Series 2 : Healthcare Claim Pricing : What is Type of Bill ( TOB) and why it matters ?

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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 ).

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.)

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

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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

Series 1 :Healthcare Claim Pricing : What is Place of Service (POS) and why it matters ?

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Place of Service is one of the most important concepts to understand for claims as well as benefit configuration.

Place of  Service : Where the service was rendered by healthcare provider. e.g. in Provider office, Patient Home, Home healthcare facility , Hospice center, Nursing Facility etc.

 Please note that this healthcare provider is Professional Providers  like physician , Nurse Practioner, specialists etc. and submitting CMS-1500 forms for reimbursement and not the Facility Providers.

e.g. 1.  we went to doctor office for treatment  then doctor will submit the claims with Place of service -11( Office)

e.g. 2. doctor come to patient home then doctor will submit claims with place of service -12( Home)

e.g.3. Patient is admitted to the hospital for treatment in a facility and physician who is not employed by Facility also called to see the patient then Facility will submit the UB-04 claims but this Physician will submit CMS-1500 forms for re-imbursement with correct place of service i.e. 21 - Hospital Inpatient.

Place of service is applicable to both Inpatient and Outpatient setting e.g. Place of service -21 means Inpatient Hospital , Place of Service 22 means Outpatient Hospital. So when Physician see a patient that is admitted in hospital i.e. patient is hospitalized ( Inpatient setting) , Physician will file the claim with Place of service - 21 however if physician see the patient in outpatient department ( Outpatient setting) then he will file the claim with place of service 22 ( Hospital Outpatient)

Place of Service is applicable to both Facility and Non-Facility.

Keeping everything simple, Place of service apply for Facility , for Non -Facility,  for Inpatient ,  for Outpatient.

It is required by the law to report correct Place of Service.

Why it is important :  Claims can be denied if provider is not submitting correct place of service. If provider has a contract to treat patient in Outpatient setting but he submits a claims with Inpatient place of service (21) that claim will be denied.

Based on place of service provider can get more or less payments e.g Place of service 23( Emergency visit) may get more re-imbursement then office visit.

provider may get less re-imbursement for all Facility place of service than Non- Facility place of service.( Because provider will be getting all the infrastructure from facility like office rent, equipment's, tools, electricity etc so his re-imbursement will be less)

Same service performed on different place of service will get different re-imbursement. CM Physician fee schedules are based on Facility and non-Facility setting.

If provider is not suppose to treat Urgent care or emergency visit and if submits such claims will be denied.

Also some of the services can not be rendered in all the place of services and that claims will be denied. eg. Pregnancy  can not be delivered in Office ( POS-11) setting and that claims will be denied by the system edits.

Also some of the service will have the limitation ( like 2 or 3 units in a year for office visits ) and that limitation is reached then its patient responsibility to pay the amount .

If provider is suppose to treat only in Office then he can submit only the claims with Place of service 11 and all others claims will be denied.


Who Maintain POS : CMS


Please see all the POS with description and where it is applied ( Facility or Non-Facility) . This has been taken from CMS website. see that  link below

https://www1d.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
01 Pharmacy (October 1, 2005) A facility or location where drugs and other medically related items and
02 Unassigned	--
03 School (January 1, 2003) A facility whose primary purpose is education.	NF
04 Homeless Shelter (January 1, 2003) A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters).  (See instructions below.)	NF
05 Indian Health Service Free-standing Facility (January 1, 2003) A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.  (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
06 Indian Health Service Provider-based Facility (January 1, 2003) A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.  (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
07 Tribal 638 Free-Standing Facility (January 1, 2003) A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization.  (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA

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POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
08 Tribal 638 Provider-Based Facility (January 1, 2003) A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. (See instructions below.)	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
09 Prison/Correctional Facility (July 1, 2006) A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.  (See instructions below.)	NF
10 Unassigned
11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.	NF
12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence.	NF
13 Assisted Living Facility (October 1, 2003) Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.	NF
14 Group Home (Code effective, October 1, 2003; description revised, effective April 1, 2004) A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).	NF

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
15 Mobile Unit (January 1, 2003) A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.	NF
16 Temporary Lodging (April 1, 2008) A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code.	NF
17 Walk-in Retail Health Clinic (No later than May 1, 2010) A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services.	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
18 Place of Employment/Worksite (No later than May 1, 2013) A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual.	Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
20 Urgent Care Facility (January 1, 2003) Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.	NF
21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.	F
22 Outpatient Hospital A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.	F

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
23 Emergency Room-Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.	F
24 Ambulatory Surgical Center A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.	F
25 Birthing Center A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of newborn infants.	NF
27-30 Unassigned	--
31 Skilled Nursing Facility A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.	F
32 Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.	NF
33 Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a longterm basis, and which does not include a medical component.	NF
34 Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.	F
35-40 Unassigned	--

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
41 Ambulance—Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.	F
42 Ambulance—Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.	F
43-48/Unassigned	--
49 Independent Clinic (October 1, 2003) A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.	NF
50 Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.	NF
51 Inpatient Psychiatric Facility A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.	F
52 Psychiatric Facility-Partial Hospitalization A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.	F
53 Community Mental Health Center A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a	F

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.
54 Intermediate Care Facility/Mentally Retarded A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.	NF
55 Residential Substance Abuse Treatment Facility A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care.  Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.	NF
56 Psychiatric Residential Treatment Center A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.	F
57 Non-residential Substance Abuse Treatment Facility (October 1, 2003) A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis.  Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.	NF
58-59 Unassigned	--
60 Mass Immunization Center A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method.  This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.	NF
61 Comprehensive Inpatient Rehabilitation Facility	F

POS Code and Name (effective date) Description	Payment Rate Facility=F Nonfacility=NF
A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities.  Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
62 Comprehensive Outpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities.  Services include physical therapy, occupational therapy, and speech pathology services.	NF
63-64 Unassigned	--
65 End-Stage Renal Disease Treatment Facility A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.	NF
66-70 Unassigned	--
71 State or Local Public Health Clinic A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.	NF
72 Rural Health Clinic A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.	NF
73-80 Unassigned
81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.	NF
82-98 Unassigned
99 Other Place of Service Other place of service not identified above.	NF