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Line Item Method for Processing UB92 / UB04 Hospital Outpatient Fee Bills

posted Apr 12, 2012, 7:24 AM by Compensate Admin

The new Hospital Outpatient Reimbursement Rule of 4/1/2012 OAC 4123-6-37.2 A (b) (ii and iii).  http://www.ohiobwc.com/downloads/blankpdf/HospOutReimburseRuleApril12.pdf  now requires that all outpatient fee bills using forms UB92 / UB04 be reduced by line item in order to reimburse the correct amount.

It is no longer acceptable to simply reduce the entire bill using the cost to charge ratio. 

The following bill types are subject to the line item procedure.  131, 132, 133, 134, 135 (found in box 4 on the UB-04)

Hospital outpatient fee bills after 4/1/2012 will contain line items that are reduced by a fee maximum schedule (found in Appendix A of this rule), or by reasonable cost (cost to charge percentage).  Some line items that are Not Routinely Covered have a fee maximum amount.  To properly reduce these bills the following procedure applies:

Outpatient bills must be reduced by line item using the CPT Payment program in Compensate®

The first thing you will need is the 11 digit BWC Provider number which is located in box 51 on the UB92 and box 57 on the UB04.

Do not use the 9 digit Tax number from box 5.

In some cases the box 51 value is only 9 digits long instead of 11.  If you use the 9 digit number the default cost to charge percentage will be 56%. Avoid overpayment by using the correct BWC provider number.

Enter the 11 digit BWC Provider ID and select the appropriate payment address.

Input the Patient ID from the fee bill.

Input the billing date, Service From and To dates.

Use place of service code 22 for all outpatient bills.

Enter the CPT code and use modifier 13 for all line items.  If there is no CPT code listed - such as for "medical supplies" - you may choose to request an itemized bill from the provider or use a general code.   The use of general codes such as W9999 will allow the reduction of items on the bill that do not have CPT codes.  Using this code, the fee bill amount will always be reduced by the proper cost to charge percentage. The procedure description can be edited when using a general code

Enter the fee bill amount and the adjusted fee maximum will show the reduced amount based on the line item instructions in the BWC fee schedule.

Some items will result in a payment value of 0.00 because the CPT code is never allowed and a message on screen will indicate Never Covered. Some items will display a dollar amount but the on screen message will indicate that the CPT code is Not Routinely Covered but if you decide to pay anyway there is an associated fee maximum amount.

Repeat the above until all line items have been processed.

Make sure you use modifier 13 on every line item… other modifiers will give much different results.  

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