NUBC's diagnosis coding improvements may reduce outpatient claims denials - Updata - National Uniform Billing Committee

Healthcare Financial Management, Nov, 1999

The National Uniform Billing Committee (NUBC) has agreed to add a "patient's reason for visit" data element to the admitting diagnosis field of the UB-92 claim form. By allowing providers to report the reason the patient presented for treatment, the modified UB-92 form provides information payers often require to more fairly adjudicate claims. Without such information, the payer would have to base its payment decision only on information regarding the condition for which the patient was treated (ie, the physician's final diagnosis), which may be much less severe than the patient's symptoms initially suggested. Health plans may deny payment or request additional documentation if the condition treated is regarded as not being serious enough to warrant high-cost emergency care, even though the patient may have had reason to believe his or her condition was seriously debilitating or life-threatening.

The changed UB-92 data set is intended to help eliminate the need for the provider to furnish a payer with additional documentation to support the reason for the emergency department visit and allows the provider to clarify why certain diagnostic tests may have been ordered. It also reduces the burden on the payer to request additional documentation in support of the claim. The result should be a less cumbersome claims-adjudication process, fewer payment delays, and, ultimately, fewer denials of claims for outpatient services following an emergency department visit. The modification will bring claims for outpatient services more in line with the intent of 1997 Balanced Budget Act provisions regarding a prudent layperson's right to seek healthcare services from a qualified provider without approval of a health plan when confronted with a health emergency. It also will make the definition of "patient's reason for visit" consistent with various national definitions, such as those used by various national commercial payers.

Specifically, the NUBC will modify the definition of the admitting diagnosis

field (Form Locator 76) on the UB-92 form to read as follows: "The ICD-9-CM diagnosis code describing the patient's diagnosis or reason for visit at the time of admission or outpatient registration." The change will allow the field to serve a dual purpose. If a patient makes an unscheduled visit to a facility's emergency room or urgent care center and receives treatment on an out-patient basis, the diagnosis code describing the patient's reason for the visit would be reported on Form Locator 76. If the encounter results in an inpatient admission, the diagnosis code for the reason for admission would be reported rather than the patient's reason for the visit.

The change is effective for services furnished on or after April 1, 2000, and applies to all payer group types. For more information, call the NUBC at (312) 422-3398.