Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 8 Common CMS-1500 Completion Guidelines

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. CMS-1500 Insurance billing form –Claims for non-hospitalized patients –Medicare –Medicaid –TRICARE –Private/Commercial insurance companies

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. CMS-1500 Guidelines Typed (keyed) data Alpha characters in CAPS Six- or eight-digit dates –MMDDYY or MMDDYYYY One space between first and last name and middle initial

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. CMS-1500 Guidelines Do not –Key letter O for zero –Use punctuation in names (except when hyphenating) –Use designations of birth order unless on insurance card E.g., Jr., Sr. –Add dollar signs, decimals, or commas in monetary fields –Add dash in front of CPT modifiers –Add parentheses around phone number area code

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Information Blocks 1-13 captures –Information about patient and patient’s health insurance policy

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Information Block 2: Patient’s name –Individual receiving services Block 4: Insured’s name –Name on insurance card –May not be patient’s name

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Information Block 8: Patient status –Student status Patients between ages 19 and 23 Insured’s dependent –Insurance may cover full-time student only

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Insurance Information Block 9a-9d: Other insured –More than one insurance plan –Secondary insurance policy information –YES in block 11d

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Information Block 10: Patient condition related to –Employment Workers’ compensation –Auto accident Auto insurance liability –Other accident Other insurance liability

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Insurance Information Blocks 11A-11C –Insurance information for person named in Block 4 –Primary insurance plan Block 11D –Identifies another (secondary) insurance plan –Relates to blocks 9A-9D

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Treatment and Provider Information Blocks captures –Illness, hospitalization, and service dates –Diagnoses codes –Services codes –Charges –Provider name, address, and ID number(s)

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Treatment and Provider Information Blocks and 18 –Dates related to Onset of illness Hospitalization Estimated time patient unable to work

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Treatment and Provider Information Blocks –Block 20: Lab tests “outside” of provider’s office –Block 21: ICD diagnosis codes Primary (first-listed) diagnosis entered first –Block 22: Medicaid claims only –Block 23: Preauthorization number If required

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Treatment and Provider Information Block 24A-J –Six services per claim form –Complete one line (A-J) at a time Block 24B: Place of service –Two-digit code –Physician office, hospital, nursing home, and others

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Treatment and Provider Information Block 24C: EMG –Emergency Immediate treatment necessary Save a life Prevent serious loss of structure or function

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Treatment and Provider Information Block 24D –CPT/HCPCS codes –Modifier(s) Block 24E –Diagnosis pointer number (block 21, lines 1-4) –Justify services in block 24D

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Provider Information Block 27: Accept assignment –Insurance reimbursement as payment in full Block 31: Signature –Electronic signature –Signature on file

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Provider Information Block 32: Service facility location –Where service(s) were provided –Facility National Provider Identification (NPI) number Block 33: Billing provider –Provider or group practice name, address, and phone number –Provider or group practice NPI

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Common Errors Patient information –Incorrect/Invalid insurance ID number Medical codes –Incorrect/Invalid CPT or ICD-9-CM code –Diagnosis code incompatible with service rendered