Wednesday, June 22, 2016

How to report total charges on UB 04 WITH example


H. Total Charges Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434;

Providers are required to report in Total Charges the actual charge for the ambulance service including all supplies used for the ambulance trip but excluding the charge for mileage. For line items reflecting HCPCS code A0380, A0390, A0435, or A0436, report the actual charge for mileage.

NOTE: There are instances where the provider does not incur any cost for mileage, e.g., if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene. In these situations, providers report the base rate ambulance trip and mileage as separate revenue code lines. Providers report the base rate ambulance trip in accordance with current billing requirements. For purposes of reporting mileage, they must report the appropriate HCPCS code, modifiers, and units as a separate line item. For the related charges, providers report $1.00 in FL48 for non- covered charges. A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non- covered mileage line, which in turn informs the beneficiaries and providers that they each have no liability.

Prior to submitting the claim to CWF, the A/B MAC (A) will remove the entire revenue code line containing the mileage amount reported in Non-covered Charges to avoid non-acceptance of the claim.

NOTE: Information regarding the claim form locator that corresponds to the Charges fields is found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 25 – Completing and Processing the Form CMS-1450 Data Set.


EXAMPLES: The following provides examples of how bills for Part B ambulance services should be completed based on the reporting requirements above. These examples reflect ambulance services furnished directly by providers. Ambulance services provided under arrangement between the provider and an ambulance company are reported in the same manner except providers report a QM modifier instead of a QN modifier.

EXAMPLE 1: Claim containing only one ambulance trip:

For the hard copy CMS-1450 Form, providers report as follows:

Revenue Code    HCPCS/ Modifiers    Date of Service         Units        Total Charges  

  0540       A0428RHQN       082701      1 (trip)      100.00
   
  0540         A0380RHQN          082701            4 (mileage)           8.00


EXAMPLE 2: Claim containing multiple ambulance trips:

For the hard copy Form CMS-1450, providers report as follows:

0540            A0429        RH         QN        082801         1 (trip)           100.00

0540          A0380        RH         QN         082801     2 (mileage)        4.00

0540           A0330      RH         QN        082901         1 (trip)           400.00

0540            A0390         RH       QN        082901        3 (mileage)           6.00


EXAMPLE 3: Claim containing more than one ambulance trip provided on the same day:

For the hard copy CMS-1450, providers report as follows:


0540      A0429      RH     QN          090201       1 (trip)        100.00

0540        A0380        RH     QN        090201         2 (mileage)        4.00

0540        A0429     HR       QN          090201         1 (trip)          100.00

0540      A0380     HR        QN      090201        2 (mileage)          4.00

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