Home Study Course for the Medical Biller

Transcription

1 Chapter 3 M E D I C A L B I L L I N G C O U R S E. C O M, L L C Home Study Course for the Medical Biller Copyright , Medical Billing Course

2 Chapter 3 Internet Resource Downloadable CMS 1500 Form You can find blank CMS 1500 Forms on our website at: gcourse.com/chapters/c hapter3_191/cms1500.p df You may wish to print a CMS 1500 form to reference while studying this chapter. Understanding the CMS 1500 Form CMS 1500 Form (formerly known as the HCFA 1500 Form) the standard insurance form used to report outpatient services to insurance carriers. In Chapter 1 Introduction to Medical Billing, you learned the basics about gathering data. In Chapter 2 Understanding Office Forms, we took you step-bystep through the various documents needed in order to ultimately complete the CMS 1500 Form. In this chapter you will learn how to take the data that you have gathered and use it to appropriately fill out a CMS 1500 Form. Throughout this chapter you will be alerted to pay special I C O N K E Y attention to certain areas with the symbols you see in the icon Valuable Information key to the left. The Valuable Information may be contained Internet Resources on your chapter exam and you may wish to use a highlighter to come back to these areas prior to taking your test. Please take Platform Opinions advantage of the Internet Resources we have compiled for you. These will be listed in the left margin on any given page of this course. Periodically, we will provide you with Platform Opinions. These are nothing more than opinions or information from one or more of the medical billing center owners involved with putting together this course. We have also provided one blank CMS 1500 Form in your Study Guide. Don t Get Overwhelmed By Details form based upon what has initially been entered into the system. In this chapter we provide you with a detailed breakdown and description of each box located on the CMS 1500 form. Understand that your Medical Billing/Practice Management Software Program will automatically fill in the appropriate information on your CMS

3 Study Guide Reference the information for the patient, Thomas Davis. Reference Marcus Welby s Provider Information. For instance: When you are creating an encounter for a patient who has Blue Cross Blue Shield as their insurance carrier, your software program will know that it needs to pull the appropriate Blue Cross Blue Shield provider identifier and it will also know which box to provide this in on the CMS 1500 form. The only reason why we are going into such detail in this chapter is because we want you to have a good understanding of what each box represents and what information should be provided. Unless you will be manually writing your claim forms (which is highly doubtful), try not to get too involved or overwhelmed with the details we provide. This chapter will come in handy when used as a reference manual when you are actually doing medical billing. When you reach Chapter 7 of this course, which includes hands-on training in the PMX3 billing software program, much of the information that you learn in this chapter will simply pull together for you. For training purposes, we will be using the patient Thomas Davis information in teaching you how to complete a CMS 1500 Form. We will also be using Marcus Welby s provider information. Please reference these documents in your study guide as you go through this chapter. The New CMS 1500 Form History The CMS 1500 Health Insurance Claim Form answers the needs of many health payers. It is the basic paper claim form prescribed by many health plans for claims submitted by physicians and suppliers, and in some cases, for ambulance services. In the 1960s there were a number of different claim forms and coding systems required by third-party payers to communicate information regarding procedures and services to agencies concerned with insurance claims. However, there was no standardized form for physicians and other health care providers to report health care services. Therefore, the American Medical Association (AMA) embraced an assignment in the 1980s to work with the Centers for Medicare & Medicaid Services (CMS; formerly known as HCFA), and many other payer organizations through a group called the Uniform Claim Form Task Force to standardize and promote the use of a universal health claim form. As a result of this joint effort, the 1500 Claim Form is accepted nationwide by most insurance entities as the standard claim form/attending physician statement for submission of medical claims. With the transition to an increase in electronic claims submission and the Health Insurance Portability and Accountability Act (HIPAA) regulations, the Uniform Claim Form Task Force was replaced by the National Uniform Claim 2

4 Committee (NUCC) in the mid 1990s. The NUCC s goal was to develop the NUCC Data Set (NUCC-DS), a standardized data set for use in an electronic environment, but applicable to and consistent with evolving paper claim form standards. The NUCC continues to be responsible for the maintenance of the 1500 Claim Form. After considerable research to determine if the claim form needed updating in the late 1990s, the NUCC determined that the cost to implement any changes to the form at that time would exceed any projected gains. Although many providers now submit electronic claims, many of their software/hardware systems depend on the existing 1500 Claim Form in its current image. Minor changes have been made to the form in order to accommodate the National Provider Identifier (NPI) as well as current identifiers for a transition period until the NPI is implemented. Internet Resource Information about the NPI (National Provider Identifier) /NationalProvIdentStand/ Notes: 3

5 Breaking Down the CMS 1500 Form There are basically 2 parts to a CMS 1500 Form. The top of the form is used to report the Patient and Insured Information. The bottom of the form is used to report the Provider, Procedure, Diagnosis and Charge Information. 1. CMS 1500 Top Patient and Insured Information CMS Top Completion Instructions by Field 4

6 CARRIER BOX The carrier box is located in the upper right margin of the form. A bar code that existed on some forms in the upper left margin has been eliminated. In order to distinguish this version from previous versions, the 1500 symbol and the date approved by the NUCC has been added to the top margin. Always Required?: Yes How to Complete: Enter the name and address of the insurance carrier. Information Comes From: The patient s Insurance Card or completed Patient Information Form 5

7 BOXES 1 13: PATIENT AND INSURED INFORMATION Box 1 Internet Resource Medicare Learning Network /home/medicare.asp Always Required?: Yes How to Complete: Indicate the type of health insurance coverage applicable to this claim by placing an X in the appropriate box. Only one box can be marked. Medicare, Medicaid, TRICARE CHAMPUS, CHAMPVA, Group Health Plan, FECA, Black Lung, or Other means the insurance type to whom the claim is being submitted. Other indicates health insurance including HMOs, commercial insurance, automobile accident, liability, or workers compensation. This information directs the claim to the correct program and may establish primary liability. Information Comes From: The patient s Insurance Card or completed Patient Information Form Box 1a Always Required?: Yes How to Complete: Enter the ID number assigned to the insured by his/her insurance company to identify the insured party. 6

8 Information Comes From: The patient or insured s Insurance Card or completed Patient Information Form Special Consideration: For Worker s Compensation and Auto Insurance Claims, you will need to speak to the Insurance Adjuster to obtain a Claim Number for this box. You can report this on your Insurance Verification Form. Box 2 Always Required?: Yes How to Complete: Enter the patient s last name, first name and middle initial separated by commas. If the patient uses a suffix (i.e. Jr.), enter it after the last name and before the first name. Titles and professional suffixes (i.e. Dr., PhD, MD) should not be included. If a last name is hyphenated, you may use a hyphen in the box. Information Comes From: The Patient Information Form Box 3 7

9 Always Required?: Yes How to Complete: Enter the patient s 8 digit (MM DD CCYY) date of birth. Place an X in the box for M (Male) if the patient is a male or F (Female) if the patient is a female. Information Comes From: The Patient Information Form Box 4 Always Required?: Yes How to Complete: Enter the insured s last name, first name and middle initial separated by commas. If the insured uses a suffix (i.e. Jr.), enter it after the last name and before the first name. Titles and professional suffixes (i.e. Dr., PhD, MD) should not be included. If a last name is hyphenated, you may use a hyphen in the box. If the patient and the insured are one in the same, enter the word Same. Information Comes From: The Patient Information Form or Insurance Card 8

10 Box 5 Always Required?: Yes How to Complete: Enter the patient s mailing address (permanent residence). Do not use commas, periods or any other punctuation. You may use a hyphen for a 9 digit zip code. Information Comes From: The Patient Information Form Box 6 Always Required?: Yes How to Complete: Place an X in the box to indicate the patient s relationship to the insurance. You may only select one box. Information Comes From: The Patient Information Form 9

11 Box 7 Always Required?: Yes How to Complete: Enter the insured s mailing address (permanent residence). Do not use commas, periods or any other punctuation. You may use a hyphen for a 9 digit zip code. If the patient and the insured are one in the same, you may use the word Same in the top field and leave the rest of the box blank. Information Comes From: The Patient Information Form 10

12 Box 8 Always Required?: Yes How to Complete: Place an X in the box on the top line that represents the patient s marital status. Please an X in the box on the bottom line that represents the patient s employment/student status. Full-time student would indicate that the patient is registered as a full-time student as defined by the post-secondary school or university. Part-time student would indicate that the patient is registered as a part-time student as defined by the postsecondary school or university. This information is important for determination of liability and coordination of benefits (COB). Information Comes From: The Patient Information Form Box 9 11

13 Always Required?: No, only required if there is an additional health insurance policy covering the patient under another insured. Boxes 9 through 9d are completed when Box 11d is marked as Yes. How to Complete: Enter the insured s last name, first name and middle initial separated by commas. If the insured uses a suffix (i.e. Jr.), enter it after the last name and before the first name. Titles and professional suffixes (i.e. Dr., PhD, MD) should not be included. If a last name is hyphenated, you may use a hyphen in the box. Information Comes From: The Patient Information Form Special Consideration: Sometimes it is very simple to tell which insurance is the primary and which insurance is the secondary. If a patient is covered under their own insurance, their insurance will most likely be primary. If their spouse also carries the patient under their policy, the spouse s policy will most likely be the secondary insurance. But what happens when a child is covered under both parent s policies? Which is primary and which is secondary? In this scenario, you would follow the birthday rule. The Birthday Rule The guideline for the designation of the primary insurance policy when dependents are concurrently enrolled in two or more policies: The rule states the following: The primary policy is the one taken out by the policyholder with the earliest birthday occurring in the calendar year. In cases where the birthdays of the policyholders are the same, the policy that has been in effect the longest is considered the primary. The year of birth does not enter into this factor. The patient, Thomas Davis, does not have a secondary insurance. No example provided. Box 9a Always Required?: No, only required if there is an additional health insurance policy covering the patient under another insured. Boxes 9 through 9d are completed when Box 11d is marked as Yes. 12

14 How to Complete: Enter the policy or group number of the other insured. Do not use any characters, hyphens or spaces. Information Comes From: The Patient Information Form or Insurance Card The patient, Thomas Davis, does not have a secondary insurance. No example provided. See Box 11 for example. Box 9b Always Required?: No, only required if there is an additional health insurance policy covering the patient under another insured. Boxes 9 through 9d are completed when Box 11d is marked as Yes. How to Complete: Enter the other insured s 8 digit (MM DD CCYY) date of birth. Place an X in the box for M (Male) if the patient is a male or F (Female) if the patient is a female. Information Comes From: The Patient Information Form The patient, Thomas Davis, does not have a secondary insurance. No example provided. See Box 11a for example. Box 9c Always Required?: No, only required if there is an additional health insurance policy covering the patient under another insured. Boxes 9 through 9d are completed when Box 11d is marked as Yes. 13

15 How to Complete: Enter the name of the other insured s employer or school, if applicable. Information Comes From: The Patient Information Form The patient, Thomas Davis, does not have a secondary insurance. No example provided. See Box 11b for example. Item Number 9d Always Required?: No, only required if there is an additional health insurance policy covering the patient under another insured. Boxes 9 through 9d are completed when Box 11d is marked as Yes. How to Complete: Enter the name of the other insured s Insurance Plan Name or Program Name. Information Comes From: The Patient Information Form or Insurance Card The patient, Thomas Davis, does not have a secondary insurance. No example provided. See Box 11c for example. Boxes 10a 10c Always Required?: Yes 14

16 How to Complete: Select only one answer per letter. If the patient s condition is not related to employment or any type of accident, all boxes next to NO should be marked with an X. If the patient s condition is work-related, place an X next to YES in the Box 10a. If the patient s condition is related to an auto accident, place an X next to YES in Box 10b. If the patient s condition is related to any other type of accident (i.e. slip and fall at a store, fell off the roof of his house, ran into a mailbox with his bicycle etc.), place an X next to YES in Box 10c. Information Comes From: The Patient Information Form/Patient Examination Study Guide Reference your Study Guide for an example Basic COB (Coordination of Benefits). Special Consideration: When you indicate that the patient s condition is related to any type of accident, the patient may be covered under another primary insurance (primary to his health insurance benefits). If you were to file Thomas s claim to Blue Cross Blue Shield indicating that the patient s condition is related to an accident, Blue Cross Blue Shield (health insurance) will perform an accident COB (Coordination of Benefits) to determine if another insurance is responsible for the charges. Basic Coordination of Benefits is a form (questionnaire) that an insurance carrier/payer uses as in fact finding about other insurances that the patient may be covered by. For Instance: Let s say Thomas Davis fell off the roof of his house while shingling. Most likely, Thomas is going to be covered under his homeowner s insurance first. Or if Thomas was involved in an auto accident, he will be covered under auto insurance first (primary). 15

17 Box 10d Always Required?: No How to Complete: Some insurance carriers may require specific to the plan information in this box. You will need to refer to the insurance plan for instructions on completion. More often than not, this box is not used. Information Comes From: The Insurance Carrier/Payer Blue Cross Blue Shield of Indiana does not use this field. No example provided. Box 11 Always Required?: If Box 4 is completed with a name, Box 11 is required. How to Complete: Provide the insured s Policy, Group or FECA Number as provided by the insurance carrier. Policy: Usually relates to the number assigned to identify the insured under an individually purchased private health insurance plan. Group: A group number is usually provided by an insurance carrier in the event that the insured is covered under a group health insurance policy (one which is provided through employment) FECA: The FECA number is the 9-digit alphanumeric identifier assigned to a patient claiming work-related condition(s) under the Federal Employees Compensation Act 5 USC Information Comes From: The Insurance Card 16

18 Thomas s Group Number (which represents his employment group health benefits under Sun Appliance. Reference Thomas s Insurance Card. Box 11a Always Required?: No. Completion of this box is required if the patient and the insured are not one in the same. How to Complete: Enter the insured s 8 digit (MM DD CCYY) date of birth. Place an X in the box for M (Male) if the patient is a male or F (Female) if the patient is a female. Information Comes From: The Patient Information Form We left this box blank because the patient is also the insured and his date of birth and sex have already been completed in Box 3. We have also indicated in Box 6 that Thomas is both the patient and the insured. Box 11b Always Required?: No How to Complete: Enter the insured s (as referenced in Box 1a) Employer or School Name. Information Comes From: The Patient Information Form or Insurance Card Thomas Davis has group health insurance coverage under his employer, Sun Appliance. 17

19 Box 11c Always Required?: No. Some software programs will repeat the name of the plan as identified in the carrier box and others will not. Unless an insurance plan requires a name in this box (rare), your claim will not be rejected if it is left blank. In some instances, the ID number of another insured will be placed in this box. How to Complete: Enter the Insurance Plan Name or Program Name for the insured as identified in Box 1a. Information Comes From: The Patient Information Form or Insurance Card Box 11d Always Required?: Yes. Either the patient does or does not have another health insurance plan. How to Complete: Place an X next to YES if the patient has another insurance plan. If an X is placed next to YES, Boxes 9 through 9d must also be completed. Place an X next to NO if the patient does not have another insurance plan. 18

20 Information Comes From: The Patient Information Form or Insurance Card Box 12 Always Required?: No. The patient or guardian of the patient (if the patient is a minor) must give permission (via their signature) to allow anyone to release any of their medical information to anyone else. If the patient or guardian has not signed a document authorizing the release of their medical information, this field can be left blank. How to Complete: If a document providing permission for release of medical information has been signed and it on file with the providers office, this field can be completed with the phrase Signature on File. The date that will print from most software programs is the date the claim form was generated. If there is no signature on file, this area can either be left blank or completed with the phrase, No Signature on File. Information Comes From: Authorization/Permission to Release Medical Information Form What is this used for? Periodically an insurance carrier will wish to perform a review for medical necessity. In order to perform this review, the insurance carrier will request medical records from the provider of service. Many insurance carriers will only cover services that are deemed medically necessary. 19

21 Box 13 Study Guide Reference your Study Guide for an example Assignment of Benefits & Authorization to Release Medical Information Form. Always Required?: No How to Complete: If the insured or authorized person agrees to have the health insurance benefits payments go directly to the provider of service (mailed to the provider and made out to the provider) and has signed such an authorization, you may enter the phrase Signature on File in this field. If there is no signature on file, this area can either be left blank or completed with the phrase, No Signature on File. Information Comes From: Authorization to Pay Benefits Directly to Provider Form 20

22 CMS 1500 TOP PORTION NOTES: 21

23 CMS 1500 TOP PORTION EXERCISE 3.1 In your Study Guide, pull out the information for Thomas M. Davis. Utilizing your Patient Information Form and Insurance Card for Thomas M. Davis, and what you have learned thus far in this chapter, complete the following: 22

24 2. CMS 1500 Bottom Provider, Procedure, Diagnosis and Charge Information 23

25 BOXES 14-33: PHYSICIAN OR SUPPLIER INFORMATION CMS Bottom Completion Instructions by Field Box 14 Always Required?: No. Visits such as annual exams and physicals will not require an illness, injury or pregnancy date. How to Complete: Enter the date of the first onset of the illness or injury that corresponds to the diagnosis listed for the patient. In the event of pregnancy, enter the date of the last menstrual period. Date format can either be 6 digit (MM DD YY) or 8 digit (MM DD CCYY). Information Comes From: Patient Examination and/or Patient Information/History Form Special Consideration: It is a good idea to check this date against the date that the insurance policy took effect. If you report an injury or illness or pregnancy prior to the effective date of an insurance policy, a pre-existing condition will come into play. Box 15 Always Required?: No, only if applicable. How to Complete: Enter the date of the first onset of the similar illness or injury that corresponds to the diagnosis listed for the patient. Date format can either be 6 digit (MM DD YY) or 8 digit (MM DD CCYY). 24

26 Information Comes From: Patient Examination and/or Patient Information/History Form Special Consideration: It is a good idea to check this date against the date that the insurance policy took effect. If you report an injury or illness or pregnancy prior to the effective date of an insurance policy, a pre-existing condition will come into play. Box 16 Always Required?: No, only if applicable. How to Complete: If the patient is employed and it unable to work due to the illness or injury reported, complete this area either with the 6 or 8 digit date format. Information Comes From: Patient Examination and/or Patient Information/History Form Special Consideration: It is a good idea to check these date against the date that the insurance policy took effect. If you report an injury or illness or pregnancy prior to the effective date of an insurance policy, a pre-existing condition will come into play. Box 17 Always Required?: No, only if applicable. How to Complete: If the patient was referred by another provider, enter then first name, middle initial, last name and credentials of the provider. Do not use commas. Information Comes From: Patient Examination and/or Patient Information/History Form 25

27 Boxes 17a and 17b Study Guide Reference your Study Guide for a list of Qualifiers and who/what they correspond to. Always Required?: No. Complete these boxes only if the patient was referred by another provider. How to Complete: First box of 17a: Enter the alphanumeric qualifier. Second box of 17a: Enter the non-npi ID (assigned to the provider by certain insurance carriers/payers) of the referring or ordering provider. Box 17b: Enter the 10 digit NPI for the referring/ordering provider. Special Consideration: For reporting to Medicare you will need to use the physician s UPIN Number. UPIN stands for Unique Provider Identification Number. Information Comes From: Patient Examination and/or Patient Information/History Form Internet Resource UPIN Look Up Database Thomas Davis was not referred by another provider. No example given. Medicare Physician Identifiers UPINs, PINs and NPI Numbers Box 18 Click Here Always Required?: No, only if applicable. How to Complete: If the procedures being reported for the patient are related to an inpatient hospitalization, enter the 6 digit or 8 digit FROM and TO dates. If the patient has not been released from the hospital, leave the TO date blank. Information Comes From: Physician s Notes No example. Box 19 26

28 Always Required?: No. In most instances, this is usually left blank. How to Complete: Sometimes an insurance payer will require certain identifying information to be placed in this box. You will need to refer to the claim guidelines from the payer to determine what, if anything, needs to be included in this box. Information Comes From: Insurance Carrier/Payer Box 20 Always Required?: No, only if applicable. How to Complete: Are there any laboratory procedures listed on the claim form that were performed at an outside lab and not within the physician s office? If so, place an X in the box next to YES. If not, place an X in the box next to NO. If YES is indicated, you will need to calculate the total charges for outside lab procedures and enter them into the $ charge section of this box. Special Consideration: If YES is selected in Box 20, the name and address of the outside lab will need to be included in Box 32 of the CMS 1500 Form. Box 21 Always Required?: Yes How to Complete: Always using the highest level of specificity, list the ICD (International Classification of Disease) diagnosis codes relating to the condition(s) that the patient is receiving services for. This section represents WHY the patient is being treated. Only digits are reported here. The written narrative/description of the diagnosis should not be included. 27

29 Internet Resource ICD Coding Guidelines for Outpatient Services delines/outpatient.htm ICD9 Look Up Database m/ List up to 4 diagnosis codes and always start with the most prevalent diagnosis first. For Instance: A diagnosis which reflects pain isn t always the most prevalent diagnosis. A diagnosis which provides the reason why the patient is experiencing the pain should always be listed before the diagnosis reflecting the pain caused by the condition, if and when possible. Special Consideration 1: Careful consideration needs to be paid to the contents of this box. The insurance payer will carefully review this section in their determination of medical necessity. Oftentimes an insurance payer will autoassign an amount of procedures to fall within medical necessity based upon the diagnosis reported. For Instance: Let s say that a patient goes to see his physician because he is experiencing pain in his left elbow. The doctor/provider of services doesn t know why the patient is experiencing pain in his left elbow, so the provider runs a series of tests to determine why the patient is experiencing pain. The first claim submitted for the patient includes a diagnosis for elbow pain and reports all the tests run on the patient to discover why the patient is experiencing pain. The elbow pain diagnosis substantiates the tests run on the patient. But, the insurance payer will assign a reasonable amount of services to be performed for the elbow pain diagnosis. If the provider is sloppy about the contents of this box and does not continue to update the diagnosis to reflect the actual condition/source of pain, and only continues to report just the elbow pain diagnosis, without reporting the condition found as the cause of the pain, eventually subsequent claims will be kicked-out for manual review for medical necessity. Special Consideration 2: The ICD-9-CM code represents the diagnosis of the patient as connected to the procedures (CPT) that you will be listing in Box 24D. As the medical biller it is not your responsibility to identify an ICD-9-CM code. This needs to be coded and provided to you either by the physician or a physician s coder! Information Comes From: Superbill, Daysheet, Information from Provider 28

30 Box 22 Always Required?: No, only if applicable How to Complete: Complete this box if you are resubmitting a Medicaid claim. You will need to refer to the requirements set-forth by the Medicaid intermediary (payer) in order to determine the proper completion of this box. Information Comes From: Previous Medicaid Claim Submission and Medicaid Guidelines Box 23 Always Required?: No, only if applicable How to Complete: An insurance payer may require a prior authorization for certain procedures performed on a patient. Prior Authorization simply means that the insurance payer has been contacted and notified that a certain procedure needs to be performed. If the insurance payer approves the procedure which requires prior authorization, a prior authorization number will be provided by the insurance payer. This number is entered into Box 23. Information Comes From: Insurance Payer Guidelines/Insurance Payer Box 24 29

31 This entire section of the CMS 1500 Form represents the WHEN, WHERE, WHAT, EXTENUATING CIRCUMSTANCES, AND $ HOW MUCH relating to the procedures/services rendered to the patient. Only 6 procedures can be listed in this section. If more services were provided, they must be reported on additional CMS 1500 claim forms. Item Number 24A Always Required?: Yes How to Complete: Enter the From and To dates that the procedure being reported was rendered. Information Comes From: Superbill or Daysheet 30

32 Box 24B Study Guide Reference your Study Guide for a list of POS (Place of Service) codes. Always Required?: Yes How to Complete: Enter the 2 digit POS (Place of Service) code to signify where the services were rendered. Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry. Information Comes From: This really depends on the type of provider. If this is the type of provider who always performs the services in his office, then you will always report the 2 digit code for office (11). Box 24C Always Required?: No EMG means emergency indicator. This box used to be used to report the TOS (Type of Service). TOS is no longer used. How to Complete: Place a Y in the box if the procedure performed is related to an emergency situation. Leave the box blank if it is not. Information Comes From: Patient Information Form, Patient Examination. 31

33 Special Consideration: The definition of an emergency may need to be verified by federal or state regulations or insurance payer guidelines. Box 24D Always Required?: Yes Study Guide Reference your Study Guide for a list Modifidiers and their description. How to Complete: Enter the 5 digit CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) code under the CPT/HCPCS column. Enter any 2 digit (up to 4) modifiers for each CPT or HCPCS code reported, if applicable. The CPT or HCPCS codes reports what service was done and the Modifier provides additional, extenuating circumstances about the procedure reported. At this point you may be feeling a little overwhelmed. I want to remind you that the purpose of this chapter is to familiarize you with the CMS 1500 Form. Don t worry about codes and modifiers right now as this will fall into place for you in the next chapter. Furthermore, you will be utilizing Practice Management Software that should definitely simplify the process of completing a CMS 1500 Form. Later in the course you will be entering your data into practice management software and you will witness just how easy the process can be. Possessing a good understanding of the process is important and will allow you to appreciate the tools you will be utilizing to get the job done. Information Comes From: Superbill or Daysheet Special Consideration: Certain procedures, especially reported to Medicare, will require a modifier. Refer to the Medicare guidelines in your state. 32

34 In this example, three procedures are reported: 99201: Evaluation & Management Code 98940: (CMT Code) Spinal Manipulation 72070: X-Ray The modifier -25 explains that the code is separate and significantly identifiable and should be paid in addition to the code, which also includes a level of evaluation and management. In some cases, if you did not modify the code with a -25, it would be denied due to being a duplicate service. Box 24E Always Required?: Yes How to Complete: Enter the number of the diagnosis listed in Box 21 that the procedure on this line is related to. You will notice that Thomas Davis only has one diagnosis. The procedures performed on Thomas are all related to that one diagnosis which is located in Box 21, number 1. Information Comes From: Superbill/Daysheet Let s say that Box 21 (Diagnosis or Nature of Illness or Injury) contains more than one diagnosis (let s add two more) and that all the procedures listed in Box 24A relate to all the diagnosis listed in Box

35 This is what Box 24E would then look like: Box 24F Always Required?: Yes How to Complete: Enter the charge amount for the procedure. Remember: Your software program will retain this information and will automatically fill in this area for you. The software program will know the charge for each procedure because the procedures and their charges will have been entered into the system. Information Comes From: Pre-loaded into the software system. 34

36 Box 24G Always Required?: Yes How to Complete: Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Information Comes From: Superbill/Daysheet Box 24H Always Required?: No EPSDT = Early & Periodic Screening, Diagnosis, and Treatment How to Complete: Some state health plans (i.e. Medicaid) covers EPSDT and will require you to complete this box if the procedure is related to EPSDT. Place a Y in the box to indicate YES. Place an N in the box to indicate No. If EPSDT isn t applicable, leave this box blank. Information Comes From: Type of Insurance 35

37 Box 24I Study Guide Reference your Study Guide for a list of Qualifiers. Always Required?: No How to Complete: Enter the alpha numeric qualifier for the non NPI provider identifier number that is listed in the next box, Box 24J. Since we are filing a claim to Blue Cross Blue Shield, we will be using the Qualifier 1B. Blue Cross Blue Shield requires the Blue Cross Blue Shield Provider Number for the rendering physician to be included in Box 24J. There are also additional insurance payers who will require for you to identify the rendering provider with the number they have assigned to that particular provider in Box 24J of the CMS 1500 Form. Remember: Your software program will know how to populate this box based upon the type of insurance that you select when you enter the insurance plan information for a patient. Information Comes From: Insurance Information for the Patient Special Consideration: The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care. In the case where a substitute provider (locum tenens) was used, enter that provider s information here. Report the Identification Number in Boxes 24I and 24J only when different from data recorded in boxes 33a and 33b. Because we are filing Thomas Davis claim with Blue Cross Blue Shield of Indiana, we will be using the qualifier 1B. 36

38 Box 24J Always Required?: No How to Complete: Enter the Rendering Provider ID Number, if applicable, that has been assigned to the provider by the insurance carrier. Since we are filing a claim to Blue Cross Blue Shield, we will be using the Blue Cross Blue Shield Provider Number for the physician, Marcus Welby. There are certain insurance payers who will require for you to identify the rendering provider with the number they have assigned to that particular provider in this box. Remember: Your software program will know how to populate this box based upon the type of insurance that you select when you enter the insurance plan information for a patient and the information you have entered for the provider. Information Comes From: Provider Information Special Consideration: The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care. In the case where a substitute provider (locum tenens) was used, enter that provider s information here. Report the Identification Number in boxes 24I and 24J only when different from data recorded in boxes 33a and 33b. Because we are filing Thomas Davis claim with Blue Cross Blue Shield of Indiana, we will be using the Blue Cross Blue Shield Provider Number for the provider, Marcus Welby. 37

39 Box 25 Always Required?: Yes How to Complete: How does this particular provider/practice report their income to the IRS? If he/she reports as a group using an EIN (Employer ID Number), enter this number into Box 25. If the income is reported using an individual SSN (Social Security Number), enter this number into Box 25. Place an X in the appropriate box for either SSN or EIN. Information Comes From: Provider Information Our provider reports as a group practice using his EIN Box 26 Always Required?: No How to Complete: Enter the patient s account number. This number can either be assigned by the provider s office or it can be automatically assigned/generated through the software system. Do not use hyphens or commas. Enter just the number or alpha numeric account identifier. Remember: Your software will automatically populate this box. Information Comes From: Patient Encounter Document/Patient Information Form 38

40 Box 27 Always Required?: No How to Complete: Enter an X in the appropriate box to indicate whether or not the provider accepts assignment under Medicare or under any other government plan being billed. Contrary to what many others believe, this is not a duplication of Box 13! Selecting YES in this box means that the provider has negotiated a participating provider contract and has agreed to accept the carrier-determined allowed fee for all services performed. Check NO if the provider has not signed a participating provider contract with the insurance carrier. Some software programs will default to YES on all claims submitted based on the information that has been provided in the software. Information Comes From: Provider Insurance Plan Agreement Box 28 Always Required?: Yes How to Complete: Enter the total of all charges listed in Box 24F. Your software program will automatically calculate this for you. Information Comes From: Adding the charges listed in Box 24F of the CMS 1500 Form 39

41 Box 29 Always Required?: No How to Complete: Enter any amount paid by the patient or by another insurance carrier. Information Comes From: Superbill/Daysheet, EOB (Explanation of Benefits) I personally prefer to leave this box blank even if the patient or another payer has paid towards the claim. The reason being is because on more than one occasion, I have included an amount paid in this box, which will deduct the amount from Box 30 (Balance Due) only to have the insurance payer pay their portion on just the amount in Box 30. This then leaves a balance on the patient s account that should have been paid by the insurance. In the event that I would be billing a secondary insurance after the primary insurance has made their payment on a claim, I would attach the primary EOB (Explanation of Benefits) to the CMS 1500 claim form so that the secondary payer could see what was paid, but I would leave Box 29 blank. For Instance: The patient has an insurance that pays 80%. The copay amount is 20%. The total charge = $ The patient pays $ You report the $20.00 payment in Box 29 which gave a Balance Due (Box 30) of $80. The insurance payer looked at the $80 and paid 80% of the $80.00 Balance Due ($64.00) when they should have actually paid 80% of the $100 charge. This would then leave a balance on the claim of $ It happens. Box 30 Always Required?: Yes 40

42 How to Complete: Enter the Balance Due amount. Information Comes From: Adding the charges on the CMS 1500 Form. Box 31 Always Required?: Yes How to Complete: Enter the name and the credentials of the billing provider and the date the claim form was generated. Information Comes From: Pre-loaded into the software program Box 32, 32a and 32b Always Required?: No, only if applicable 41

43 How to Complete: If the procedures listed were rendered at a location other than the provider s office or patient s home, enter the name and address of the facility here. If you have selected YES in Box 20 of the CMS 1500 Form, you will need to enter the name and address of the laboratory where the procedures were actually performed in Box 32. If you have completed Box 32, you will need to provide the NPI # in Box 32a for the facility/supplier listed in Box 32. Box 32b (other ID#): If applicable, enter the two digit qualifier identifying the non- NPI number followed by the ID number with no spaces or hyphens in between. Information Comes From: Superbill which includes information about the outside facility used. Box 33, 33a and 33b Always Required?: Yes How to Complete: Enter the appropriate name, address and phone number of the Billing Provider (the provider who is requesting payment) in Box 33. If the billing provider is set up as a group practice, the name of the practice should be used. If the provider is set up as an individual who uses his SSN (fee for service), use the personal name of the provider. Box 32a: Enter the NPI # for the Billing Provider. Box 32b: If applicable, enter the Qualifier and the non-npi billing provider number without any spaces or hyphens. Information Comes From: Practice Information Since we are filing this claim to Blue Cross Blue Shield, we are reporting the Qualifier for BCBS (1B) and the Billing Provider ID number assigned to the provider by BCBS. 42

44 And Box 33 is the last box to complete on the CMS 1500 Form. Clear as mud? 43

45 CMS 1500 BOTTOM PORTION EXERCISE 3.2 In your Study Guide, using the Encounter Document for Thomas Davis, and what you have learned thus far in this chapter, complete the following: 44

46 CMS 1500 FULL FORM COMPLETION EXERCISE 3.3 You have 2 options for completing a full CMS 1500 Form for Thomas Davis: 1. Print a blank CMS 1500 form (provided in the Chapter 3 area) and complete the form by hand. There is also one blank CMS 1500 form in your Study Guide. OR 2. Go to the Chapter 3 area and use the WEB CMS 1500 Form. (recommended) To go directly to the WEB CMS 1500 Form, point your browser to: You will not be graded on this exercise. This exercise is purely for practice. When you begin medical billing, you will not be manually completing CMS 1500 forms. Your software will handle this for you after you have keyed in pertinent information. The point of this exercise is to provide you with a good understanding of the boxes on the CMS 1500 Form. When you are finished with your form, compare it to the form provided in your Study Guide. 45

47 Chapter 3 Motivation Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit. -.Aristotle I know of no more encouraging fact than the unquestionable ability of man to elevate his life by conscious endeavor. - Henry David Thoreau A smooth sea never made a skilled mariner. - English Proverb 46