Medical Billing by MikeJenny


									    Medical Billing Chapter 6
         Health Care Claim

    Learning Outcomes
     6-1 Describe the process of using medical
      billing programs to prepare health care
     6-2 Discuss the content of the pt.
      information section of the CMS-1500 claim.
     6-3 Discuss the content of the physician or
      supplier information section of the CMS-
      1500 claim.

    Learning Outcomes
     6-4 Briefly describe the information
      contained in the five major sections of the
      HIPAA claim
     6-5 Compare billing provider, pay-to
      provider, rendering provider, and referring
     6-6 Discuss the importance and use of claim
      control numbers and line-item control
      numbers on HIPAA claims.
    Key Terms (know all for test)
     837P claim          claim filing
     administrative       indicator code
      code set            claim frequency
     billing provider     code (claim
     carrier block       submission
     claim attachment     reason code)
     claim control
    Key Terms (know for test)
     CMS-1500 claim       legacy number
     condition code       line item control
     database              number
     data element         National Uniform
     destination payer     Claim Committee
     HIPAA claim
                           outside
     individual
     relationship code      laboratory

    Key Terms (know for test)
     pay-to provider       service line
     place of service       information
      (POS) code            subscriber
     qualifier            • taxonomy code
     referring provider   • transactions
     rendering

    Medical Billing Programs
     Medical billing      databases-an
     programs are          organized
     efficient, because    collection of
     information that      related facts, so
     is used over and      that they can be
     over again is         quickly accessed.
     stored in

    Items Stored in Databases
     Major databases in   in the medical office.
      billing programs     • Information such
      are:                   as addresses and
     Provider-contains      national provider
      information about      IDs are stored in
      licensed medical       the database.
      professional staff
      members working

    Items stored in Database
     Patient/guarantor    account number,
     The data from        personal info.,
                           name, address,
     each patient
                           phone number,
     information form      birthdate, Social
     are stored in the     Security number,
     pt./guarantor         gender, marital
     database. These       status, employer,
     data include: Pt’s    and guarantor (the
                           insured person, if it
                           is not the patient).
     Items Stored in Database
      Insurance Carriers-    Diagnosis Codes-
      contains the names,     This database
      addresses, plan         contains the ICD-
      types, and other        9-CM codes that
      data about the          indicate the reason
      major health plans      that the services
      used by the             are provided.
      practice’s patients.

     Items Stored in Database
      Procedure Codes     Transactions-all
      This database       the financial
      contains the data    aspects of visits-
      needed to create     charges and
      charges. The CPT     payments
      codes most often
      used are in this
     Preparing a Claim
      Three steps

      1. Recording pt. information. This is
       obtained from the pt. information form and
       the patient’s insurance card.
      Facts about established patients need to be
       updated, and each office will have a policy
       on how often they need to be updated.

     Preparing a Claim
      2. Recording diagnoses, procedures,
       charges, and payments for patient
       encounters. After the physician sees the
       patient, the diagnosis and procedure codes
       are recorded in the billing program.
      The provider that the pt. saw is selected
       from the practice’s list of staff members.
      The source of the information is the
       encounter form (ex. on pg. 87).

     Creating a Claim
      3. When all of the data has been entered and
       checked, the billing program is instructed to
       create a claim.
      The programs draws the needed facts from
       the stored information and organizes theses
       date into a claim file.
      These claims can either be transmitted
       electronically or by mail to payers.

     Preventing Errors
     •    In order to prevent human error, there are some
         things that are not done when entering data in
         medical billing programs.
     •   Do not use prefixes for people’s names, such as Mr.,
         Ms., or Dr.
     •   Unless required by a particular insurance carrier, do
         not use special characters, such as hyphens, commas,
         or apostrophes.
     •   Use only valid data in all fields.
     •   Enter the required number of characters for each
         data element, such as four numbers for the year

     Health Care Claims
      HIPAA X12 837 Health Care Claim or
      Equivalent Encounter Information-is
      also known as the HIPAA claim or the
      837P claim. This is an electronic claim
      form.The P in 837 P is for professional.
      For hospital billing, the claim form is
      the 837 I, where the I stands for
     Claim Background
      HIPAA claims are based on the old
       CMS-1500 claim (formerly the HCFA-
       1500, which is the paper claim form.
      HIPAA now requires electronic
       transmission of all claims, except from
       very small practices.
      Only these providers can still mail or
       fax paper claims.
     The National Uniform Claim
     Committee (NUCC)
      Led by the American Medical
      Organization that determines the
       content of both HIPAA and CMS-1500

      The current version of the CMS-1500 was updated
       by NUCC to allow reporting of the National
       Provider Identifier (NPI)-under HIPAA, this is a
       unique 10-digit number assigned to each provider
       by the National Provider System; replaces both the
       UPIN and Medicare PIN.
      A provider’s identification number that is issued by
       a payer (before implementation of the National
       Provider Identification System) (such as UPIN
       and PIN) is called a legacy number.

              Test Your
      What is some of the information that is
       contained within the provider’s database?
      provider information
      pt. information
      insurance information
      diagnosis codes
      procedure codes

     Test Your Knowledge
      In medical billing, why do we avoid using
       prefixes in front of someone’s name?
      In order to prevent errors.
      What is the 837P?
      An electronic claim form.
      What does the P stand for?
      Professional

     CMS-1500 Claim(paper claim form)
      Contains 33 form locators (FLs), or
       information boxes (see pg. 116). FLs 1-13
       refer to the pt. and the pt.’s insurance
      FLs 14-33 contain info. About the provider
       and pt’s condition, including diagnoses,
       procedures, and charges.
      This information is obtained from the
       encounter form and clinical documentation.

               Carrier Block
      Located in the upper right of the CMS-
      It allows for a four-line address for the
      Note that commas, periods, or other
       punctuation are not used in the address.
       However, when entering a 9-digit zip
       code, the hyphen is included.
            Patient Information
      Form locator 1 is used to indicate the
       patient’s type of insurance coverage.
      Five specific government programs are
       listed (Medicare, Medicaid,
       Black Lung), as well and Group Health Plan
       and Other.
      If the client has group health insurance,
       select Group Health Plan.

      The OTHER box is used when a client
      has an individual health plan, HMO,
      commercial insurance, automobile
      accident, liability, and worker’s

     Test Your Knowledge
      What is the CMS-1500?
      It is the paper claim form.
      Who can use the CMS-1500 to file
      Only small practices.
      What information goes in the carrier
      The address for the payer.
       Test Your Knowledge
      If a condition code was necessary,
       where would it be entered on the
       claim form?
      FL10d
      What does a condition code start
      BG
      When dates are added on the claim
       form, how are they written?
      DD/MM/CCYY
            Patient Information
      Form locator la is the insured’s ID number.
       This is the ID number issued by the payer for
       the person who holds the policy or the
       dependent patient.
      Form locator 2 is the patient’s name. It should
       be listed as last name comma first name comma
       middle initial period
      When entering names with a last name suffix
       (e.g., Jr. or Sr.) enter the suffix after the last
       name and before the first name.

             Patient Information
      Form locator 3is the patient’s birthdate/sex
      The birthdate should be entered in eight-digit
      (MM/DD/CCYY)
      Use zeros before single digits
      Use an X in the correct box to indicate the sex of
       the pt.
      Form locator 4 is the insured’s name.
      If the insured is the patient, then enter SAME.
      Use commas to separate the last name, first name,
       and middle initial.
           Patient Information
      FL 5 is the pt’s address and telephone
      First line is for the address
      Second line is for the city and state
      Third line is for the zip code and phone
      Do not use a space or hyphen as a
       separator within the telephone number.
            Patient Information
      FL 6 is the pt’s relationship to the insured
       (listed in FL 4). Choosing self indicates that
       the insured is the pt.
      Spouse indicates that the pt. is either the
       insured’s husband or wife.
      Child means this is a minor dependent of the
      Other means that the pt. is someone other
       than the insured, spouse, or child.
            Patient Information
      FL 7 is the insured’s permanent address. If it is
       the same as pt’s write SAME.
      FL8 Patient Status- Enter an X in the box for
       the pt’s marital status and for the pt’s
       employment or student status.
      FL9 is used when there is a holder of another
       policy that may cover the pt.
      Enter the last name, first name, and middle
       initial of enrollee, if different from the pt.
      Otherwise, use SAME.

               Patient Information
      FL 9a Other insured’s policy or group number. Enter
         the policy or group number of the other insurance plan.
        Do not use a hyphen as a separator with the policy or
         group number.
        FL 9b Other Insured’s Date of Birth
        Enter the 8-digit date of birth as MM/DD/CCYY and
         the sex of the other insured indicated in FL 9. Leave
         the box blank if unknown.
        FL 9c Employer’s Name or School Name
        Enter the name of the other insured’s employer or

            Patient Information
      FL 9d Insurance Plan Name or Program Name
      FL 10a-c Is pt’s condition related to
       employment, auto accident, or other accident.
      FL10d is reserved for local use. Some payers
       want the word Attachment in this FL if there is
       a claim attachment-an additional form or
       medical record item needed to process the

                Patient Information
      FL 10d If a condition code is required, it
      must be entered in this field. Use the two-
      digit qualifier BG to indicate that the
      following is a condition code, then the code.
      Examples of condition codes are listed on
      pg. 121.

            Patient Information
      FL 11 The insured’s policy or FECA number
       is the alphanumeric identifier for the health,
       auto, or other insurance plan coverage.
      FECA-Federal Employees’ Compensation
       Act number is the 9-digit alphanumeric id
       assigned to an employee of the federal
       government claiming work-related
       condition(s) under the Federal Employees
       Compensation Act.
           Patient Information
      FL 11a Insured’s date of birth (DOB)/Sex
      Should be listed as eight-digit birth date
       MM/DD/CCYY and sex of insured.
      FL 11b Employer’s name or school name
      FL 11c Insurance plan name or program
      FL 11d Is there another health benefit plan?
      If answer is yes, then FL 9a through 9d must
       also be completed.
           Medical Claim Form
      FL 13Insured or authorized person’s signature
      This entry authorizes payment of medical benefits
       directly to the provider of the services listed on the
      Physician or Supplier Information
      FL 14 Date of Current Illness, Injury, or Pregnancy
      Enter as 6 or 8 digit date for the first date of the
       onset of the present illness, injury, or pregnancy.
      For pregnancy, use the date of the last menstrual
       period (LMP) as the first date.
     Physician or Supplier Information
      FL 15: If pt. had the same or similar illness
      If known, enter as MM/DD/YY. If not, leave blank.
      FL 16 Dates Pt. unable to work in current occupation.
      Time span the pt. is or was unable to work.
      FL 17 Name of referring physician or other source
      The name of the referring provider, ordering provider,
       or other source must be shown if the service or item
       was ordered or referred by a provider.
      The first name, middle initial, last name and
       credentials of the professional who referred the service
       should be on the claim.
            Physician or Supplier
      FL 17a and 17b ID Number of Referring
       physicians (split field).
      17a is the non-NPI (payer-assigned) ID
       number of the referring provider, ordering
       provider, or other source
      The qualifier-a code indicating what the
       number represents, should also be reported
       above the dotted line and on the left side of
       the box before the Other ID# is entered.
     Physician or Supplier Information
      See top of pg. 134 for a list of some
      The NPI is entered in FL 17b.
      FL 18 Hospitalization dates related to
       current services-this refers to an in-patient
       stay and indicate the admission and
       discharge dates associated with the services
       on the claim.

            Physician or Supplier
      FL 19 Reserved for local use
      Some payers require certain identifiers in
       this field. If identifiers are reported, the
       appropriate qualifiers describing the
       identifier should be used.
      If there are more than four modifiers to be
       included with FL 24D, three of them plus
       modifier -99 go in 24D, and the additional
       modifiers go in FL 19.
     Physician or Supplier Information
      Outside lab? $ Charges indicates that
       services have been rendered by an
       independent provider as indicated in
       FL32 and shows the related costs
      If an outside lab was used, mark an X
       by Yes, and indicate the amount of the
       cost under charges

     Physician or Supplier Information
      FL 21 Diagnosis or Nature of Illness or
       Injury (relate items 1, 2, 3, or 4 to item 24e
       by line)
      The ICD-9-CM codes that describe the pt’s
       condition are entered in priority order. The
       primary diagnosis is listed first. If other
       numbers are listed separate, each with a
       space (accommodated by the period)
      If entering more than 3 digits, enter the
44     fourth digit above the period.
     Physician or Supplier Information
      FL 22 Medicaid Resubmission and/or
       Original Reference Number
      Medicaid resubmission means the code and
       original reference number assigned by the
       payer or receiver, to indicate that the claim
       had previously been submitted.

     Physician or Supplier Information
      When re-submitting a claim, enter the
       appropriate bill frequency code all the way
       to the left, on the left hand side of the field.
      7 is the code for replacement of prior claim
      8 is the code for void/cancel of prior claim

     Physician or Supplier Information
      FL 23 Prior Authorization Number
      This will be a number assigned by the
       payer authorizing the service/s.
      FL 24 The term service line
       information describes section 24 or the
       claim, the part that reports the
       procedures, or services performed for
       the patient. This is where the procedure (CPT
      codes go)
     Physician or Supplier Information
      FL 24A Give the dates of service (DOS), if
       it is the same day, enter the same date in
       both from and to on the claim form.
      24B Place of service (POS), code list for
       each item used or service performed. A
       place of service (POS) code describes the
       location where the service was provided.
       This is also called the facility type code.
      See pg. 128 for POS codes.
     Test Your Knowledge
      If you needed a qualifier, what box would it
       go into?
      FL 17a on the left side of the box before
       OTHER ID# is entered.
      If there was a claim attachment, what might
       need to be indicated on the claim form? And

     Test Your Knowledge
      What is the NPI?
      National Payer ID
      What is the service line information?
      Information given about procedures and
       services to pt.
      What line is considered the service line?
      FL 24


To top