for forward mapping :

E8020
E8029
E8300
E8301
E8309
E8310
E8319
E8330
E8331
E8332
E8339
E8340
E8341
E8342
E8349
E8350
E8351
E8352
E8359
E8381
E8389
E8411
E8419
E848
E851
E8801
E8809
E8840
E8841
E8842
E8849
E8881
E8889
E895

interesting thing to note that even these codes are equal but there description is different e.g
ICD-9 codes : E8020 its description is Railway accident involving derailment without antecedent collision injuring railway employee where as for ICD-10 its description is Unspecified porphyria

make sure to have your database distinguish the ICD-9 and ICD-10 codes otherwise all the claims processing and data analytics will have problem .

- post a comment if you have any and subscribe to my post for any update.

What next after ICD-10 implementation

2013-09-22T14:32:00.000-05:00

http://urtesting.blogspot.com/

We might be thinking what next after ICD-10 implementation. The Answer is HPID( Health Plan ID) similar to NPI ID for Providers. Thats one of the way CMS is simplyfing the eHealth process.

More detail is available in CMS website.

CMS link for HPID

How to prepare ICD-10 EDI claims file from existing ICD-9 files or convert ICD-9 files to ICD-10 files( Part-2)

2013-09-17T18:28:00.000-05:00

http://urtesting.blogspot.com/
This is in continuation of part-1...
HIPAA 5010 ICD-9 claims with conversion to ICD-10 claims. This example has a ICD-9 diagnois code 0340 that has 2 ICD-10 X-walk .. so 2 ICD-10 EDI files has been created for testing.

ICD-9 Professional Claim example

ISA*00* *00* *ZZ*Sender *ZZ*Receiver *130915*1025*^*00501*201309150*1*T*:~
GS*HC*Sender*Receiver*20130915*1020*123456*X*005010X222A1~
ST*837*2013*005010X222A1~
BHT*0019*00*23456*20130915*1023*CH~
NM1*41*2*Sender Name*****46*Senderid~
PER*IC*ContactPersonName*TE*TelephoneNumberofContactperson*FX*FaxNumber~
NM1*40*2*ReceiverName*****46*ReceiverID~
HL*1**20*1~
NM1*85*2*Billing provider name*****XX*NPI~
N3*Billing Provider Address~
N4*Billing provider city*Billing provider State*Billing Provider Zipcode~
HL*2*1*22*0~
SBR*P*18*Subscriber group ID******BL~
NM1*IL*1*Subscriber Last Name*First Name*Middle Name***IL*subscriberid~
N3*Subscriber address~
N4*Subscriber city*state*zipcode~
DMG*D8*SubscriberDOB*SubscriberSEX~
NM1*PR*2*PayerName *****PI*payerID~
N3*PayerAddress~
N4*PayerCity*PayerState*Payerzipcode~
CLM*claimNumber*100***13:B:1*Y*A*Y*Y*P~
HI*BK:0340~
NM1*82*1*rendering provider name*****XX*NPI~
LX*1~
SV1*HC:99214*100*UN*1***1**N~
DTP*472*RD8*20130910-20130910~
SE*30*2013~
GE*1*123456~
IEA*1*201309150~

First ICD-10 claim for the above ICD-9 claim
ISA*00* *00* *ZZ*Sender *ZZ*Receiver *130915*1025*^*00501*201309150*1*T*:~
GS*HC*Sender*Receiver*20130915*1020*123456*X*005010X222A1~
ST*837*2013*005010X222A1~
BHT*0019*00*23456*20130915*1023*CH~
NM1*41*2*Sender Name*****46*Senderid~
PER*IC*ContactPersonName*TE*TelephoneNumberofContactperson*FX*FaxNumber~
NM1*40*2*ReceiverName*****46*ReceiverID~
HL*1**20*1~
NM1*85*2*Billing provider name*****XX*NPI~
N3*Billing Provider Address~
N4*Billing provider city*Billing provider State*Billing Provider Zipcode~
HL*2*1*22*0~
SBR*P*18*Subscriber group ID******BL~
NM1*IL*1*Subscriber Last Name*First Name*Middle Name***IL*subscriberid~
N3*Subscriber address~
N4*Subscriber city*state*zipcode~
DMG*D8*SubscriberDOB*SubscriberSEX~
NM1*PR*2*PayerName *****PI*payerID~
N3*PayerAddress~
N4*PayerCity*PayerState*Payerzipcode~
CLM*claimNumber*100***13:B:1*Y*A*Y*Y*P~
HI*ABK:J020~
NM1*82*1*rendering provider name*****XX*NPI~
LX*1~
SV1*HC:99214*100*UN*1***1**N~
DTP*472*RD8*20130910-20130910~
SE*30*2013~
GE*1*123456~
IEA*1*201309150~

Second ICD-10 claim for the above ICD-9 claim

ISA*00* *00* *ZZ*Sender *ZZ*Receiver *130915*1025*^*00501*201309150*1*T*:~
GS*HC*Sender*Receiver*20130915*1020*123456*X*005010X222A1~
ST*837*2013*005010X222A1~
BHT*0019*00*23456*20130915*1023*CH~
NM1*41*2*Sender Name*****46*Senderid~
PER*IC*ContactPersonName*TE*TelephoneNumberofContactperson*FX*FaxNumber~
NM1*40*2*ReceiverName*****46*ReceiverID~
HL*1**20*1~
NM1*85*2*Billing provider name*****XX*NPI~
N3*Billing Provider Address~
N4*Billing provider city*Billing provider State*Billing Provider Zipcode~
HL*2*1*22*0~
SBR*P*18*Subscriber group ID******BL~
NM1*IL*1*Subscriber Last Name*First Name*Middle Name***IL*subscriberid~
N3*Subscriber address~
N4*Subscriber city*state*zipcode~
DMG*D8*SubscriberDOB*SubscriberSEX~
NM1*PR*2*PayerName *****PI*payerID~
N3*PayerAddress~
N4*PayerCity*PayerState*Payerzipcode~
CLM*claimNumber*100***13:B:1*Y*A*Y*Y*P~
HI*ABK:J0300~
NM1*82*1*rendering provider name*****XX*NPI~
LX*1~
SV1*HC:99214*100*UN*1***1**N~
DTP*472*RD8*20130910-20130910~
SE*30*2013~
GE*1*123456~
IEA*1*201309150~

in the above example of ICD-9 to ICD-10 conversion .. everything is remains same except the HI qualifiers and X-walk.
I have created a utility that takes the ICD-9 claims and creates all possible ICD-10 claims. Please let me know if someone is interested. Next post I will give some examples of Institutional claims with Diagnosis and procedure codes.

Disclaimer - The post is for educational purposes and help to prepare well for the ICD-9 to ICD-10 conversion. Above example just help to understand the 837 changes for ICD-10 claims. Please do not use this claims in your testing as it will not work as data has been masked for security and confidentiality.

How to prepare ICD-10 EDI claims file from existing ICD-9 files or convert ICD-9 files to ICD-10 files - Part1

2013-09-13T14:45:00.000-05:00

http://urtesting.blogspot.com/

A quick guide to prepare ICD-10 Edi files

There are 2 change that need to be done to prepare ICD-10 claim from existing ICD-9 claims

1. Daignosis and procedure code Qualifers mapping and
2. ICD-9 to ICD-10 mappings( using GEMS or any custom X-walk by any vendor)

Qualifers Mapping

ICD-9 Qualifer	Qualifers Definition	ICD-10 Qualifers
BK	Primary Diagnosis code	ABK
BF	Secondary Diagnosis code	ABF
BN	External Cause of injury	ABN
BJ	Admitting Diagnosis	ABJ
PR	Patient Reason for Visit	APR
BR	Primary Procedure code	BBR
BQ	Secondary Procedure code	BBQ

note : there are some HI qualifers like DR for DRG HI*DR, value codes HI*BE, conditon codes , occurance codes has no change from ICD-9 to ICD-10 codes

2. Gems X-walk

Use the CMS published GEMS X-walk for ICD-9 codes to ICD-10 codes.

Here is a link to download the X-walk CMS GEMS

GEMS has 2 files to download - one is for Diagnosis code(CM)and other is for Proecdure code(PCS). Note that PCS codes are only applicable with Inpatient Instuitional claims.See my next post on details of Gems and how to x-walk the codes and how to decide on one to many code mappings.

if you have no knowledge of GEMS mapping , you can use this widget to X-walk ICD-9 to ICD-10 provided by aapc.

Example

To convert ICD-9 to ICD-10 claim files, entire HIPAA 5010 837 EDI file remain same except the HI segement.

e.g ICD-9 claim HI segment with one of the most used Princiapl diagnosis code ( 0340 -shore throat) with Secondary diagnosis code -V202 for - child well visit.

HI*BK:0340*BF:V202~

ICD-10 HI segment: the ICD-9 Principal diagnosis code 0340 has 2 X-walk for ICD-10 CM codes J020 and J0300, I have selected the J020 as it is more specified for this example, you may create 2 edi files one for each diagnosis code.( Note :to select the best code See the description of codes or use the backward mapping to select the best usally the medical codes assigne the codes by reading the patient medical record or charts)

The secondary ICD-9 diagnosis code V20.2 (chid visit) has ICD-10 x-walk :Z00129.

here is ICD-10 HI segment after the X-walk and Qualifier mapping

HI*ABK:J020*ABF:Z00129~

Apart from the HI segment change there is nothing has changed in ICD-10 claims .The LX segment that contain the service lines details contains the HCPCS /CPT code and that is same as it is in ICD-9 codes. You might be woundering then how the pricing is going to be different as price is charged for every HCPCS/CPT codes. This I will explain in next post.Also I will cover the gems in details for why back-ward mapping from ICD-10 to ICD-9 is important for X-walk. Please feel free to leave a comment and send an email - urtesting@gmail.com , if you have any clarification.

See my next post for 837 EDI files examples in details

Can a Software has a Zero Defect?

2010-11-06T13:52:00.000-05:00

http://urtesting.blogspot.com/

When I was preparing for engineering exams, in the physics book it is mentioning that an Apple and a Bird Feather if drop from the same height both will land to the ground at the same time. I got surprised, simply the answer is never possible. But the law of motion in physics says it is absolutely possible. Reason the time being same for the Apple and the Bird feather to reach ground is because of the physics formula to calculate the time.It depends on the height and acceleration of gravity and it is independent of mass.For Apple and Bird Feather both are dropped from the same height and gravity acceleration g is also same for both. So the time taken is same.

But is this possible in realty no way ...

The important consideration for the above rule of physics is that it is Under Ideal Conditions, keeping the external factors away like the wind velocity , weather conditions or any unfavorable conditions and the number of such external factors are enormous and unknown .Only then the Apple and Bird Feather will land the ground at the same time.

Many time my laptops and desktops machines hangs . Many times I am unable to call my friends over mobile phones.Many times many software stops working without being the failure notice and many time the missiles and aeronautical software fails and tolls the human life's.

But why this happens. Do the manufacturers have any clue of the same?Answer is No, because the number of external factors are enormous and unknown like the dropping of Apple and Bird Feather.Most of the time manufacuring company want to know the problems when software stop working a pop up message appears stating that "DO you want to report this error?" and usually we click on NO button and close the program and again launch the program.Manufacturing company want to known all the unnotticed external behaviours under which application failed so that they can fix it in next release.

Now come to topic of this post - Can a Software has a Zero Defect.
My answer is Yes under the ideal condition like the Apple and Bird Feather.

Most Used Websites

2010-11-02T09:45:00.000-05:00

http://urtesting.blogspot.com/

Let me ask a question , Can you tell me the name of the site which is most used for gaming or social networking or perfessional networking or QTP or Automation testing and so on..

Got puzzled...
Yes you can tell the above and also you can find the site which is most used for the particular purpose.

There are so many websites that track the traffic and analyze website for the use.

one of such site is http://www.alexa.com/

In this site type Game and see the list of of gaming site based on network traffice i.e mostly used website.

So next time when you are looking for something and want to know which is that site that is most used of a specific purpose , go to that site and used that.
That site also list the all top website based on country.

Google Search - Shortcuts

2010-11-01T09:02:00.000-05:00

http://urtesting.blogspot.com/

Let me ask a question, how do you search in Google ?
The answer is obvious , go to google site and enter the search word and hit enter key ....
Yes thats obvious ..
But do you know , you can do the same without going to google website..
Here you go , directly enter the seach word in internet address and hit enter key , now see the magic you directly go the search result.( without going to google website)

Like enter - selenium and you will directly lands to Selenium search result.
enter railway reservation and you will get the railways resevation site result.

Note this will happen in internet explorer - 7 and above and firefox 3 and above because in these browser after the address bar there is also google search text box. when the exact internet address is not found then this default google text box takes that values and populates the search result.

Database:Records Sorting

2010-09-14T01:47:00.000-05:00

Here is my question, how do you sort the records of the displayed data of SQL query result?

Answer is simple by using the ASC and DESC keyword (i.e. Ascending and descending followed by column name or list of column name separated by comma, where ascending is default).

Absolutely correct, but have you tried it without the column name and replacing the column name by number like 1 , 2 etc.

No, then there you go:

Traditional query,

Select columnA, columnB, columnC from tableA order by columnA, columnB

Now try this query

Select columnA, columnB, columnC from tableA order by 1,2

Both the above query will result the same.

Here 1,2, 3 represent the column name in the select statements.

The same is true for group by also

Note: This is in Oracle DB , not sure in other DB

Tips:Open the application by finger tips

2010-09-14T01:16:00.000-05:00

Have you ever wondered why typing cmd and enter opens the command prompt window, typing notepad opens the notepad editor, typing iexplore opens the internet explorer, typing mspaint opens Microsoft paint and so on. Do you know why this is happening?

What do you think, is this only possible with some of the thing for which operating system has given us command? Of course not , think like type o and your outlook is opened, type I and your internet explorer is opened, type f and your Firefox is opened, type w and your Microsoft word is opened and literally anything you like to open .

This is of course possible. Here is a tip.

Have you ever heard of Environmental Variable, if not don’t worry.

If I ask you a question how do you open (execute) a particular file or application. The answer is simple, go to the location where the application or file is and click on it. Exactly the same happens when you type cmd and enter or type notepad and enter.

Maker of Operating systems are very smart, what they have thought is, if you want to open anything either you need to do these thing

Go to the location and open it
Don’t go to the location and open it

Second statement is confusing, isn’t it but it is true. For this to happen they have given us a provision. They have given a text box where you enter the path of all application or files you want to open separated by semi colon. When you type and enter we will look on the present working location and if it is not found then we will look at this text box path and open it .This is known as environment variable concept.

How to open environmental variable:

Right click My Computer->Properties->advanced tab ->Environmental variable button this will open the Environment variable window

See the System variable section Path is highlighted, that has the collection of all the paths. C:\windows\system32 is default there that is why when you enter cmd and click enters, it opens the cmd.exe available in C:\windows\system32 location.

We need not to go to C:\windows\system32 and the click on cmd.exe to open the command window. Think about the pain if this functionality is not there.

Now I am going to create some batch file and show you how type i and your Internet Explorer is opened.

Here are the steps:

1. Crate a folder in C driver and name it BatchFiles ( C:\BatchFiles)

2. Go to BatchFiles folder and create a notepad

3. In the notepad enter the following lines of code

@echo off

cd C:\Program Files\Internet Explorer

iexplore.exe

4. Save it as i.bat

5. Go to the Environment variable window and in system variable Path enter the created folder path

i.e. (C:\BatchFiles) in Path variable (all location is separated by semicolon)

(How to open Environmental variable -Right click My Computer->Properties->advanced tab ->Environmental variable button)

6. Click on OK button

Now you are all set to execute it.

Click Start->Run -> type i and enter, wonder happened!!! Internet explorer is opened.

Note: i is same as the name of batchfile that is i.bat

Now what you need to do is create a notepad and enter the above code with the application location and exe name and save it as a batch file

------------------------------------------------------------------------------------

For excel – save as e.bat and enter the following code

@echo off
cd C:\Program Files\Microsoft Office\Office12

excel.exe

For Outbool – save as o.bat and enter the following code

@echo off

cd C:\Program Files\Microsoft Office\Office12

outlook.exe

Note: you need to create the notepad file and enter and code and save it as batch, no need to go to environment variable window as you have already added it.

So if you want to open any exe of your project , creates the batch file of that and put the file inside the C:\batchFiles folder and enjoy

Test Data Creation

2010-04-20T08:58:00.000-05:00

http://urtesting.blogspot.com/

Most of the time during testing we put any data in application and test the application behavior and some how thats ok as far as testing team is concern. most of the time we need the valid test data in our test cases similar to the production test data or UAT test data or infact we need the test data to validate from a vast array of data .
lets assume we need the test data for address or telephone number in US or UK - in this case we put the test data of our nation and assume that it will workk for US or UK without knowing the pattens of US or UK address or better say the telephone number where the format vary from nation to nation.As a test engineer always in the shoes of end user must replicate the near real test data.

Same problem was with me , as I used to put any junk data and proceeds for testing ,but that was not acceptable as long as you becomes the senior in corporate ladder.

I resolve the problem of Test data that is some how the real test data.

There is a site -http://www.generatedata.com/#generator

that generated the test data for testing purposes . And it has the functionality of export in different format as Excel, XML ,HTML etc.