Preventing & Resolving Hospital Billing Rejections: Maternity Room & NDC Numbers

Hospital billing departments frequently encounter complex challenges leading to maternity billing rejections and NDC billing errors. These issues can result in significant hospital claim denials, impacting revenue cycles and operational efficiency. This comprehensive guide will help you understand, prevent, and effectively resolve common billing rejections related to maternity room and board, accurate NDC reporting, and proper split billing procedures, ensuring smoother claim processing.

Understanding Maternity Room and Board Revenue Codes & Preventing Billing Rejections

Maternity services require precise coding to ensure proper reimbursement. Maternity Room and Board Revenue Codes are crucial for accurate hospital billing. The 012x series, such as revenue code 0121 for daily room and board, is commonly utilized for general medical/surgical care, which often applies to maternity stays. Best practices dictate using the most appropriate revenue code that accurately reflects the services provided. However, even with appropriate codes, specific payer rules can cause hospital claim denials. For instance, Molina has observed instances where maternity claims have been denied or paid zero because they lacked the appropriate maternity room and board revenue codes. While rare exceptions exist, consistently billing with the correct maternity room and board revenue code, when applicable, will significantly improve claim processing efficiency and reduce maternity billing rejections.

Navigating NDC Billing Instructions & Preventing Hospital Claim Denials

NDC Billing Instructions are vital for pharmaceutical claims. The National Drug Code (NDC) is a unique, three-segment number that serves as a universal product identifier for human drugs. It’s essential for tracking drugs, ensuring proper reimbursement, and preventing NDC billing errors. General formatting requires the 11-digit NDC, often preceded by a qualifier (e.g., N4), and the corresponding NDC unit of measure (e.g., ML, GR, UN). Common errors include incorrect NDC units, invalid NDCs, or issues with multiple NDCs on a single service line. The Molina EDI Help Desk has specifically reported claims being rejected because more than one NDC code was billed on a single service line. To address this and prevent hospital claim denials, specific guidelines must be followed. For more detailed information on general NDC billing codes, unit requirements, frequently asked questions, and manufacturer rebate programs, providers may refer to official state Medicaid/BMS websites, such as www.wvdhhr.org/bms.

Molina-Specific NDC Billing for Multiple Drugs

At times, providers may need to report multiple NDCs for a single procedure code. When dealing with multiple NDCs for a single drug (excluding compounds, which may have separate guidelines), Molina requires specific modifier usage:

• The first claim line should use the procedure code with a KP modifier, along with the corresponding procedure code units, NDC qualifier, NDC, NDC unit qualifier, and NDC units. This line must reflect the charge for the amount of the drug dispensed for that specific NDC.
• Any subsequent line item for the same procedure code, utilizing a different NDC for the same drug, must be billed with a KQ modifier, along with its procedure code units, charge, and NDC information for that portion of the drug.

It is crucial to remember that payer-specific rules can vary significantly. Always consult Molina’s latest provider manual or communication for the most up-to-date NDC billing instructions.

Split Billing Guidelines: Understanding Rationale for Outpatient and Inpatient Services

Split Billing Guidelines are critical for certain outpatient services that span different contract periods. The rationale behind split billing often stems from contract updates or changes in reimbursement policies, which necessitate separate reporting periods to ensure accurate payment. For Molina, hospital contracts are updated every July 1st and October 1st. Therefore, if you are billing an outpatient claim that extends from June into July, or from September into October, it is imperative to split the claim into two distinct submissions. The first claim should end on June 30th or September 30th, and the subsequent claim should begin on July 1st or October 1st, reflecting the new contract period. It’s important to note a key distinction for inpatient services: Inpatient acute care claims cannot be split billed. These claims must be billed upon the patient’s discharge only, regardless of contract update dates.

UB-04 Billing for Maternity Services: Specific Considerations

When submitting claims for maternity services, the UB-04 maternity billing form is the standard for institutional providers. Ensuring accurate completion of this form is paramount to preventing hospital claim denials. All relevant Maternity Room and Board Revenue Codes, along with precise NDC billing information for drugs administered, must be correctly populated in the appropriate fields on the UB-04. Proper placement of modifiers, accurate dates of service, and correct patient demographic information are also essential for successful UB-04 maternity billing. Errors in any of these areas can lead to significant maternity billing rejections.

Troubleshooting & Prevention: Resolving Maternity & NDC Billing Rejections

Effective troubleshooting and proactive prevention are key to minimizing maternity billing rejections and NDC billing errors.

• Review Remittance Advice (RA): Always meticulously review your Remittance Advice or Explanation of Benefits (EOB). Pay close attention to claim adjustment reason codes for maternity and NDC-related denials. These codes provide specific details on why a claim was rejected or denied.
• Common Rejection Codes: Be familiar with common rejection codes related to missing revenue codes, incorrect NDCs, or date-of-service conflicts. Understanding these codes is the first step in successful claim correction.
• Internal Audits: Regularly audit a sample of your maternity and NDC claims before submission to identify and correct common errors proactively.
• Payer Communication: Establish clear lines of communication with payers. If a claim is denied, contacting the payer’s provider relations or EDI help desk can provide clarification on specific billing requirements or common errors.
• Correction and Resubmission: When correcting a denied claim, ensure all identified errors are addressed. Use appropriate claim adjustment reason codes for maternity on the corrected claim, and resubmit it within the payer’s timely filing limits. Document all correction efforts for future reference.

For comprehensive guidance on hospital billing and UB-04 form completion, refer to official resources such as the CMS Internet-Only Manuals (IOMs), which provide detailed billing instructions for various services including hospital claims. A foundational resource for general billing principles can be found at CMS.gov. Additionally, for official guidelines regarding the UB-04 claim form, consult the National Uniform Billing Committee (NUBC) resources, available at nucc.org.