source: FOIAVistA/trunk/r/INTEGRATED_BILLING-IB-PRQ--IBD--IBQ--PRQS/IBCBB3.m@ 1311

Last change on this file since 1311 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version

File size: 8.0 KB
Line 
1IBCBB3 ;ALB/TMP - CONTINUATION OF EDIT CHECKS ROUTINE (MEDICARE) ;06/23/98
2 ;;2.0;INTEGRATED BILLING;**51,137,155,349,371,377**;21-MAR-94;Build 23
3 ;;Per VHA Directive 2004-038, this routine should not be modified.
4 ;
5EDITMRA(IBQUIT,IBER,IBIFN,IBFT) ;
6 ; Requires execution of GVAR^IBCBB, IBIFN defined
7 ; File IB ERROR (350.8) contains error codes/text
8 ;
9 N IBMRATYP,Z,IBZP,IBZP1,IBOK
10 S IBQUIT=0 ;Flag to say we have too many errors - quit edits
11 ;
12 S IBMRATYP=$$MRATYPE^IBEFUNC(IBIFN,"C")
13 ;
14 I IBFT=3 D
15 . D PARTA
16 ;
17 I IBFT=2 D PARTB^IBCBB9
18 ;
19 K IBXDATA D F^IBCEF("N-ADMITTING DIAGNOSIS",,,IBIFN)
20 ; Req. for UB-04 type of bills 11x!18x
21 I $G(IBXDATA)="",IBFT=3 D Q:IBQUIT
22 . N Z
23 . I "^11^18^"[(U_IBTOB12_U) S IBQUIT=$$IBER(.IBER,231) Q
24 . I $$INPAT^IBCEF(IBIFN,1) S Z="Admitting Diagnosis may be required by payer, please verify" D WARN^IBCBB11(Z)
25 ;
26 D GETPRV^IBCEU(IBIFN,"2,3,4",.Z)
27 S IBOK=1,Z=0,IBZP=U F S Z=$O(Z(Z)) Q:'Z S:$S($P($G(Z(Z,1)),U,3)["VA(200":1,1:0) IBZP=IBZP_+$P(Z(Z,1),U,3)_U
28 D ALLPROC^IBCVA1(IBIFN,.IBZP1)
29 S Z=0 F S Z=$O(IBZP1(Z)) Q:'Z I $P(IBZP1(Z),U,18),IBZP'[(U_$P(IBZP1(Z),U,18)_U) S IBOK=0 Q
30 I 'IBOK D WARN^IBCBB11("At least one provider on a procedure does not match your "_$S(IBFT=2:"render",1:"attend")_"ing or operating provider")
31 I IBFT=2 D EN^IBCBB2
32 ; edit checks for UB-04 (institutional) forms
33 I IBFT=3 D EN^IBCBB21(.IBZPRC92)
34 ;
35 Q
36 ;
37PARTA ; MEDICARE specific edit checks for PART A claims (UB-04 formats)
38 ;
39 N IBI,IBJ,IBX,IBCTYP,VADM,VAPA,IBSTOP,IBDXC,IBDXARY,IBPR,IBLABS,REQMRA
40 N IBS,IBTUNIT,IBCAGE,IBREV1,IBOCCS,IBOCSDT,IBVALCD,IBOCCD,IBNOPR
41 N IBCCARY1,IBPATST,IBZADMIT,IBZDISCH,IBXIEN,IBXERR,IBXDATA,IBOCSP
42 N IBCOV,IBNCOV,IBREVC,IBREVDUP,IBBCPT,IBREVC12,IBREVTOT,IBECAT,IBINC
43 ;
44 ; Medicare is the current payer, but no diagnosis codes
45 I $$WNRBILL^IBEFUNC(IBIFN) D SET^IBCSC4D(IBIFN,.IBDX,.IBDXO) I '$P(IBDX,U,2) S IBQUIT=$$IBER(.IBER,120) Q:IBQUIT
46 ;
47 ; Type of Bill must be three digits
48 I IBTOB'?3N S X=$$IBER(.IBER,103) Q
49 ;
50 ; Covered Days
51 S IBCTYP=0
52 S IBCOV=$P(IBNDU2,U,2),IBNCOV=$P(IBNDU2,U,3)
53 ;
54 ; If interim bill, covered days must not be greater than 60
55 I "23"[$E(IBTOB,3),IBCOV>60 S IBQUIT=$$IBER(.IBER,"096") Q:IBQUIT
56 ;
57 ; I bill type is 11x or 18x or 21x then we need covered days
58 I "^11^18^21^"[(U_IBTOB12_U) S IBCTYP=1 I IBCOV="" S IBQUIT=$$IBER(.IBER,106) Q:IBQUIT
59 ;
60 S (IBI,IBJ)=0
61 K IBXDATA D F^IBCEF("N-CONDITION CODES",,,IBIFN)
62 ; Re-sort the condition codes by code
63 S IBI=0 F S IBI=$O(IBXDATA(IBI)) Q:'IBI S IBCCARY1($P(IBXDATA(IBI),U))=""
64 ;
65 ; for condition code 40, covered days must be 0
66 I $D(IBCCARY1(40)),IBCOV'=0 S IBQUIT=$$IBER(.IBER,107) Q:IBQUIT
67 ;
68 ; cov days+non=to date -from date unless the patient status = 30 (still
69 ; pt) or outpatient or if the to date and from date are same then add 1
70 S IBPATST="",IBX=$P(IBNDU,U,12),IBPATST=$P($G(^DGCR(399.1,+IBX,0)),U,2)
71 S IBINC=$S(IBPATST=30!(IBFDT=IBTDT):1,1:0)
72 I $$INPAT^IBCEF(IBIFN,1),(IBCOV+IBNCOV)'=($$FMDIFF^XLFDT(IBTDT,IBFDT)+IBINC) S IBQUIT=$$IBER(.IBER,108) Q:IBQUIT
73 ;
74 ; if covered days >100 and type of bill is 21x or 18x error
75 I IBCOV>100,(IBTOB12=18!(IBTOB12=21)) S IBQUIT=$$IBER(.IBER,109) Q:IBQUIT
76 ;
77 S (IBJ,IBTUNIT,IBS,IBREVTOT("AC"),IBREVTOT("AI"),IBREVTOT("AO"),IBREVTOT)=0
78 ;
79 K IBXDATA D F^IBCEF("N-UB-04 SERVICE LINE (EDI)",,,IBIFN) ;Get rev codes
80 ;
81 ; Re-sort the revenue codes by code
82 ;>> IBREV1(rev code,x)=Rev code^ptr cpt^unit chg^units^total^tot unc
83 ; IBREV1(rev code) = revenue code edit category
84 ;
85 ; IBNOPR = flag that determines if there are revenue codes with
86 ; charges that do not have a procedure - no need to check
87 ; for billable MCR procedures if at least one RC is billable
88 ; 1 = there is at least one billable revenue code without a
89 ; procedure
90 ;
91 S REQMRA=$$REQMRA^IBEFUNC(IBIFN)
92 S (IBNOPR,IBI)=0
93 F S IBI=$O(IBXDATA(IBI)) Q:'IBI D
94 . I REQMRA D GYMODCHK(IBXDATA(IBI)) ; IB*2*377 GY modifier check
95 . S IBJ=$P(IBXDATA(IBI),U),IBECAT=""
96 . I 'IBNOPR D
97 .. I $P(IBXDATA(IBI),U,2)'="" S IBPR($P(IBXDATA(IBI),U,2))=IBI Q
98 .. S IBNOPR=1 K IBPR
99 . S:$D(IBREV1(IBJ)) IBECAT=$G(IBREV1(IBJ))
100 . I '$D(IBREV1(IBJ))!(IBECAT="") D S IBREV1(IBJ)=IBECAT
101 . . ;
102 . . ; Accomodations (AC)
103 . . I (IBJ'<100&(IBJ'>219))!(IBJ=224) S IBECAT="AC" Q
104 . . ;
105 . . ; Ancillary Outpatient (AO)
106 . . I '$$INPAT^IBCEF(IBIFN,1) S IBECAT="AO" Q
107 . . ;
108 . . ; Ancillary Inpatient (AI)
109 . . S IBECAT="AI"
110 . ;
111 . S IBREV1(IBJ,+$O(IBREV1(IBJ,""),-1)+1)=IBXDATA(IBI)
112 . S IBREVTOT(IBECAT)=IBREVTOT(IBECAT)+$P(IBXDATA(IBI),U,6)
113 . I IBECAT="AC" S IBTUNIT=IBTUNIT+$P(IBXDATA(IBI),U,4)
114 ;
115 I $$NEEDMRA^IBEFUNC(IBIFN),$O(IBPR(""))'="" D Q:IBQUIT
116 . ; Don't allow a bill containing only billable procedures for:
117 . ; Oxygen, labs, or influenza shots
118 . ; OR a bill with prosthetics on it
119 . ; to be sent to MEDICARE for an MRA
120 . D NONMCR(.IBPR,.IBLABS) ; Remove Oxygen, labs, influenza shots
121 . 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
122 . I $O(IBPR(""))="" D
123 .. S IBQUIT=$$IBER(.IBER,"098")
124 ;
125 ; covered days+non covered = units of accom rev codes
126 ; Check room and board
127 I IBTUNIT,IBTUNIT'=(IBCOV+IBNCOV) S IBQUIT=$$IBER(.IBER,114) Q:IBQUIT
128 ;
129 ; Non Covered Days
130 ; required when the type of bill is 11x,18x,21x or covered days=0
131 I IBNCOV="",(IBCTYP!(IBCOV=0)) S IBQUIT=$$IBER(.IBER,115) Q:IBQUIT
132 ;
133 ; if cc code=40 then non-covered days must be 1
134 I $D(IBCCARY1(40)),IBNCOV'=1 S IBQUIT=$$IBER(.IBER,116) Q:IBQUIT
135 ;
136 ; Patient Sex
137 ; must be "M" or "F"
138 D DEM^VADPT
139 I $P(VADM(5),U)'="M",$P(VADM(5),U)'="F" S IBQUIT=$$IBER(.IBER,124) Q:IBQUIT
140 ;
141 ; esg - 10/17/07 - patch 371
142 ; For Part A replacement MRA request claims, make sure
143 ; the Medicare ICN/DCN number is present and also text in FL-80.
144 I $$REQMRA^IBEFUNC(IBIFN),$F(".137.138.117.118.","."_IBTOB_".") D Q:IBQUIT
145 . N IBZ,FL80TXT
146 . D F^IBCEF("N-CURR INS FORM LOC 64","IBZ",,IBIFN) ; see CI3-11
147 . I IBZ="" S IBQUIT=$$IBER(.IBER,205) Q:IBQUIT ; missing ICN/DCN
148 . S FL80TXT=$P($G(^DGCR(399,IBIFN,"UF2")),U,3)
149 . I FL80TXT="" S IBQUIT=$$IBER(.IBER,206) Q:IBQUIT ; missing FL80 text
150 . Q
151 ;
152 D ^IBCBB4
153 Q
154 ;
155IBER(IBER,ERRNO) ; Sets error list
156 ; NOTE: add code to check error list > 20 ... If so, display message and
157 ; quit so we don't get too many errors at once to handle
158 ; Print all if printing list
159 ;
160 I '$G(IBQUIT) D
161 . I ERRNO?1N.N S:$L(ERRNO)<3 ERRNO=$E("00",1,3-$L(ERRNO))_ERRNO
162 . I $L(IBER,";")>19,'$G(IBPRT("PRT")) S IBER=IBER_"IB999;",IBQUIT=1
163 . I $G(IBER)'[("IB"_ERRNO_";") S IBER=IBER_"IB"_ERRNO_";"
164 Q IBQUIT
165 ;
166NONMCR(IBPR,IBLABS) ; Delete all oxygen and lab, flu shot CPT entries from IBPR
167 ; IBPR = array subscripted by CPT codes from bill
168 ; IBLABS = flag returned =1 if labs found on bill
169 N Z S IBLABS=0
170 ; Oxygen
171 F Z="A0422","A4575","A4616","A4619","A4620","A4621","E0455","E1353","E1355" K IBPR(Z)
172 F Z=77:1:85 S Z0="E13"_Z K IBPR(Z0)
173 ; Labs
174 S Z="80000" F S Z=$O(IBPR(Z)) Q:Z'?1"8"4N S IBLABS=1
175 ; Flu shots
176 F Z="90724","G0008","90732","G0009","90657","90658","90659","90660" K IBPR(Z)
177 Q
178 ;
179MCRANUM(IBIFN) ; Determine MEDICARE A provider ID # from bedsection for
180 ; bill ien IBIFN
181 N IBX
182 ; PART A MRA (only) needed - determine if psych/non-psych claim
183 N IBX,IBI
184 S IBI=$P($G(^DGCR(399,IBIFN,"U")),U,11)
185 S IBX=$S($TR($P($G(^DGCR(399.1,+IBI,0)),U),"psych","PSYCH")'["PSYCH":670899,1:674499)
186 Q IBX
187 ;
188MCRACK(IBIFN,X,IBFLD) ; Check for MEDICARE A for bill IBIFN
189 ; Called from CLAIM STATUS MRA field (#24) xrefs in file 399
190 ; X = current value of field 399;24
191 ; IBFLD = 1 for primary ins co, 2 for secondary, 3 for tertiary
192 N IB
193 S IB=0
194 I +X,$$COBN^IBCEF(IBIFN)=IBFLD,$$WNRBILL^IBEFUNC(IBIFN,IBFLD),$$MRATYPE^IBEFUNC(IBIFN,"C")="A" S IB=1
195 Q IB
196 ;
197GYMODCHK(Z) ; GY modifier check procedure. IB*2*377 - 2/4/08
198 ; Z is the IBXDATA(IBI) service line EDI
199 N MODS
200 I IBER["IB123" Q ; error already found
201 S MODS=$P(Z,U,9) ; list of modifiers separated by commas
202 I MODS'["GY" Q ; GY modifier not here on this line item
203 I $P(Z,U,6) Q ; non-covered charges exist on this line item
204 S IBQUIT=$$IBER(.IBER,123)
205GYMODX ;
206 Q
207 ;
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