MAA 102 Intro to Billing & Coding Lesson 4 Topic 2 Claim Preparation & Errors

Optical Scanning Dos and Don’ts DO: use black typewriter ink, high carbon content one-time Mylar, or OCR printer ribbons. DO: use original claim forms printed in red ink; photocopies cannot be scanned. DO: align the typewriter or printer correctly so characters appear in the proper fields. DO: enter all information In upper case letters. DO: use alpha or numeric symbols. DO: enter eight-digit date formats. DO: keep signature within signature block. Explain the benefits of OCR. (More control over data input, improved accuracy, increased efficiency in processing)

Optical Scanning Dos and Don’ts (cont’d.) DON’T: allow characters to touch lines. DON’T: use script, slant, minifont, or italicized fonts or expanded, compressed, bold, or proportional print. DON’T: hand write information on the document. DON’T: strike over errors when correcting or crowd preprinted numbers. DON’T: use highlighter pens or colored ink. DON’T: use symbols (#, -, /), periods(.), ditto marks, parentheses, or commas(,). DON’T: use N/A or DNA when information is not applicable.

CMS-1500 Claim Form Instructions Top of Form The next several slides include selected blocks from the form and what information should be entered for certain carriers. Leave the top area of the claim blank, for information that will be printed during the initial processing stage.

CMS-1500 Claim Form Instructions Block 1 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Medicaid: Remind students to check to see if a patient receives Medicaid. TRICARE and CHAMPVA: Remind students to also check for these benefit systems on patient forms.

CMS-1500 Claim Form Instructions Block 1a Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. TRICARE: If patient and sponsor are the same, provide patient’s SSN. CHAMPVA: Use the Veterans Affairs file number without prefix or suffix. Workers’ compensation: Use the patient’s SSN here only if there is no claim number or you can’t find a policy number for the employer.

CMS-1500 Claim Form Instructions Block 4 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. For Blocks 2 and 3: Enter the name(s) as shown on the identification card. Do not use nicknames, abbreviations, or commas. The patient’s age must correlate with the diagnosis (newborn, pediatric, maternity, adult, etc.) Medicaid: Refer to Medicaid guidelines for this block. TRICARE: Enter sponsor’s full name, not nicknames. Don’t fill in this block if Block 6 is marked “self.”

CMS-1500 Claim Form Instructions Block 7 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Block 5: Punctuation is not necessary in the address. For TRICARE and CHAMPVA, enter an actual address, not an APO/FPO. Block 6: Check “Other” for unmarried domestic partners. TRICARE and CHAMPVA: If sponsor and patient are different, enter sponsor info here. Workers’ comp: Enter the employer’s address here.

CMS-1500 Claim Form Instructions Block 9 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. TRICARE and CHAMPVA: Follow instructions for Medicaid. Blocks 11a through 11d should be used to report any other health insurance that the patient owns. Workers’ comp: Leave blank. If case has not been declared workers’ comp, put in info on other insurance.

CMS-1500 Claim Form Instructions Block 9a Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers, TRICARE, CHAMPVA: Enter policy or group number for secondary (or other) insurance for patient. Medicaid and workers’ comp: Leave blank.

CMS-1500 Claim Form Instructions Block 9c Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers, TRICARE, and CHAMPVA: Enter name of secondary insurance held by someone other than patient in this box. Medicaid and workers’ comp: Leave blank.

CMS-1500 Claim Form Instructions Block 9d Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payer: Enter name of secondary insurance plan or program. Medicaid and workers’ comp: Leave blank. CHAMPVA: Same as TRICARE.

CMS-1500 Claim Form Instructions Block 10d Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Block 10a: All payers require a yes or no answer here. Block 10b: “Yes” could indicate a third-party liability case or the use of liability insurance. Private payers, Medicare, and workers’ comp: Leave blank. Medicare: Leave blank. Follow Medicaid guidelines as necessary. TRICARE and CHAMPVA: Leave blank unless you have special guidelines.

CMS-1500 Claim Form Instructions Block 11 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers, Medicaid, TRICARE, and workers’ comp: Leave blank. CHAMPVA: Enter the three-digit number of the VA station that issued the ID card.

CMS-1500 Claim Form Instructions Block 11b Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers: If primary policy is a group plan, list info here if submitting to secondary insurance. Medicaid: Leave blank. TRICARE and CHAMPVA: List sponsor’s branch of the service (use abbreviations). Workers’ comp: If patient works for large corporation, list local branch or office here. Block 11c: Leave blank in most cases. Enter “TRICARE,” for TRICARE. MSP requires a PAYERID number. Follow MSP guidelines.

CMS-1500 Claim Form Instructions Block 12 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Medicaid and workers’ comp: Leave blank. CHAMPVA: Use TRICARE guidelines.

CMS-1500 Claim Form Instructions Block 13 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers: Signature on File (SOF) may be used here. If benefits are assigned, patient needs to sign this box. For all others, leave blank.

CMS-1500 Claim Form Instructions Block 14 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Medicaid: Leave blank. CHAMPVA: Use TRICARE rules. Workers’ comp: Enter first date of injury or accident. Block 15: Leave blank for Medicaid, Medicare. Enter 8-digit date (if applicable) for private payers, TRICARE, and CHAMPVA.

CMS-1500 Claim Form Instructions Block 16 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Medicaid: Leave blank. TRICARE and CHAMPVA: Use Medicare rules.

CMS-1500 Claim Form Instructions Block 17 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers, Medicaid, and workers’ comp: Enter name and degree of physician. TRICARE and CHAMPVA: Enter name, degree, and address of referring provider. Attached DD Form 2161 if referred from MTF. Box 17a: Enter referring physician’s NPI number for private payers, Medicaid, or Medicare. Enter state late license number for TRICARE and CHAMPVA. Leave blank for worker’s comp. Box 17b: Enter physician’s NPI for ALL payers. Box 18: Complete this block if the service is due to an inpatient hospitalization.

CMS-1500 Claim Form Instructions Block 19 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Medicare: This block is usually reserved for local use, but Medicare allows other uses under very specific rules. Medicaid, TRICARE, and CHAMPVA: Usually reserved for local use. Workers’ comp: Leave blank. Box 20: For private payers, Medicare, TRICARE, CHAMPVA, and worker’s comp, check “yes” if tests were performed outside the physician’s office. Check “no” if the test were performed in the office. For Medicaid, always check “no,” because outside laboratories must bill directly.

CMS-1500 Claim Form Instructions Block 21 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Enter up to four diagnostic codes in this box. Block 22: can be left blank, unless needed for Medicare/Medicaid.

CMS-1500 Claim Form Instructions Block 23 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers and Medicaid: Enter peer review organization (PRO) 10-digit authorization code. TRICARE and CHAMPVA: Use 10-digit preauthorization or precertification number. Workers’ comp: Leave blank.

CMS-1500 Claim Form Instructions Block 24A Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payer and workers’ comp: Add month, day, and year for each procedure without spaces in eight-digit numbers. Medicaid and Medicare: Use guidelines for workers’ comp but do not allow date ranges. TRICARE and CHAMPVA: Refer to workers’ comp guidelines.

CMS-1500 Claim Form Instructions Block 24B Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. All payers: List appropriate place of service (POS) code, shown on next slide.

CMS-1500 Claim Form Instructions Block 24B (cont’d.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. CMS-1500 Claim Form Instructions Block 24B (cont’d.) Fig. 7-4 (p. 263). All payers: List appropriate place of service (POS) code.

CMS-1500 Claim Form Instructions Block 24C Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. All payers: List type of service (TOS) code in this block from list on next slide.

CMS-1500 Claim Form Instructions Block 24D Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers, Medicaid, TRICARE, and CHAMPVA: Enter appropriate CPT/HCPCS and modifiers for each provided service. Worker’s comp: Enter appropriate RVS codes and modifiers.

CMS-1500 Claim Form Instructions Block 24E Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Medicaid: Refer to Medicare guidelines. TRICARE and CHAMPVA: Enter the diagnosis reference number to relate the service to the diagnosis. Worker’s comp: A maximum of four diagnosis pointers may be referenced. Place commas between the numbers. Block 24F: For private payers, enter the fee for each listed service. Block 24G: Enter the number of days or units that apply to each line of service. Follow Medicare guidelines for TRICARE, CHAMPVA, and Worker’s Comp. For Medicaid, each service must be listed on separate lines. Block 24E: Leave blank, except for Medicaid (enter “E” for EPSDT services or “F” for family planning services) Block 24I: Enter ID qualifier IC, if the provider does not have an NPI.

CMS-1500 Claim Form Instructions Block 24J Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. All payers: Enter the NPI of the rendering physician in the lower portion. Block 25: For all payers, enter the physician or supplier’s federal tax ID number (EIN or SSN). Medicaid cases may not require a tax ID. Block 26: For all payers, enter the patient’s account number, as assigned by the physician’s accounting system.

CMS-1500 Claim Form Instructions Block 27 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Private payers: Check whether or not the physician accepts assignment payments. Medicaid, TRICARE, and CHAMPVA: Check the “yes” box. Workers’ comp: Leave blank. Block 28: For all payers, enter total charges for services listed in Block 24E. Multiply by units listed in Block 24G, if necessary. Block 29:For private payer and Medicare, enter only the amount paid for charges. For Medicaid, enter only the payment by a third-party payer (not Medicare). For TRICARE/CHAMPVA, enter only the amount paid by other carrier. Leave blank for worker’s comp. Block 30: For Medicare, leave blank. For all other payers, enter balance due. Block 31: For all payers, fill in the information and complete the signature, using an approved method.

CMS-1500 Claim Form Instructions Block 32 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Enter only the name, address and zip code in the box. Additional entries require separate claim forms.

CMS-1500 Claim Form Instructions Block 33 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. The NPI is now required in this box for all payers.

Common Reasons Claims are rejected or delayed Claims submitted to secondary insurer first Information missing Patient insurance numbers incorrect Failure to indicate claim related to work injury (Block 10) Patient signature missing