Q&A: Billing on UB-04 Claims

July 19, 2016
Medicare Web

Q. Can a hospital that is not a critical access hospital (CAH) bill professional charges on UB-04 claims, Type of Bill (TOB) 013X? I have not read anywhere that hospitals cannot bill this way, but usually when discussing revenue 96X and other professional revenue codes there is mention of CAHs only.

A. Revenue codes 96X, 97X, and 98X are exclusively for use by a CAHs when reporting services on a TOB 851 only. This allows the CAH to bill its outpatient services and the related professional fees when they have elected to bill under Method II for that professional. A CAH is unique in that it will be reimbursed 115% of what the MPFS would usually pay for the related professional service. Since this is a cost-based payment methodology, these professional fee revenue codes are excluded from reporting on TOB 131 – OPPS claim. (See 42 CFR 413.70(b)(3), Medicare Claims Process Manual, Chapter 4 § 250.2.)

Debbie Mackaman, RHIA, CPCO, CCDS, a regulatory specialist for HCPro, a division of BLR, answered this question.

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