Chapter 8 Claim Forms Flashcards
1
Q
Claim Forms
s/p/s (my own term. it means service, procedure, supplies)
A
Are used to report the s/p/s and the reason the s/p were performed to the Ins Carrier to obtain payment.
2
Q
Two claim forms.
A
CMS-1500 and (P837 electronic)
UB-04 claim forms
3
Q
CMS-1500
A
to report professional services performed by providers and ASC Ambulatory Surgical Centers.
4
Q
UB-04
A
To report facility services.
5
Q
National Uniform Claim Committee
responsible for development and maintenance of CMS 1500 form.
A
CMS 1500 is public domain not subject to copyright.
NUCC represents interest of
*Providers
*Payers
*DSMO designated Standards Maintenance Organization
*Vendors
*Public Health Organizations.
6
Q
Billing Claim Process
6 Steps
A
Step 1: Charge Entry
Step 2: Claims edits/scrubber (software)
Step 3: Bill Claims (send through a clearinghouse to the insurance carriers, or directly to the insurance carrier.
Step 4: Receive notification back from carrier (payment, denial)
Step 5: Post payments
Step 6: Work denials.
7
Q
Cost-Based Fee Schedules
*Lease/ Rent payments, utilities
*Office supplies equipment
*Loan fees, maintenance fees
*Employee labor
*Malpractice/Liability Insurance
*Health Ins and other benefits cost
A
RVU-Based Fee Schedule
Use current Physician Fee Schedule Relative Value Units (PFS RVU)
*Create conversion factor
*Multiply by a given number.
8
Q
Example:
If the national conversion factor for the 2023 is $33.89, and the PFS RVU file lists CPT 99214 w/ a non-facility RVU value of $3.76, the RVUs assigned are multiplied by the conversion factor to calculate the fee.
A
CPT 99214
$33.89 x 3.76 = $127.43 (round off)
If the office chooses to double the CMS fee … the conversion factor would be $67.78 (round off)
$67.78 x 3.76 = $254.85 (round off)
$255.
Can also be done using the national fee schedule for 99214 (127.43) and multiply by 2:
$127.43 x2 = $254.86 round off to $255.
9
Q
A transposed code can cause
A
a denial for wrong code.
10
Q
To help Reduce Payment Delay
A
*Verify Ins
*Submit Clean Claims
*Submit Claims electronically
*Check Status Reports
*Submit Documentation
*Post Contractual Adjustments
11
Q
Prior Authorization
A
Required to obtain approval from health plan prior to providing a s/p/s
12
Q
Claim Scrubbers
Software to Review Claims
SRC to check for errors before submitting claim.
A
A software that reviews claims for key components to id errors before claim is submitted.
13
Q
Claim Scrubber common edits.
LCD: Local Coverage Determination
NCD: National Coverage Determination
A
*Demographic data entry
*Medical Necessity LCD/NCD
*Gender and age specific s/p
*DOS
*POS place of service
*Modifiers
*NCCI edits (bundling)
14
Q
AR
Accounts Receivable
A
Money owed to practice for s/p rendered.
15
Q
Daily Deposits
A
Balance each day - amount posted in the practice management system must match deposit amount for the batch.
16
Q
Direct Deposits
A
Should match RA remittance advice sent to the provider from Ins carrier.
17
Q
EDI
don’t confuse this w/ the Political
DEI: Diversity Equity Inclusion.
A
Electronic Data Interchange.
Minimizes claim rejections and resubmissions.
Delivers claims in real time.
Expedite payer response times.
Reduce cost of claim submissions.
Must meet HIPAA requirements.
18
Q
DSL
Digital Subscriber Line
A
is a very high-speed connection.
software installed on the computer to use DSL.
19
Q
Extranet
A
Is a private computer network that allows controlled access to the payer’s system.
It’s limited access to the payer patients only.
20
Q
Internet
A
Vast computer network linking smaller computer networks worldwide.
Allows providers secure transmission of claims w/out the need for additional software.
21
Q
Magnetic tape, disk, compact disc media magnetic tape, compact disc media
A
Claim can be mailed by disc
22
Q
Clearinghouse
A
Billing companies and Practices utilize clearinghouses to submit claims.
23
Q
Start on Video of Billing
Audits
Sample Encounter Form
1500 Claim Form
Report of Operation
A
24
Q
Page 91
The term “item”
A
is used for the field on the paper CMS1500 claim form.
25
The term "loop"
is used in the electronic fields for the data elements to be sent.
26
The ASCA
Administrative Simplification Compliance Act
requires that claims be sent electronically, unless unusual circumstances are met.
27
EDI
ERA: Electronic Remittance Advice
Electronic Data Interchange.
Is computer-to-computer exchange of claims.
28
EDI replaces postal, fax, email etc.
for more information on the CMS1500 see web.
https://www.cms.gov/Outreach-and-Education/MLN/WBT/MLN4462429-MLN-WBT-1500/1500/index.html
29
The specific version for healthcare professionals and suppliers to transmit claims electronically is ANSI ASC X12N 837P. This is translated as:
aka P837 (electronic version of CMS1500)
ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting healthcare claims electronically
P = Professional version of the 837 electronic format
Version 5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for healthcare professionals and suppliers.
30
Billing Tip
HIPAA allows filing paper claims when it has been determined that due to limitations in the claims’ transaction formats adopted, it would not be possible to submit the claim electronically. Exceptions allowing for paper claims to be filed to Medicare include:
MSP: Medicare Secondary Payer
*Roster billing of inoculations covered by Medicare.
*Claims for payment under a Medicare demonstration project that specifies paper submission.
*“Obligated to Accept as Payment in Full” (OTAF) Medicare Secondary Payer (MSP) claims when there is more than one primary payer
*MSP claims when there is more than one primary payer and more than one allowed amount.
31
Electronic claims can be submitted from the provider's computer...
to a clearinghouse or directly to a payer.
32
Process
Claim is submitted to MAC
Medicare Admin Contractor
MAC sends claim through initial edits to determine claim has all requirements to meet the basic HIPAA requirements.
33
If errors are detected, at this level?
the entire batch of claims is rejected for correction and resubmission.
34
Once claims pass these front-end-edits
they are then edited against the HIPAA implementation guide requirements.
35
Claims that don't meet these standards...
are rejected on an individual level and returned electronically to the provider for correction and resubmission.
36
After claim passes the first two edits...
the claim is then edited for compliance w/ Medicare coverage and policy requirements.
37
Claim is then adjudicated or processed by either?
denied or approved
38
After claims are successfully transmitted...
an acknowledgement report is generated.
39
Private payers
also process medical claims electronically, utilizing edits that reflect CPT coding guidelines and conventions, NCCI rules and CMS guidelines.
40
Paper claims are submitted to Medicare only on a limited basis.
Providers who qualify for a waiver as a result of an unusual circumstance must submit their waiver to a/b MACs DME MACs to who they submit their claims.
41
All fields of CMS1500 and UB04 claim forms must be?
completed according to payer specifications.
42
More information about the Accredited Standards Committee (ASC) X12 can be found at
https://x12.org.
43
The HIPAA implementation guide requirements are purchased through the Washington Publishing Company
(wpc-edi.com)
Many clearinghouse companies have the implementation standards built into their editing systems.
44
All major insurance payers have developed their individual claims submission methods...
*United Healthcare
*WellPoint
*Kaiser
*Humana
*Aetna
*Cigna
and others
45
Payers may offer...
claim submission/real-time adjudication options.
46
Review 8.1
Facility charges are reported on which claim form?
UB 04 Claim Form
47
What does the acronym NUCC stand for?
Answer: D.
National Uniform Claim Committee
48
What revisions does the CMS-1500 claim form undergo?
Multiple reviews prior to approval and implementation
49
Which transaction is NOT specified in the 5010 transaction standards?
Acknowledgement for Patient Payments
Rationale: The 5010 transaction standards include Claims (837 Institutional, Professional, Dental, COB [Professional and Institutional] and, NCPDP), Claims Status Inquiry/Response (276/277), Remittance (835), Enrollment (834), Premium Payment (820), Eligibility Inquiry/Response (270/271), Referrals and Prior Authorizations (278), Claims Acknowledgements (277CA), Acknowledgement for Healthcare Insurance (999).
50
What regulation requires claims to be sent electronically unless unusual circumstances are met?
Answer: A. Administrative Simplification Compliance Act (ASCA)
Rationale: It is important to understand that the Administrative Simplification Compliance Act (ASCA) requires that claims be sent electronically unless unusual circumstances are met.
51
CMS 1500
"Items" are fields for data elements
52
CMS 1500 claim for the 837P
Format differs from Electronic to Paper CMS 1500 form
Paper = mmddccyy
Month - Day - Century- Year
Electronic = ccyymmdd
Century - Year - Month - Day
53
NUCC
National Uniform Claim Committee
54
02/12 1500 Claim Form Map
to the
X12 Health Care Claim:
Professional (837)
Includes data elements, identifiers, descriptions and codes from the Accredited Standards Committe X12, Ins Committee, ASC X12N, Health Care Claim: Professional (837) etc. etc.
55
The following is a crosswalk of the 02/12 version 1500 Health Care Form (1500 Claim Form) to the ...
see example below on card 56 of changes from one form to another.
X12 837 Health Care Claim: Professional Version 5010-5010A1 electronic transaction.
see example below on card 56 of changes from one form to another.
56
1500 Form Locator
Item Title
Number
837P
Loop Id Segment/Data
Element
57
Overview of a claim
(by MAC)
c/r correction & resubmission
1. Claim Received
2. Initial Edits. The MAC sends the claim through initial edits to determine if the claim has all of the requirements necessary to meet basic HIPAA requirements. If any errors are found, the entire batch of claims is rejected for correction and resubmission.
3. Edited against the HIPAA implementation guide requirements. Once the claims pass these front-end edits, they are then edited against HIPAA guidelines. Claims are rejected on an individual level and returned electronically to the provider for c/r.
4. Edited for Compliance: after a claim passes through the first two sets of edits, the claim is then edited for compliance w/ Medicare coverage and payment policy requirements.
5. Claim is then adjudicated: is the legal process by which an arbiter or judge reviews evidence and argumentation including legal reasoning set forth by opposing parties or litigants to come to a decision.
6. Acknowledgement Report Generated: after claims are successfully transmitted and acknowledgement report is generated. The acknowledgement report can either be sent back to the provider or placed in an electronic mailbox for provider.
58
Services reported on the CMS 1500 claim form 837P.
*Inpatient s/p
*Observation, ER, Inpatient
*Surgeon's charges
*Combined medical/surgical s/p
*Any s/p by Physician or supplier
*Ambulatory Surgical Centers ASCs
59
CMS 1500 Claim Form
is separated by a bold line in the middle of the form.
*Patient info top half of form
*Professional info bottom half of form.
60
CMS 1500 Claim Form
Blocks:
5, 4, 9, 17, 31, 33 for entering names.
61
When entering professional names
no commas are needed:
First name
Middle initial
Last name
Credentials
62
Patient's name
example: commas are needed, last name first. see below.
Smith Jr, Ronald, B
63
CMS 1500 Claim Form
Block 5
Entering mailing address and phone
*Use only permanent address
on file w/ Ins Co
*Phone on file w/ Ins Co
*No dashes (except for 9-digit zip code) or other punctuation is allowed.
64
CMS 1500 Form
Block 7
When insured address is different than the beneficiary address.
For Worker's Comp the address of the Employer is reported here.
65
CMS 1500 Claim Form
Block 9 and 11:
Primary vs. Secondary Payers
Block 9: is for Secondary payer info
Block 11: is for Primary payer info
66
Medigap Example on Block 9
9. SAME (insured's name)
a. MGAP12345678
d. 5500 (plan name or program name)
67
Block 10: Responsible Payers
10. Is patient's condition related to:
a. employment
b. auto accident
c. other accident
d. Claim Codes (designated by NUCC)
68
Block 13
Insured's or authorized person's signature.
69
Block 14
Date of IID
and
QUAL: qualifier 431 or 484
Current IID injury, illness, disease
or
LMP: Last Menstrual Period.
431: is for Onset of IID
484: is for LMP (for OB Visits)
70
Block 15
Other Date
QUAL:
enter applicable qualifier:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last Xray
471 Prescription
090 Report Start (Assumed care date)
091 Report End (relinquished care date)
444 First Visit/Consultation
71
Block 16
Dates patient unable to work in current occupation.
DOI? maybe but it doesn't say that
72
Block 18
Hospitalization dates related to current s/p.
73
Block 17
Block 17: is for the referring provider.
17a:
Medicare: leave blank
OB State license number
1G Provider UPIN number
G2 Provider Commercial Number
LU Location Number (used for the Supervising Provider only)
17b:
NPI
74
Block 24 J:
A common reason for electronic claims rejection is for an invalid NPI.
J: Rendering Provider id #
On the shaded area of the block enter the non-NPI ID
On the non-shaded area enter the rendering provider's NPI.
75
Block 12
Assignment of Benefits
Patient's or Authorized person's signature.
Signature on file
76
Block 27 Accepting Assignment
check box.
Yes or No
has to do with honoring the fee schedule. this does not mean you cannot appeal payments.
DO NOT CONFUSE:
Assignment of Benefits w/
Accept Assignment.
77
Block 21: Diagnoses
Sequencing diagnoses guidelines must be followed.
Primary diagnosis goes in A.________
78
CMS 1500 Claim Form
*One of the most common reasons for denials is inaccurate coding.
*Cannot use "probable", "rule-out" etc.
*Signs and symptoms when definitive dx is unavailable.
*Must follow the documentation
*All dx codes must be reported w/ highest degree of specificity.
79
Block 24 Some Reminders
24. A.
*Dates of service
*When "from" and "to" dates are show for a series of identical s/p.. enter the number of days or units in column G.
it's a required item.
*The claim will NOT be processed if a DOS extends more than one day and a valid "to" date is not present.
80
Block 24 Reminders
24. B.
Place of service is required.
Place of service code can be found in the front of the CPT codebook.
POS are necessary to support validity of services and must track to the HCPCS level 11 / CPT chosen.
81
Block 24. C.
EMG: Emergency s/p
82
Block 24. D.
s/p/s: service, procedure, supplies
*Enter the s/p/s using CPT and HCPCS
*You can also enter up to four modifiers.
*DO NOT use hyphens.
*When using an unlisted code (e.g. 77499) a narrative description of the s/p/s should be included.
*If NO description is included, claim will be rejected.
83
Block 24. E.
Diagnosis Pointer
*Enter the diagnosis code reference letter (A -L) not a letter as in una carta.
*letter show in item 21 to relate the DOS and s/p/s to the primary diagnosis code.
*Most payers only allow one reference number per line item
*It there are two or more dx that support s/p/s enter reference number as follows:
When multiple s/p/s... enter primary reference letter from A-L for each service first. DO NOT use commas if reporting multiple dx reference letters for one service.
For Medicare: If there are two or more dx that support s/p/s, the provider references only one of the dx in item 21.
84
Block 24. F.
$ Charges
*Enter charge for each s/p/s
*From fee schedule and are the same for each payer.
*Typed w/ no extra characters and dollar and cents go into their proper sections.
85
CMS 1500 Claim Form
Block 25: National Standard Employer Identifier
25. Federal Tax I.D. Number
SSN EIN
SSN: Social Security Number
EIN: Employer Id Number
86
Block 33
Who gets the check.
The Biling Entity
87
Block 20: Outside Lab
*Outside lab reimbursement is equal to expense
88
Block 22 and 23: Medicaid
22. Resubmission Code
Check w/ payer to determine utilization of this field.
When resubmitting a claim, enter the appropriate bill frequency:
7 Replacement of prior claim
8 Void/Cancel of prior claim
This item number is not used for original claim submissions.
Medicare: leave blank. not required.
89
Block 23
Prior Authorization Number
*NOT all payers require prior authorization.
*Can also be used for referral number
*Mammogram pre-certification number
*CLIA number for Lab when a CLIA s/p performed
*For HCPCS G0181 or G0182, the NPI of the home health agency or hospice agency is entered here.
*Only one condition is reported in this field. If additional conditions are required, they are reported on additional CMS 1500 claim forms.
90
Page 92
Billing Tip
More information about the Accredited Standards Committee (ASC) X12 can be found at https://x12.org.
The HIPAA implementation guide requirements are purchased through the Washington Publishing Company (wpc-edi.com). Many clearinghouse companies have the implementation standards built into their editing systems.
91
Review 8.1
Facility charges are reported on which claim form?
Answer: C. UB-04 claim form
92
What does the acronym NUCC stand for?
Answer: D. National Uniform Claim Committee
93
What revisions does the CMS-1500 claim form undergo?
Answer: D. Multiple reviews prior to approval and implementation
94
Which transaction is NOT specified in the 5010 transaction standards?
Answer: D. Acknowledgement for Patient Payments
Rationale: The 5010 transaction standards include Claims (837 Institutional, Professional, Dental, COB [Professional and Institutional] and, NCPDP), Claims Status Inquiry/Response (276/277), Remittance (835), Enrollment (834), Premium Payment (820), Eligibility Inquiry/Response (270/271), Referrals and Prior Authorizations (278), Claims Acknowledgements (277CA), Acknowledgement for Healthcare Insurance (999).
95
What regulation requires claims to be sent electronically unless unusual circumstances are met?
Answer: A. Administrative Simplification Compliance Act (ASCA)
Rationale: It is important to understand that the Administrative Simplification Compliance Act (ASCA) requires that claims be sent electronically unless unusual circumstances are met.
96
I have this Question already but remember the changes from the paper CMS1500 to the electronic claim 837P columns.
1500 837P
Item / Title Loop ID
Segment,
Data Element
97
CMS 1500 Claim Form
For Tricare
*Enter the DoD Benefits Number DBN (11-digit number) it's found on the back of the card and it's aka Electronic Data Interchange-Personal Identification number EDI-PI.
98
CMS 1500 Claim Form
For BCBS enter the ID number
99
CMS 1500 Claim Form
Item 8
*Leave blank
*This field is for NUCC use
Item 9b
*Leave blank. Field is for NUCC use.
Item 9c
*Leave blank if Item 9d is completed
100
Item 9—Enter the last name, first name, and middle initial of the insured if the patient has a secondary insurance. This is completed if Item 11d is marked YES.
Medigap: Complete this information if the patient has a Medigap (Medicare supplemental insurance) policy and the insured’s name 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 or her benefits under a MEDIGAP policy to the participating physician or supplier.
101
Item 9a—Enter the policy and/or group number of the secondary insurance. (for example, Medigap policy number 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.
102
Item 9b— Leave blank. This field is reserved for NUCC use.
Item 9c— Leave blank if Item 9d is completed. This field is reserved for NUCC use.
Item 9d—Enter the other insured’s insurance plan or program name.
103
Medigap: Enter the 5-digit Coordination of Benefits Agreement (COBA) Medigap-based Identifier (ID).
9. SAME if name is spelled same as primary
9a. MGAP12345678
104
Items 10a through 10c—Check YES or NO to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the state postal code. Any item checked YES indicates there may be other insurance primary to the patient’s health insurance.
For example, if the encounter was to treat a patient’s injury while at work, workers’ compensation is the primary payer not the patient’s health insurance. Identify primary insurance information in item 11.
105
Item 10d—When applicable, use to report appropriate claim codes. Please refer to the most current instructions from the public or private payer regarding the need to report claim codes.
Claim codes can be entered in this item to identify additional information about the patient’s condition on the claim. Current claim codes include condition codes. Condition codes approved for use in this item can be found at: https://www.nucc.org/index.php/code-sets-mainmenu-41/condition-codes-mainmenu-38
106
MCD
the patient's Medicaid number
107
Item 11—This item contains the insured’s policy, group, or FECA number (9-character identifier assigned to a patient claiming work-related condition(s) under the Federal Employees Compensation Act 5 USC 8101) as it appears on the insured’s healthcare identification card. Do not use a hyphen or space as a separator within the policy or group number. If item 4 is completed, this item must also be completed.
Medicare: This item is required by Medicare. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is primary or secondary payer. If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to items 11a–11c. This is determined by having the patient complete the Medicare Secondary Questionnaire. Items 4, 6, and 7 must also be completed.
108
FECA
Federal Employees Compensation Act
109
Billing Tip
Medicare provides a list of questions to ask beneficiaries during the registration process to determine if Medicare is the secondary payer. This can be found in the Medicare Secondary Payer (MSP) Manual, Chapter 3, Section 20.2.1—Admission Questions to Ask Medicare Beneficiaries.
110
Item 11a—Enter the insured’s 8-digit birth date (MM|DD|CCYY) and sex. If the gender is unknown, leave it blank.
Item 11b—Enter a qualifier (for example, Y4 Property Casualty Claim Number) followed by the identifier number.
111
11b
For Medicare, enter employer’s name. If there is a change in the insured’s insurance status (for example, retired), enter either a 6-digit (MM|DD|YY) or 8-digit (MM|DD|CCYY) retirement date preceded by the word RETIRED. This information should be entered to the right of the vertical dotted line.
112
Item 11c—Enter the name of the insurance plan or program of the insured.
Some insurers require an identification number of the primary insurer rather than the name in this field.
113
11c
Medicare: Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s explanation of benefits (EOB) does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in item 11.
114
Item 11d—This is marked to indicate if the patient has secondary insurance. If this item is marked, items 9, 9a, and 9d must also be completed.
Medicare: Leave blank. It is not required.
BILLING TIP
If the patient has a primary and secondary insurance, the secondary insurer will not pay the claim until the primary insurance has decided. For Medicare, if the patient has a secondary insurance on file, Medicare will cross the claim over to the secondary payer once Medicare has made a payment determination (paid or denied). For payers that do not cross claims over, once the EOB is received from the primary insurance apply the payment or denial and submit a claim and copy of the primary insurance EOB to the secondary payer for consideration.
115
Item 12—The patient or authorized representative must sign and enter either a 6-digit date (MM|DD|YY), 8-digit date (MM|DD|CCYY), or an alpha-numeric date (for example, January 1, 2016) unless the signature is on file. In lieu of signing the claim form, the patient may sign a statement to be retained by the provider, physician, or supplier. This form is signed by the patient when completing new patient paperwork or updating paperwork.
NOTE: This can be Signature on File, SOF, or a computer-generated signature. A date is only entered when a legal signature is used.
116
The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.
By accepting assignment, the provider or facility agrees to the payer’s fee schedule.
117
Item 13—The patient’s signature or the statement Signature on File, or SOF 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.
Item 14—Enter either an 8-digit (MM|DD|CCYY) or 6-digit (MM|DD|YY) date of current illness, injury, or pregnancy (LMP).
Enter the applicable qualifier to the right of the vertical dotted line to identify which date is being reported. Qualifiers include:
431 Onset of Current Symptoms or Illness
484 Last Menstrual Period
118
Medicare: Medicare does not
use the qualifier information. Do not enter a qualifier for Medicare claims.
119
Billing Tip
Medicare commonly rejects claims for an invalid future date within the Onset, Acute Manifestation, Initial Treatment, Accident, or Last Menstrual Period date fields.
120
Item 15—Enter another date related to the patient’s condition or treatment in either an 8-digit (MM|DD|CCYY) or a 6-digit (MM|DD|YY) format. Check with your payers to determine if this item needs to be completed.
For Medicare: Leave blank. This item is NOT required..
121
Item 15
Enter the applicable qualifier to identify which date is being reported:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-ray
471Prescription
090 Report Start (Assumed Care Date)
091Report End (Relinquished Care Date)
444 First Visit or Consultation
122
Page 95
BILLING TIP
Medicare commonly rejects claims for?
*Invalid future date within the Onset, *Acute Manifestation,
*Initial Treatment,
*Accident, or
*Last Menstrual Period date fields.
123
Item 15—
Enter another date related to the patient’s condition or treatment.
Check with your payers to determine if this item needs to be completed.
also, enter applicable qualifier from Q above card 121 (see qualifiers)
For Medicare:
Leave blank. This item is not required.
124
Item 16
Patient unable to work due to injury, enter DOI. If it's work injury claim goes to Worker's Comp.
125
Item 17
*Referring or Ordering Physician.
First Name, Middle Initial, Last Name, followed by credentials.
Do NOT use commas or periods.
Hyphen allowed for hyphenated name.
126
Item 17
In addition to the information above, the supervising physician can also be reported in this field.
Medicare: All physicians who order services or refer Medicare beneficiaries must report this data. When more than one provider is involved, use a separate CMS-1500 claim form for each referring, ordering, or supervising physician.
When multiple providers are involved...
Enter one provider using the following priority order:
1.Referring Provider (Qualifier DN)
2.Ordering Provider (Qualifier DK)
3.Supervising Provider (Qualifier DQ)
Enter the applicable qualifier to the left of the vertical dotted line.
127
Item 17a—Enter the Other ID number of the referring, ordering, or supervising provider.
For Medicare: Leave blank.
Enter the qualifier to indicate what number is being reported:
0B State License Number
1G Provider UPIN Number
G2 Provider Commercial Number
LU Location Number (used for the supervising provider only)
128
Item 17b—
Enter the National Provider Identifier (NPI)
Item 18—
*Date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
129
Item 19—
Payers have different uses for this item.
For example, enter the drug’s name and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs. NOC means the code is unspecified and the code alone will not adequately report the drug administered. The drug administered needs to be identified for the payer to determine proper reimbursement.
In addition, report Qualifier to describe the identifier.
Qualifiers are found in the NUCC claim form manual and include Work Comp qualifiers for the report type and transmission type.
When modifier 99 (multiple modifiers) is entered in item 24d, enter all applicable modifiers. 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.
130
BILLING TIP
Item 19 allows for supplemental claim information. Sometimes, an attachment containing the supplemental information is required.
For example, when an unlisted procedure code is reported, the operative note may be required for the carrier to process the claim. Claims requiring attachments, that are submitted electronically, require paperwork (PWK) information in loop 2300 or 2400:
Segment Electronic Description
PWK01 Report Type Code
PWK02 Transmission Code
(BM = By mail, EL = Electronic only)
PWK05 Identification code qualifier = AC
PWK06 Identification code
(Attachment control number)
Medicare carriers have specific coversheets to fax information using the control number to match the claim attachment to the electronic claim. Attachments for Medicare claims must be sent to the carrier within 7 days; otherwise, the claim will be processed without it.
131
Item 20—Complete this item when billing for purchased services by entering an X in YES (for example, diagnostic tests subject to the anti-markup payment limitation).
This is not used in an ASC. When YES is marked, charges are entered to the left of the vertical line, justified right. See the example below for $25.00 charge.
20. Outside Lab?
Yes or No $ Charges
132
Item 21—Enter the ICD-9-CM or ICD-10-CM codes for the patient’s diagnosis/condition.
Enter the codes without decimals in the proper coding sequence. The applicable ICD indicator is entered to identify which version of ICD codes are being reported:
In the box it says: ICD ind
9 is used for ICD-9-CM
0 is used for ICD-10-CM
Do NOT insert a period.
example E11.9 becomes E119
133
BILLING TIP
ICD-10-CM became effective October 1, 2015. Some payers may still accept ICD-9-CM codes (such as workers’ compensation).
You should never use both ICD-9-CM and ICD-10-CM on the same claim form.
134
Item 22—Enter the original reference number for resubmitted claims. Check with the payer to determine utilization of this field. When resubmitting a claim, enter the appropriate bill frequency:
7 Replacement of prior claim
8 Void/cancel of prior claim
This item number is not used for original claim submissions.
Medicare: Leave blank. Not required.
135
Item 23—The prior authorization number is entered here. Not all payers require a prior authorization. This item can also be used to report the referral number, mammography pre-certification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer.
The 10-digit CLIA number can also be entered in this field when a CLIA covered procedure is performed. For providers reporting HCPCS codes G0181 or G0182, the NPI of the home health agency or hospice agency is entered here. Only one condition is reported in this field. Additional conditions are reported on a separate CMS-1500 claim form.
136
Item 24—
The six service lines in section 24 have been divided horizontally to accommodate submission of supplemental information to support the billed service.
The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.
137
Item 24A
Date of s/p/s when "From" and "To" dates are shown for a series of identical services.
Enter the number of days or units in column G.
The claim will not be processed if a date of service extends more than 1 day and a valid “To” date is not present.
138
Item 24B—Enter the appropriate place of service code(s). Place of service codes can be found in the front of the CPT® code book. Place of service codes are necessary to support validity of services.
For example, if E/M code 99285 (Level 5 emergency department visit) is billed with POS 11 (Office), this might trigger an edit. Emergency Department E/M codes can only be reported with POS 23 (Emergency Room-Hospital).
139
Item 24C—
Not all payers require this item.
For Medicaid, E is entered for an emergency. Other payers may require a Y for Yes or an N for No to indicate if the service was an emergency.
Medicare providers are not required to complete this item.
140
E/M is
Evaluation and Management.
141
Item 24D
*Enter p/s/s using CPT and HCPCS.
*DO NOT use hyphens.
*For unlisted codes; a narrative description should be included.
*If no description included it will cause rejection.
*When more than 4 modifiers are required for a line item, enter modifier 99 here and list of modifiers in Item 19.
142
Item 24E—
Enter the diagnosis code reference letter as shown in item 21 to relate the date of service and the procedures performed to the diagnosis.
If there are two or more diagnoses that support a procedure code enter the reference letter for the primary diagnosis that supports the procedure first, then enter the other diagnosis codes as applicable. When multiple services are performed, enter the primary reference letter from A-L for each service first. Do not use commas if reporting multiple diagnosis reference letters for one service.
Medicare: Only the letter reference to the primary diagnosis is entered in Item 24E for Medicare patients. Only one reference letter is accepted per line item.
143
Item 24F—
Enter the charge for each listed service.
144
Item 24G—
*Enter the number of days or units.
*This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume.
*If only one service is performed, the numeral 1 must be entered.
*For anesthesia services based on time, the number of minutes must be reported as the units.
145
Item 24H—
This item is used by Medicaid and reports services related to Early & Periodic Screening, Diagnosis, and Treatment (EPSDT). If there is no requirement (for example, state requirements) to report a reason code, enter Y for Yes and N for No
*If there is a state requirement, enter the two-character code for the reason. If there is a state requirement, refer to the NUCC Claims Manual for valid codes.
Medicare: Leave blank. Not required.
146
Item 24I—
Enter the qualifier identifying if the number is a non-NPI.
The qualifier identifies what type of number is used in 24J.
Medicare: Leave blank. Not required.
147
Item 24J—Enter the non-NPI number in the shaded area of the field and enter the rendering provider’s NPI number in the unshaded portion.
A common reason for electronic claims rejection is for an invalid NPI. Verify all NPI numbers are correct when entering them into the practice management system.
148
EXAMPLE
A provider removes 30 skin tags (11200, 11201 x 2) on a patient at his office on January 1, 20XX.
In this example:
24A -The procedure was performed on January 1, 20XX. Date of service 01 01 XX is entered in 24A.
24B -The procedure was performed at the office. Place of Service code 11 is entered in 24B.
24C -Left blank for most payers.
24D -The procedure codes reported are 11200 and 11201 with no modifiers. Enter 11200 in line 1 and 11201 in line 2 for 24D (procedure 11201 is reported twice, this will be reported by adding 2 units to this line item in 24G).
24E -The diagnosis pointer is A. This refers to the ICD-10-CM code that is entered in Item 21A.
24F -The fee for 11200 is $150.00. The fee for two units of 11201 is $100.00. These amounts are entered in item 24F on the line item with the respective CPT® code.
24G -Days or Units. There is one unit of 11200 reported and two units of 11201 reported. 1 is reported in 24G for line item 1 and 2 is reported in 24G for line item 2.
24H -Left blank. This item is used for Medicaid EPSDT.
24I -Left blank. This item is used to report a non-NPI qualifier ID.
24J -The NPI of the provider is entered in the nonshaded portion.
149
BILLING TIP
Two of the top 10 reasons for electronic claims rejections by Medicare are for an invalid HCPCS Level II or CPT® code, or modifier for the date of service. The code sets are updated each year. Codes within a practice management system should be updated annually.
Item 25—Enter the Federal Tax ID number (Employer Identification Number or Social Security Number) of the provider of service or supplier and check the appropriate check box. This number is usually in the billing system and is not manually entered. A common reason for an electronic batch of claims to be rejected is when the Tax ID is not associated with the billing provider’s NPI.
Item 26—Enter the patient’s account number assigned by the provider of service’s or supplier’s accounting system. This item is optional to assist the provider in patient identification. Any account numbers entered here will be returned to the provider by the payer, so the patient can quickly be identified. Do not enter hyphens in this field. This field is typically auto populated by the practice management system.
Item 27—Check the appropriate block to indicate whether the provider of service or supplier accepts assignment. Accepting assignment means the provider agrees to the allowed amount (negotiated rate) for the charge.
150
BILLING TIP
When a provider accepts assignment, the difference between the charged amount and the allowed amount will be a contractual write-off for the provider.
Medicare requires the following types of providers to accept assignment:
*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
*Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine
151
Item 28—Enter total charges for the services (for example, total of all charges in item 24f).
Do not enter a dollar sign. Dollars are entered to the left of the vertical line (justified right) and cents are entered to the right of the vertical line.
152
Item 29—Enter the total amount the patient and/or other payers paid on the covered services only.
If the patient paid the copayment, enter the amount here.
153
Item 30—Leave blank.
This field is reserved for NUCC use.
154
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 (for example, January 1, 2014) the form was signed.
This can be completed as Signature on File, SOF, or a computer-generated signature. This field does not exist in the electronic version.
155
Item 32—Enter the address where the services were provided
if different from the billing provider’s address.
156
Item 32a—If required by the payer,
enter the facility’s NPI.
157
Item 32b—Enter the qualifier identifying the non-NPI number followed by the ID number.
Medicare: Leave blank.
158
Item 33—Enter the provider of service/supplier’s billing name, address, 9-digit ZIP code (without the hyphen), and telephone number. This is a required item.
The 5010A1 electronic version requires the billing provider address to be a physical address. This cannot be a P.O. box number. A P.O. box number in this field will cause the claim to be rejected.
159
Item 33b—Enter the qualifier identifying the non-NPI number followed by the ID number.
Qualifiers for use in the 5010A1 version are:
0B State License Number
159
Item 33a—
Enter the NPI of the billing provider or group.
160
G2
Provider Commercial Number
161
PXC Provider Taxonomy for electronic claims
(ZZ is the Provider Taxonomy qualifier for paper claims)
162
Medicare: This field is generally left blank;
however, you may be required by some carriers to complete this field. If the payer requires this field, follow the carrier’s instructions.
163
For instruction on the proper completion of the CMS-1500 claim form for Medicare, see Medicare Claims Processing Manual Chapter 26 at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf
164
Section Review 8.2 Page 98
When two or more diagnoses codes reported in item 21 support a procedure, how many diagnosis codes should the provider report in item 24E for Medicare claims?
Answer: A. 1
Rationale: According to the Medicare Claim Processing Manual - Item 24E – This is a required field. Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number/letter per line item. CMS states that when multiple services are performed, enter the primary reference number/letter for each service only.
165
When a provider “accepts assignment”, what happens to the difference between the charged amount and the allowed amount?
Answer: D. It is considered a contractual write off
Rationale: Accepting assignment means that the provider agrees to accept the payer’s contracted amount. The provider must write off the difference between the charged amount and the contracted amount as a contractual write off.
166
3.What is the appropriate POS code to report services rendered in an urgent care facility?
Answer: D. 20
Rationale: POS code 20 is reported when services are provided in an Urgent Care Facility. POS code 23 for services provided in an Emergency Room of a Hospital, POS code 24 for Ambulatory Surgical Center services, and POS code 17 for services rendered in Walk-in Retail Health Clinic. Place of Service codes can be found in the front of the CPT® code book.
167
5. Prior authorization is reported in Item 23.
What other information can be reported in this area of the CMS-1500 claim form?
Answer: B. Mammography pre-certification number
Rationale: Not all payers require a prior authorization. Item 23 can also be used to report the referral number, mammography pre-certification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer.
168
Page 99
Video Lectures: Outpatient Facility Billing
UB-04 (CMS1450)
169
The UB04 is submitted for IN &OP hospital, CAHs, and CORFs.
The electronic version of the UB04 is the 837I
170
FL are the fields in the UB form
FL means Form Locator
171
Format on the electronic differences are...
Fields are now Loops
Date format is also different.
172
UB04 Claim Form
FL 1
Billing Provider into.
173
UB04 Claim Form
FL 3B
Medical/Health Record Number assigned by the facility.
174
UB04 Claim Form
FL 4 TOB
Type Of Bill
Bill Type Code
013X: Hospital Outpatient
018X: Hospital Swing Bed
072X: Clinical ESRD
073X: Federally Qualified Health Center
074X: Clinic OPT
075X: Clinic CORF
083X: Hospital Outpatient ASC
085X: Critical Access Hospital
175
UB04 Claim Form
FL 8 - 11
are for Patient Information
Patient info
176
UB04 Claim Form
FL 12 -
Admission Date
177
UB04 Claim Form
FLs 18-28
Condition Codes (in numerical order)
178
UB04 Claim Form
FL 42 and 44 - Coding
*Facility enters revenue codes
to identify accommodation and/or ancillary charges.
On FL42 enter appropriate numeric revenue code on the adjacent line in FL42 to explain each charge in FL47.
Additionally, there is no fixed "total" line in the charge area. The provider must enter revenue code 0001 instead in FL42. Thus, the adjacent charges entry in FL47 is the sum of charges billed.
179
UB04 Claim Form
FL 46
Units of service
180
UB04 Claim Form
FL 47
Total Charges.
Provider sums total for FL42
The last 0001 represents the total sum of all charges billed.
181
UB04 Claim Form
FL48
Non covered charges pertaining to FL42 are entered here.
182
UB04 Claim Form
FL Form Locator
FL50
Payer Identification
If Medicare is primary enter on line "A"
183
UB04 Claim Form
Is used for OP at Hospitals
FL 67
Principal Diagnosis Code
184
FLs 67a - 67Q
Other diagnosis codes
185
FL 69
Admitting Diagnosis.
186
CMS 1450 Data Sheet saved on my Downloads
It's a very long list of information.
187
Page 99
The UB04
Is the X12 837 Institutional Claim
aka
Electronic 837I
188
UB04
Code Structure
2nd Digit-Type of Facility (CMS will process this as the 1st digit)
188
UB04
Code Structure
3rd Digit-Bill Classification (Except Clinics and Special Facilities) (CMS will process this as the 2nd digit)
189
UB04
Code Structure
3rd Digit-Classification (Clinics Only) (CMS will process this as the 2nd digit)
190
UB04
Code Structure
3rd Digit-Classification (Special Facilities Only) (CMS will process this as the 2nd digit)
191
UB04
Code Structure
4th Digit-Frequency—Definition (CMS will process this as the 3rd digit)
192
Bill Type Codes reported by outpatient facilities:
Bill Type Code
013X Hospital Outpatient
018X Hospital Swing Bed
072X Clinic ESRD
073X Clinic—Freestanding
074X Clinic OPT
075X Clinic CORF
083X Hospital Outpatient (ASC)
085X Critical Access Hospital
193
FL 6
FL = Form Locator on UB04
Electronic version of UB04 is 837I
The facility enters the beginning and ending dated of the period on this bill in numeric format.
193
FL 5
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Federal Tax Number.
This information is stored in the billing system and is not keyed for every claim.
194
FL 7
FL = Form Locator on UB04
Electronic version of UB04 is 837I
This FL is not used.
195
FL 8
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Patient's Id
196
FL 9
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Patient's address
197
FL 10
FL = Form Locator on UB04
Electronic version of UB04 is 837I
DOB
198
FL 11
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Patient's Sex
199
FL 12
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Admission/Start of Care date.
Required for
*inpatient
*home health
*hospice
*outpatient rehab
200
FL 13
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Admission Hour. This is NOT required.
201
FL 14
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Priority (type) of Admission or Visit.
Example: Emergency
202
FL 15
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Point of Origin for Admission.
Example FL indicates an emergency.
203
Fl16 - Discharge Hour.
FL = Form Locator on UB04
Electronic version of UB04 is 837I
This is not required.
204
FL 17 - Patient Discharge status.
FL = Form Locator on UB04
Electronic version of UB04 is 837I
This code indicates the patient's discharge status as of the through date of the billing period. (FL6)
205
FLs 18-28 - Condition codes.
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Codes (in ascending order, beginning with numbers followed by letters) to describe any conditions that apply to the billing.
Example: Coded 44 (inpatient services). but upon review the Claim does not meet its inpatient criteria. Submit as OP.
206
FL 29
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Accident State. This FL is not used.
207
FL 30
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Untitled. This FL is not used.
208
FLs 31, 32 33, 34
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Occurrence Codes and Dates.
*Enter code and associated dates, define specific events.
*Event codes are two alpha-numeric
**Numbered codes are entered before alpha code in the following order.
*31A-34A followed by 31B-34B.
*Codes 01-04 and 24 must include value code in FLs 39-41, if there is another payer involved.
209
FLs 35 and 36
FL = Form Locator on UB04
Electronic version of UB04 is 837I
Occurrence Span Code and Dates. This is for inpatient only. Do not complete for outpatient claims.
210
FL 37—(Untitled). This FL is not used.
FL = Form Locator on UB04
Electronic version of UB04 is 837I
FL 38—Responsible Party Name and Address. This FL is not used.
211
FLs 39, 40, and 41—
Value Codes and Amounts.
FL = Form Locator on UB04
Electronic version of UB04 is 837I
*Code(s) and related dollar or unit amount(s) identify data of a monetary nature that are necessary for the processing of the claim.
*The codes are two alpha-numeric digits, and each value allows up to nine numeric digits (0000000.00).
*Negative amounts are not allowed except in FL 41.
*If more than value code must be in ascending order.
There are four lines of data, line A through line D. The provider uses FLs 39A through 41A before 39B through 41B (for example, it uses the first line before the second). For example, 50 is for physical therapy visits.
212
Hoy conecto con la Inteligencia DCS dentro de mi.
Tengo capacidad fotografica para aprender y recordar sin importar mi edad fisica.
213
Negative amounts are not allowed except in FL 41.
If more than one value code is shown for a billing period, codes are shown in ascending numeric sequence. There are four lines of data, line A through line D. The provider uses FLs 39A through 41A before 39B through 41B (for example, it uses the first line before the second). For example, 50 is for physical therapy visits.
214
FL 42—Revenue Code. The facility enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges.
*It must enter the appropriate numeric revenue code on the adjacent line in FL 42 to explain each charge in FL 47.
*Additionally, there is no fixed Total Line in the charge area. The facility must enter revenue code 0001 instead in FL 42. Thus, the adjacent charges entry in FL 47 is the sum of charges billed. This is the same line on which non-covered charges, in FL 48, if any, are summed.
*To assist in bill review, the facility must list revenue codes in ascending numeric sequence and not repeat on the same bill to the extent possible.
*To limit the number of line items on each bill, it should sum revenue codes at the “zero” level to the extent possible. An example of a revenue code is 0450 for emergency department.
215
FL 43—
FL= Form Locator
UB04
Electronic version 837I
*Revenue Description/IDE Number/Medicaid Drug Rebate.
*This is not a required FL.
*The facility can use this form locator to enter a narrative description or standard abbreviation for each revenue code shown in FL 42 on the adjacent line in FL 43.
216
FL44 HCPCS/Rates HIPPS Rate Code
FL= Form Locator
UB04 for Hospital OP Claims
Electronic version 837I
*For outpatient claims, enter the CPT® and HCPCS Level II codes.
*The UB-04 accommodates up to four modifiers, two characters each.
*Medicare has identified invalid information within the HCPCS field as one of the top 10 claims submission errors.
217
FL 45 Service Date
FL= Form Locator
UB04 Hospital OP Claims
Electronic Version is 837I
*This is a required FL for outpatient services.
*Community Mental Health Centers (CMHC) and hospitals (with the exception of CAHs, Indian Health Service hospitals, and hospitals located in American Samoa, Guam, and Saipan) report line-item dates of service on all bills containing revenue codes, procedure codes or drug codes.
*This includes claims where the “from” and “through” dates are equal. This change is due to a HIPAA requirement.
*There must be a single line-item date of service (LIDOS) for every iteration of every revenue code on all outpatient bills (TOBs 013X, 014X, 023X, 024X, 032X, 033X, 034X, 071X, 072X, 073X, 074X, 075X, 076X, 077X, 081X, 082X, 083X, and 085X and on inpatient Part B bills (TOBs 012X and 022X). If a service is rendered 5 times during the billing period, the revenue code and HCPCS code must be entered 5 times, once for each service date.
218
LIDOS
Line-Item Date of Service
219
TOBs
Type of Bills
220
FL 46 Units of Service
FL= Form Locator
UB04 for Hospital OP Claims
837I Electronic Version of UB04
*The entries in this column quantify services by revenue code category
*(for example, number of days in a particular type of accommodation, pints of blood).
*When reporting the procedure codes, the units indicate the number of times the procedure was performed.
221
FL 47 - Total Charges.
FL= Form Locator
UB04 Hospital OP Claims
Electronic Version 837I
*This is the FL in which the provider sums the total charges for the billing period for each revenue code (FL 42);
*or, if the services require, in addition to the revenue center code, a CPT® or HCPCS Level II procedure code, where the provider sums the total charges for the billing period for each procedure code.
*The last revenue code entered in FL 42 is “0001” which represents the grand total of all charges billed.
*The amount for this code, as for all others is entered in FL 47. Each line for FL 47 allows up to nine numeric digits (0000000.00).
222
FL 48—Non-covered Charges.
FL= Form Locator
UB04 Hospital OP Claims
EV is 837I
*The total non-covered charges pertaining to the related revenue code in FL 42 are entered here.
223
Yo puedo...
Mi POF
procedencia origen fuente
Es la misma del AB
Q resplandece como una
exhibicion impresionante
de la inteligencia superabundante.
224
FL 49—(Untitled). This FL is not used.
FL = Form Locator
UB04 Hospital OP Claims
EV is 837I
Note: the “PAGE ____ OF ____” and CREATION DATE on line 23 should be reported on all pages of the UB-04.
225
FL 50A, B, and C—n
FL = Form Locator
UB04 is for Hospital OP Claims
The EV is 837I
Payer Identification
*If Medicare is the primary payer, the provider must enter Medicare on line A.
*All additional entries across line A (FLs 51-55) supply information needed by the payer named in FL 50A.
*If Medicare is the secondary or tertiary payer, the provider identifies the primary payer on line A and enters Medicare information on line B or C as appropriate.
226
FL 51A, B, and C—
FL= Form Locator
UB04 is for Hospital OP
The EV is 837I
Health Plan ID. Report the NPI.
227
FLs 52A, B, and C—
FL = Form Locator
UB04 is for Hospital OP
EV if 837I
*Release of Information Certification Indicator.
*A Y code indicates that the provider has on file a signed statement permitting it to release data to other organizations to adjudicate the claim.
*Required when state or federal laws do not supersede the HIPAA privacy rule by requiring that a signature be collected.
*An I code indicates informed consent to release medical information for conditions or diagnoses regulated by federal statutes. Required when the provider has not collected a signature and state or federal laws do not supersede the HIPAA privacy rule by requiring a signature be collected.
228
FL 53A, B, and C—
FL = Form Locator
UB04 is for the Hospital OP
EV is 838I
Assignment of Benefits Certification Indicator. These FLs are not used.
229
FLs 54A, B, and C—
FL = Form Locator
UB04 Hospital OP
EV is 837I
Prior Payments. Situational. For all services other than inpatient hospital or SNF the provider must enter the sum of any amounts collected from the patient towards deductibles (cash and blood) and/or coinsurance on the patient (fourth/last line) of this column.
230
FL 55A, B, and C—
FL = Form Locator
UB04 Hospital OP
EV 838I
Estimated Amount Due from Patient. This is not required.
231
FL 56—Billing Provider National Provider ID (NPI).
*Each provider and facility is required to have an NPI.
*Two of the top 10 reasons Medicare rejects institutional electronic claims is due to the billing provider NPI not being associated with the billing provider’s Tax ID or for the billing provider’s NPI being invalid.
232
FL 57—
FL = Form Locator
UB04 Hospital OP Claims
EV is 838I
Other Provider ID (primary, secondary, and/or tertiary). This FL is not used.
233
FLs 58A, B, and C—Insured’s Name.
FL = Form Locator
UB04 Hospital OP Claims
EV is 838I
*The name of the insured is entered here.
*This information is obtained from the patient’s insurance card.
*The name on the claim must match the beneficiary’s name on the Medicare ID card identically. Incomplete or invalid completion of this field is one of the top 10 claim submission errors identified by Medicare.
234
FL 59A, B, and C—Patient’s Relationship to Insured.
FL = Form Locator
UB04 Hospital OP Claims
EV is 838i
Patient’s Relationship to Insured. This is represented by a two-character code for each payer in A-C. This is completed to communicate to the payer the relationship between the insured and the patient. This information is obtained from the patient during registration.
235
FLs 60A, B, and C—Insured’s Unique ID Number
FL = Form Locator
UB04 is for Hospital OP
EV is 838i
(Certificate/Social Security Number/Medicare beneficiary identifier). This is the policy ID assigned by the payer. This information is on the patient’s insurance card.
236
FL 61A, B, and C—Insurance Group Name.
FL = Form Locator
Where the provider is claiming payment under the circumstances described in FLs 58A, B, or C and a Workers’ Compensation (WC) or an Employer Group Health Plan (EGHP) is involved, it enters the name of the group or plan through which that insurance is provided.
237
FL 62A, B, and C—Insurance Group Number.
Where the provider is claiming payment under the circumstances described in FLs 58A, B, or C and a WC or an EGHP is involved, it enters the identification number, control number or code assigned by that health insurance carrier to identify the group under which the insured individual is covered.
238
FL 63A, B, and C—Treatment Authorization Code.
Required when an authorization or referral number is assigned by the payer. Whenever quality improvement organization (QIO) review is performed for outpatient preadmission, pre-procedure, or home intravenous (IV) therapy services, the authorization number is required for all approved admissions or services.
239
FL 64A, B, and C—Document Control Number (DCN).
The control number assigned to the original bill by the health plan or the health plan’s fiscal agent as part of their internal control.
240
FL 65A, B, and C—Employer Name (of the Insured).
Where the provider is claiming payment under the circumstances described in the second paragraph of FLs 58A, B, or C and there is WC involvement or an EGHP, it enters the name of the employer that provides healthcare coverage for the individual identified on the same line in FL 58.
241
FL 66—Diagnosis and Procedure Code Qualifier (ICD Version Indicator).
The qualifier that denotes the version of International Classification of Diseases (ICD) reported. The following qualifier codes reflect the edition portion of the ICD: 9—Ninth Revision, 0—Tenth Revision.
242
FL 67—Principal Diagnosis Code.
FL = Form Locator
UB04 is for Hospital OP Claims
EV is 837i
*The hospital enters the ICD-10-CM (or ICD-9-CM if the payer does not accept ICD-10-CM) code for the principal diagnosis, which is the main reason for the encounter.
243
FLs 67A-67Q—Other Diagnosis Codes.
FL is Form Locator
UB04 is for Hospital OP Claims
EV is 838i
Report as many ICD-10-CM codes as necessary to report the diagnoses of the patient.
244
FL 68—Reserved.
This FL is not used.
245
FL 69—Admitting Diagnosis.
This is required for inpatient claims.
246
FL70A–70C—
FL is Form Locator
UB04 is for Hospital OP Claims
EV is 838i
*Patient’s Reason for Visit.
*This FL is required for Medicare institutional claims processing on Type of Bill 013x and 085x when; a) Form Locator 14 (priority (Type) of Admission or Visit) codes 1, 2, or 5 are reported; and b) Revenue Codes 045x, 0516, or 0762 are reported.
*The requirement for reporting Patient’s Reason for Visit is restricted to the outpatient bill types above.
*If the Patient’s Reason for Visit is not required, it may be reported on other 013x and 085x bill types that fail to meet the criteria in a) or b) above at the sender’s discretion when this information substantiates the medical necessity of services
The ICD-10-CM codes to identify the reason for the patient’s visit are entered here.
247
FL72—External Cause of Injury (ECI) Codes.
*Usually this FL is not used unless the payer requires external cause codes, which identify the external cause of an injury (for example, fall or car accident).
248
FL 73—Reserved.
This FL is not used.
249
FL 74A–74E—Other Procedure Codes and Dates.
FL is Form Locator
UB04 is for Hospital OP Claims
EV is 838i
Required on inpatient claims when additional procedures must be reported. Not used on outpatient claims.
250
FL 75—Reserved.
This FL is not used.
251
FL 76—Attending Provider Name and Identifiers (including NPI).
FL is Form Locator
UB04 is for Hospital OP Claims
EV is 837i
*Required when claim/encounter contains any services other than nonscheduled transportation services.
*If not required, do not send. The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment reported for the encounter. A common reason for Medicare rejecting an electronic claim is for invalid or missing information in the attending physician field.
252
Secondary Identifier Qualifiers:
0B—State License Number
1G—Provider UPIN Number
G2—Provider Commercial Number
253
FL 77—Operating Provider Name and Identifiers (including NPI).
*Required when a surgical procedure code is listed on the claim. If not required, do not send.
*The name and identification number of the individual with the primary responsibility for performing the surgical procedure(s) is listed here.
254
Secondary Identifier Qualifiers:
0B—State License Number
1G—Provider UPIN Number
G2—Provider Commercial Number
255
FLs 78 and 79—Other Provider Name and Identifiers (including NPI).
The name and ID number of the individual corresponding to the qualifier category indicated in this section of the claim.
256
Provider Type Qualifier Codes/Definition/Situational Usage Notes:
DN—Referring Provider. The provider who sends the patient to another provider for services. Required on an outpatient claim when the referring provider is different than the attending physician. If not required by the payer, do not send.
257
Provider Type Qualifier Codes/Definition/Situational Usage Notes:
ZZ—Other Operating Physician. An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved. If not required by the payer, do not send.
258
Secondary Identifier Qualifiers:
0B—State License Number
1G—Provider UPIN Number
G2—Provider Commercial Number
259
FL 80—Remarks.
FL is Form Locator
UB04 is for Hospital OP Claims
EV is 837i
Where Medicare is not the primary payer because WC, automobile medical, no-fault, liability insurer or an EGHP is primary, the provider enters special annotations. In addition, the provider enters any remarks needed to provide information that is not shown elsewhere on the bill but is necessary for proper payment.
260
FL 81—Code-Code FL. Used to report additional codes related to a FL or to report external code list approved by the NUBC for inclusion to the institutional data set.
FL = Form Locator
UB04 is for Hospital OP Claims
EV = 837i
For complete instructions for proper UB-04 completion see Medicare Claims Processing Manual chapter 25. For private payers, review the instructions provided in manuals or online resources. See the individual payer website for instructions.
261
Section Review 8.3
What does the abbreviation FL refer to?
Form Locator
262
What is the type of bill code that is reported for a free-standing clinic?
Answer: A. 073X
Rationale: A free-standing outpatient clinic would report services with type of bill code 073X
263
Where can the guidelines for proper completion of claim forms be found?
B. Private payer website and policy manual
C. Medicare Claims Processing Manual
264
When reporting procedure codes on the UB-04 claim form, what is FL46- Units of Service?
Answer: B. Indicates the number of times the procedure was performed.
FL 46—Units of Service
265
A patient is admitted to the hospital with pneumonia. Which FL would be used to report the patient’s admitting diagnosis?
Answer: D. FL 69
266
Adjudication
Insurer's payment
267
Claim Form
To report procedure and reason for procedure.
268
Edit
A tool used in the electronic claims that checks and evaluates claims data rcvd against payer's criteria.
269
EDI
Electronic Data Interchange:
computer to computer communication
270
Ordering Provider
Physician, FNP, PA etc.
271
Referring Provider
The one who requests service.
272
Supervising Provider
provides oversight.
273
Important Links:
Fact Sheet for Medicare Billing: 837I and Form CMS-1450
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/837I-FormCMS-1450-ICN006926.pdf
274
Fact Sheet for Medicare Billing: 837P and Form CMS-1500
https://www.cms.gov/Outreach-and-Education/MLN/WBT/MLN4462429-MLN-WBT-1500/1500/index.html
275
Medicare Claims Processing Manual
https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms018912.html
276
