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As we discussed Place of Service(POS) is required for all Professional claims similarly Type of Bill ( TOB) is required for all Institutional claims ( 837I).
TOB means what types of facility and what care was provided to the patient.
All claims need to billed with correct Types of bill otherwise claims will be denied.
Based on Types of bill we can say claim is Inpatient or Outpatient.
Claims Pricing is hugely varied between inpatient and outpatient setting so Types of Bill has many implication for reimbursement. Some of the services can only be performed in Inpatient facility but if claimed is billed with outpatient facility then it will be denied and vice versa.
e.g Ambulatory surgical center ( ASC) claims are outpatient is nature and must be billed with correct Type of bill.(083) means they need to bill 83X series TOB.
e.g SNF( skilled nursing facility ) claims are inpatient in nature and must be billed with correct type of bill.(02X-02X) where X anything between 1 to 9 . Means they need to bill 2X series TOB.( anything between 021-029) *
* Please see below how Types of Bill is defined and its structure( logic ).
* Please see below how Types of Bill is defined and its structure( logic ).
Example :
| Bill Types | Description |
| 011X | Hospital Inpatient (Part A) |
| 012X | Hospital Inpatient Part B |
| 013X | Hospital Outpatient |
| 014X | Hospital Other Part B |
| 018X | Hospital Swing Bed |
| 021X | SNF Inpatient |
| 022X | SNF Inpatient Part B |
| 023X | SNF Outpatient |
| 028X | SNF Swing Bed |
| 032X | Home Health |
| 033X | Home Health |
| 034X | Home Health (Part B Only) |
| 041X | Religious Nonmedical Health Care Institutions |
| 071X | Clinical Rural Health |
| 072X | Clinic ESRD |
| 073X | Federally Qualified Health Centers |
| 074X | Clinic OPT |
| 075X | Clinic CORF |
| 076X | Community Mental Health Centers |
| 081X | Nonhospital based hospice |
| 082X | Hospital based hospice |
| 083X | Hospital Outpatient (ASC) |
| 085X | Critical Access Hospital |
Structure of TOB :
Type of bill is a 4 character starting with leading Zero like 011X ( Inpatient hospital care.)
Type of bill is a 4 character starting with leading Zero like 011X ( Inpatient hospital care.)
First character - leading Zero - 0 ( claims processing engine will ignore this)
Second Character - Facility Type
Third Character - Type of Care
Fourth Claims - Claims frequency
Description and Values of Second Character - Facility Type
| Second Character | Description |
| 1 | Hospital |
| 2 | Skilled Nursing |
| 3 | Home Health (Includes Home Health PPS claims, for which CMS determines whether the services are paid from the Part A Trust Fund or the Part B Trust Fund.) |
| 4 | Religious Nonmedical (Hospital) |
| 5 | Reserved for national assignment (discontinued effective 10/1/05). |
| 6 | Intermediate Care |
| 7 | Clinic or Hospital Based Renal Dialysis Facility (requires special information in second digit below). |
| 8 | Special facility or hospital ASC surgery (requires special information in second digit below). |
| 9 | Reserved for national assignment (discontinued effective 10/1/05). |
Description and Values of Third Character - Type of Care
| Third Character | All Facility except Clinic and other special facility | For Clinic | For Special Facility |
| 1 | Inpatient (Part A) | Rural Health Clinic (RHC) | Hospice (Nonhospital Based) |
| 2 | Inpatient (Part B) - (For HHA non PPS claims, Includes HHA visits under a Part B plan of treatment, for HHA PPS claims, indicates a Request for Anticipated Payment - RAP.) Note: For HHA PPS claims, CMS determines from which Trust Fund payment is made. Therefore, there is no need to indicate Part A or Part B on the bill. | Hospital Based or Independent Renal Dialysis Facility | Hospice (Hospital Based) |
| 3 | Outpatient (For non-PPS HHAs, includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment). For home health agencies paid under PPS, CMS determines from which Trust Fund, Part A or Part B. Therefore, there is no need to indicate Part A or Part B on the bill. | Free Standing Provider-Based Federally Qualified Health Center (FQHC) | Ambulatory Surgical Center Services to Hospital Outpatients |
| 4 | Other (Part B) - Includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for “nonpatients,” and referenced diagnostic services. For HHAs under PPS, indicates an osteoporosis claim. NOTE: 24X is discontinued effective 10/1/05. | Other Rehabilitation Facility (ORF) | Free Standing Birthing Center |
| 5 | Intermediate Care - Level I | Comprehensive Outpatient Rehabilitation Facility (CORF) | Critical Access Hospital |
| 6 | Intermediate Care - Level II | Community Mental Health Center (CMHC) | Reserved for National Assignment |
| 7 | Reserved for national assignment (discontinued effective 10/1/05). | Reserved for National Assignment | Reserved for National Assignment |
| 8 | Swing Bed (may be used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement). | Reserved for National Assignment | Reserved for National Assignment |
| 9 | Reserved for National Assignment | OTHER | OTHER |
Fourth Character : Claims Frequency
| Frequency Code | Description |
| 0 | Non-payment/zero claims |
| 1 | Admit thru discharge claim |
| 2 | Interim - first claim |
| 3 | Interim - continuing claim (not valid for PPS claims) |
| 4 | Interim - last claim (not valid for PPS claims) |
| 5 | Late charge(s) only claim |
| 6 | Adjustment of prior claim |
| 7 | Replacement of prior claim (eff 10/93) provider debit |
| 8 | Void/cancel prior claim (eff 10/93) provider cancel |
| 9 | Final claim -- used in an HH PPS episode to indicate the claim should be processed like debit/credit adjustment to RAP (initial claim) (eff. 10/00) |
| A | Admission election notice - used when hospice or Religious Nonmedical Health Care Institution is submitting the HCFA-1450 as an admission notice - hospice NOE only |
| B | Hospice/Medicare Coordinated Care Demonstration/RNCHI - Termination/Revocation Notice - hospice NOE only (eff 9/93) |
| C | Hospice change of provider notice - hospice NOE only (eff 9/93) |
| D | Hospice/Medicare Coordinated Care Demonstration/RNHCI - void/cancel - hospice NOE only (eff 9/93) |
| E | Hospice change of ownership - hospice NOE only (eff 1/97) |
| F | Beneficiary initiated adjustment claim (eff 10/93) |
| G | CWF generated adjustment claim (eff 10/93) |
| H | CMS generated adjustment claim (eff 10/93) |
| I | Misc adjustment claim (other than PRO or provider) - used to identify a debit adjustment initiated by CMS or an intermediary (other than QIO or Provider) - eff 10/93, used to identify intermediary initiated adjustment only |
| J | Other adjustment request (eff 10/93) |
| K | OIG initiated adjustment (eff 10/93) |
| M | MSP adjustment (eff 10/93) |
| P | Adjustment required by Quality Improvement Organization (QIO) -- formerly Peer Review Organization (PRO) |
| X | Special adjustment processing - used for QA editing (eff 8/92) |
| Z | Hospital Encounter Data alternate submission (TOB '11Z') used for MCO enrollee hospital discharges 7/1/97-12/31/98; not stored in NCH. Exception: Problem in startup months may have resulted in this abbreviated UB-92 being erroneously stored in NCH. |
Please see the complete list with all the 4 character together.
| Bill Types | Description |
| 011X | Hospital Inpatient (Part A) |
| 012X | Hospital Inpatient Part B |
| 013X | Hospital Outpatient |
| 014X | Hospital Other Part B |
| 018X | Hospital Swing Bed |
| 021X | SNF Inpatient |
| 022X | SNF Inpatient Part B |
| 023X | SNF Outpatient |
| 028X | SNF Swing Bed |
| 032X | Home Health |
| 033X | Home Health |
| 034X | Home Health (Part B Only) |
| 041X | Religious Nonmedical Health Care Institutions |
| 071X | Clinical Rural Health |
| 072X | Clinic ESRD |
| 073X | Federally Qualified Health Centers |
| 074X | Clinic OPT |
| 075X | Clinic CORF |
| 076X | Community Mental Health Centers |
| 081X | Nonhospital based hospice |
| 082X | Hospital based hospice |
| 083X | Hospital Outpatient (ASC) |
| 085X | Critical Access Hospital |
Advance Concept : Above tables can be loaded in database and validate the claims based on facility types for billing . e.g Hospice provider must submit a claims with TOB of 81 or 82 .If they submit other TOB .. that claims should be denied by the system .
Also based on the TOB payment may be different e.g TOB of 81 means Hospice care when patient is getting taken care at home .. so member home will derive the payment ( per diem rate) than 82 means member is getting taken care in facility so per diem is defined based on provider location.
Also based on outpatient and inpatient care reimbursement amount may vary .. provider should read provider contract carefully what they need to bill and how much they will get based on TOB.
Also clinical editing software will deny the claims if they submit a claims with TOB that is not suppose to bill for a specific type of service .. like TOB and Revenue codes combination or TOB and Procedure code condition.
Source :
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1775CP.pdf
http://www.resdac.org/cms-data/variables/Claim-Frequency-Code
