Questions and Answers
Where can the information to determine if Medicare is primary or secondary be found?
MSP Manual, Chapter 3, Section 20.2.1 Admission Questions to Ask Medicare Beneficiaries.
The assignment of benefits is confirmed if a patient signs which Item?
Which item on the CMS-1500 form is the father's date of birth listed?
Item 11a.
Which form locator on the UB-04 claim form reports the main reason for the encounter?
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Professional suffixes and titles should be included in Item 2 of the CMS-1500 claim form.
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Which item on the CMS-1500 claim form contains information regarding Medigap?
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When sequencing diagnosis codes, how are they listed?
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What does accepting assignment by a provider mean?
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What is the correct format to enter the date of birth on a paper CMS-1500 claim form?
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What is true regarding condition codes?
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What does Item 24D on the CMS-1500 claim form report?
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What type of code reports events related to the billing period on the UB-04 claim form?
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What must be entered in FL 50A on the UB-04 claim form when Medicare is the primary payer?
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What is the abbreviation for supplemental insurance coverage?
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Who requires claims to be sent electronically unless unusual circumstances occur?
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Who is responsible for the development and maintenance of the CMS 1500 claim form?
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What does HHS require regarding electronic transactions in healthcare?
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What is required to ensure that covered entities can send and receive electronic transactions as of 01/01/12?
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Study Notes
Medicare and Assignment of Benefits
- Medicare's list of questions for beneficiaries helps determine if Medicare is the primary or secondary payer, found in the MSP Manual, Chapter 3, Section 20.2.1.
- Item 13 on the CMS-1500 form confirms assignment of benefits with the patient's signature or "Signature on File".
CMS-1500 and UB-04 Forms
- Item 11a on the CMS-1500 form captures the insured's 8-digit birth date and sex; gender can be left blank if unknown.
- FL 67 on the UB-04 claim form is used for reporting the principal diagnosis code, representing the main reason for the encounter.
- Professional titles and suffixes should not be included in Item 2 on the CMS-1500 claim form.
Medigap and Insurance Details
- Item 9 on the CMS-1500 form records Medigap information, including policyholder names and numbers.
- If insurance is primary to Medicare, Items 4, 6, and 7 must be completed, alongside Item 11.
Claims Processing and Billing
- Adjudication is the process determining the insurer's payment amount after applying the member's insurance benefits.
- Occurrence codes on the UB-04 form (FLs 31-34) document events related to the billing period with specific codes and dates.
Sequence and Formatting
- The primary diagnosis must be listed first, followed by secondary diagnoses according to coding guidelines.
- Date of birth on paper CMS-1500 claims is entered as MM/DD/CCYY, whereas the electronic format is CCYYMMDD.
Submission Procedures and Requirements
- The UB-04 form is used for both inpatient and outpatient reporting, ensuring correct diagnosis codes are submitted without combining ICD-9-CM and ICD-10-CM codes.
- Claims must be submitted electronically unless there are unusual circumstances as required by the ASCA.
Modifiers and Codes
- Item 24D on the CMS-1500 form can contain up to four modifiers for procedures, services, or supplies.
- When Medicare is the primary payer, FL 50A on the UB-04 claim must state "Medicare" to indicate primary payment responsibility.
Governance and Regulatory Compliance
- The CMS-1500 claim form undergoes multiple reviews by the NUCC before implementation, ensuring compliance with healthcare transaction standards.
- HIPAA mandates the HHS to adopt standards permitting electronic transactions in healthcare, with ASCA enforcing the electronic submission requirement.
Special Cases and Additional Considerations
- For multiple page claims, only diagnoses from the first page can be reported; if more than 12 are needed, separate claims must be filed.
- If billing incident-to a physician, the ordering physician's NPI must be entered in Item 17b of the CMS-1500 claim form.
Insurance Supplement and Overall Responsibility
- MEDIGAP, MG, and MGAP acronyms indicate supplemental insurance coverage for patients.
- The attending provider is the individual with overall responsibility for a patient's medical care during hospitalization.
Studying That Suits You
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Description
Test your understanding of key concepts from Chapter 8 of the AAPC CPB course. This quiz focuses on Medicare guidelines, specifically how to determine if Medicare is primary or secondary and other related topics. Use these flashcards to reinforce your knowledge and prepare effectively.
