Chapter 11: CMS-1500 and UB-04 Claims

comma

.The only form of punctuation allowed on a CMS-1500 is a(n):

eight digits with spaces between the digits representing the month, day, and the four-digit year (MM DD YYYY)

For CMS-1500 claims, birth dates are entered as

Reporting Diagnoses

ICD-10-CM Codes

Block 11 is where the insurance information will be entered because this is the primary (only) policy.

Where should Ms. Jones's insurance plan name and group number be entered?

failing to properly link each procedure with the correct diagnosis

Which is a common error that can delay CMS-1500 claims processing?

open assigned cases

Which is a file maintained for claims that have been submitted to the payer, but for which processing is still incomplete?

submitting the completed CMS-1500 claim to the payer or clearinghouse

Which is considered a final step in processing CMS-1500 claims?

Self

What box should be checked in Block 6?

CPT

What codes are used by physicians to report patient service provided in a hospital setting?

The patient's handwritten signature SIGNATURE ON FILE (SOF)

What should be entered in Blocks 12 and 13?

The claim is flagged for further review, may be denied, or reimbursed upfront. If any of the boxes in block 10 are checked 'Yes', the claim will be flagged for review, because that may mean that payment is the responsibility of another insurance provider.

What will it mean if any of the boxes in Block 10 are checked YES? (Is the patient's condition related to Employment, Insurance, Other Accident)

assignment of benefits

When a patient allows the provider to bill their insurance company and collect payment from the insurer, this is known as:

homeowner's

When an X is entered in one or more of the YES boxes in Block 10 of the CMS-1500 claim, payment might be the responsibility of a ____ insurance company.

Block 24G (Days or Units) contains an entry.

When entering a CPT code in Block 24, identical procedures performed can be reported on the same line if which of the following circumstances apply?

upper case

When entering patient claims data onto the CMS-1500 claim, enter alpha characters using

NUBC

Which is responsible for developing data elements reported on the UB-04?

A0101 - no period or punctuation

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

99212 25 - enter a space between code and modifier

Which is the correct format for adding a modifier to a CPT code in Block 24 of the CMS-1500 claim?

the payer is instructed to reimburse the provider directly.

Which statement is an accurate interpretation of the phrase "assignment of benefits"? If signed by the patient on the CMS-1500 claim:

suspicious for urinary tract infection

While it is acceptable to report codes for uncertain diagnoses when a definitive diagnosis has not been established for inpatient hospitalizations, it is never appropriate to report a code for uncertain diagnoses for physician office and outpatient claims. Which is an example of an uncertain diagnosis?

modifiers

_ _ _ are used to alter a CPT or HCPCS code.

Dates of Service(MM DD YYYY).

CMS-1500 Block 24A

Block 1a

Ms. Jones is only covered by one policy. Where should the policy number be entered?

agrees to accept as payment in full what payer reimburses

Accept assignment: When CMS-1500 Block 27 contains X in Yes box, provider

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

A supplier is a

supplemental

A type of plan that usually covers deductible, copayment, and coinsurance amounts, and is also known as a Medigap plan, is a Medicare __________ plan.

standard format for submission of electronic claims for institutional health care services.

ANSI ASC X12N 837I (837I)

standard format for submission of electronic claims for professional health care services.

ANSI ASC X12N 837P (837P)

11 for physicians office and 21 for inpatient hospital

Common codes for block 24b are

•Subject to normal claims processing timely filing requirements, such as submission within one year of the date of service.•Form locators 4 (type of bill) and 18-28 (condition codes) are completed.

Adjustment claim

CMS-1500 Block 13 to instruct payer to directly reimburse provider.

Assignment of benefits: Patients sign

charges for services or procedures. When entering charges in Block 24F, when 2 or greater is entered in Block 24G (as days or units), add together the charges for all units on that line. For example, if a service is $45 and Block 24G contains 2, enter $90 in Block 24F. Then, the total charge entered in Block 28 is calculated by adding together charges on each line of Block 24F.

Block 24F

the number of encounters, units of service or supplies, amount of drug injected, and so on, has room for only three digits

Block 24G

Place of Service

CMS-1500 Block 24B

Procedures and Services CPT and HCPCS level II procedure and service codes and modifiers are reported in CMS-1500 Claim Block 24D.

CMS-1500 Block 24D

entry of either the provider's social security number (SSN) or the employer tax identification number (EIN). If completing claims for a group practice, enter the practice's EIN in this block. Do not enter the hyphen

CMS-1500 claim Block 25

professional services ie physicians and suppliers

CMS-1500 claims

data

Claims are electronically transmitted as __________ packets between provider and billing company, clearinghouse, or payer using the Internet or other packet-exchange network.

the payment system established for each type of provider

Claims are submitted for reimbursement according to

•NUBC balances payers' need to collect information against burden of providers to report that information.•HIPAA administrative simplification provisions are applied when developing data elements.•Each data element is assigned to a unique UB-04 form locator (FL).

Data Specifications for the UB-04

HIPAA

Electronic claims must meet requirements adopted as the national standard under

view claims text using optical character recognition technology

The optical character reader (OCR) is a device that is used to

•Step 1—Double-check claim for errors/omissions.•Step 2—Add necessary attachments.•Step 3—Post submission of claim to patient account.•Step 4—Save claim in practice management software.•Step 5—Submit claim to payer or clearinghouse.

Final Steps in Processing CMS-1500 Claims

revenue

Four-digit _____ codes are preprinted on a facility's chargemaster to indicate the service provided to an institutional patient (e.g., hospital inpatient), which is populated on the UB-04.

JONES, ALICE, R

How should Ms. Jones' name be entered in Block 2?

MM DD YYYY

How should you enter the date of birth for Ms. Jones according to the instructions in your text?

•File open assigned cases by month and payer.•File closed assigned cases by year and payer.•File batched remittance advice notices.•File unassigned or nonparticipating claims by year and payer.

Insurance File Set-Up

Blocks 5 and 7

Into which Block(s) would Ms. Jones' address be entered?

This information is no longer required as of the 2012 update of the CMS-1500 claim form.

Ms. Jones is a widow. In which block will you indicate this information?

Group Health Plan

Ms. Jones is covered by CarePlusOne, ID # IMH25963211 and Group Number JMH436. Which box should you check in Block 1?

standard format for retail pharmacy.

National Council for Prescription Drug Programs (NCPCP) Telecommunication Standard

•Similar to role of National Uniform Claims Committee (NUCC) (that develops CMS-1500)•NUBC identifies and revises data elements.•UB-04 revisions eliminate ambiguity and create consistency.

National Uniform Billing Committee (NUBC)

global fee

One charge that covers the pre-op, operation, and post-op care is known as

twelve

Only _ _ _ _ _ _ ICD-10-CM codes are entered on a single claim form.

CPT/HCPCS level II

Physicians submit _____ service/procedure codes to payers.

Remittance advice reconciliation

Processing Assigned Paid Claims

•Generated when need for correction/supplementation is discovered after claims processing timely filing limit.•Claims determinations may be reopened within 1 year of date of receipt of initial determination for any reason.•When reopened within 1-4 years of date of receipt of initial determination, good cause must be demonstrated.•Is a separate and distinct process from appeals process•Form locators 4 (type of bill) and 18-28 (condition codes) are completed.

Reopened claim

HCPCS Level II and CPT Codes

Reporting Procedures and Services

legal business name of the practice

The billing entity in Block 33 should represent the

medical practice.

The billing entity, as reported in Block 33 of the CMS-1500 claim, includes the legal business name of the

when the patient contacts a healthcare provider's office and schedules an appointment.

The development of an insurance claim begins when the:

main reason patient was seen

The first-listed diagnosis on a claim should be the:

the same service is provided on consecutive dates

The from and to date field in Block 24 of the CMS-1500 should be completed when:

four

The type of bill (TOB) is a required element that is entered in FL4 on the UB-04, and it contains _____ digits.

government programs.

The reverse of the CMS-1500 claim contains special instructions for

•Used to bill institutional services, such as services performed in hospitals.•Contain data entry blocks called form locators (FLs) for input of information.•Automatically generated from chargemaster data entered by providers.

UB-04 Claims

•Contains form locators (e.g., required, not used, and situational).•Data entered according to third-party payer guidelines that contain instructions for completing the UB-04.•Providers that submit the UB-04 claim include ambulance companies, home health care agencies, and more.

UB-04 Claims Submission

institutional services ie hospitals, skilled nursing facilities, end-stage renal disease providers, home health agencies, hospices, outpatient rehabilitation clinics, comprehensive outpatient rehabilitation facilities, community mental health centers, critical access hospitals, federally qualified health centers, histocompatibility laboratories, Indian Health Service facilities, organ procurement organizations, religious non-medical health care institutions, and rural health clinics

UB-04 claims

Format of electronic claims transmission, which are routed between provider and billing company, clearinghouse, or payer using the Internet or other packet-exchange network.

data packets