Accurate billing for continuous inpatient stays on the UB-04 form is critical for healthcare providers. Incorrectly filed claims, especially regarding sequential submission, frequency codes (FL 4), and patient discharge status (FL 17), can lead to claim denials, delayed reimbursements, and significant administrative burdens. This comprehensive guide will walk you through the intricacies of billing continuous care, ensuring your claims are clean, compliant, and processed efficiently.
Understanding the UB-04 Type of Bill Code (FL 4)
The Type of Bill (FL 4) is a crucial three-digit code on the UB-04 form that informs Medicare Administrative Contractors (MACs) about the type of facility, the bill classification, and the frequency of the claim. Understanding each digit is fundamental for correct submission, especially for continuous inpatient stays.
The three digits are structured as follows:
- First Digit (Facility Type): Identifies the type of institution submitting the bill. Common examples for continuous care include:
1: Hospital (including skilled nursing facilities (SNF) operating as a hospital department)7: Clinic or Community Mental Health Center (CMHC)8: Special Facility (e.g., Hospice)
- Second Digit (Bill Classification): Specifies the type of care being billed. For continuous stays:
3: Inpatient (e.g., for general acute care, SNF, TEFRA hospital)6: Outpatient (e.g., for partial hospitalization programs)5: Hospice (e.g., general inpatient care)
- Third Digit (Frequency Code): This is the most critical digit for continuous stays, indicating where the claim falls in a series of submissions for a single, continuous episode of care. This digit is the focus of the following section.
Understanding UB-04 Frequency Digits for Inpatient Stays
For patients requiring continuous inpatient care beyond a single billing cycle (e.g., a calendar month), providers must submit interim bills. The third digit of the Type of Bill (FL 4) – the frequency code – is essential for communicating the claim’s status to the MACs. Here’s a detailed breakdown:
Key Differences: Interim vs. Final Claims on UB-04
- Interim Claims (Frequency Codes 2, 3): These claims are submitted periodically during an ongoing inpatient stay or course of treatment. They indicate that the patient is still receiving care and that more claims will follow. These claims are crucial for maintaining cash flow for extended stays.
- Final Claims (Frequency Codes 1, 4): These claims represent the complete billing for a stay or the last claim in a series for a continuous stay. They signify that the patient has been discharged or that the course of treatment has concluded.
Let’s look at each frequency digit:
- Frequency Code ‘1’ – Admit Through Discharge Claim:
- Definition: This code is used when the “from” and “through” dates (FL 6) on the claim encompass the entire period of service from admission to discharge for a complete course of treatment.
- Scenario: A patient is admitted and discharged within the same billing period (e.g., a single calendar month) and only one claim is required for the entire stay.
- Example Type of Bill: 131 (Hospital Inpatient, Admit through Discharge), 761 (Clinic Outpatient, Admit through Discharge), 851 (Hospice Inpatient, Admit through Discharge).
- Patient Discharge Status (FL 17): A final patient discharge status code (e.g., 01-Discharged to Home, 02-Discharged to another short-term hospital) must be entered.
- Frequency Code ‘2’ – Interim – First Claim:
- Definition: This code marks the first claim in a series for a continuous inpatient stay or course of treatment where additional services are expected to be billed subsequently.
- Scenario: A patient is admitted for an extended stay spanning multiple billing periods. This is the initial claim submitted, covering the first segment of their continuous care.
- Example Type of Bill: 132, 762, or 852.
- Patient Discharge Status (FL 17): Must be
30(Still Patient).
- Frequency Code ‘3’ – Interim – Continuing Claim:
- Definition: Used for any claims submitted between the ‘First Claim’ (2) and the ‘Last Claim’ (4) in a series for a continuous stay.
- Scenario: The patient’s continuous inpatient stay extends beyond the period covered by the ‘Interim – First Claim’ and is not yet concluded. Multiple ‘3’ claims may be submitted.
- Example Type of Bill: 133, 763, or 853.
- Patient Discharge Status (FL 17): Must be
30(Still Patient).
- Frequency Code ‘4’ – Interim – Last Claim:
- Definition: This code signifies the final claim in a series for a continuous inpatient stay or course of treatment, indicating that no further claims are expected for this episode of care.
- Scenario: The patient’s continuous stay has ended, and this claim covers the final segment of services up to their discharge.
- Example Type of Bill: 134, 764, or 854.
- Patient Discharge Status (FL 17): A final patient discharge status code must be entered.
Providers have the flexibility to submit interim bills daily, weekly, or monthly, provided that the claims use the correct frequency code and are submitted sequentially.
Patient Discharge Status Code 30 and its Application (FL 17)
Field Locator 17 (FL 17) on the UB-04 form indicates the patient’s discharge status at the end of the “through” date for the services billed. For continuous inpatient stays, this field is particularly important for interim claims.
- Code
30– Still Patient: This specific code is mandatory for all ‘Interim – First Claim’ (frequency code 2) and ‘Interim – Continuing Claim’ (frequency code 3) submissions. It communicates to the MACs that the patient’s care is ongoing, and they have not been discharged from the facility. - Final Discharge Codes: For ‘Admit Through Discharge Claim’ (frequency code 1) and ‘Interim – Last Claim’ (frequency code 4), a definitive patient discharge status code must be reported. Common examples include:
01: Discharged to Home or Self Care02: Discharged to Another Short Term General Hospital03: Discharged to Skilled Nursing Facility (SNF)06: Discharged to Home Health Service20: Expired40: Discharged to a Hospice – Home41: Discharged to a Hospice – Medical Facility
The correct final discharge code accurately reflects the patient’s disposition at the conclusion of their continuous stay.
Handling Out-of-Sequence UB-04 Claims for Continuous Treatment
Submitting claims for a continuous inpatient stay or course of treatment requires strict adherence to sequential billing. When a patient remains an inpatient (e.g., in a SNF, TEFRA hospital, swing-bed, or hospice) beyond a single calendar month, providers must submit a bill for each calendar month in service date sequence. Medicare Administrative Contractors (MACs) are equipped with systems to prevent the acceptance of a continuing stay claim until all prior bills have been processed.
Consequences of Out-of-Sequence Claims
If an out-of-sequence claim is received, MACs will attempt to locate the prior bill in their claims history. The implications vary depending on whether it’s a general claim or a hospice claim:
- For General Inpatient Claims (e.g., Hospital, SNF):
- If the prior bill is not found in the finalized claims history, the incoming bill will be returned to the provider. The MACs will issue an error message requesting the prior bill be submitted first.
- The returned bill cannot be resubmitted until the provider receives notice of the adjudication of the prior, missing bill. This causes significant payment delays and additional administrative work.
- A typical error message might state: “Bills for a continuous stay or admission or for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. If you have not already done so, please submit the prior bill. Then, resubmit this bill after you receive the remittance advice for the prior bill.”
- For Hospice Claims:
- If the MAC finds the prior hospice claim has been received but is not yet finalized (e.g., suspended for additional development), they will hold the out-of-sequence claim. It will not be returned immediately.
- The held claim will only be processed after the prior claim has been finalized.
- However, if the prior hospice claim has not been received at all, the out-of-sequence claim is returned to the provider with an error message similar to general claims.
- Impact on Timeliness and Interest: Hospice claims received out of sequence, even if held, do not meet the definition of “clean claims”. Consequently, they are not subject to mandated claims processing timeliness standards and are not eligible for interest payments. MACs will enter condition code 64 on these held claims to denote their non-clean status.
Failure to submit claims sequentially directly impacts reimbursement timeliness and can lead to financial penalties or increased operational costs due to rework.
Best Practices for UB-04 Continuous Stay Billing Compliance
To ensure smooth processing and avoid denials for continuous inpatient stays, providers should adopt the following best practices:
- Accurate Date Ranges (FL 6): Always ensure that the “from” and “through” dates on each UB-04 claim accurately reflect the services provided during that specific billing period, and that these periods sequentially follow each other without gaps or overlaps.
- Verify Patient Discharge Status (FL 17): Rigorously check that the Patient Discharge Status code is correctly applied:
30for interim claims (frequency codes 2 and 3) and a final, appropriate discharge code for “Admit Through Discharge” (frequency code 1) and “Interim – Last Claim” (frequency code 4). - Establish Internal Protocols for Sequential Submission: Implement clear internal workflows and checks to guarantee that claims for continuous stays are submitted in the correct chronological order. This includes tracking prior claim adjudication and ensuring that subsequent claims are only sent once the previous claim has been finalized.
- Regularly Review MAC Guidance: Stay updated with the latest guidelines and transmittals from your specific Medicare Administrative Contractor regarding UB-04 billing for continuous care. Official CMS guidance on claim adjustments can be found on their website.
- Staff Training: Provide ongoing education and training for billing and coding staff on the nuances of continuous stay billing, emphasizing frequency codes, patient status, and the consequences of out-of-sequence submissions.
Frequently Asked Questions (FAQ) about UB-04 Continuous Stay Billing
- Q: What is the significance of the third digit in the UB-04 Type of Bill (FL 4)?
- A: The third digit, known as the frequency code, indicates where the current claim falls within a series of claims for a single, continuous inpatient stay. It tells the MACs if it’s the first, a continuing, or the final claim.
- Q: Why is Patient Discharge Status Code ’30’ used for interim claims?
- A: Code ’30’ (“Still Patient”) is used for interim claims (frequency codes 2 and 3) to inform the MACs that the patient’s care is ongoing, and they have not been discharged, indicating that more claims for this continuous stay are expected.
- Q: What happens if a UB-04 claim for a continuous stay is submitted out of sequence?
- A: For most claims, an out-of-sequence submission will result in the claim being returned to the provider with an error message, requiring resubmission after the prior claim has been processed. For hospice claims, they might be held if the prior claim is merely suspended, but if the prior claim is missing, it will also be returned. Out-of-sequence claims lead to payment delays and are not considered “clean claims.”
- Q: How frequently can interim UB-04 bills be submitted?
- A: Providers can submit interim bills daily, weekly, or monthly, as long as they use the correct frequency codes and maintain strict sequential order of submission based on service dates (FL 6).
- Q: Where can I find official guidance on UB-04 billing from Medicare?
- A: Official guidance, including manuals and transmittals, can be found on the Centers for Medicare & Medicaid Services (CMS) website. Your specific Medicare Administrative Contractor (MAC) also provides localized guidance.