Wednesday, June 30, 2010

How to submit CMS 1500 claim form - Healthnet

Claims Submission Information Instructions -- Healthnet for Non-participating Providers

When submitting claims, providers must include, at a minimum, all of the following required information:
•    Member's (subscriber's) ID number
•    Patient's name and date of birth
•    Employer group number
•    Submitting provider's tax ID number or Social Security number
•    State license number of attending provider
•    Submitting provider's name and address
•    ICD-9 diagnosis code
•    Date(s) of service Billed charges
•    Current year CPT or HCPCS procedure code (physician) with all applicable modifiers LML or UB-92 revenue code with narrative description (hospital)
•    CMS place of service code (professional claims only)
•    UB bill type
•    Number of days or units for each service line (professional claims only)
•    Authorization number and all applicable information, when authorization is required
•    UPIN number for professional claims
•    Medicare number for institutional claims when applicable



To avoid possible denial or delay in processing, the above information must be correct and complete.

The following providers must include additional information as outlined:

•    Emergency services providers: The claim must include a legible emergency department report and any state-designated data requirements included in statutes or regulations

•    Dentists and other professionals providing dental services: The form and data set approved by the American Dental Association (ADA), Current Dental Terminology (CDT) codes and modifiers, and any state-designated data requirements included in statutes or regulations

•    On-call physicians: Where applicable, physicians who are on call for a primary care physician (PCP) do not require a referral. The name of the PCP should be noted on the claim in Box 19 or 23 on the CMS-1500 claim form. For self-referrals the provider should indicate Self-Referred in Box 17 of the CMS-1500

•    Providers not specified: A properly completed paper or electronic billing instrument submitted in accordance with Health Net's specifications and any state-designated data requirements included in statutes or regulations
General Billing Requirements:
•    ID number: Enter the corresponding identification (ID) number as noted:
o    Member ID number (Medi-Cal): The nine-character ID found on patient's Health Net ID card
o    Subscriber ID number (HMO, POS, PPO, EPO, Flex Net,AIM, and Healthy Families Program): The nine-character ID (the letter "R" followed by eight digits) found on patient's Health Net ID card
•    Employer group number: The number assigned to the subscriber's employer group located on the member's ID card.
•    UPIN or state license number:Six-digit universal provider identification number (UPIN) or state license number of all attending providers.
o    When billing for more then one attending provider, indicate the UPIN on the appropriate detail line
o    For physicians, the state license number should be entered as a seven-digit number "A0nnnnn." When "a" is the alpha character shown on the state license (A, C, G), "0" is the filler zero and "nnnnn" are the five numeric characters in the state license number
o    All other providers use their state-assigned license number without modifications

Friday, June 25, 2010

CMS 1500 - BOX 32: SERVICE FACILITILY LOCATION INFORMATION

If services were in a location other than the Provider’s office
or the member’s home, enter the name and address of that
facility.

32 a. Enter the Facility NPI number. Not required at this
time.

32 b. Enter the 2-digit MaineCare Identifier (1D) and one
space followed by the Facility Provider number. Do not
enter the Servicing Provider ID number here. Not required at
this time.

BOX 29: AMOUNT PAID - secondary claim field

Attach the third party Explanation of Benefits (EOB)
for all claims involving a third party when balance billing
secondary after you have received payment or denial from
the primary health plan

If payment was made, you must enter the amount
of the insurance payment in Box 29, as well as attach
the third party Explanation of Benefits (EOB).

In order for the claims payment system to properly
distribute third party payments, only those line items
paid by the third party can be billed on the same claim
form.

Those charges that have been denied by the insurer,
where no third party payment was made, must be
billed on a separate claim form, and you must include
the third party Explanation of Benefits (EOB).

Do not enter the Medicare payment in Box 29 if you
are billing for Medicare coinsurance or deductible

TIP:
Do not enter the member’s anticipated copay amount. It will be
automatically deducted in the claims process.

Box 24F: Charges must equal the allowed amount that you and the
insurance company agreed to, as shown on insurance company’s
Explanation of Benefits (EOB).

Box 28: Enter the total charges. This must equal the total of the
individual line item charges in 24F.

Box 29: Enter the amount paid by insurance company/third party. The
third party amount must equal the actual third party payment, plus any
withheld amount shown on the insurance company’s Explanation of
Benefits. You must enter this amount on the claim form, and you must
attach the Explanation of Benefits.

Box 30: Enter balance due. This can not exceed the member
responsibility shown on the Explanation of Benefits

cms 1500 BOX 24 A - 24J- how to fill.

For each line item billed, you must include one date, one place
of service, one procedure code, and one amount charged per line.
For a paper claim, you may not bill more than six lines.


BOX 24A: DATE(S) OF SERVICE

Enter both “From” and “To” dates of service using either
six-digit (MMDDYY) or eight-digit (MMDDYYYY)
format. Do not use commas, dashes, or slashes in the date.

Dates must be consecutive and continuous. If the service
was provided on only one day, just put that date in the
From field. On each line, the From and To dates must be
during one month. Use the next line for the next month.


BOX 24B: PLACE OF SERVICE
Enter a two-digit Place of Service code

BOX 24C: EMG
Enter a Y to prevent copay from being deducted if you are not
billing services that are exempt from copay

BOX 24D: PROCEDURES, SERVICES OR SUPPLIES
Enter the appropriate procedure code and modifier(s), if necessary in the unshaded area..

NOTE: The shaded area at the top of this box is to be used for supplemental information
only


BOX 24E: DIAGNOSIS POINTER
From Box 21, enter the line number or numbers (1, 2, 3,
and/or 4) that list the diagnosis codes. Do not enter the codes
themselves. List only the line numbers.

BOX 24F: $ CHARGES
Enter the usual charge for the service you provided based on the
policy section under which you are billing.

BOX 24G: DAYS OR UNITS
Enter the number of days of service or the units of supplies
provided. Do not use decimal points or fractions. Round off
to the nearest whole number. Enter 1 only if 1 unit was
provided. (For example: For Indian Health Centers or Rural
Health Centers, 1 unit of a visit is 1, not the units of itemized
services provided in that visit.)

24I: ID QUALIFIER

You must enter the appropriate qualifier in the shaded area of this
box
1D indicates MaineCare Servicing Provider Number should be
in Box J.


24J: RENDERING PROVIDER ID NUMBER
Enter the Servicing Provider ID number in the shaded area, if
applicable.
Enter the Servicing Provider NPI number in the area that is
not shaded. MaineCare does not require an NPI at this time.
If a Servicing Provider ID number is not required, leave this
field empty.

CMS1500 - BOX 19: RESERVED FOR LOCAL USE

If you are billing a J code in Box 24D, enter the National
Drug Code (NDC) for that drug. Do not enter the description
of the drug, and do not enter NDC before the actual NDC
code. Only one J code may be billed per claim.

NDCs printed on packages often have fewer then 11 digits,
with hyphens (-) separating the number into three segments.
For a complete 11-digit number, the first segment must have 5
digits, the second segment must have 4 digits, and the third
segment must have 2 digits. Leading zeros are added leftjustified,
wherever they are needed to complete a segment with
the correct number of digits.

Package Number                 Zero Fill (5-4-2)                             11-digit NDC
1234-1234-12                     (01234-1234-12)                        01234123412
12345-123-12                      (12345-0123-12)                        12345012312

CMS 1500 - BOX 11: INSURED’S POLICY GROUP OR FECA NUMBER

If the member has a secondary insurance these boxes must be completed.

BOX 11a: INSURED’S DATE OF BIRTH AND SEX

If YES is checked in Box 11d, enter the month, day and year
the policyholder was born. The format for a birth date must be
MMDDYYYY.

Enter an X in the appropriate box for the policyholder’s sex.
BOX 11b: EMPLOYER’S NAME OR SCHOOL NAME
If YES is checked in Box 11d, enter the name of the policyholder’s
employer or school.

BOX 11c: INSURANCE PLAN NAME OR PROGRAM NAME

If YES is checked in Box 11d, enter the name of the policyholder’s
insurance plan or program. Do not enter Medicare or the name of
any State program.

BOX 11d: IS THERE ANOTHER HEALTH BENEFIT PLAN?


If the member is covered by other primary insurance
and he/she is not the policyholder, enter an X in the YES box
and also complete Fields 9a–9c. If there is no other insurance, enter an X in the NO box.

Thursday, June 24, 2010

Who Must Use the CMS/HCFA 1500

If you are one of the following providers, you must use the CMS/HCFA 1500
form:
Advance Practice Registered Nursing Services
Ambulances
Ambulatory Care Clinics
Ambulatory Surgical Centers
Audiologists
Chiropractic Services
Community Support Services
Consumer Directed Attendant Services
Day Habilitation Services for Persons with Mental Retardation
Day Health Services
Day Treatment Services
Developmental and Behavioral Clinics
Medical Supplies and Durable Medical Equipment
Early Intervention Services
Family Planning Clinics
Federally Qualified Health Centers
Genetic Testing and Clinical Genetic Services
Hearing Aids and Services
Home and Community Based Benefits for the Elderly and
for Adults with Disabilities
Home and Community Based Benefits for Members
with Mental Retardation
Home and Community Based Benefits for the Physically Disabled
Home Based Mental Health Services
Independent Laboratories
Licensed Clinical Social Workers, Licensed Clinical Professional
Counselors, and Licensed Marriage and Family Therapist Services
Medical Imaging Services
Occupational Therapy Services
Optometrists
Outpatient Mental Health Providers
Physical Therapy Services
Physician Services
Psychological Services
Podiatrist Services
Rehabilitation Services
Rural Health Clinic Services
School Based Rehabilitation Services
Speech and Hearing Services
Substance Abuse Treatment Services
Targeted Case Management Providers
Transportation/Wheelchair Van Services
VD Clinics
Vision Services

What is ID qualifier in CMS 1500

The other ID number of the referring provider,
ordering provider, or other source should be
reported in 17a in the shaded area. The qualifier
indicating what the number represents should be
reported in the qualifier field to the immediate
right of 17a. The NUCC defines the following
qualifiers, since they are the same as those used
in the electronic 837 Professional 4010A1:

• 0B – State license number
• 1B – Blue Shield provider number
• 1C – Medicare provider number
• 1D – Medicaid provider number
• 1G – Provider UPIN number
• 1H – CHAMPUS identification number
• EI – Employer’s identification number
• G2 – Provider commercial number
• LU – Location number
• N5 – Provider plan network identification
number
• SY – Social Security number (The Social
Security number may not be used for
Medicare)
• X5 – State industrial accident provider
number
• ZZ – Provider taxonomy – A list of the
valid Taxonomy codes

CMS 1500 - Federal Tax id - box 25

Federal Tax ID number
and type:

• Social Security
Number or
•Employer
Identification
Number

Enter the nine-digit Employee Identification
Number (EIN) or Social Security Number under
which payment for services is to be made for
reporting earnings to the IRS. Enter an "X" in the
appropriate box that identifies the type of ID
number used for services rendered

CMS 1500 box 10 A - C

Field Name -

Is the patient’s
condition related to:
•Employment?
•Auto accident?
• Other accident?

Instructions

Place an "X" in the box indicating whether or not
the condition for which the patient is being
treated is related to current or previous
employment, an automobile accident or any other
accident. Enter an "X" in either the YES or NO
box for each question

NOTE: The state postal code must be shown if
“yes” is marked in 10b for “auto accident”. Any
item marked yes indicates there may be other
applicable insurance coverage that would be
primary such as automobile liability insurance.
Primary insurance information must then be
shown in item 11.

10d Reserved for local use Not required Please leave blank.

Sample authorization form

SAMPLE WORDING FOR AUTHORIZATIONS

ONE-TIME AUTHORIZATION

For Use by Provider

Beneficiary Name____________________________HIC#___________________________
I request that payment of authorized Medicare benefits be made to me or on my behalf to (Provider Name) for any services furnished me. I authorize holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.
___________________________________________Date_________________
(Beneficiary signature)





For Use by a Facility

Beneficiary Name_______________________________________HIC#________________
I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished me by or in (Name of Facility), including provider services. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or benefits for related services.
____________________________________________Date________________
(Beneficiary signature)



                                                    MEDIGAP AUTHORIZATION



Beneficiary Name________________________________________HIC#_______________
Medigap Policy Number_______________________________________
I request that payment of authorized Medigap benefits be made to either me or on my behalf to (Provider Name), for any services furnished to me by this provider. I authorize any holder of medical information to release to (Name of Medigap Insurer) any information needed to determine these benefits or the benefits payable for related services.
_____________________________________________Date_______________
(Beneficiary signature)

Accept assignment - Field 27 of cms 1500

Item 27

Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If Medigap is indicated in item 9 and Medigap payment
authorization is given in item 13, the provider of service or supplier shall also be a Medicare
participating provider of service or supplier and must accept assignment of Medicare
benefits for all covered charges for all patients.

The following providers of service/suppliers and claims can only be paid on
assignment basis:

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Participating physician/supplier services;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives,
certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals and
• Simplified billing roster for influenza virus vaccine and pneumococcal vaccine

who is Referring physician and ordering physician

Item 17

Enter the name of the referring or ordering physician if the service or item was ordered or  referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring service.

Referring physician is a physician who requests an item or service for the beneficiary for
which payment may be made under the Medicare program.



Ordering physician is a physician or, when appropriate, a non-physician practitioner, who orders non-physician services for the patient. See Pub. 100-02, Chapter 15 for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service.

The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare covered services and items that are the result of physician’s order or referral shall include the  ordering/referring physician’s name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s NPI.

The following services/situations require the submission of the referring/ordering provider
information:
  •  Medicare covered services and items that are the result of a physician's order
or referral;
  •  Parenteral and enteral nutrition;
  •  Immunosuppressive drug claims;
  •  Hepatitis B claims;
  •  Diagnostic laboratory services;
  •  Diagnostic radiology services;
  •  Portable x-ray services;
  •  Consultative services;
  •  Durable medical equipment
  •  When the ordering physician is also the performing physician (as often is the case
with in-office clinical laboratory tests);

  •  When a service is incident to the service of a physician or non-physician practitioner,
the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;

  •  When a physician extender or other limited licensed practitioner refers a patient for
consultative service, submit the name of the physician who is supervising the limited licensed practitioner;

cms 1500 paper claim, font, size

If you are not billing electronically, consider it! However, when you bill on paper, follow these tips when completing your CMS-1500 forms:

The font should be:

• Legible (Change typewriter ribbon/PC printer cartridge frequently, if necessary. Laser printers are
recommended)
• In Black Ink
• Pica, Arial 10, 11 or 12 font type
• CAPITAL letters

The font must NOT have:

• Broken characters
• Script, Italics or Stylized font
• Red ink
• Mini-font
• Dot Matrix font

Do NOT bill with:

• Liquid correction fluid changes.
• Data touching box edges or running outside of numbered boxes (left justify information in each box).
Exception: when using the 8-digit date format, information may be typed over the dotted lines shown
in date fields, i.e., Item 24a.
• More than six service lines per claim (use a new form for additional services);
• Narrative descriptions of procedure, narrative description of modifier or narrative description of
diagnosis (the CPT, Modifier or ICD-9-CM codes are sufficient);
• Stickers or rubber stamps (such as “tracer,” “corrected billing,” provider name and address, etc.);
• NHIC’s address at top of the form;
• Special characters (i.e., hyphens, periods, parentheses, dollar signs and ditto marks).
• Handwritten descriptions;
• Attachments smaller than 8 1/2 x 11.


The claim form must be:

• An original CMS-1500 printed in red “drop out “ ink with the printed information on back (photocopies are not acceptable);
• Size - 8½” x 11” with the printer pin-feed edges removed at the perforations;
• Free from crumples, tears, or excessive creases (to avoid this, submit claims in an envelope that is full letter size or larger);
• Thick enough (20-22 lbs.) to keep information on the back from showing through;
• Clean and free from stains, tear-off pad glue, notations, circles or scribbles, strike-overs, crossed-out information or white out.

Tuesday, June 22, 2010

Tips for submitting error-free paper claims

TROUBLESHOOTING BASICS:
• Use only an original red-ink-on-white-paper Form CMS-1500 claim form.
• Use dark ink
.• Do not print, hand-write, or stamp any extraneous data on the form.
• Do not staple, clip, or tape anything to the Form CMS-1500 claim form.
• Remove pin-fed edges at side perforations
.• Use only lift-off correction tape to make corrections.
• Place all necessary documentation in the envelope with the Form CMS-1500 claim form.


FORMAT HINTS:
• Do not use italics or script.
• Do not use dollar signs, decimals, or punctuation.
• Use only upper-case (CAPITAL) letters.
• Use 10- or 12-pitch (pica) characters and standard dot matrix fonts.
• Do not include titles (e.g., Dr., Mr., Mrs., Rev., M.D.) as part of the beneficiary’s name.
• Enter all information on the same horizontal plane within the designated field
.• Follow the correct Health Insurance Claim Number (HICN) format. No hyphens or dashes should be used. The alpha prefix or suffix is part of the HICN and should not be omitted. Be especially careful with spouses who have a similar HICN with a different alpha prefix or suffix.
• Ensure data is in the appropriate field and does not overlap into other fields
.• Use an individual’s name in the provider signature field, not a facility or practice name.

CMS 1500 - Claim error

Claim Errors

“Unprocessable claims” is a term used by Medicare for claims that contain certain incomplete or invalid
information and are returned to the provider. For example, a claim may be returned as unprocessable because the contractor requires additional information or a correction to the submitted claim data. Because there is no initial determination on the claim, health care professionals and suppliers who submit unprocessable claims have no appeal rights. The phrase “return as unprocessable” does not mean that in every case a claim is physically returned. Contractors may return the actual unprocessable claim (or a copy of it) to the health care professional or supplier with a letter of explanation or generate a Remittance Advice (RA), which we will discuss later in this fact sheet. Some contractors may suspend a claim that contains incomplete or invalid information, and then provide notice of the errors to the provider and afford a period of time for corrections to be submitted. When adequate corrections are submitted, the contractor will then resume processing of the claim.

Providers need to be aware that an unprocessable claim that has been returned for correction and resubmission does not toll the timely filing period. A correct claim must be resubmitted within the timely filing period. Where a contractor has suspended a claim and allowed a period for submission of corrections, the timely filing requirements will have been met if the corrections are received within the allotted time.Form CMS-1500 incomplete and invalid claims processing guidelines may be found in the Medicare Claims Processing Manual at http://www.cms.gov/manuals/downloads/clm104c01.pdf

What is CMS 1500 AND WHO can submit paper claim to Medicare

What is the Form CMS-1500?

The Form CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors (A/B MACs and DME MACs).

A claim is a request for payment of Medicare benefits for services furnished by a health care professional or supplier. Claims must be submitted within one year from the date of service and Medicare beneficiaries cannot be charged for completing or filing a claim. Offenders may be subject to penalty for violations.


Exceptions to Mandatory Electronic Claim Submission
The Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies not submitted to Medicare electronically, with limited exceptions. Medicare will receive and process paper claims from health care professionals and suppliers who meet the exceptions to the requirements set forth in the ASCA.

Some circumstances always meet the exception criteria

Health care professionals and suppliers that experience one of these unusual circumstances are automatically waived from the electronic claim submission requirement for either the indicated claim type or the period when the unusual circumstance exists.

A listing of these definitive exceptions and the latest information on CMS regulations regarding the limited acceptance of paper claims in lieu of electronic billing may be found at
http://www.cms.gov/ElectronicBillingEDITrans/05_ASCASelfAssessment.asp on the CMS website. These circumstances include:

• A physician, practitioner, or supplier that bills a Medicare Carrier, A/B MAC, or DME MAC and has fewer than 10 Full-Time Equivalent (FTE) employees.

• A health care professional or supplier experiencing a disruption in electricity and communication connections that is beyond its control.

Health care professionals and suppliers are to self-assess to determine if they meet one or more of these situations and should not submit a waiver request to their contractor. If one of these circumstances applies, they may submit claims to Medicare on paper or via other non-electronic means.

FILING CMS 1500 CLAIM - TIPS

Additional Tips on Filing

Here’s other important information you need to know before you begin filling out
your form:

Use current CPT (Current Procedural Terminology) of the American
Medical Association, ICD 9 (International Classification of Diseases)
Diagnostic Codes, or HCPCS (Healthcare Common Procedure Coding
System) Codes maintained by the Centers for Medicare and Medicaid
Services. Or,

Use the Procedure Codes in Chapter III of the MaineCare Benefits Manual
policy section under which you bill. You may access these codes at the
following website: http://www.maine.gov/sos/cec/rules/10/ch101.htm

The required format for a birth date is MMDDYYYY. (Example: January
19, 1947 = 01191947.)

Whether you fill in your claim form by typing, computer, or handwriting,
keep all information within the designated boxes. Do not overlap
information into other fields. If the information is not in the required fields
your claims will be returned to you with a cover letter stating that the
information is not aligned correctly

Denial list - CMS 1500 data missing in particular field

1a - CMS 1500 - Field
A claim lacks a valid (or contains an invalid) Health Insurance Claim Number (HICN).
MA61

2
A claim lacks a valid (or contains an invalid) patient’s last name and first name as seen on the patient’s Medicare card.
MA36

11
A claim does not indicate whether or not a primary insurer to Medicare exists.
MA83 or MA92

12
A claim lacks a valid (or contains an invalid) patient or authorized person’s signature.
MA75

24a
A claim lacks a valid (or contains an invalid) “from” date of service.
M52

24b
A claim lacks a valid (or contains an invalid) place of service for each detail.
M77

24d
A claims lacks a valid (or contains an invalid) procedure or HCPCS code.
M20 or M51

24f
A claim lacks a charge for each listed service.
M79

24g
If the claim does not indicate at least one day or unit
M53

31
A claim lacks a signature from a provider of service or supplier, or their representative.
MA70 or MA81

33
A claim does not contain a billing name, address, ZIP code and telephone number of a provider or supplier of service and a valid NPI in Item 33a.
N256, N257, N258 or MA112

33a
A claim lacks the NPI of the billing provider, supplier or group.
N257 or MA112

Returned or unprocessable claim - cms 1500

Returned Claims
Please correct “returned” claims promptly because only when this is done will a provider have met his legal obligation for submitting a Medicare claim.

Definitions
Unprocessable Claim – Any claim with incomplete or missing required information, or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally.

Incomplete Information – Missing, required or conditional information on a claim (e.g., no National Provider Identifier (NPI)).

Invalid Information – Complete required or conditional information on a claim that is illogical or incorrect (e.g., incorrect NPI) or no longer in effect (e.g., an expired number).

Required – Any data element that is needed in order to process a claim (e.g., provider name, date of service).

Not Required – Any data element that is optional or is not needed by Medicare in order to process a claim (e.g., patient’s marital status).

Conditional – Any data element that must be completed if other conditions exist (e.g., if there is insurance primary to Medicare, the primary insurer’s group name and number must be entered on a claim or if the insured is different from the patient, the insured’s name must be entered on the claim).

Friday, June 11, 2010

Provider specialty code

Nonphysician Practitioner, Supplier, and Provider Specialty Codes

The following list of 2-digit codes and narrative describe the kind of medicine non-physician practitioners or other healthcare providers/suppliers practice.

Code  Non-physician Practitioner/Supplier/Provider Specialty
15       Speech Language Pathologists
32       Anesthesiologist Assistant
42       Certified Nurse Midwife (effective July 1, 1988)
43       Certified Registered Nurse Anesthetist (CRNA)
45       Mammography Screening Center
47       Independent Diagnostic Testing Facility (IDTF)
49      Ambulatory Surgical Center
50      Nurse Practitioner
51      Medical supply company with orthotic personnel certified by an accrediting organization
52      Medical supply company with prosthetic personnel certified by an accrediting organization
53      Medical supply company with prosthetic/orthotic personnel certifiedby an accrediting organization
54      Medical supply company not included in 51, 52, or 53
55      Individual orthotic personnel certified by an accrediting organization
56      Individual prosthetic personnel certified by an accrediting organization
57      Individual prosthetic/orthotic personnel certified by an accrediting organization
58      Medical Supply Company with registered pharmacist
59      Ambulance Service Supplier, e.g., private ambulance companies, funeral homes
60      Public Health or Welfare Agencies (Federal, State, and local)
61      Voluntary Health or Charitable Agencies (e.g., National Cancer Society, National Heart Association, Catholic Charities)
62      Clinical Psychologist (Billing Independently)
63      Portable X-Ray Supplier (Billing Independently)
64      Audiologist (Billing Independently)
65     Physical Therapist in Private Practice
67     Occupational Therapist in Private Practice
68     Clinical Psychologist
69     Clinical Laboratory (Billing Independently)
71     Registered Dietician/Nutrition Professional
73     Mass Immunization Roster Billers (Mass Immunizers have to roster bill assigned claims and can only bill for immunizations)
74     Radiation Therapy Centers
75     Slide Preparation Facilities
80     Licensed Clinical Social Worker
87     All other suppliers, e.g., Drug Stores
88     Unknown Supplier/Provider
89     Certified Clinical Nurse Specialist
95     Available
96     Optician
97     Physician Assistant
A0    Hospital
A1    Skilled Nursing Facility
A2    Intermediate Care Nursing Facility
A3    Nursing Facility, Other
A4    Home Health Agency
A5    Pharmacy
A6    Medical Supply Company with Respiratory Therapist
A7    Department Store
A8    Grocery Store
B2     Pedorthic Personnel
B3     Medical Supply Company with Pedorthic Personnel
B4     Rehabilitation Agency

NOTE: Specialty Code Use for Service in an Independent Laboratory. For services performed in an independent laboratory, show the specialty code of the physician ordering the x-rays and requesting payment. If the independent laboratory requests payment, use type of supplier code "69".

MTUS indicator of CMS 1500

Methodology for Coding Number of Services, MTUS Count and MTUS Indicator Fields

The following instructions should be used as a guide for coding the number of services, MTUS Count and MTUS Indicator fields on the Part B Physician/Supplier Claim. These fields are documented in the CMS National Claims History Data Dictionary as CWFB_SRVC_CNT, CWFB_MTUS_CNT, and CWFB_MTUS_IND_CD, respectively.

Services not falling into examples B, C, E, or F should be coded as shown in example D (services/pricing units).

A. No Allowed Services – (CWFB_MTUS_IND_CD = 0)

For claims reporting no allowed services, the following example should be used to code the line item:
A total of 2 visits was reported for HCPCS code 99211: Office or other outpatient visit for the management of an established patient. Both services were denied.
Number of services: 2 (furnished)
                              MTUS (services): 0 (allowed)
                              MTUS indicator: 0

B. Ambulance Miles - (CWFB_MTUS_IND_CD = 1)

For claims reporting ambulance miles, the following example should be used to code the line item:
Mileage Reporting: A total of 10 miles (1 trip) was reported for HCPCS code A0425: Ground mileage, per statute mile.
                          Number of services: 10
                          MTUS (miles): 10
                         MTUS indicator: 1

C. Anesthesia Time Units - (CWFB_MTUS_IND_CD = 2)

For claims reporting anesthesia time units in 15-minute periods or fractions of 15-minute periods, the following example should be used to code the line item:
A total of 1 allowed service is reported for HCPCS code 00142: Anesthesia for procedures on eye; lens surgery. The anesthesiologist attended the patient for 35 minutes.
                   Number of services: 1
                  MTUS (time units): 23 (one decimal point implied) *
                  MTUS indicator: 2
* Two 15-minute periods + 1/3 of a 15-minute period equals 2.3

D. Services/Pricing Units - (CWFB_MTUS_IND_CD = 3)

For claims reporting a service or pricing unit, the following examples should be used to code the line item:

Example 1-A total of 2 visits was reported for HCPCS code 99211: Office or other outpatient visit for the management of an established patient.
                   Number of services: 2
                   MTUS (services): 2
                   MTUS indicator: 3

Example 2 - A total of 500 milligrams was administered for HCPCS code J0120: Injection, Tetracycline, up to 250 mg.
NOTE: The number of milligrams should not be reported in the service or MTUS fields. Instead, report the number of pricing units. In this case, up to 250 mg equals 1 unit/service. Thus, 500 mg equals 2 units/services.
                    Number of services: 2
                    MTUS (services): 2
                    MTUS indicator: 3

Example 3-A total of 24 cans was purchased, each containing 300 calories for HCPCS code B4150: Enteral Formulae, 100 calories.
NOTE: Neither number of cans nor the number of calories should be reported in the services or MTUS fields. Instead, report the number of pricing units. In this case, 100 calories equals 1 unit/service. Thus, 24 cans * 300 calories / 100 calories equals 72 units/services.
                         Number of services: 72
                        MTUS (services): 72
                        MTUS indicator: 3


E. Oxygen Services - (CWFB_MTUS_IND_CD = 4)

For claims reporting oxygen units, the following example should be used to code the line item:
A total of 2 allowed services was reported for HCPCS code E0441: Oxygen contents, gaseous, 1 month’s supply = 1 unit. The claim reported a 2 month’s supply of oxygen.
                               Number of services: 2
                               MTUS: 2
                               MTUS indicator: 4

F. Blood Services - (CWFB_MTUS_IND_CD = 5)
For claims reporting blood units, the following example should be used to code the line item:
A total of 6 units of blood (services) was furnished for HCPCS code P9010: Blood (whole), for transfusion, per unit. Two units were denied.
                            Number of services: 6 (furnished)
                            MTUS (units): 4 (allowed)
                            MTUS indicator: 5

Thursday, June 10, 2010

Miles, Times, Units, Services (MTUS) Indicator Field of CMS 1500

Miles/Times/Units/Services (MTUS)

Miles/Times/Units/Services (MTUS) count and MTUS indicator fields are on Part B Physician/Supplier Claims. These fields are documented in the CMS National Claims History Data Dictionary.

Standard systems are to put MTUS count and MTUS indicators on all claims at the line item level.
The purpose of the MTUS Count Field on the line item is to document additional information reflecting certain volumes related to indicators. In most cases, the value in this field will be the same as in the Service Count Field on the line item; however, for services such as anesthesia the field values will differ. In this case, the service count field will likely contain a value of 1 for the occurrence of the surgery while the MTUS Count Field will contain the actual time units that the anesthesiologist spent with the patient in 15 minute increments or a fraction thereof.

The purpose of the Miles, Times, Units, Services (MTUS) Indicator Field is to indicate what the value entered into the MTUS Count Field means. There are 6 indicator values, as follows:

0 - No allowed services
1 - Ambulance transportation miles
2 - Anesthesia Time Units
3 - Services
4 - Oxygen units
5 - Units of Blood

What is the importance of accept assignment?

Field 27 

Item 27 - Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients.

The following providers of service/suppliers and claims can only be paid on an assignment basis:
• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Participating physician/supplier services;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals; and
• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.

Signature of provider - Box 31 CMS 1500

Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.

NOTE: This is a required field, however the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature.

Wednesday, June 9, 2010

How to Filing Form CMS-1500 - Tips to submit claim

Filing Form CMS-1500

Medicare Part B physicians may use the red-printed Form CMS-1500 to file various health insurance claims to private insurers and government programs. However, payment for paper claims takes substantially longer than payment for electronically submitted claims. Generally, electronic claims can be paid 14 days after submission, as opposed to paper claims that process in about four weeks. 

How Paper Claim Submission 

Works When filing paper claims, physicians must type or machine-print all mandated claim fields on the red-printed Form CMS-1500 and mail it to the local carrier. Some carriers may be able to accept a black and white copy of Form CMS-1500. Other carriers may not accept black and white copies of the form if they are using Optical Character Recognition (OCR) equipment to process the form.

Optical Character Recognition 

Carriers that process claims with OCR, use an automated scanning process similar to scanners that read price labels in grocery stores. OCR claims processing is faster and more accurate than systems requiring manual input. However, to work properly, OCR must accurately read and interpret the characters entered in each field. It reads only typed or machine-printed data. Only an original, red and white Form CMS-1500 may be submitted. Black and white photocopies cannot be machine read and will be returned. 

After claims information is scanned, it is transmitted to the claims processing system, where it is validated. 

To ensure accurate, quick claim processing, the following guidelines must be followed: 

*Do not staple, clip, or tape anything to Form CMS-1500
*Place all necessary documentation in the envelope with Form CMS-1500 
* Put the patient ’ s name and Medicare number on each piece of documentation submitted 
* Use dark ink 
* Use only upper-case (CAPITAL) letters 
* Use 10 or 12 pitch (pica) characters and standard dot matrix fonts 
* Do not mix character fonts on the same form 
* Do not use italics or script 
* Avoid using old or worn print bands or ribbons
* Do not use dollar signs, decimals, or punctuation 
* Enter all information on the same horizontal plane within the designated field 
* Do not print, hand-write, or stamp any extraneous data on the form 
* Use only lift-off correction tape to make corrections 
* Ensure data is in the appropriate field and does not overlap into other fields 
* Remove pin-fed edges at side perforations 
* Use only an original red-ink-on-white-paper Form CMS-1500




How Electronic Data Interchange (EDI) work

Electronic Data Interchange (EDI)

EDI, electronic submission of Medicare Part B claims eliminates mailroom processing and manual data entry. The Medicare claims processing system can usually pay electronic claims faster than pa- per claims. Generally, electronic claims can be paid on the 14th day after submissions, but paper claims cannot be paid earlier than the 27 th day after submission. 

EDI saves the physician time and money through more accurate, faster processing of claims and reduced postage costs. Physicians should contact the local Medicare carrier for information about EDI. 

How EDI Works  

The claim is electronically transmitted in data “ packets ” from the physician ’ s computer modem to the carrier ’ s modem over a telephone line. The carrier checks ( “ edits ” ) the data for required information. Claims that pass these initial edits, commonly known as front-end edits or pre-edits, are then processed according to Medicare policy and guidelines. Claims with inadequate or incorrect information do not pass the initial edits. They are rejected and are not paid because they lack sufficient in- formation to make a payment decision. 

After successful transmission, an acknowledgement report is generated and is either transmitted back to the physician or placed in an electronic mailbox for the physician to download. This report con- firms that the file was received and lacks format errors. Once the claims are processed another report is generated that indicates the number of claims accepted and the total dollar amount transmitted. Additionally, this report lists claims that were rejected, as well as, the reason(s) for being rejected. The physician should review this report carefully. At this point, the physician can make necessary corrections to the rejected claim(s) and resubmit them.

Claim submission

How to Submit Claims 

Claims may be filed to the Medicare Part B carrier in one of two ways: 

* Electronic transmission from the physician ’ s office or from a billing service contracting with the physician

* Paper claim (Form CMS-1500) where not prohibited under the mandatory Medicare electronic filing requirements October 16, 2003 and later

Claims may be electronically submitted to Medicare from a physician ’ s office using a computer with software that meets electronic filing requirements. A sender number is issued, and claims are transmitted directly from the physician ’ s office, giving the physician control over timeliness and accuracy of claims. Medicare carriers offer free or low-cost billing software that allows electronic transmission directly to the Medicare carrier. Commercial software is also available that can be used to bill multiple health plans, including Medicare, as well as perform other practice management services. If the physician does not have a computer system meeting the requirements, a billing service may be used to submit claims. Either way, specific processing requirements–and benefits–are associated with filing claims electronically.

Where the service rendered - Field 32 of CMS 1500 Form

Item 32 - Enter the name and address, and ZIP Code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patient's home or physician's office. Effective for claims received on or after April 1, 2004, enter the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, only one name, address and ZIP Code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted.

Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP Code when billing for purchased diagnostic tests. When more than one supplier is used, a separate Form CMS-1500 shall be used to bill for each supplier.

For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid ZIP Code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP Code.

For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order was accepted must be entered (DMERC only). This field is required. When more than one supplier is used, a separate Form CMS-1500 shall be used to bill for each supplier. This item is completed whether the supplier's personnel performs the work at the physician's office or at another location.

If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than home.

If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number.

Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed.

Type of Service Indicators - CMS BOX 24

The place of service or diagnosis may be considered when determining the appropriate TOS. The descriptors for each of the TOS codes listed in the following table are:

Type of Service Indicators

0    Whole Blood
1    Medical Care
2    Surgery
3    Consultation
4    Diagnostic Radiology
5    Diagnostic Laboratory
6    Therapeutic Radiology
7    Anesthesia
8    Assistant at Surgery
9    Other Medical Items or Services
A   Used DME
B    High Risk Screening Mammography
C     Low Risk Screening Mammography
D    Ambulance
E    Enteral/Parenteral Nutrients/Supplies
F    Ambulatory Surgical Center (Facility Usage for Surgical Services)
G    Immunosuppressive Drugs
H    Hospice
J     Diabetic Shoes
K    Hearing Items and Services
L     ESRD Supplies
M    Monthly Capitation Payment for Dialysis
N     Kidney Donor
P     Lump Sum Purchase of DME, Prosthetics, Orthotics
Q     Vision Items or Services
R      Rental of DME
S      Surgical Dressings or Other Medical Supplies
T      Outpatient Mental Health Treatment Limitation
U      Occupational Therapy
V      Pneumococcal/Flu Vaccine
W     Physical Therapy

Physician Specialty Codes to file the claim

Physician Specialty Codes

Code   Physician Specialty
01    General Practice
02   General Surgery
03   Allergy/Immunology
04   Otolaryngology
05   Anesthesiology
06   Cardiology
07   Dermatology
08   Family Practice
09   Interventional Pain Management
10   Gastroenterology
11   Internal Medicine
12   Osteopathic Manipulative Therapy
13   Neurology
14   Neurosurgery
15   Available
16   Obstetrics/Gynecology
17   Available
18   Ophthalmology
19   Oral Surgery (dentists only)
20   Orthopedic Surgery
21   Available
22   Pathology
23   Available
24   Plastic and Reconstructive Surgery
25   Physical Medicine and Rehabilitation
26   Psychiatry
27   Available
28   Colorectal Surgery (formerly proctology)
29   Pulmonary Disease
30   Diagnostic Radiology
31   Available
32   Anesthesiologist Assistants
33   Thoracic Surgery
34   Urology
35   Chiropractic
36   Nuclear Medicine
37   Pediatric Medicine
38   Geriatric Medicine
39   Nephrology
40   Hand Surgery
41   Optometry
44   Infectious Disease
46   Endocrinology
48   Podiatry
66   Rheumatology
70   Single or Multispecialty Clinic or Group Practice
72   Pain Management
73   Mass Immunization Roster Biller
74   Radiation Therapy Center
75   Slide Preparation Facilities
76   Peripheral Vascular Disease
77   Vascular Surgery
78   Cardiac Surgery
79   Addiction Medicine
81   Critical Care (Intensivists)
82   Hematology
83   Hematology/Oncology
84   Preventive Medicine
85   Maxillofacial Surgery
86   Neuropsychiatry
90   Medical Oncology
91   Surgical Oncology
92   Radiation Oncology
93   Emergency Medicine
94   Interventional Radiology
98   Gynecological/Oncology
99   Unknown Physician Specialty

Tuesday, June 8, 2010

Importance of Box 28 - CMS 1500

When not to show patient paid amounts on claims form in Field 28


Some providers who accept assignment have a concern that Medicare issues partial checks to beneficiaries. Such checks are generally issued because of a patient paid amount in item 28 of the CMS-1500 (08/05) claim form. Here are a few notes concerning this situation:
When assignment is accepted, Medicare Part B recommends:
Since it is difficult to predict when deductible/coinsurance amounts will be applicable - and over-collection is considered program abuse - it is recommended that providers do not collect these amounts until Medicare Part B payment is received.
If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. It is recommended that providers do not collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse. In addition, this practice can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.
Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.
There is no need to show a patient paid amount in item 28 of form CMS-1500 (or electronic equivalent) when assignment is not accepted.

CMS 1500 - Reserved for local use - BOX 19

Field 19 - Reserve for Local Use:

Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date patient was last seen and the UPIN (NPI when it becomes effective) of his/her attending physician when a physician providing routine foot care submits claims.

For physical therapy, occupational therapy or speech-language pathology services, effective for claims with dates of service on or after June 6, 2005, the date last seen and the UPIN/NPI of an ordering/referring/attending/certifying physician or non-physician practitioner are not required. If this information is submitted voluntarily, it must be correct or it will cause rejection or denial of the claim. However, when the therapy service is provided incident to the services of a physician or nonphysician practitioner, then incident to policies continue to apply. For example, for identification of the ordering physician who provided the initial service, see Item 17 and 17a, and for the identification of the supervisor, see item 24J of this section.

NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of an NPI.

Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) x-ray date for chiropractor services (if an x-ray, rather than a physical examination was the method used to demonstrate the subluxation). By entering an x-ray date and the initiation date for course of chiropractic treatment in item 14, the chiropractor is certifying that all the relevant information requirements (including level of subluxation) of Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, is on file, along with the appropriate x-ray and all are available for carrier review.

Enter the drug's name and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs.
Enter a concise description of an "unlisted procedure code" or an NOC code if one can be given within the confines of this box. Otherwise an attachment shall be submitted with the claim.

Enter all applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d. If modifier -99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item.

Enter the statement "Homebound" when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, "Laboratory Services From Independent Labs, Physicians and Providers," and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," respectively for the definition of "homebound" and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)

Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign benefits to a non-participating physician/supplier who accepts assignment on a claim. In this case, payment can only be made directly to the beneficiary.

Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s) is used to obtain intentional denials when other payers are involved.

When dental examinations are billed, enter the specific surgery for which the exam is being performed.
Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS codes do not cover them.
Enter a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or relinquished date for a global surgery claim when providers share post-operative care.
Enter demonstration ID number "30" for all national emphysema treatment trial claims.
Enter the NPI/PIN of the physician who is performing a purchased interpretation of a diagnostic test. (See Pub. 100-04, chapter 1, section 30.2.9.1 for additional information.)
NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of an NPI.

Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD beneficiaries on dialysis. (See Pub. 100-04, chapter 8, section 60.7.2.)

Individuals and entities who bill carriers or A/B MACs for administrations of ESAs or Part B anti-anemia drugs not self-administered (other than ESAs) in the treatment of cancer must enter the most current hemoglobin or hematocrit test results. The test results shall be entered as follows: TR= test results (backslash), R1=hemoglobin, or R2=hematocrit (backslash), and the most current numeric test result figure up to 3 numerics and a decimal point [xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for Hematocrit tests: TR/R2/27.0.

Description of Field 17 of CMS 1500 claim



 Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician.

The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:

1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;

2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;

3. A doctor of podiatric medicine for purposes of §§(k), (m), (p)(1), and (s) and §§1814(a), 1832(a)(2)(F)(ii), and 1835of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them;

4. A doctor of optometry, but only with respect to the provision of items or services described in §1861(s) of the Act which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or

5. A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets uniform minimum standards specified by the Secretary, but only for purposes of §§1861(s)(1) and 1861(s)(2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of §1862(a)(4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in §1862(a)(4) of the Act) are furnished.


Referring physician - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. See Pub 100-02, Medicare Benefit Policy Manual, chapter 15 for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service.

Thursday, June 3, 2010

Service required referring physician - BOX 17 A

All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s UPIN and/or NPI. The following services/situations require the submission of the referring/ordering provider information:

• Medicare covered services and items that are the result of a physician's order or referral;
 
• Parenteral and enteral nutrition;
 
• Immunosuppressive drug claims;
 
• Hepatitis B claims;
 
• Diagnostic laboratory services;
 
• Diagnostic radiology services;
 
• Portable x-ray services;
 
• Consultative services;
 
• Durable medical equipment;

• When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests);

• When a service is incident to the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;
 
• When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner;
 
Item 17a – Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

Item 17b Form CMS-1500 – Enter the NPI of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.

NOTE: Effective May 23, 2008, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.

Who is ordering physician and who is referring physician

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician.

The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:

1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs such function or action;

2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions;

3. A doctor of podiatric medicine for purposes of §§(k), (m), (p)(1), and (s) and §§1814(a), 1832(a)(2)(F)(ii), and 1835of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the State in which he/she performs them;

4. A doctor of optometry, but only with respect to the provision of items or services described in §1861(s) of the Act which he/she is legally authorized to perform as a doctor of optometry by the State in which he/she performs them; or

5. A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets uniform minimum standards specified by the Secretary, but only for purposes of §§1861(s)(1) and 1861(s)(2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of §1862(a)(4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in §1862(a)(4) of the Act) are furnished.

Referring physician - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. See Pub 100-02, Medicare Benefit Policy Manual, chapter 15 for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service.

CMS 1500 Box 13 - patient Singnature on file

The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.

The presence of or lack of a signature or “signature on file” in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

In addition, the signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in item 9 and its subdivisions. The patient or his/her authorized representative signs this item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

NOTE: This can be "Signature on File" signature and/or a computer generated signature.

What are the circumstance when Medicare is secondary.

Insurance Primary to Medicare - Circumstances under which Medicare payment may be secondary to other insurance include:

• Group Health Plan Coverage
o Working Aged;
o Disability (Large Group Health Plan); and
o End Stage Renal Disease;

• No Fault and/or Other Liability; and

• Work-Related Illness/Injury:
o Workers' Compensation;
o Black Lung; and
o Veterans Benefits.

NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.

Entering secondary insurance information on primary Medicare cliam

Item 9 - Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

NOTE: Only participating physicians and suppliers are to complete item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a MEDIGAP policy to the participating physician or supplier..
Participating physicians and suppliers must enter information required in item 9 and its subdivisions if requested by the beneficiary. Participating physicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer.

Medigap - Medigap policy meets the statutory definition of a "Medicare supplemental policy" contained in §1882(g)(1) of title XVIII of the Social Security Act (the Act) and the definition contained in the NAIC Model Regulation that is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as "specified disease" or "hospital indemnity" coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees, as well as that offered by a labor organization to members or former members.

Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim.

Item 9a - Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.

NOTE: Item 9d must be completed, even when the provider enters a policy and/or group number in item 9a.
 
Item 9b - Enter the Medigap insured's 8-digit birth date (MM | DD | CCYY) and sex.

Item 9c - Leave blank if a Medigap PayerID is entered in item 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP code copied from the Medigap insured's Medigap identification card. For example:
 
1257 Anywhere Street
Baltimore, MD 21204
is shown as "1257 Anywhere St. MD 21204."
 
Item 9d - Enter the 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.

If the beneficiary wants Medicare payment data forwarded to a Medigap insurer through the Medigap claim-based crossover process, the participating provider of service or supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d.

A Medicare participating provider or supplier shall only enter the COBA Medigap claim-based ID within item 9d when seeking to have the beneficiary’s claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within item 9d, the Medicare Part B contractor or Durable Medical Equipment Medicare Administrative Contractor (DMAC) will be unable to forward the claim information to the Medigap insurer prior to October 1, 2007, or to the Coordination of Benefits Contractor (COBC) for transfer to the Medicare insurer on or after October 1, 2007.

Date format of CMS 1500

Providers and suppliers must report 8-digit dates in all date of birth fields (items 3, 9b, and 11a), and either 6-digit or 8-digit dates in all other date fields (items 11b, 12, 14, 16, 18, 19, 24a, and 31).


Providers and suppliers have the option of entering either a 6 or 8-digit date in items 11b, 14, 16, 18, 19, or 24a. However, if a provider of service or supplier chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19, or 24a, he or she must enter 8-digit dates for all these fields. For instance, a provider of service or supplier will not be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a 6-digit date for item 24a. The same applies to providers of service and suppliers who choose to submit 6-digit dates too. Items 12 and 31 are exempt from this requirement.

Legend                                    Description
MM                                    Month (e.g., December = 12)
DD                                        Day (e.g., Dec15 = 15)
YY                                  2 position Year (e.g., 1998 = 98)
CCYY                            4 position Year (e.g., 1998 = 1998)

(MM | DD | YY) or (MM | DD | CCYY)        A space must be reported between month, day, and year (e.g., 12 | 15 | 98 or 12 | 15 | 1998). This space is delineated by a dotted vertical line on the Form CMS-1500)

(MMDDYY) or (MMDDCCYY)                     No space must be reported between month, day, and year (e.g., 121598 or 12151998). The date must be recorded as one continuous number.

Wednesday, June 2, 2010

KIDNEY DISEASE PROGRAM BILLING - how to fill HCFA

CMS-1500  KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS

CMS 1500 BLOCK TO BLOCK BILLING INSTRUCTIONS

Providers must use the CMS-1500 form to bill the Program. The CMS-1500 forms are available from the Government Printing Office, the American Medical Association, major medical oriented printing firms, or visit: (http://www.cms.hhs.gov/providers/edi/cms1500.pdf)

For Kidney Disease claims processing, THE TOP RIGHT SIDE OF THE CMS-1500 MUST BE BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed.

The following fields MUST be completed on the CMS-1500:


Block 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Kidney Disease Program card.

Block 10d RESERVED FOR LOCAL USE – Enter the 6 digit Kidney Disease Program Patient Identification Number. If this field is left blank, the claim will be returned as invalid.

Block 21 DIAGNOSIS OR NATURE OF THE ILLNESS OR INJURY – Enter the 3, 4, or 5 character code from the ICD-9 related to the procedures, services, or supplies listed in Block #24d. List the primary diagnosis on Line 1 and secondary diagnosis on Line 2. Additional diagnoses are
optional and may be listed on Lines 3 and 4.

Block 24A DATE(S) OF SERVICE – Enter each separate date of service as a 6-digit numeric date (e.g. June 1, 2005 would be 06/01/05) under the FROM heading. Leave the space under the TO heading blank. Each date of service on which a service was rendered must be listed on a separate line. Ranges of dates are not accepted on this form.

Block 24B PLACE OF SERVICE – For each date of service, enter the appropriate 2- digit place of service code to describe the site.


Block 24C EMG – Leave Blank.

Block 24D PROCEDURES, SERVICES OR SUPPLIES – Enter the five-character procedure code that describes the service provided and two-character modifier, if required.

Block 24E DIAGNOSIS POINTER – Enter appropriate information.

Block 24F CHARGES – Enter the usual and customary charges. Do not enter the Maryland Medicaid maximum fee unless that is your usual and customary charge. If there is more then one unit of service on a line, the charge for that line should be the total of all units.

Block 24G DAYS OR UNITS – Enter appropriate days or units.

Block 24H EPSDT FAMILY PLAN – Leave Blank.

Block 24I ID. QUAL. – Leave Blank

Block 24J RENDERING PROVIDER ID. # – Leave Blank

Block 25 FEDERAL TAX I.D. NUMBER – Enter your Federal Tax ID number. In addition, enter your store number if one has been assigned to your store.


Block 28 TOTAL CHARGE – Enter the sum of the charges shown on all lines of Block #24F of the invoice.

Block 29 AMOUNT PAID – Enter the amount of any collections received from any third party payer, except Medicare.

Block 30 BALANCE DUE – Enter coinsurance and/or deductible amounts due, if Medicare eligible. Enter total charges due, if not Medicare eligible. If other third party payment is made, enter coinsurance and/or deductible amounts due.

Block 33 BILLING PROVIDER INFO & PH# - Enter the name, complete street address, city, state, and zip code of the provider. This should be the address to which claims may be returned.

Block 33a
NPI - Enter the NPI number of the billing provider in Block # 33. Errors or omissions of this number will result in non-payment of claims.

CMS-1500 KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS




CLAIM SUBMISSION CHECKLIST

Prior to submitting your claims to the Kidney Disease Program, use the following checklist:
�� Is your copy legible? Did you type or print your form? Although not required, typing the form will speed up the process.
�� Did you follow the Billing Instructions?
�� Do you have the correct address for submitting your claims? Correct address for submission is listed on page 1 of these billing instructions.


CLAIM TROUBLESHOOTING

This section provides information about the most common billing errors encountered when
providers submit claims to the Kidney Disease Program. Preventing errors on the claim is
the most efficient way to ensure that your claims are paid in a timely manner.


Claims commonly reject for the following reasons:1. The appropriate provider and/or recipient identification is missing or inaccurate.

�� Verify that the 6 digit Kidney Disease Program Patient Identification number is entered in Block 10D. This ID number must be entered or claim will reject for invalid KDP recipient.

�� Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.

�� Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.

�� Verify that the recipient’s name is entered in Block #2, last name first.


2. Provider and/or recipient eligibility was not established on the dates of services covered by the claim.
�� Verify that you did not bill for services provided prior to or after your provider enrollment dates.
�� Verify that you entered the correct dates of service in the Block #24a of the claim form.
�� Verify Medical Assistance eligibility. If patient has full Medical Assistance coverage, do not bill KDP.


3. The medical services are not covered or authorized for the provider and/or recipient.
�� There are limits to the number of units that can be billed for certain services. Verify that you entered the correct number of units on the claim form.

�� A valid 2-digit place of service code is required.

�� Some tests are frequently performed as groups or combinations and must be billed as such. Verify the procedure codes and modifiers that were entered on the claim form and determine if they should have been billed as a group.

�� Claims will be denied if the procedure cannot be performed on the recipient indicated because of gender, age, prior procedure or other medical criteria conflicts. Verify that you entered the correct 11-digit recipient identification number, procedure code and modifier on the claim form.

�� Some procedures cannot be billed with certain place of service codes. Verify that you entered the correct procedure and place of service codes in the appropriate block on the claim form.


�� Primary diagnosis must be ESRD (end stage renal disease) related. Our program only reimburses for the primary diagnosis, which must be directly related to a recipients ESRD or a condition that is a direct result of their ESRD.


4. The claim is a duplicate, has previously been paid or should be paid by another party.

�� KDP edits all claims to search for duplications and overlaps by providers. Verify that you have not previously submitted the claim.

�� If the Program has determined that a recipient has third party coverage that will pay for medical services, the claim will be denied. Submit the claim to the thirdparty payer first.

Finally, some errors occur simply because the data entry operators have incorrectly keyed or were unable to read data on the claim. In order to avoid errors when a claim is keyed, please ensure that this information is either typed or printed clearly. When a claim is denied, always compare data from the remittance advice with the file copy of your claim. If the claim denied because of a keying error, resubmit the claim.

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