Part 1 Filing 3 rd Party Claims Addressing: The CMS-1500 Form & Its Electronic Equivalent The CMS-1500 Form & Its Electronic Equivalent Diagnosis CodingDiagnosis Coding

Disclaimers This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD. To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free. It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

Disclaimer The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services. The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

4 Filing Claims – Info provided Who (patient & insured) Who (patient & insured) Why (diagnosis) Why (diagnosis) What (service provided) What (service provided) When (date provided) When (date provided) How Much (fees) How Much (fees) Where (provided) Where (provided) By Whom (provider) By Whom (provider)

5 Filing Claims –Format Used Medical Insurance Claims Medical Insurance Claims – Electronic – Generally filed through a Clearinghouse – Must use HIPAA 5010 Format – Paper – CMS-1500 paper form (less than 10 FTE employees) Routine Care Claims Routine Care Claims – Proprietary paper forms – CMS-1500 paper form – Internet direct filing

6 CMS-1500 to Electronic Claims Crosswalk Claim information based on CMS-1500 Claim Form Claim information based on CMS-1500 Claim Form For those who file electronically, there is a WPS source that explains where to insert the CMS-1500 data items into which electronic claim data loop. For those who file electronically, there is a WPS source that explains where to insert the CMS-1500 data items into which electronic claim data loop. This is referred to as the CMS-1500 Electronic Claim Crosswalk, and can be found at This is referred to as the CMS-1500 Electronic Claim Crosswalk, and can be found at –

7 CMS-1500

8 TOP OF CMS-1500 Insurance Type

9 TOP OF CMS-1500 Patient Demographic data

10 TOP OF CMS-1500 Insured Person’s Data

11 TOP OF CMS-1500 Other Insured Person’s Data

12 TOP OF CMS-1500 Subrogation Data

13 TOP OF CMS-1500 Other Insurance

14 TOP OF CMS-1500 Patient Authorization to File Claim

15 TOP OF CMS-1500 Patient Authorization to Pay to Provider (So Dr. can accept assignment)

16 BOTTOM CMS-1500 Referring Dr. Data

17 BOTTOM CMS-1500 Qualifying Information Example: Date assumed + date relinquished post-op care + # Post-op care days.

18 BOTTOM CMS-1500 Diagnosis Data MORE TO COME ON THIS AREA….

19 BOTTOM CMS-1500 Date of Service Data

20 BOTTOM CMS-1500 Service & Materials Supplied MORE TO COME ON THIS AREA….

21 BOTTOM CMS-1500 Charges/Fee Data

22 BOTTOM CMS-1500 Group Practice: Providing Dr’s NPI

23 BOTTOM CMS-1500 Provider Data

24 Medicare Provider Manual Billing Instructions Including what data in which box CMS Medicare Claims Processing Manual Website – (chapter 26) CMS Medicare Claims Processing Manual Website – (chapter 26)

25 Medicare Provider Manual Billing Instructions Including what data in which box

26 Medicaid Provider Manual Billing Instructions What data in which box Payments section: Payments section: regs/regsearch/Rules/Health_and_Human_Services_System/Title- 471/Chapter-03.pdf regs/regsearch/Rules/Health_and_Human_Services_System/Title- 471/Chapter-03.pdf regs/regsearch/Rules/Health_and_Human_Services_System/Title- 471/Chapter-03.pdf regs/regsearch/Rules/Health_and_Human_Services_System/Title- 471/Chapter-03.pdf Form CMS-1500 Instructions Form CMS-1500 Instructions –

27 Routine Care Claims Companies may still use proprietary claim forms (or on-line via Internet) Companies may still use proprietary claim forms (or on-line via Internet) Patient & Insured demographics Patient & Insured demographics Policy data Policy data Service provided Service provided Diagnosis (refractive ICD-9-CM) Diagnosis (refractive ICD-9-CM) Materials provided Materials provided

28 BOTTOM CMS-1500 Diagnosis Data

29 Diagnosis Codes Don’t write “cataracts” or “presbyopia” Don’t write “cataracts” or “presbyopia” Instead, use a standard code Instead, use a standard code ICD-9-CM is standard resource for diagnosis codes ICD-9-CM is standard resource for diagnosis codes ICD-10-CM is coming soon, codes are completely different. ICD-10-CM is coming soon, codes are completely different.

30 Diagnosis Codes 1 st look up in alphabetical listing

31 Then refine in tabular listing

32 Diagnosis Codes An ICD-9-CM code for every eye disorders An ICD-9-CM code for every eye disorders – Cataract, senile: E-codes for external causes E-codes for external causes – E960.0 due to unarmed fight V-codes for other situations V-codes for other situations – V58.69 observation due to use of toxic medication Routine Care Claims Routine Care Claims – Use ICD-9-CM Refractive codes

33 Diagnosis Codes ICD-9-CM is soon to be replaced by ICD-10-CM ICD-9-CM is soon to be replaced by ICD-10-CM Completely different diagnosis coding system Completely different diagnosis coding system More comprehensive More comprehensive Defines disorders more explicitly Defines disorders more explicitly Required on all claim by October, 2013? (2014?) Required on all claim by October, 2013? (2014?) Quick Reference Guide at Quick Reference Guide at More information at More information at

Thank You for Listening We hope this information has been helpful. Thank you for listening! See our NOA Website for more 3 rd Party Educational Videos. 3 rd Party Services Nebraska Optometric Association