AAPC CPB Chapter 8 Flashcards

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.