IBCBB3 ;ALB/TMP - CONTINUATION OF EDIT CHECKS ROUTINE (MEDICARE) ;06/23/98 ;;2.0;INTEGRATED BILLING;**51,137,155,349,371,377**;21-MAR-94;Build 23 ;;Per VHA Directive 2004-038, this routine should not be modified. ; EDITMRA(IBQUIT,IBER,IBIFN,IBFT) ; ; Requires execution of GVAR^IBCBB, IBIFN defined ; File IB ERROR (350.8) contains error codes/text ; N IBMRATYP,Z,IBZP,IBZP1,IBOK S IBQUIT=0 ;Flag to say we have too many errors - quit edits ; S IBMRATYP=$$MRATYPE^IBEFUNC(IBIFN,"C") ; I IBFT=3 D . D PARTA ; I IBFT=2 D PARTB^IBCBB9 ; K IBXDATA D F^IBCEF("N-ADMITTING DIAGNOSIS",,,IBIFN) ; Req. for UB-04 type of bills 11x!18x I $G(IBXDATA)="",IBFT=3 D Q:IBQUIT . N Z . I "^11^18^"[(U_IBTOB12_U) S IBQUIT=$$IBER(.IBER,231) Q . I $$INPAT^IBCEF(IBIFN,1) S Z="Admitting Diagnosis may be required by payer, please verify" D WARN^IBCBB11(Z) ; D GETPRV^IBCEU(IBIFN,"2,3,4",.Z) S IBOK=1,Z=0,IBZP=U F S Z=$O(Z(Z)) Q:'Z S:$S($P($G(Z(Z,1)),U,3)["VA(200":1,1:0) IBZP=IBZP_+$P(Z(Z,1),U,3)_U D ALLPROC^IBCVA1(IBIFN,.IBZP1) S Z=0 F S Z=$O(IBZP1(Z)) Q:'Z I $P(IBZP1(Z),U,18),IBZP'[(U_$P(IBZP1(Z),U,18)_U) S IBOK=0 Q I 'IBOK D WARN^IBCBB11("At least one provider on a procedure does not match your "_$S(IBFT=2:"render",1:"attend")_"ing or operating provider") I IBFT=2 D EN^IBCBB2 ; edit checks for UB-04 (institutional) forms I IBFT=3 D EN^IBCBB21(.IBZPRC92) ; Q ; PARTA ; MEDICARE specific edit checks for PART A claims (UB-04 formats) ; N IBI,IBJ,IBX,IBCTYP,VADM,VAPA,IBSTOP,IBDXC,IBDXARY,IBPR,IBLABS,REQMRA N IBS,IBTUNIT,IBCAGE,IBREV1,IBOCCS,IBOCSDT,IBVALCD,IBOCCD,IBNOPR N IBCCARY1,IBPATST,IBZADMIT,IBZDISCH,IBXIEN,IBXERR,IBXDATA,IBOCSP N IBCOV,IBNCOV,IBREVC,IBREVDUP,IBBCPT,IBREVC12,IBREVTOT,IBECAT,IBINC ; ; Medicare is the current payer, but no diagnosis codes I $$WNRBILL^IBEFUNC(IBIFN) D SET^IBCSC4D(IBIFN,.IBDX,.IBDXO) I '$P(IBDX,U,2) S IBQUIT=$$IBER(.IBER,120) Q:IBQUIT ; ; Type of Bill must be three digits I IBTOB'?3N S X=$$IBER(.IBER,103) Q ; ; Covered Days S IBCTYP=0 S IBCOV=$P(IBNDU2,U,2),IBNCOV=$P(IBNDU2,U,3) ; ; If interim bill, covered days must not be greater than 60 I "23"[$E(IBTOB,3),IBCOV>60 S IBQUIT=$$IBER(.IBER,"096") Q:IBQUIT ; ; I bill type is 11x or 18x or 21x then we need covered days I "^11^18^21^"[(U_IBTOB12_U) S IBCTYP=1 I IBCOV="" S IBQUIT=$$IBER(.IBER,106) Q:IBQUIT ; S (IBI,IBJ)=0 K IBXDATA D F^IBCEF("N-CONDITION CODES",,,IBIFN) ; Re-sort the condition codes by code S IBI=0 F S IBI=$O(IBXDATA(IBI)) Q:'IBI S IBCCARY1($P(IBXDATA(IBI),U))="" ; ; for condition code 40, covered days must be 0 I $D(IBCCARY1(40)),IBCOV'=0 S IBQUIT=$$IBER(.IBER,107) Q:IBQUIT ; ; cov days+non=to date -from date unless the patient status = 30 (still ; pt) or outpatient or if the to date and from date are same then add 1 S IBPATST="",IBX=$P(IBNDU,U,12),IBPATST=$P($G(^DGCR(399.1,+IBX,0)),U,2) S IBINC=$S(IBPATST=30!(IBFDT=IBTDT):1,1:0) I $$INPAT^IBCEF(IBIFN,1),(IBCOV+IBNCOV)'=($$FMDIFF^XLFDT(IBTDT,IBFDT)+IBINC) S IBQUIT=$$IBER(.IBER,108) Q:IBQUIT ; ; if covered days >100 and type of bill is 21x or 18x error I IBCOV>100,(IBTOB12=18!(IBTOB12=21)) S IBQUIT=$$IBER(.IBER,109) Q:IBQUIT ; S (IBJ,IBTUNIT,IBS,IBREVTOT("AC"),IBREVTOT("AI"),IBREVTOT("AO"),IBREVTOT)=0 ; K IBXDATA D F^IBCEF("N-UB-04 SERVICE LINE (EDI)",,,IBIFN) ;Get rev codes ; ; Re-sort the revenue codes by code ;>> IBREV1(rev code,x)=Rev code^ptr cpt^unit chg^units^total^tot unc ; IBREV1(rev code) = revenue code edit category ; ; IBNOPR = flag that determines if there are revenue codes with ; charges that do not have a procedure - no need to check ; for billable MCR procedures if at least one RC is billable ; 1 = there is at least one billable revenue code without a ; procedure ; S REQMRA=$$REQMRA^IBEFUNC(IBIFN) S (IBNOPR,IBI)=0 F S IBI=$O(IBXDATA(IBI)) Q:'IBI D . I REQMRA D GYMODCHK(IBXDATA(IBI)) ; IB*2*377 GY modifier check . S IBJ=$P(IBXDATA(IBI),U),IBECAT="" . I 'IBNOPR D .. I $P(IBXDATA(IBI),U,2)'="" S IBPR($P(IBXDATA(IBI),U,2))=IBI Q .. S IBNOPR=1 K IBPR . S:$D(IBREV1(IBJ)) IBECAT=$G(IBREV1(IBJ)) . I '$D(IBREV1(IBJ))!(IBECAT="") D S IBREV1(IBJ)=IBECAT . . ; . . ; Accomodations (AC) . . I (IBJ'<100&(IBJ'>219))!(IBJ=224) S IBECAT="AC" Q . . ; . . ; Ancillary Outpatient (AO) . . I '$$INPAT^IBCEF(IBIFN,1) S IBECAT="AO" Q . . ; . . ; Ancillary Inpatient (AI) . . S IBECAT="AI" . ; . S IBREV1(IBJ,+$O(IBREV1(IBJ,""),-1)+1)=IBXDATA(IBI) . S IBREVTOT(IBECAT)=IBREVTOT(IBECAT)+$P(IBXDATA(IBI),U,6) . I IBECAT="AC" S IBTUNIT=IBTUNIT+$P(IBXDATA(IBI),U,4) ; I $$NEEDMRA^IBEFUNC(IBIFN),$O(IBPR(""))'="" D Q:IBQUIT . ; Don't allow a bill containing only billable procedures for: . ; Oxygen, labs, or influenza shots . ; OR a bill with prosthetics on it . ; to be sent to MEDICARE for an MRA . D NONMCR(.IBPR,.IBLABS) ; Remove Oxygen, labs, influenza shots . I $G(IBLABS) D WARN^IBCBB11("The only possible billable procedures on this bill are labs -"),WARN^IBCBB11(" Please verify that MEDICARE does not reimburse these labs at 100%") Q . I $O(IBPR(""))="" D .. S IBQUIT=$$IBER(.IBER,"098") ; ; covered days+non covered = units of accom rev codes ; Check room and board I IBTUNIT,IBTUNIT'=(IBCOV+IBNCOV) S IBQUIT=$$IBER(.IBER,114) Q:IBQUIT ; ; Non Covered Days ; required when the type of bill is 11x,18x,21x or covered days=0 I IBNCOV="",(IBCTYP!(IBCOV=0)) S IBQUIT=$$IBER(.IBER,115) Q:IBQUIT ; ; if cc code=40 then non-covered days must be 1 I $D(IBCCARY1(40)),IBNCOV'=1 S IBQUIT=$$IBER(.IBER,116) Q:IBQUIT ; ; Patient Sex ; must be "M" or "F" D DEM^VADPT I $P(VADM(5),U)'="M",$P(VADM(5),U)'="F" S IBQUIT=$$IBER(.IBER,124) Q:IBQUIT ; ; esg - 10/17/07 - patch 371 ; For Part A replacement MRA request claims, make sure ; the Medicare ICN/DCN number is present and also text in FL-80. I $$REQMRA^IBEFUNC(IBIFN),$F(".137.138.117.118.","."_IBTOB_".") D Q:IBQUIT . N IBZ,FL80TXT . D F^IBCEF("N-CURR INS FORM LOC 64","IBZ",,IBIFN) ; see CI3-11 . I IBZ="" S IBQUIT=$$IBER(.IBER,205) Q:IBQUIT ; missing ICN/DCN . S FL80TXT=$P($G(^DGCR(399,IBIFN,"UF2")),U,3) . I FL80TXT="" S IBQUIT=$$IBER(.IBER,206) Q:IBQUIT ; missing FL80 text . Q ; D ^IBCBB4 Q ; IBER(IBER,ERRNO) ; Sets error list ; NOTE: add code to check error list > 20 ... If so, display message and ; quit so we don't get too many errors at once to handle ; Print all if printing list ; I '$G(IBQUIT) D . I ERRNO?1N.N S:$L(ERRNO)<3 ERRNO=$E("00",1,3-$L(ERRNO))_ERRNO . I $L(IBER,";")>19,'$G(IBPRT("PRT")) S IBER=IBER_"IB999;",IBQUIT=1 . I $G(IBER)'[("IB"_ERRNO_";") S IBER=IBER_"IB"_ERRNO_";" Q IBQUIT ; NONMCR(IBPR,IBLABS) ; Delete all oxygen and lab, flu shot CPT entries from IBPR ; IBPR = array subscripted by CPT codes from bill ; IBLABS = flag returned =1 if labs found on bill N Z S IBLABS=0 ; Oxygen F Z="A0422","A4575","A4616","A4619","A4620","A4621","E0455","E1353","E1355" K IBPR(Z) F Z=77:1:85 S Z0="E13"_Z K IBPR(Z0) ; Labs S Z="80000" F S Z=$O(IBPR(Z)) Q:Z'?1"8"4N S IBLABS=1 ; Flu shots F Z="90724","G0008","90732","G0009","90657","90658","90659","90660" K IBPR(Z) Q ; MCRANUM(IBIFN) ; Determine MEDICARE A provider ID # from bedsection for ; bill ien IBIFN N IBX ; PART A MRA (only) needed - determine if psych/non-psych claim N IBX,IBI S IBI=$P($G(^DGCR(399,IBIFN,"U")),U,11) S IBX=$S($TR($P($G(^DGCR(399.1,+IBI,0)),U),"psych","PSYCH")'["PSYCH":670899,1:674499) Q IBX ; MCRACK(IBIFN,X,IBFLD) ; Check for MEDICARE A for bill IBIFN ; Called from CLAIM STATUS MRA field (#24) xrefs in file 399 ; X = current value of field 399;24 ; IBFLD = 1 for primary ins co, 2 for secondary, 3 for tertiary N IB S IB=0 I +X,$$COBN^IBCEF(IBIFN)=IBFLD,$$WNRBILL^IBEFUNC(IBIFN,IBFLD),$$MRATYPE^IBEFUNC(IBIFN,"C")="A" S IB=1 Q IB ; GYMODCHK(Z) ; GY modifier check procedure. IB*2*377 - 2/4/08 ; Z is the IBXDATA(IBI) service line EDI N MODS I IBER["IB123" Q ; error already found S MODS=$P(Z,U,9) ; list of modifiers separated by commas I MODS'["GY" Q ; GY modifier not here on this line item I $P(Z,U,6) Q ; non-covered charges exist on this line item S IBQUIT=$$IBER(.IBER,123) GYMODX ; Q ;