1 Training Module 3 Part A – Institutional Basic Claims Entry PC-ACE Pro32

Palmetto GBA – October Objectives Our objective for this training module is to assist you with entering information necessary to submit a basic Institutional Medicare Encounter Claim. This module is based on your knowledge of module two, titled Building Reference Files. After completing this training module, you should be able to:  Create a basic Medicare Part A Encounter claim using PC-ACE Pro32 software Please note the data used in this training module is for demonstration purposes only. Your specific information may differ.

Palmetto GBA – October Disclaimer The information provided in this presentation was current as of 10/14/2011. Any changes or new information superceding the information in this presentation are provided in articles with publication dates after 10/14/2011 posted on our Web site at: Palmetto GBA strongly encourages you to check the Web site for updates that may have occurred after the publication date of this module.

Palmetto GBA – October Software Shortcuts  Hold your cursor still over a field and a small pop-up will display information on that field.  Right-click or press F2 to bring up a list or reference file  Press F5 to duplicate all the fields from the previous line  Press F4 to duplicate a single field from the previous line  Press F7 to delete an entire line Software shortcuts help provide a quick and easier method of navigating and using computer programs. Listed here are shortcuts to be used with PC ACE Pro 32:

Palmetto GBA – October Once reference files have been established, data entry can begin In the Institutional Claims menu, the following options are available: Import Claims Enter Claims List Claims Process Claims Prepare Claims Note: This presentation only covers the process of entering claims Institutional Claims Part A

Palmetto GBA – October Institutional Claims Part A To begin the claims entry process, select the INST button on the PC-ACE Pro32 Claims Processing System Toolbar When navigating through the various screens for claims entry, remember that the PC- ACE Pro32 Institutional Claim screens were designed originally to provide a data entry flow that resembles the flow of the CMS-1450 or UB-04 Institutional Paper Claim. You will be able to use the TAB key to move through the various fields on each page of the Claim Entry screens in addition to using your mouse to click through the fields and pages.

Palmetto GBA – October Entering Institutional Claims The Institutional Claims Menu screen will display Select the Enter Claims Button Claims can be imported using the Import Claims Button. However, only the Electronic Media Claims (EMC – 837) format is supported. Since we are entering data to create an EMC – 837 output file, we will not be discussing this option in this training manual.

Palmetto GBA – October Entering Institutional Claims The Institutional Claim Form screen will be displayed in the Patient Info & Codes tab

Palmetto GBA – October Entering Institutional Claims There are several fields which are required on Patient Info & Codes Tab. These fields include: Line of Business (LOB)  This value will be defaulted to MCA. Type of Bill (TOB)  Type in the TOB code, or right click on this field to get a list of TOB codes. Patient Information  If this Patient is entered in the Patient Reference File the Patient Control Number can be used to access that record and populate the following Patient fields on the claim, otherwise these fields will need to be entered manually.  Patient Control Number  Patient Name, Address, City, State, Zip  Patient Date of Birth (DOB)  Patient Sex Statement Covers Period Type of Service Code Patient Discharge Status Note: Use the TAB key to move from field to field, or use the mouse to pick fields

Palmetto GBA – October To retrieve Patient information from the Patient Reference File, you can do one of two things.  You can type the Patient Control Number into the Patient Control No. field; right click on the field and be taken straight to the Patient on the Patient Selection Screen. Press the Select button and the record will be pulled into the claim.  You can right click on the empty Patient Control No. field and be taken straight to the Patient Selection Screen. Scroll down the list until you find the Patient. Press the Select button and the record will be pulled into the claim. Adding a Patient to the Claim DOEJOHN CIRCLEWOOD DRIVE COLUMBIA SC /12/1930 M 12345DOE JOHN MCA

Palmetto GBA – October Adding Other Information on the Claim Manually enter the following information: Statement Covers Period (from and through dates) Type (Admission Type) Stat (Patient Status) DOEJOHN CIRCLEWOOD DRIVE COLUMBIA SC /12/1930 M 10/01/

Palmetto GBA – October Entering the Type of Bill (TOB) To populate the Type of Bill field, you can do one of two things.  Enter the Type of Bill Info directly into the field  Right click on the Type of Bill field to be taken to the Type of Bill (TOB) Codes screen. Scroll down the list until you find the TOB Code. Press the Select button and the record will populate the claim DOEJOHN CIRCLEWOOD DRIVE COLUMBIA SC /12/1930 M 1

Palmetto GBA – October Adding Other Information based on Type of Bill There are two types of Institutional Claims, In-Patient and Out-Patient. Each has additional fields to be populated  In-Patient and Out-Patient Admission Source  In-Patient Admission Date Admission Hour Discharge Hour Accumulated Days Total DOEJOHN CIRCLEWOOD DRIVE COLUMBIA SC /12/1930 M 10/01/ /01/ CIRCLEWOOD DRIVE 11/12/1930 M1 10/01/

Palmetto GBA – October Entering Optional Information on the Claim  When it is necessary to add Condition Codes to the Claim: Right click in the Condition Codes field and select the appropriate code. A listing of all available Condition Codes is available in the CMS Medicare Claims Processing Manual (Pub ), Chapter 25.CMS Medicare Claims Processing Manual (Pub ), Chapter 25

Palmetto GBA – October Entering Optional Information on the Claim  Occurrence Codes Right click and select the appropriate code Manually enter the appropriate date  Occurrence Span Codes Right click select the appropriate code Manually enter the appropriate dates

Palmetto GBA – October Entering Optional Information on the Claim  Value Codes Value Codes may be required on some institutional claims Right click in the Value Code field to select the appropriate code Manually enter the corresponding value

Palmetto GBA – October Claim Entry – Billing Line Items Click on the Billing Line Items Tab to display that section of the claim entry form. The Line Item Details Tab will display first.

Palmetto GBA – October Claim Entry - Billing Line Items The required fields on the Line Item Details Tab are: Revenue Code The From and Thru Dates Units/Days Total Charges  If charges for a Revenue Code were added to your Charges Master File they will automatically be displayed Additional Optional fields are: HCPCS Codes Modifier Codes The information for any code can either be manually entered or selected from a list of codes from one of the Reference Files. When you are finished entering Line Items, click the Recalculate button to total your charges.

Palmetto GBA – October Claim Entry - Billing Line Items Billing Line Items Tab Recalculate Button

Palmetto GBA – October Adding Payer Information  Payer Info Tab (third tab) Most of the required information on this page will be pulled from the Patient Reference File automatically and added to this claim.  Some providers (e.g., home health providers) are required to submit claims with a treatment authorization code. This information is manually entered in the Authorization Code/Type field Each line in the Authorization Code/Type field contains two boxes in which to enter information. When an Authorization Code is entered, in the second, smaller box a qualifier needs to be selected.

Palmetto GBA – October Adding Payer Information Payer Info Tab Authorization Code/Type

Palmetto GBA – October Diagnosis/Procedure Codes  Diagnosis and procedure codes will be entered on the Diagnosis/Procedure tab (fourth tab)  Enter the following information: Principal Diag. (principal diagnosis with no decimal point) Other Diagnosis Codes (if applicable) Admitting Diagnosis (if applicable) Principal Procedure Code/Date (if applicable) Other Procedure Codes/Dates (if applicable) Remarks (if applicable)

Palmetto GBA – October Diagnosis/Procedure Codes

Palmetto GBA – October Diagnosis/Procedure Codes The Attending Physician is a required entry On the ATT line Right Click on the Last/Org Name or the Provider Ids field Find the Attending Physician record on the Physician Setup screen, highlight that record and press the Select button. The Operating Physician (OPR) and Other Physician (OTH) can also be entered on this screen using the same method as the Attending Physician above. For claims with Medicare as Secondary Payer, right click in the COB? field and choose “Y”

Palmetto GBA – October Diagnosis/Procedure Codes The Diag/Proc (2) Tab provides additional Diagnosis and Procedure fields. The Extended General Tab provides fields for Facility Information. The Ext. General (2) Tab provides additional Condition Code, Occurrence Code, and Value Code fields.

Palmetto GBA – October The CN1 is used to identify the Claim as Capitated The CN1 can be found on the Extended Payer Tab  The CN1 should be entered on the Secondary Payer Sub-Tab  The CN1 can be selected in the Add’l Ref No/Type fields Entering Capitated Claims Info The Contract Code must be filled in so the segment will show up in the output file. When the output file is created this claim will have a CN1 segment in the 2300 Loop. The CN101 field will have a value of “09”.

Palmetto GBA – October PC-ACE Pro32 Training Modules  Module 1 – Introduction, Download and Installation  Module 2 – Building Reference Files  Module 3 Part A – Institutional Basic Claims  Module 3 Part B – Professional Basic Claims  Module 4 – Uploading EMC Files and Downloading Reports

Palmetto GBA – October Additional Resources  Available in the Encounter Data Resources section of the Web site for your line of business: PC-ACE Pro32 User’s Guide PC-ACE Pro32 Reference Guide EDFS User Guide  Join the Encounter Data mailing list for updates on PC- ACE Pro32 and other topics.

Palmetto GBA – October Contact Information PC-ACE Pro32 questions EDFS questions Encounter Claim questions Technical issues related to transmitting your claims Contact the CSSC Operations at: (877)

Palmetto GBA – October Thank you for completing PC-ACE Pro32 Training Module 3A! Please return to the module links to launch additional PC-ACE Pro32 training modules.