Questions and Answers
Which of the following are examples of keyboarding errors in processing claims? (Select all that apply)
What elements might be omitted that could lead to a claim being processed incorrectly? (Select all that apply)
What is the purpose of the 'Final Steps in Processing CMS-1500 Claims'?
To double-check claims for errors, add attachments, save claims, and submit to the payer.
Providers are required to keep copies of all insurance claims for a period of five years.
Signup and view all the answers
The UB-04 claim is designed for billing institutional services such as services performed in ______.
Signup and view all the answers
What are the responsibilities of the National Uniform Billing Committee (NUBC)?
Signup and view all the answers
Which of the following is a required entry in the UB-04 claims form?
Signup and view all the answers
FL5 requires the entry of the facility's ______ identification number in the format 00-0000000.
Signup and view all the answers
In what format should the admission start of care date be entered in the UB-04 form?
Signup and view all the answers
Handwritten items on the claim are acceptable.
Signup and view all the answers
What is the purpose of CMS-1500 claims?
Signup and view all the answers
What are data packets?
Signup and view all the answers
What is ANSI ASC X12N 837P?
Signup and view all the answers
What does the ANSI ASC X12N 837I standard represent?
Signup and view all the answers
What is the National Council for Prescription Drug Programs (NCPCP) Telecommunication Standard?
Signup and view all the answers
What is the purpose of CMS-1500 and 837P?
Signup and view all the answers
What is the relationship between UB-04 and 837?
Signup and view all the answers
Why might some claims require attachments?
Signup and view all the answers
Data entry for CMS-1500 claims requires that all alpha characters are entered in lowercase.
Signup and view all the answers
What does the National Provider Identifier (NPI) signify?
Signup and view all the answers
For CMS-1500 claims, block 3 requires an entry of ___ to designate the patient's gender.
Signup and view all the answers
How do you separate the patient's name in CMS-1500 claims?
Signup and view all the answers
HIPAA mandates that health care providers communicate electronically without obtaining a National Provider Identifier (NPI).
Signup and view all the answers
What is a reason claims may be flagged for review?
Signup and view all the answers
What is the process for applying for an NPI?
Signup and view all the answers
What is the supervising physician's role?
Signup and view all the answers
What is a rendering provider?
Signup and view all the answers
What does 'assignment of benefits' mean?
Signup and view all the answers
Which of the following codes are entered in Block 21 of the CMS-1500 claim?
Signup and view all the answers
What is the maximum number of ICD-10-CM codes allowed on a single CMS-1500 claim?
Signup and view all the answers
The diagnosis pointer letter can be entered with spaces or commas.
Signup and view all the answers
What should the first-listed code reported on a CMS-1500 claim indicate?
Signup and view all the answers
What is required for Block 24F of the CMS-1500 claim?
Signup and view all the answers
What are modifiers used for in CMS-1500 claims?
Signup and view all the answers
What effect do Medically Unlikely Edits (MUE) have on Medicare claims?
Signup and view all the answers
What needs to be reported in Block 25 of the CMS-1500 claim?
Signup and view all the answers
What must be included in Block 33 of the CMS-1500 form?
Signup and view all the answers
What must be consistently documented in a patient's record for claims submission?
Signup and view all the answers
What time format should be used for discharge hour?
Signup and view all the answers
What is required to specify if an accident occurred?
Signup and view all the answers
What should you leave blank for FL30?
Signup and view all the answers
What does FL47 report?
Signup and view all the answers
What should you do with FL49?
Signup and view all the answers
Study Notes
General Claims Information
- CMS-1500 is for professional services; UB-04 for institutional services.
- Claims submitted electronically via third-party clearinghouses or payers, adhering to HIPAA standards.
- Rejections can occur based on initial edits for HIPAA compliance and coverage requirements.
- Acknowledgment reports confirm successful transmission of claims.
Data Packets
- Claims transmitted as units of data called data packets, routed through the Internet or packet-exchange networks.
ANSI ASC X12N 837P (837P)
- Standard format for electronic claims submission for professional healthcare services, used by physicians and suppliers.
ANSI ASC X12N 837I (837I)
- Standard format for electronic claims submission for institutional healthcare services, utilized by various institutional providers such as hospitals and nursing facilities.
NCPCP Telecommunication Standard
- Standard format for retail pharmacy claims, essential for billing services like vaccination administration.
CMS-1500 and 837P
- CMS-1500 claims generated via medical practice management software and follow the 837P electronic format for claims transmission.
UB-04 and 837
- UB-04 claim, or CMS-1450, uses the 837I standard for electronic claims, incorporating data from an institution's electronic health record.
Claims Attachments
- Certain claims require attachments such as operative reports or clinic notes to support reimbursement determinations.
- Attachments must include patient identification and avoid medical jargon for clarity.
CMS-1500 Data Entry
- Key inputs include patient and policyholder details, provider identifiers (NPI, EIN), and specific formatting instructions for codes and dates.
- Follow strict guidelines for data entry to ensure claims processing without delays.
Patient and Policyholder Names
- Separate names with commas for CMS-1500; use spaces for UB-04 when entering names.
Entering Provider Names
- Enter full provider names without punctuation on CMS-1500 and include NPI for UB-04.
Entering Mailing Addresses
- Follow specific formatting for addresses in CMS-1500 and UB-04 forms, ensuring accuracy without punctuation.
Recovery of Funds from Responsible Payers
- Claims may be flagged for review based on ICD-10-CM codes indicating potential responsibility of alternative payers (e.g., workers' compensation).
- Clear submission of documentation may be required for reimbursement from responsible parties.
ICD-10-CM External Causes of Morbidity
- Most external cause codes are in Chapter 20, aiding in detailing conditions related to external factors.
National Provider Identifier (NPI)
- A permanent 10-digit number for individual providers and healthcare organizations, essential for electronic healthcare transactions.
HIPAA Mandated Unique Identifiers
- Utilization of national identifiers for employers (EIN), providers (NPI), and individuals (currently on hold) to streamline healthcare transactions.
HIPAA Covered Entities
- Covered entities include health plans, healthcare providers, and clearinghouses that engage in electronic transactions, mandated to use NPI.
NPI Application Process
- NPI is obtained through web-based, paper-based, or electronic file applications, ensuring provider identification in transactions.
Practices that Bill "Incident To"
- Nonphysician practitioners can bill under a supervising physician's name, necessitating specific entries on claims for compliance.
Supervising Physician
- A licensed physician providing direct oversight to nonphysician practitioners, with requirements for presence in the facility.
Rendering Provider
- A physician or nonphysician practitioner who delivers healthcare services to patients, essential in billing practices.
Assignment of Benefits vs. Accept Assignment
- Assignment of benefits allows direct payment to providers upon patient authorization; accepting assignment dictates payment acceptance terms from payers.### Reporting Diagnoses: ICD-10-CM Codes
- CMS-1500 Block 21: Enter diagnosis codes (no decimals) for a maximum of 12 ICD-10-CM codes. If additional codes are needed, generate a new claim.
- UB-04 Reporting: Also requires ICD-10-CM codes in specific form locators without decimals.
- Chronic Conditions: Always code chronic conditions like diabetes mellitus and hypertension affecting patient care.
Diagnosis Pointer Letter
- Block 21 includes letters A through L as diagnosis pointers.
- When using multiple pointers in Block 24E, do not include spaces or commas.
Sequencing Multiple Diagnoses
- CMS-1500: Report the main reason for treatment first; secondary diagnoses must justify services rendered.
- Uncertain Diagnoses: Do not report uncertain diagnoses in outpatient claims but may do so in inpatient settings.
CMS-1500 Block 24-Shaded Lines
- Shaded rows in Block 24 allow reporting of additional service information.
- Identifiers must be entered correctly corresponding to services, including NPI in the appropriate blocks.
CMS-1500 Block 24A: Dates of Service
- Each date of service must follow the six-digit format (MM DD YYYY).
CMS-1500 Block 24B: Place of Service
- Place of Service (POS) codes are required and must align with the service descriptions provided.
CMS-1500 Block 24C: EMG
- If emergency services were provided, a 'Y' should be entered in Block 24C as per payer requirements.
CMS-1500 Block 24D: Procedures and Services
- Enter CPT and HCPCS codes and modifiers.
- For multiple procedure coding, list by highest charge first and ensure all coding is accurately represented.
CMS-1500 Modifiers
- Up to four modifiers can accompany CPT/HCPCS codes to indicate specifics of service delivery.
Days or Units
- Block 24G specifies the number of service units; when entering units greater than one, total charges must reflect this in Block 24F.
Medically Unlikely Edits (MUE) Project
- MUE was introduced to reduce excessive Medicare claims through checks comparing reported unit counts against code definitions.
National Standard Employer Identifier
- Block 25 requires either a provider's SSN or EIN; entering accurate numbers is essential for proper reimbursement reporting.
Reporting the Billing Entity
- Block 33 captures the billing entity's legal name, address, and contact information, including NPI.
Processing Secondary CMS-1500 Claims
- For secondary claims, input primary and secondary payer details on the same claim form following specified steps.
Common Errors in CMS-1500 Claims
- Keying Mistakes: Incorrect procedure codes, diagnosis codes, policy IDs, and patient information can lead to claim rejection.
- Omissions: Missing essential information, such as diagnosis codes or proper linking, compromises claim validity.
Final Steps in Processing CMS-1500 Claims
- Review claims for errors, add attachments, and ensure proper record-keeping before submitting to payers.
Maintaining CMS-1500 Insurance Claim Files
- Claims need to be retained for up to five years according to Medicare guidelines. Organize files by case status and payer type.
Insurance File Set-Up
- Organize claims by open/closed status, year, payer types, and process remittance advice for efficient claims management.
Processing Assigned Paid Claims
- Upon receiving remittance advice, review claims for payments, noting discrepancies, and initiate appeals for any errors identified in processing.### Federal Privacy Act
- Enacted in 1974, it restricts payers from notifying providers about unassigned claims or payments sent to patients.
- For providers to assist patients with appeals, patients must provide an Explanation of Benefits (EOB) and a signed error explanation letter.
- The EOB and letter are required for reconsideration of claims.
UB-04 Claim
- Insurance claim form used for billing institutional services such as those performed in hospitals.
- Contains form locators (FLs) for data entry, previously referred to as the UB-92.
- Used for Medicare Part A reimbursements and for various institutional providers like hospitals and skilled nursing facilities.
- The claim is often generated through electronic health records to the billing department.
UB-04 Claim Development and Implementation
- Claims submitted to payers by institutional providers for patient service reimbursement.
- Managed by the National Billing Committee (NUBC) in coordination with State Uniform Billing Committees (SUBCs).
National Uniform Billing Committee (NUBC)
- Responsible for revising data elements on the UB-04 form, ensuring clarity and uniformity.
- Originally designed as the UB-82 in 1982, updated to UB-04 in 2004, implemented in 2007.
- Aims to support public health reporting and eliminate ambiguities in data collection.
Data Specifications for the UB-04
- Developed considering payer needs and provider reporting burdens; adheres to HIPAA provisions.
- Each data element is assigned to a specific UB-04 form locator (FL).
UB-04 Claims Submission
- Contains 81 form locators with instructions for completing claims according to payer guidelines.
- Collects NUBC-approved data for audit trails, even if not all elements are required by every payer.
Providers Submitting UB-04 Claims
- Includes hospitals, ambulance companies, home health agencies, hospice organizations, skilled nursing facilities, and various outpatient clinics.
Form Locator (FL) Descriptions
- Indicate requirements regarding data entry for Medicare claims (required, not required, situational).
- Payer-specific instructions can be found online.
Specific Form Locators (FL) Details
- FL1: Billing provider information is mandatory; verifies provider identity.
- FL3a: Patient control number is required to facilitate record retrieval.
- FL4: Type of bill (TOB) requires a four-digit alphanumeric code outlining facility type, type of care, and bill sequence.
- FL5: Federal tax number is mandatory for provider identification.
- FL6: Statement covers period (dates) required.
- FL11: Patient sex must be indicated as M (male) or F (female).
- FL14: Type of admission/visit code required for inpatient claims, specifying if it's emergency, urgent, etc.
- FL17: Patient discharge status indicates outcome using standardized codes.
Condition Codes and Occurrence Dates
- FL18-28: Condition codes are used situationally to describe events or circumstances applicable to the billing period.
- FL31-34: Occurrence codes date specific events related to the billing period, if necessary.
- FL35-36: Occurrence span codes detail specific timeframes relevant for inpatient claims, per payer requirements.
Responsible Party Information
- FL38: Responsible party name and address is required if specified by the payer; includes the individual's last name, first name, and middle initial.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Explore essential concepts from Chapter 11 on CMS-1500 and UB-04 claims. This quiz covers the definitions and details concerning reimbursement processes for professional and institutional services. Test your knowledge of claims submission and payment systems.
