How To Guidelines For Split Billing Medicare Claims   

No one claims coding and billing is easy. Beyond CPTs, ICDs, and modifiers, coding delves into employment, ownership of equipment, location of services, and more. This post focuses on a specialty situation, “Split-Claim Billing”, that can impact how a claim is billed.

Most claims are comprised of two types of charges – professional and technical. 

  • Professional charges cover the fee of the physician.
  • Technical charges can cover the facility overhead, materials, medications, nurses, support staff, etc. 

Typically, hospitals and RHCs bill charges to Part A Medicare on a UB-04 form. Outpatient clinics bill Part B Medicare using a CMS 1500 form. Nearly all claims are billed using the electronic version of these claim forms.

Let’s get into the exceptions to these rules…

RHC Split Claim Scenario

Medicare has defined a list of “non-RHC services” that are covered however they are not reimbursed under the RHC reimbursement model. RHCs must bill these “non-RHC services” on separate claims from their RHC claims. Non-RHC services include:

  • Lab services
  • X-rays and EKGs – technical only
  • Hospital services
  • Ambulance services
  • Leg, arm, back and neck braces
  • Prosthetic devices
  • Hospice care (related conditions)
  • Durable Medical Equipment

Freestanding RHCs bill professional charges to Medicare Part A  on a UB-o4 and technical charges, such as labs, on a CMS 1500 to Medicare Part B. Provider-based RHCs bill professional charges on a UB-04 and technical components to Part A on a UB-04 under their parent provider. 

How Do You Bill Medicare Split Claims?

Depending on your EHR and billing system, billing both, UB-04 and CMS 1500, might not even be possible. Many systems focus on handling one or the other types of billing, few do both well. This can lead to the adoption of another software or service often not in communication with other solutions causing inefficiency, higher collection cost, and even a loss of revenue.

Even with systems that can handle both billing methods, split-claim billing is a process that doesn’t get much love from software companies. To accomplish splitting a claim you might have to go through multiple steps and screens to clean up generated claims and rebill new claims. In order to understand the true pain of inefficiency, often you have to experience it yourself.

We know because we did!

A Better Way – RHC Split-Claim Billing With Azalea

With Azalea’s roots in medical billing and our excellent track record providing billing services for hundreds of physicians, we identified this scenario and created a solution. A solution that is hard to beat. Splitting a claim with Azalea’s PM takes one click!

One click? Yes! 

With many EHRs and PMs focusing on either hospital or ambulatory billing, situations involving both types of billing become more of a “specialty” situation. Does your system handle split-claim billing? Is there room for error? Does it cost you more in time than it has to?

US San Diego Health reported encountering challenges with split-claim billing and after finding a new solution reported seeing its “clean claim rate increase and coding productivity skyrocket, with colonoscopy coding down from 12 minutes to less than five minutes.”

With many EHRs and PMs focusing on either hospital or ambulatory billing, situations involving both types of billing become more of a “specialty” situation. Does your system handle split-claim billing? Is there room for error? Does it cost you more in time than it has to?

US San Diego Health reported encountering challenges with split-claim billing and after finding a new solution reported seeing its “clean claim rate increase and coding productivity skyrocket, with colonoscopy coding down from 12 minutes to less than five minutes.”

Can your split billing process use a refresh?

Additional Resources

 

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