A Georgia Psychiatric Hospital's Netsmart UB-04 Configuration Had 4 Revenue Code Errors. They'd Been There Since Go-Live.
Table of Contents
THE SITUATION
This 36-bed inpatient psychiatric facility has used Netsmart myEvolv since opening in 2022. UB-04 claims were going out. Payers were processing them.
Nobody had compared what was being paid against what the contracts said should be paid until a CFO audit in Q1 2024 flagged that revenue per patient day was running 17% below projected. We were brought in to find the gap.
The Netsmart configuration had four revenue code errors that had been generated on every UB-04 since go-live.
WHAT WAS ACTUALLY WRONG
Revenue code 0124 was missing on behavioral health room and board:
Inpatient psychiatric facilities billing UB-04 must include revenue code 0124 (room and board behavioral health) as the primary accommodation code. Netsmart was defaulting to 0120 (room and board general). Several payers were applying lower room-and-board reimbursement rates for 0120 versus 0124 a $45–$80 per patient day difference.
Therapy service revenue codes were too generic:
Individual therapy was billed under revenue code 0900 (behavioral health treatment services general) rather than 0915 (individual psychotherapy). Group therapy was billing 0900 rather than 0910 (group psychotherapy). Payers that track service-specific revenue codes were reimbursing at general service rates rather than therapy-specific rates.
Psychiatric evaluation revenue code was absent:
Revenue code 0917 (psychiatric evaluation) was not configured in Netsmart. Admission psychiatric evaluations were being included in the room-and-board revenue line rather than as a separate billable service line meaning the evaluation was generating no additional reimbursement.
Condition code 44 missing on all short-stay claims:
Condition code 44 is required on inpatient claims where the patient’s admission was initially planned as an outpatient observation stay. GA Medicaid requires this on all applicable claims. Netsmart wasn’t including it.
WHAT WE DID
Weeks 1–2: Corrected all four revenue code configurations in Netsmart. Rebuilt the UB-04 template with 0124, 0915, 0910, and 0917 as separate service lines with correct charge amounts.
Week 3: Added condition code 44 to GA Medicaid UB-04 template with a flag for applicable admission types.
Weeks 4–12: Filed underpayment disputes for 24 months of 0120 vs 0124 rate differences with Aetna and Cigna. Filed corrected claims for 0915/0910 revenue code changes. Submitted 0917 charges retroactively for all admission psychiatric evaluations within dispute windows.
THE RESULTS
| Metric | Before | After |
|---|---|---|
| Revenue Code Errors | 4 active since go-live | 0 |
| Revenue Recovered (disputes + corrections) | — | $231,000 |
| Revenue Per Patient Day | 17% below projected | Within 2% of projected |
| Condition Code 44 Compliance | 0% | 100% |
| 0917 Psych Eval Revenue | $0 | $4,100/month ongoing |
WHAT THIS MEANS FOR YOUR PRACTICE
Netsmart myEvolv is highly customizable and that’s where inpatient psych billing errors happen. Outpatient or SUD revenue code defaults don’t fit inpatient psychiatry. If your UB-04 setup hasn’t been audited, every claim may be underpaid.