CMS- with 100% correct questions and answers

CMS-1500 used to request payment from health insurance payers, like Medicare, after a patient has been treated. To fill out the form you must have: -the patient registration form -patient health record documentation -superbill/encounter form patient registration form contains the patient's demographic information and health insurance payer information. This information must be up to date, and most practices will institute a policy of verifying the information upon each visit. This form is usually accompanied by photocopies of the insurance card(s) to ensure accurate spelling, group numbers, and contact information. patient health record documentation comprised of all of the information pertaining to the assessment and treatment of the patient. Generally, these will be separated by encounter. superbill/encounter form This preprinted form is filled out on each visit and contains the codes that are used in the particular healthcare setting. This form will have the diagnosis codes and procedure codes designated by the physician at the completion of the encounter. How should the CMS-1500 be filled out? with all capital letters and no punctuation "CARRIER" this is where the name and address of the third-party payer handling the claim will go PATIENT AND INSURED INFORMATION Item 1 will require you to identify the type of health insurance held by the patient. The correct insurance type will be marked with a capital X PATIENT AND INSURED INFORMATION Item 1a identifying number of the person who is insured by the policy. This is found on the insurance identification card. PATIENT AND INSURED INFORMATION Item 2 will include the patient's full name: last name, first name, and middle initial. Only use the punctuation or suffixes (e.g., Jr., III) exactly as they appear on the patient's insurance card. PATIENT AND INSURED INFORMATION Item 3 contains two fields. The first piece of information in this field is the patient's date of birth. This must be entered in the MM DD YYYY format (e.g., 09 22 19XX). There is also a place to indicate whether the patient is male or female in this field. PATIENT AND INSURED INFORMATION Item 4 requires the insured's name. This is the name of the insurance policyholder, which may be the same as the patient. If the insured and the patient are the same person you can write SAME in this box. PATIENT AND INSURED INFORMATION Item 5 patient's full address. It is broken into spaces for the street address, city, state, zip, and telephone number. Enter these without any punctuation. Use no spaces or hyphens in the telephone number. The parentheses for the area code are provided. PATIENT AND INSURED INFORMATION Item 6 indicates what the relationship the patient is to the policyholder. If the patient is the policyholder, then self would be marked with an X. PATIENT AND INSURED INFORMATION Item 7 requires the full address of the insured to be entered. If the address of the insured is the same as the patient you can write SAME in this box. PATIENT AND INSURED INFORMATION Item 8 required by most third-party payers. Medicaid is the only 3rd party payer that should have this box blank. It asks for the marriage and employment status of the patient, which may change from visit to visit, causing incorrect or out-of-date demographic information. PATIENT AND INSURED INFORMATION Item 9 asks for the other insured's name. This will be used if the patient is covered by secondary health coverage. The name of the policyholder of this secondary coverage will be entered in the same manner as the name in item 4. If there is no secondary payers then leave it blank. PATIENT AND INSURED INFORMATION Item 9a will include the group number of the secondary insurance. This will be written with no space and no punctuation. PATIENT AND INSURED INFORMATION Item 9b will include the birthdate (mm dd yyyy) and sex of the policyholder of the other insurance. PATIENT AND INSURED INFORMATION Item 9c asks for the employer or school attended by the policyholder of the secondary insurance PATIENT AND INSURED INFORMATION Item 9d requires the name of the company or plan that was referenced in item 9 PATIENT AND INSURED INFORMATION Item 10 requires you to mark "yes" or "no" for each of the questions regarding the patient's condition. Automobile, work, or other possible liability claims are handled differently from other visits. PATIENT AND INSURED INFORMATION Item 10d reserved for local use. Some payers will request certain information be filled in here. What's special about Items 10a and 10b? If questions 10a or 10b are answered "YES," then Medicare or Medicaid cannot be billed as the primary insurance. PATIENT AND INSURED INFORMATION Item 11 asks for the policy number of the primary policy as it appears on the insured's card (the insured listed in Item 4). Do not use spaces or hyphens in this field. this is different from the insurer's ID number in box 1a. It could be listed as group or FECA number on the card. PATIENT AND INSURED INFORMATION Item 11a asks for the insured's birthdate (mm dd yyyy) and the insured's sex. PATIENT AND INSURED INFORMATION Item 11b asks for the employer or school attended by the person insured by the primary insurance. PATIENT AND INSURED INFORMATION Item 11c requires the name of the company or plan that was referenced in Item 1a. PATIENT AND INSURED INFORMATION Item 12 you will be required to obtain a signed release of medical information from each patient. If you have a signed and dated release of information on file, and it is not out of date, you will fill in "Signature on File" or "SOF." If you do not have an authorization on file, you will leave this space blank or enter "No Signature on File." PATIENT AND INSURED INFORMATION Item 13 asking for the reader to obtain permission to authorize payment from the third-party payer to the healthcare provider. If you have a signature, you will fill in "Signature on File" or "SOF." If you do not have an authorization on file, you will leave this space blank or enter "No Signature on File." PHYSICIAN OR SUPPLIER INFORMATION Item 14 asks for the date of the current illness, accident, or pregnancy. Since there are really three options here as to the nature of the encounter, we need to understand what they are requesting for each. Again dates will be given in the mm dd yyyy format. Item 14: the claim is for an illness the date of the first symptom recorded in the health record documentation should be used. If no date is given, the date of service (Item 24) will be used. Item 14: the claim is for an injury the date of the accident or injury will be entered. This is absolutely required for Worker's Compensation claims and automobile accident claims. Item 14: the claim is for a pregnancy the date of the last menstrual cycle is used. PHYSICIAN OR SUPPLIER INFORMATION Item 15 It asks for dates of similar illnesses. This item is not often used. It would be used if the documentation clearly indicates the patient had a similar illness at a prior date that is also documented. Medicare and many private insurers do not require this information so it is often left blank. PHYSICIAN OR SUPPLIER INFORMATION Item 16 really deals solely with worker's compensation claims. These fields will have the beginning and ending dates the patient was unable to work (mm dd yyyy). Check with individual payers as to the requirements for this item because most do not require this to be filled in. PHYSICIAN OR SUPPLIER INFORMATION Item 17 the full name and the professional credentials of the physician who referred the service/supplies or who ordered the service/supplies. Even if a service was referred or ordered by a physician and was completed by a technician, the ordering physician's name goes in this space. The name is written first name space middle initial space last name space professional credentials. Do not use any punctuation. PHYSICIAN OR SUPPLIER INFORMATION Item 17b where the National Provider Identifier number will go. HIPAA required all physicians and anyone else who will be reimbursed by insurance companies to apply for one of these numbers. PHYSICIAN OR SUPPLIER INFORMATION Item 18 used when a physician admits a patient to a hospital for any length of stay. The coder/biller would enter the date of admission in the "from" box and the date the patient is discharged from the hospital in the "to" box. Note: The UB-04 form would be utilized by the hospital for inpatient encounters. The CMS-1500 form is utilized by the physician. PHYSICIAN OR SUPPLIER INFORMATION Item 19 "reserved for local use." As the description says, some third-party payers want this box left blank, while others will instruct you to put various information in here based on different circumstances. All third-party payers will want you to put information in this box if you are billing a Not Otherwise Classified (NOC) CPT® code or if you are billing a NOC drug. PHYSICIAN OR SUPPLIER INFORMATION Item 20 used for Medicare only. It is used when a physician pays an outside entity to perform a service. If the physician has an agreement to pay for the service himself and he wants to be reimbursed for the service, he will mark "yes" and enter the amount he paid for it. Payment is entered with no dollar sign and no decimal point and will all be entered to the left of the vertical dividing line. PHYSICIAN OR SUPPLIER INFORMATION Item 21 contains spaces for ICD-10 diagnosis codes to be entered. A maximum of four codes can be entered. Depending on the medical billing software you will be working on, you may either enter the ICD-10 diagnosis codes without the period or you will place the period in the appropriate place. PHYSICIAN OR SUPPLIER INFORMATION Item 22 This box pertains to Medicaid only. You only use it when you are resubmitting a rejected claim for additional money or if there was a coding error that you have corrected. The code is typically the rejection code for that particular claim line and the original reference number is a number that has been assigned by Medicaid for that particular claim line. You will want to verify with the state that you are working in what they expect when resubmitted a corrected claim. PHYSICIAN OR SUPPLIER INFORMATION Item 23 used if the third-party payer requires a preauthorization or precertification of a service. Usually these are reserved for inpatient services, but there are some outpatient services that require these. Medicare does not require preauthorization for services. Preauthorization/precertification numbers should be written with no spaces or punctuation. For Medicare only there are a few other times when box 19 needs information filled in: A Part When a patient who sees a non-participating physician and the physician decides to participate on this claim but the patient refuses to assign benefits. Then enter in box 19 the following statement: "Patient refuses to assign benefits." In this case, the payments can only be made to the beneficiary. For Medicare only there are a few other times when box 19 needs information filled in: B Part When physicians share post-operative care on a patient, then enter a 6 digit or 8 digit assumed date of care or relinquished date of care in box 19. PHYSICIAN OR SUPPLIER INFORMATION Item 24 most detailed item concerning the encounter that there is on the CMS-1500. Item 24 is broken down into many parts allowing you to give details of exactly what happened and when it happened. PHYSICIAN OR SUPPLIER INFORMATION Item 24a requests the dates of service in a "from ___ to ___" format. If you are reporting one day of service only, fill in the "from" column and put in the same date in the "to" column. You should not leave this column blank (or it may cause a rejection). However if your physician saw a patient in the hospital for subsequent daily visits, you would enter in the "from" column the first date of the "subsequent visits" for that one code and in the "to" column enter the last day the physician visited for the same CPT® code. PHYSICIAN OR SUPPLIER INFORMATION Item 24b requires you to code the place of service (POS) for each of the corresponding service dates. The POS codes are standard for every third-party payer. Every physician's office can create an internal code for the different place of services to distinguish one hospital from another if the physician(s) goes to multiple hospitals. Physician's office POS code 11 (needed for item 24b) Patient's home POS code 12 (needed for item 24b) Assisted living POS code 13 (needed for item 24b) Inpatient hospital POS code 21 (needed for item 24b) Outpatient hospital POS code 22 (needed for item 24b) Emergency room- hospital POS code 23 (needed for item 24b) Skilled nursing facility POS code 31 (needed for item 24b) Urgent care POS code 20 (needed for item 24b) PHYSICIAN OR SUPPLIER INFORMATION Item 24c generally only used for Medicaid. Here you indicate whether or not the patient's treatment was an emergency by marking Y (yes) or leaving it blank for no. PHYSICIAN OR SUPPLIER INFORMATION Item 24d In the first box enter the CPT or HCPCS code. The remaining four boxes are used for up to four modifiers (a two-digit modifier per box). There is a note to explain unusual circumstances, which would apply to a modifier 99—unlisted code. In this instance you would be required to attach the patient's medical record and/or a written explanation of the service or procedure. PHYSICIAN OR SUPPLIER INFORMATION Item 24e asks for the diagnosis pointer. The pointer is the corresponding number from Item 21 (the diagnosis codes). This allows the payer to verify the procedure is appropriate for the diagnosis. Make sure you enter the single-digit list number in this box and not the diagnosis code. PHYSICIAN OR SUPPLIER INFORMATION Item 24f Here you enter the charges in dollars and cents, which are separated by the embedded vertical line, for each procedure. Use no dollar signs or commas. PHYSICIAN OR SUPPLIER INFORMATION Item 24g requests the days or units for each service. Most services/procedures that are billed will have a unit of 1 since most services/procedures can only be billed once per 24 hours. However there are always exceptions: if a medication comes in 15mg and the physician wants the patient to have 30mg, then the units would be 2 because 2 15mg units were given to the patient. Another example of billing multiple units would be billing subsequent hospital days. Remember box 24A has "from" and "to" columns for the dates of service. The number of units counted would be the number of days starting with the date in the "from" column, all the days in between and including the date in the "to" column. The number you come up with is entered in the "units" column. PHYSICIAN OR SUPPLIER INFORMATION Item 24h pertains to Medicaid patients only. There is a special exam and form that needs to be filled out when performing this special exam. ESPDT- Early Screening Periodic Diagnosis and Treatment for children from birth to age 21. If the physician participates in this program, he must indicate if he has performed this evaluation on the claim form for appropriate reimbursement. PHYSICIAN OR SUPPLIER INFORMATION Item 24i It is where the modifier explaining the type of identification number that will go in Item 24J belongs. If your payer requires an identification number in addition to the NPI number, that number will go in the shaded area of Item 24J and the modifier will be entered in the shaded area of Item 24I. PHYSICIAN OR SUPPLIER INFORMATION Item 24j will require the provider's NPI number in the unshaded blank and the additional identification number (if required) in the shaded area. PHYSICIAN OR SUPPLIER INFORMATION Item 25 for the provider's SSN or EIN. Every physician practice files a business name with the IRS when they apply for a Federal Tax ID number, which is also known as the Employer Identification Number (EIN). This identifies to the third-party payer which physician or physician practice rendered the services and to whom to make the check payable. It is also a verification method for the third party payer to see if this physician or physician group has reported services to them before. Another important fact is that this number is how the revenue that the practice receives is reported to the IRS. Whether entering the EIN or the SSN, no hyphens or spaces are used in this field. PHYSICIAN OR SUPPLIER INFORMATION Item 26 where the patient's account number is entered. This number is assigned by the provider and should be entered with no spaces or hyphens. PHYSICIAN OR SUPPLIER INFORMATION Item 27 gives the third-party payer consent to mail the payment to the physician's office. For government plans such as Medicare, Medicaid and TRICARE and those third-party payers where the physician has a "signed contract," marking "yes" in box 27 means that you as the medical biller cannot bill the patient the difference between the charge amount and the allowed amount. PHYSICIAN OR SUPPLIER INFORMATION Item 28 indicates the total amount billed on the claim form. This is gathered by adding lines 1-6 together in Item 24F PHYSICIAN OR SUPPLIER INFORMATION Item 29 asks for the amount already paid and will generally be left blank when making submission to the primary insurer. If sending the claim to the secondary insurer, you would fill in the amount of the claim paid by the primary insurer. PHYSICIAN OR SUPPLIER INFORMATION Item 30 follows up on the previous two boxes. Generally this will be blank if the claim is going to the primary insurer. If the primary insurer has paid on the claim and the remainder is going to a secondary insurer, the difference would go in this box. PHYSICIAN OR SUPPLIER INFORMATION Item 31 requires the physician's signature, credentials, and date. If you were actually filling this out by hand, he/she would sign here or "SOF" would be entered. Software will complete this by inserting the physician's name and the date the claim is printed in the correct spaces. PHYSICIAN OR SUPPLIER INFORMATION Item 32 large space for the name and location where the service was provided. PHYSICIAN OR SUPPLIER INFORMATION Item 32a reserved for the NPI number of the service facility PHYSICIAN OR SUPPLIER INFORMATION Item 33 requires you to enter the healthcare provider clinic name that is filing the claim for payment. You must keep in mind that the name that appears in this box must match the name that owns the EIN/Federal Tax ID number in box 25. You will also enter the full address (no punctuation is needed used, unless a hyphen is required in a 9-digit zip code), and telephone number (no parentheses, dashes, or spaces). PHYSICIAN OR SUPPLIER INFORMATION Item 33a reserved for the NPI number of the facility requesting payment Once a claim is complete, what should be done? a copy should be kept for the providers' records and one should be submitted to the insurance company.