CMS 1500 - 24 A shaded field importance

DATE(S) OF SERVICE:

Dates: In the bottom, white half of the claim line, enter the begin (“From”) and end (“To”) dates of service in MM DD YY format. If a service was provided on one day only, enter the same date twice.

Physician Administered Drugs: Beginning January 1, 2008, an NDC is required in this field to bill for physician administered drugs.

In the top, shaded half of the claim line, enter qualifier N4 followed by the drug’s 11-digit NDC without any dashes, hyphens or other punctuation. The first, second and third sections of the NDC (separated by hyphens on the container label) must contain 5, 4 and 2 digits, respectively, when entered on the claim form.

To facilitate this, you must add leading zeros to one or more sections of the NDC if the container label does not display:

· 5 digits in the first section of the NDC

· 4 digits in the second section of the NDC

· 2 digits in the third section of the NDC

All point about Signature on File filed box 12 on CMS 1500

Signature-on-File Requirements

When a TRICARE beneficiary has signed a Release of Information statement, you should indicate “signature on file” in Box 12 of the CMS-1500. A new signature is required every year for professional claims submitted on a CMS-1500 and for every admission for claims submitted on a UB-04.

If the beneficiary is under age 18, the parent or legal guardian should sign the claim. However, a beneficiary under the age of 18 may sign the claim form if the beneficiary is (or was) the spouse of an active duty service member (ADSM) or retiree, or if the services are related to venereal disease, drug or alcohol abuse, or abortion

  

In situations when a beneficiary is mentally incompetent or physically incapable, the person signing should either be the legal guardian or, in the absence of a legal guardian, a spouse or parent of the beneficiary. See the Important Provider Information section of this handbook

for more information about the release of patient information.

If the beneficiary is deceased, and you do not have a valid signature-on-file agreement, you

must submit one of the following: 

•  A claim form signed by the legal representative of the estate.

•  Documentation accompanying the claim form to show the person signing is the legally appointed representative.

•  If no legal representative has been appointed, the parent, spouse, or next of kin may sign the claim form. The signer must provide a statement that no legal representative has been appointed. The statement should contain the date of the beneficiary’s death and the signer’s relationship to the beneficiary.

Rules of DX code in CMS 1500

ICD-9-CM Codes

Physicians and Non-Physician Practitioners (NPP) must use the appropriate
diagnosis code or codes to identify symptoms, conditions, problems, complaints
or other reasons for the encounter or visit.

Claims will be returned as unprocessable when the ICD-9-CM code is invalid.

Rules for Reporting Diagnosis Codes

*Use the ICD-9-CM code that describes the patient’s diagnosis, symptom,
     complaint, condition or problem. Do not code a suspected diagnosis.

* Use the ICD-9-CM code that is chiefly responsible for the item or service
   provided.


* Assign codes to the highest level of specificity. Use the fourth and fifth digits
   where applicable.

* Code a chronic condition as often as applicable to the patient’s treatment. Code
    all documented conditions that coexist at the time of the visit that require or affect

  patient care or treatment. Do not code conditions that no longer exist.
ICD-9-CM Codes and Date of Service

what is complete claims?

Complete claims

For proper payment and application of deductibles and coinsurance, it is important to accurately code all diagnoses and services (according to national coding guidelines). It is particularly important to accurately code because a member’s level of coverage under his or her benefit plan may vary for different services. You must submit a claim for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member at the time of service.

To assist you in understanding how your claims will be paid, UnitedHealthcare’s Claim Estimator includes a feature called Professional Claim Bundling Logic which helps you determine allowable bundling logic and other claims processing edits for a variety of CPT (CPT is a registered trademark of the American Medical Association) and HCPCS procedure codes. Note: Only bundling logic and other claims processing edits are available under this option.

Pricing and payment calculations are not included.

Different way of electronic claim submission EDI

How Does It Work?

Providers have several alternatives for entering and electronically submitting claims data:

• Providers may work through a software vendor who can provide the level of practice management system support they need for their practice.

• Providers may submit their Medicare Part B claims directly to TrailBlazer Health Enterprises® or choose to submit claims through a clearinghouse.

Providers may choose to have a billing agent handle all or part of their Medicare billing.

• If the provider’s office has the required hardware, it may choose to use Medicare’s free billing software.

Welcome to the exciting world of electronic billing! If a provider is new to the concept of electronic claims submission or has never used a computer, the following tips and hints may make the transition to a computerized billing system easier.

• When buying or leasing a system, deal with a knowledgeable, established vendor. Avoid the temptation to base a buying decision solely on price. Ask for references from current users of the systems considered and check them. Providers should try to find another provider in their specialty that is using that particular software or someone who has billing practices similar to their office.

• A dedicated phone line is recommended; this will eliminate interrupted transmissions.

• Regularly make backups of all patient and claim data. Disaster-recovery procedures suggest two backup files be kept – one on-site and one off-site. Keep backups in a safe and protected place. In the event of fire or system problems, a current backup will enable a provider to reconstruct his office’s records.

Electronic claim submission basic overview

INTRODUCTION TO ELECTRONIC DATA INTERCHANGE (EDI)

EDI is the process of transacting business electronically. It includes submitting claims electronically, or “paperless” claims processing, as well as electronic remittance, Electronic Funds Transfer (EFT) and electronic inquiry for claim status and patient eligibility.

What Are the Benefits of EDI?

The benefits of EDI are as follows:

• Medicare Part B claims process faster and providers are reimbursed sooner, improving their cash flow. Payment for electronic claims may be released after 13 days; payment for paper claims can be released after 29 days.

• Mailing and administrative costs are significantly reduced.

• Because of GPNet editing, fewer claims are returned with development letters, saving staff time and effort (refer to the GPNet Edits Manual on Medicare’s Web site at http://www.trailblazerhealth.com/Publications/Training%20Manual/GPNetEditManual.pdf in the “EDI Publication” section for a list of GPNet edits).

Guidance Regarding NDC’s on the CMS-1500 Form

Guidance Regarding NDC’s on the CMS-1500 Form

Effective August 2008, Alabama Medicaid mandated that the National Drug Code (NDC) number be included on the CMS-1500 claim form for the Top 20 physician administered drugs as defined by CMS. Alabama Medicaid would like to clarify the required format for the NDC number that is submitted on this claim form. Medicaid requires that each submitted NDC contain 11-digits (no dashes or spaces). The first 5-digits identify the labeler code of the manufacturer of the drug. The next 4-digits identify the specific strength, dosage form, and formulation of that drug. The last 2- digits identify the package size of the drug.

There may be some instances when an NDC does not contain all eleven digits on the product’s container.

Rules of DX code in CMS 1500

DIAGNOSIS OVERVIEW

ICD-9-CM Codes

Physicians and Non-Physician Practitioners (NPP) must use the appropriate
diagnosis code or codes to identify symptoms, conditions, problems, complaints
or other reasons for the encounter or visit.

Claims will be returned as unprocessable when the ICD-9-CM code is invalid.

Rules for Reporting Diagnosis Codes

*Use the ICD-9-CM code that describes the patient’s diagnosis, symptom,
     complaint, condition or problem. Do not code a suspected diagnosis.

* Use the ICD-9-CM code that is chiefly responsible for the item or service
   provided.


* Assign codes to the highest level of specificity. Use the fourth and fifth digits
   where applicable.

* Code a chronic condition as often as applicable to the patient’s treatment. Code
    all documented conditions that coexist at the time of the visit that require or affect

  patient care or treatment. Do not code conditions that no longer exist.
ICD-9-CM Codes and Date of Service

The ICD-9-CM codes must be coded to the highest level of specificity for the date of  service, i.e., coding to the fourth or fifth digit. This is a requirement for all physician and NPP claims.

Diagnosis codes must be reported based on the date of service on the claim and not the date the claim is prepared or received.

Updated ICD-9-CM codes are effective each October 1.