Managing the inpatient non-ambulatory billing for institutions or facilities entails heavy lifting and it requires a team and the tools that are up to task. Software systems designed to manage complex UB-04 billing departments can be expensive, and if not designed specifically for your institutional setting, they can be a poor fit and more of a hindrance. Following is a comprehensive breakdown in specific detail of features required in UB04 software to ensure UB-04 billing success.

Cloud-based Institutional Billing Systems

2023 Top Web Based UB-04 Software Solutions

837i (electronic) and CMS-1450 (paper) claim preparation by hospitals, surgery centers, and other institutions who bill out facility-services separate from professional services, requires software that can produce the UB-04 claims by which facilities obtain reimbursement.  PracticeSuite  is not only one of the most affordable UB-04 software, but it’s also one of the most feature-rich choices. With a 99.2 percent client retention rate and more than 41,000 medical professionals rating it number one, PracticeSuite is completely cloud-based and accessible on any device with an internet connection.

Who Can Use The CMS-1450?

• Community Mental Health Centers (CMHC)
• Comprehensive Outpatient Rehabilitation (CORF)
• Critical Access Hospitals (CAH)
• End-Stage Renal Disease Facilities (ESRD)
• Federally Qualified Health Centers (FQHC)
• Histo-Compatibility Laboratories (HCLs)
• Home Health Agencies (HHA)
• Hospices – Hospitals
• Indian Health Services Facilities (IHS)
• Organ Procurement Organizations
• Outpatient Physical Therapy Services
• Occupational Therapy Services
• Speech Pathology Services
• Religious Non-Medical Health Care Institutions (RNHCI)
• Rural Health Clinics (RHC)
• Skilled Nursing Facilities (SNF)

Understanding UB-04 Billing

Professional  Billing Verses  Institutional  Billing

When medical professionals such as doctors bill Medicare and other insurance carriers their fees for services rendered, they submit the  CMS-1500  uniform professional healthcare insurance claim form––otherwise known as the HCFA. In contrast, the cost of a facility’s hospital beds, equipment use, and ancillary items such as sutures and surgical supplies are billed to Medicare on  Form  CMS-1450,  or the Uniform  Institutional  Claim Form. The electronic version of these claim-forms are respectively 837P (professional) verses 837i for institutional billing.

Out-patient vs  In-patient,  Ambulatory vs  Non-ambulatory

When a patient visits their primary care or a specialist they are billed for a date-of-service (DOS). When they visit a hospital there’s an intake date of admission (Box 12) and a discharge hour and status (Box16 and 17) on the CMS-1450 claim form.

Types of UB-04 Solutions

Billing Programs  vs  Hospital Systems

While PracticeSuite can handle the billing for Mayo Clinic, it is not designed to run Mayo Clinic itself. On one side of the continuum you have colossal systems like  Epic,  Centricity,  or  AllScripts  that can run the Veterans Administration’s entire medical system soup-to-nuts; and on the other hand, you have simpler systems like PracticeSuite that allow any size billing department to bill institutional claims. While PracticeSuite is as fine a billing system as you will see, it is not an internal component found within a hospital’s Health Information Systems (HIS). However, PracticeSuite does  interface  with any Stage 2 or Stage 3 Certified software system and it is an  integrated  billing program for many partner software.

Cloud Based vs Locally Installed Systems

Locally installed  software systems typically require a purchase with a traditional licensing model, and require expensive servers, networks, network administrators, and expensive support contracts and annual upgrade costs.
Cloud based  systems on the other hand, are most often subscription-based, and there is no software to install, maintain, or purchase. Support and updates are included in the cost of your monthly subscription. PracticeSuite is a pure cloud based subscription software, or SAAS, software as a service that can be access securely anywhere and on any device connected to the internet.

Who Makes UB04 Software?

The companies that make and support the largest of these systems are household names like GE Healthcare. Here are a few companies that focus on institutional billing software for small to mid-sized enterprises:
Carevoyant
eClinicalWorks
HealthFusion
PracticeSuite

Evaluation and Selection of UB-04 Software

Formulating a Criteria

When selecting software for any size institution, key considerations arise, such as:

• Organizational Setting: Does the new system offer flexible workflows that fit your needs and setting?
• Essential Features: Be sure to nail down any ‘Must Have’ features required in the new system.
• Identify revenue cycle management needs verses the new software’s capabilities.
• Make certain that your institutional specific needs are supported.
• Size of the organization: It’s important that organizations of similar size find the software a fit.
• Affordability: Subscription-based pricing or traditional purchase model licensing?
• Cloud-based vs locally networked systems. Local systems require administration and know how.
• Support: Make certain that the availability of support matches your organizational needs. These expectations need to be present in the EULA (End User Licensing Agreement) and your final Service Level Agreement (SLA).

What Is The UB-04 and the CMS-1450 Claim Form?

What makes Institutional billing unique?

In addition to intake date of admission and discharge hour and status, the 837i and CMS-1450 require the use of codes that are not found on the CMS Professional 1500 form (837p). Codes that are maintained by the National Uniform Billing Committee (NUBC).
Unique UB-04 codes include:

1. Condition codes
2. Occurrence codes
3. Occurrence Span codes
4. Value codes
5. Revenue codes

In addition to entering codes unique to facility billing, institutions regularly need to verify insurance, track authorizations, produce pre-collection notifications, report financial and employee performance, and of course enter CMS-1450 charges. Hospitals specifically can have extremely complex and ever changing fee schedules.

Mastering The UB-04 Claim Form

A Field by Field Explanation of the UB-04 Claim Form

There are 81 entry fields or boxes on the 837i and CMS-1450 Uniform Institutional Claim Form:
Box 1: Billing provider name, street address, city, state, zip, telephone, fax, and country code
Box 2: Billing provider’s pay-to name, address, city, state, zip, and ID if it is different from field 1
Box 3: Patient control number and medical record number for your facility
Box 4: Type of bill (TOB) This is a four digit code beginning with zero, according to the National Uniform Billing Committee guidelines.
Box 5: Federal tax number for your facility
Box 6: Statement from and through dates for the service covered on the claim, in MMDDYY format.
Box 7: Not in use
Box 8: Patient name in Last, First, MI format
Box 9: Patient street address, city, state, zip, and country code
Box 10: Patient birthdate in MMDDCCYY format
Box 11: Patient sex – M, F, or U
Box 12: Admission date in MM/DD/YYYY format
Box 13: Admission hour using two-digit code from 00 for midnight to 23 for 11 pm
Box 14: Type of visit: 1 for emergency, 2 for urgent, 3 for elective, 4 for newborn, 5 for trauma, 9 for information not available.
Box 16: Discharge hour in same format as line 13.
Box 17 Discharge status – use the two-digit codes from the NUBC manual.
Box 18-28 Condition codes – use the two-digit codes from the NUBC manual for up to 11 occurrences.
Box 29 Accident state (if applicable) two-digit state code
Box 30 Not in use
Box 31-34 Occurrence codes and dates – use NUBC manual for codes
Box 35-36 Occurrence span codes and dates in MMDDYY format
Box 37 Not in use
Box 38 Responsible party name and address
Box 39-41 Value codes and amounts for special circumstances from the NUBC manual
Box 42 Revenue codes from the NUBC manual
Box 43 Revenue code description, investigational device exemption (IDE) number, or Medicaid drug rebate NDC (national drug code)
Box 44 HCPCS (Healthcare Common Procedure Coding System), accommodation rates, HIPPS (health insurance prospective payment system) rate codes
Box 45 Service dates
Box 46 Service units
Box 47 Total charges
Box 48 Non-covered charges
Box 49 Page_of_ and Creation date
Box 50 Payer Identification (a) Primary, (b) Secondary, and (c) Tertiary
Box 51 Health plan ID (a) Primary, (b) Secondary, and (c) Tertiary
Box 52 Release of information (a) Primary, (b) Secondary, and (c) Tertiary
Box 53 Assignment of benefits (a) Primary, (b) Secondary, and (c) Tertiary
Box 54 Prior payments (a) Primary, (b) Secondary, and (c) Tertiary
Box 55 Estimated amount due (a) Primary, (b) Secondary, and (c) Tertiary
Box 56 Billing provider national provider identifier (NPI)
Box 57 Other provider ID (a) Primary, (b) Secondary, and (c) Tertiary
Box 58 Insured’s name (a) Primary, (b) Secondary, and (c) Tertiary
Box 59 Patient’s relationship (a) Primary, (b) Secondary, and (c) Tertiary
Box 60 Insured’s unique ID (a) Primary, (b) Secondary, and (c) Tertiary
Box 61 Insurance group name (a) Primary, (b) Secondary, and (c) Tertiary
Box 62 Insurance group number (a) Primary, (b) Secondary, and (c) Tertiary
Box 63 Treatment authorization code (a) Primary, (b) Secondary, and (c) Tertiary
Box 64 Document control number also referred to as Internal control number (a) Primary, (b) Secondary, and (c) Tertiary
Box 65 Insured’s employer name (a) Primary, (b) Secondary, and (c) Tertiary
Box 66 Diagnosis codes (ICD)
Box 67 Principle diagnosis code, other diagnosis and present on admission (POA) indicators
Box 68 Not in use
Box 69 Admitting diagnosis codes
Box 70 Patient reason for visit codes
Box 71 Prospective payment system (PPS) code
Box 72 External cause of injury code and POA indicator
Box 73 Not in use
Box 74 Other procedure code and date
Box 75 Not in use
Box 76 Attending provider NPI, ID, qualifiers, and last and first name
Box 77 Operating physician NPI, ID, qualifiers, and last and first name
Box 78 Other provider NPI, ID, qualifiers, and last and first name
Box 79 Other provider NPI, ID, qualifiers, and last and first name
Box 80 Remarks
Box 81 Taxonomy code and qualifier

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