Intellect™
CHARGES MENU OPTIONS
UB Encounter
Sample UB-04
and
BILLING MENU OPTIONS
Insurance
Paper Claim Resources
Sample UB-04
UB-04 Form
Effective version 20.12.21: Box 39a - 41d
Per CMS, effective January 1, 2021, CMS is implementing Value Code (VC) D6: The total number of minutes of dialysis provided during the billing period. Designation: NM (Non-Monetary). See Information from CMS for details. For example:
A patient is dialyzed 3 hours per day, 3 days a week, for 4 weeks. The ESRD facility would report 2160 minutes (that is, (60 x 3) x (3 x 4) = 2160) as “0002160.00” in VC D6.
To accommodate the new D6 code, effective in the 20.12.21 Intellect release, when the Value Code ‘D6’ is entered in any of the <Value Code 1-8> fields on the Charges --►Encounter --►UB Encounter screen and the <Amount> field is populated, the program now changes the format and adds applicable zeros to the start of the value based on the minutes entered (e.g., 2160 minutes becomes 0002160.00).
When the UB04 is printed, the <Value Code> prints in Box 39a as D6.
When claims are submitted electronically via Intellect, the ANSI 837 consists of the same value as is in the Paper UB04. For example:
005010X223 • 837 • 2300 • HI ASC X12N
VALUE INFORMATION
HI*BE:48:::9.5*BE:A8:::82.1*BE:A9:::170.18*BE:D6:::0002160.00
Effective version 9.12.29, these changes were made to the UB04 for Worker's Compensation patients:
Box8a Prints the patient's social security number as shown in the <Social Security No> field on the Registration --►Worker --►Worker screen. To have the SSN print, call PCS and ask to have it added to the form; it is not automatically inserted.
Box 51 Prints blank.
Box 59 Prints '20' for all Workers Comp patients.
Box 62 Prints information from the <Claim No. 1> field on the Registration --►Worker --►Worker Insurance screen. When that field is blank, the system prints 'Unknown'. Additionally, if the patient is not a Worker's Comp patient, Intellect prints whatever is in the <Group No.> field on the Registration --►Regular --►Patient Insurance screen.
Box 80 Per the client's request, the address where the employee works, as shown in the <Address> field of the Registration --►Worker --►Worker Insurance screen, can be added.
Box 81 The third part of Box 81 prints: 'AC'+CI_REPORT_TYPE_CODE+CI_REPORT_TRANSMISSION_CODE+ CI_IDENTIFICATION_CODE
When the report type is blank, then the third part of Box 81 is blank. The WC Claims now require the <Report Type Code>, <Report Transmission Code>, and <Identification Code>. If they are completed in the Encounter screen, the values entered print here.
