Chapter 11: CMS-1500 and UB-04 Claims

referring provider

A physician or non-physician practitioner who sends a patient to a specialist for diagnosis or treatment.

consulting physician

A physician who is qualified by specialty to make a professional diagnosis regarding the patient's condition.

six

All other CMS-1500 blocks that require date(s) are entered as ___ digits with spaces between the digits representing the month, day, and two-digit year (e.g., MM DD YY) except for Block 31 where no spaces are entered between the digits (e.g., MMDDYY).

simple

Any letter written by the provider should contain clear and ______ English rather than "medicalese."

form locators

Data entry blocks on a UB-04 claim form that provide specific information necessary to process a claim are called what?

Data entry for CMS-1500 requirments

-Entering patient and policyholder names, provider names, and mailing addresses (Telephone numbers are entered for providers.) -Recovery of funds from responsible payers -National provider identifier (NPI) and National standard employer identifier (EIN) -Assignment of benefits versus accept assignment -Reporting ICD-10-CM diagnosis codes and HCPCS Level II and CPT procedure/service codes -Reporting the billing entity

Optical character recognition guidelines

-Proper alignment of claim form information is required. Information should be entered within the confines of each block on the claim form. When entering an "X," it must be centered completely within the box. -Enter all alpha characters in uppercase (capital letters). -Do not enter a suffix or a person's title (Sr., Jr., II or III, Sister, Dr.) unless printed on the insurance card. -Do not substitute the alpha character O for the number zero. -When a dollar amount is entered, do not use a dollar sign and use two zeroes in the cents column. -Birthdates should be entered as eight digits: MM DD YYYY.

group practice

2 or more physicians share space, equipment, supplies, and personnel. May consist of physicians from a single specialty or multiple specialties. Income is divided in a manner agreed upon by the group.

AV

ESPEDT available - not used; patient refused referral

EPSDT

Early & periodic screening, diagnosis, and treatment

Provider agrees to accept the approved amount from insurance company as payment in full.

What does checking yes on accept assignment data field/block 27 mean?

ICD-10-CM code pointer letter

What is entered on data field/block 24E of CMS-1500 claim form?

TEMPLETON, SOPHIA, G

What is the correct way to enter the patient's name on the claim form?

CMS-1500

What is the name of the medical claim form that is submitted by physicians?

8371 (institutional)

What is the standard format that hospitals use to submit claims electronically?

837P (professional)

What is the standard format used by healthcare professionals and suppliers to transmit medical claims electronically?

NPI

What is the standard, unique health identifier that is mandated by HIPAA for each healthcare provider and used for claims processing, patient eligibility inquiries, claims inquiries, patient referrals, and generation of remittance advices?

patient data

What is used from a physician's office practice management software to populate the CMS-1500 claim?

patient and policy identification information

What should be included in claims attachment?

Procedures were performed on consecutive days in the same month, same code is assigned to procedure/services reported, identical charges apply to the assigned codes, Block 24G is completed

When can identical procedures or services be reported on the same line?

when CPT unlisted codes are reported

When do claims require attachments?

NO

When entering ICD-10-CM does for CMS-1500 claim or UB-04 claim, do you enter the decimal?

when the addresses to be reported for the patient and insured are the same

When is it okay to leave data field/block 7 blank?

data field/block 24D

Where are CPT/HCPCS Level II codes reported on CMS-1500 claim form?

practice management software (PMS)

Where is data pulled from to populate the CMS-1500 claim form?

25

Which block of the CMS-1500 claim form requires entry of either the Social Security number (SSN) or the employer identification number (EIN)?

CMS-1500

Which claim form is used for professional (non-institutional) claims?

M2551

Which of the following is the appropriate format for an ICD-10-CM code in Block 21 of the CMS-1500 form?

The patient authorizes the payer to send payment directly to the physician.

Which statement is an accurate interpretation of the phrase "assignment of benefits?"

NUCC

Who is responsible for the maintenance of the 1500 claim form?

the name of the solo practitioner or in the case of a physician group practice, it would be the legal name of the practice (e.g., Bloomfield Medical Associates)

Who is the billing provider?

health insurance specialist

Who must assign valid codes and report the necessary information on the insurance claim in a timely manner?

Clinical staff

Whose responsibility is it to record complete and accurate documentation about the diagnoses and services rendered to the patient at each visit?

Administrative staff

Whose responsibility is it to verify the patient's demographic and insurance information during the registration process and to keep that information updated at every visit.

Such an entry indicates that the service provided to the patient was due to an injury that occurred on the job or as a result of an auto accident or other accident. These events might be the responsibility of another payer, such as workers' compensation insurance, automobile insurance, or liability insurance (e.g., homeowners). As a result, commercial and government payers will not process the claim until the provider submits documentation from worker's compensation, auto insurance, or other liability payer denying the claim.

Why will payers flag claims for investigation when an X is entered in 1 of the YES boxes in data field/block 10 of the CMS-1500 claim form?

Claims

______ are submitted electronically to a third-party administrator, clearinghouse, or payer using a computer with software that meets electronic submission requirements as established by the Health Insurance Portability and Accountability Act (HIPAA) claim standard.

UB-04

also known as CMS-1450; universal claim form accepted by Medicare and Medicaid, as well as other insurance carriers, for services provided by a facility. Generated when chargemaster and patient data from the institution's electronic health record are transmitted to the facility's billing department.

24 (POS code)

ambulatory surgery center

UB-04 claim

designated as the CMS-1450 by CMS, uses ANSI ASC X12N 837I as its standard format to electronically transmit health care claims for inpatient and outpatient institutional services.

National Uniform Billing Committee (NUBC)

developed and revises the UB-04 claim and includes an instructional manual on their website.

supervising physician

licensed physician in good standing who, according to state regulations, engages in the direct supervision of nonphysician practitioners whose duties are encompassed by the supervising physician's scope of practice.

carrier block

located at the top of the claim form in the open area, near the right margin. Enter name and address of payer to whom claim form is being sent. DO NOT USE COMMAS, PERIODS, OR OTHER SYMBOLS IN THE ADDRESS.

LU

location number for supervising provider only

claims attachment

medical report substantiating the medical condition

ST

new service requested; patient referral to another provider for diagnostic or corrective treatment

NU

not used; used when no EPSDT patient referral was given

DK

ordering provider

Medicare Part D sponsor

organization that has 1 or more contracts with the Centers for medicare and Medicaid Services to provide Part D benefits to Medicare beneficiaries

22 (POS code)

outpatient hospital/observation area

S2

patient currently under treatment for referred diagnostic or corrective health problem

assignment of benefits

patient's written authorization giving the insurance company the right to pay the physician directly for billed charges

policyholder or insured

person who holds the policy. Example: employee for employer-provided health insurance.

ordering provider

physician or nonphysician practitioner who orders services for the patient

supplier

physician or other health care practitioner or any entity other than a provider that furnishes health care services.

solo practice

physician practices alone without any partners.

Medicare Part D

prescription drug coverage

1G

provider UPIN number

G2

provider commercial number

11 (POS code)

provider's office

DN

referring provider

optical character recognition (OCR)

requires the conversion of scanned images that contain print or cursive text into machine-encoded text so computer software can read the text.

31 (POS code)

skilled nursing facility

National Council for Prescription Drug Programs (NCPCP) Telecommunication Standard

standard format for retail pharmacy. For example, retail pharmacy submits Medicare claims to the patient's Medicare Part D sponsor

ANSI ASC X12N 837I

standard format for submission of electronic claims for institutional health care services. Institutional providers include hospitals, SNF, end-stage renal disease providers, home health agencies, hospices, outpatient rehab clinic, comprehensive outpatient rehab facilities, community mental health centers, critical access hospitals, federally qualified health centers, histocompatibility labs, Indian Health Service facilities, organ procurement organizations, religious non-medical health care institutions, and rural health clinics. For example, hospitals submit Medicare claims for inpatient admissions to MACs

ANSI ASC X12N 837P

standard format used for submission of electronic claims for professional health care services. Professional providers include physicians and suppliers. For example, physicians submit Medicare claims to Medicare administrative contractors (MACs) and durable medical equipment suppliers submit Medicare claims to DMEMAC.

0B

state license number

CMS-1500 claim

submitted electronically after being generated by medical practice management software, and the ANSI ASC X12N 837P is the standard format used to electronically transmit health care claims.

DQ

supervising provider

02 (POS code)

telehealth

place of service (POS)

two-digit code to identify the location where the patient received the service.

national provider identifier (NPI)

unique 10-digit number issued to individual providers (e.g., physicians, dentists, pharmacists) and health care organizations (e.g., group physician practices, hospitals, nursing facilities).

data packets

unit of data routed from provider to clearinghouse, payer, or third-party administrator using the Internet or other packet-exchange network.

National Uniform Claim Committee (NUCC)

voluntary organization that develops a standardized data set to be used by the healthcare industry for professional (non-institutional) claims. Chaired by the AMA and CMS, and committee members represent a broad spectrum of the healthcare industry. Scope has broaden to include uniform data elements for both paper and electronic claim formats.

National Plan and Provider Enumeration System (NPPES)

developed by CMS to assign the unique health care provider and health plan identifiers and to serve as a database from which to extract data (e.g., health plan verification of provider NPI).

23 (POS code)

emergency room

FL

form locators

nonphysician practitioner (NPP)

include nurse practitioners, clinical nurse specialists, and physician assistants who practice under the supervision of a physician.

21 (POS code)

inpatient hospital

Yes

Can providers still collect deductible, copayment, and coinsurance amounts from the patient if they participate in accept assignment?

DO NOT

For CMS-1500 claims, __ ___ enter a person's title or other designations, such as Sr., Jr., II, or III, unless printed on the patient's insurance ID card.

zero

For CMS-1500 claims, do NOT enter the alpha character "O" for a _____.

NOT

For CMS-1500 claims, do ___ enter hyphens or spaces in the 9-digit ZIP code, social security number, employer identification number (EIN), or national provider identifier (NPI).

punctuation

For CMS-1500 claims, do not use ___________ in a patient's or policyholder's name, except for a hyphen in a compound name.

two

For CMS-1500 claims, enter ___ zeroes in the cents column when a fee or a monetary total is expressed in whole dollars. Do not enter any leading zeroes in front of the dollar amount.

commas

For CMS-1500 claims, enter ______ between the patient or policyholder's last name, first name, and middle initial.

space

For CMS-1500 claims, enter a _____ between the CPT or HCPCS code and its modifier (instead of a hyphen). If multiple modifiers are reported enter one space between each modifier.

uppercase

For CMS-1500 claims, enter all alpha characters in _________.

as data packets

How are claims electronically transmitted?

CMS-1500: X in appropriate box; UB-04 claims: M or F

How is gender determined on claims?

6

How many service lines are on a CMS-1500 claim form in data field/block 24?

11 03 1988

How should a patient's date of birth (DOB) be entered on a medical claim form?

10

If the service provided to the patient was related to a work injury, in which block of the CMS-1500 claim form is an X entered in the YES box?

errors that need to be corrected or reasons for denials

Rejected or denied claims that are not compliant with coverage and payment policy requirements include what?

The medical practice

The billing provider is reported in Block 33 of the CMS-1500 form and includes the legal business name of what?

rendering provider

The physician or non-physician practitioner in a group practice who provides (or renders) medical care to patients.

accept assignment

The provider agrees to accept what the insurance company approves as payment in full for the claim.

data field and block

What 2 words are used interchangeably?

Permanent address; no temporary address should be used.

What address should be used for a patient on CMS-1500 claim form?

major reason the patient was treated by the health vare provider

What code is listed first in CMS-1500 claims?

Provider's federal tax ID number

What does an insurance company need in order to report reimbursement to the IRS?