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Billing > Chapter 8: Claim Forms > Flashcards

Chapter 8: Claim Forms Flashcards

1
Q

Item 14 Qualifier is used to indicate what information?

A

Date of Current illness, Injury, or Pregnancy (LMP).
DO NOT enter a qualifier for MC claims

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2
Q

What is the appropriate POS code to report services rendered in an UC Facility?

A

POS 20

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3
Q

When 2 or more DX Codes reported in item 21 to support a procedure, how many DX Codes should the provider report in item 24E for Medicare claims?

A

1 – Per the Medicare Claims Processing Manual, 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.

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4
Q

What does the abbreviation FL refer to?

A

Form Locator on the UB-04 claim form

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5
Q

When reporting procedure codes on the UB-04 claim form, what is FL46-Units of Service?

A

Indicated the number of times the procedure was performed

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6
Q

When a provider “accepts assignment”, what happens to the difference between the charged amount and the allowed amount?

A

It is considered a contractual write-off

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7
Q

Where can the guidelines for proper completion of claim forms be found?

A

Private payers website or Medicare Claims Processing Manual

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8
Q

A patient is admitted to the hospital for pneumonia. Which FL would be used to repair the patients admitting diagnosis?

A

FL69 - Admitting Diagnosis
* required for inpatient claims

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9
Q

What regulation requires claims to be sent electronically unless unusual circumstances are met?

A

Administration Simplification Compliance Act (ASCA)

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10
Q

Facility charges are reported on which claim form?

A

UB-04

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11
Q

Who can use the CMS 1500 claim form?

A

its for professional services performed by providers and ASCs

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12
Q

What is Adjudication?

A

it is used to describe the process of determining the validity of a claim and the amount the insurer will pay on the claim after the members insurance benefits have been applied.

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13
Q

What does NUCC stand for?

A

National Uniform Claim Committee

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14
Q

What revisions does the CMS-1500 claim undergo?

A
  1. Multiple reviews
  2. Updates approved by NUCC
  3. Submitted to CMS for approval
  4. Awaits public comment through CMS & Office of Management and Budget
  5. Final approval & implementation
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15
Q

What transactions are specified in the 5010 Electronic Transaction Standards?

A

Transaction Standards include:
(837) Claims: institutional, professional, dental, COB, & NCPDP
(276/277) Claims status inquiry/requests
(835) remittance
(834) Enrollment
(820) Premium payment
(270/271) Eligibility inquiry/response
(278) Referrals and PA
(277CA) Claims Acknowledgements
(999) Acknowledgment for Health Insurance

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16
Q

For reporting multiple providers on the CMS-1500 form, what is the priority order and the qualifier?

A
  1. Referring Provider (Qualifier DN)
  2. Ordering Provider (Qualifier DK)
  3. Supervising Provider (Qualifier DQ)
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17
Q

What is the type of bill code that is reported for a free-standing clinic?

A

073X

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18
Q

What is the type of bill code that is reported for a OPT Clinic?

A

074X

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19
Q

What is the type of bill code that is reported for a CORF Clinic?

A

075X

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20
Q

What is the type of bill code that is reported for a Hospital Outpatient (ASC)?

A

083X

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21
Q

What is the type of bill code that is reported for a Critical Access Hospital?

A

085X

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22
Q

What is the type of bill code that is reported for a Hospital Outpatient?

A

013X

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23
Q

What is the type of bill code that is reported for a Hospital Swing Bed?

A

018X

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24
Q

What is the type of bill code that is reported for an ESRD Clinic?

A

072X

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25
Q

What is an Ordering Provider?

A

Physician or non-physician practitioner who orders non-physician services for the patient (DK)

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26
Q

What is a Supervising Provider?

A

The provider who provided oversight of the rendering provider and the care being reported. (DQ)

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27
Q

What is a Attending Provider?

A

The provider with overall responsibility for the patients medical care during hospitalization

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28
Q

What is a Referring Provider?

A

The provider who requests an item or service for the beneficiary. (DN)

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29
Q

The patient is a child covered under the fathers insurance policy. Which item on the CMS-1500 form is the father DOB listed?

A

11a - 8 digit DOB

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30
Q

Item 10 on the CMs-1500 form has 3 boxes to be completed that will provide liability information. What are the?

A

If they are related to:
Employment
Auto accident
other Accident

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31
Q

what is the correct format to enter the DOB on a PAPER CMS 1500 form? ELECTRONIC?

A

PAPER - MM/DD/CCYY
ELECTRONIC - CCYYMMDD

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32
Q

What is the specific EDI version for healthcare professionals and suppliers to transmit claims electronically?

A

ANSI ASC X12N 837P

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33
Q

What is the current version of the HIPPA electronic transaction standards for healthcare professionals and suppliers?

A

Version 5010A1

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34
Q

What are some exceptions that allow a paper claim to be filed to Medicare?

A
  1. roster billing for inoculations
  2. Medicare demonstration project that specifies paper submission
  3. “Obligated to accept payment in full” (OTAF)
  4. MSP - more than one primary payer
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35
Q

In ANSI ASC X12N 837P, what does ANSI stand for?

A

ANSI - American National Standards institute

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36
Q

In ANSI ASC X12N 837P, what does ASC stand for?

A

ASC - Accredited Standards Committee

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37
Q

In ANSI ASC X12N 837P, what does X12N stand for?

A

X12N - Insurance section of ASC X12

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38
Q

In ANSI ASC X12N 837P, what does 837P stand form?

A

837 - Standard format for transmitting healthcare claims electronically
P - Professional version of the 837 electronic format

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39
Q

If a patient has insurance primary to Medicare, which items must be completed in addition to Item 11?

A

items 4, 6, 7 and 11a-11c

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40
Q

How are the procedural charges on a UB-04 claim form sequenced?

A

by revenue code in ascending numerical order and not repeat.

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41
Q

What does the facility enter appropriately to identify specific accommodation and/or ancillary charges and in which box?

A

Revenue codes in FL 42 to explain each charge in FL 47.
*The last revenue code in FL 42 is 0001 = represents the grand total of all charges billed

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42
Q

To limit the number of line items on each bill, what should you do in FL42?

A

sum revenue codes at the “zero” level to the extent possible

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43
Q

Item 24D on the CMS 1500 claim form is used to report procedures, services, or supplies. How many modifiers can be added to item 24D?

A

4

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44
Q

For patients who have Medicare primary and secondary insurance, how is the secondary insurance filed?

A

IF it’s a cross over insurance, Medicare will cross the claim over to the secondary payer

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45
Q

When an item is checked yes in boxes 10a -10c, what does this mean?

A

the claim may be covered by workers comp, auto insurance, or liability insurance

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46
Q

What is the process of applying the members insurance benefits to determine the insurers payment responsibility to a medical claim?

A

Adjudication

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47
Q

The assignment of benefits is confirmed if a patient signs which item?

A

item 13 - “signature on file” or “SOF” = authorizes payment of medical benefits to the physician or supplier

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48
Q

What is the purpose of the standard CMS1500 claim form?

A

bill professional services for physicians.

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49
Q

What item on the CMS 1500 claim form contains information regarding Medigap?

A

items 9, 9a, 9d
Item 9 = enter SAME is subscriber is pt or sub information
item 9a = policy/group number of secondary insurance preceded by MEDIGAP, MG, or MGAP)
item 9d = 9 digit payer id

50
Q

When completing the CMS 1500 form, date(s) of service are found in item 24; a series of identical services were performed, and the claim was denied. What is the reason for the denial?

A

the DOS “from” and “to” dont match the number of units. each day =1 unit

51
Q

In item 4 of the CMS 1500 form, what is entered on a Medicare claim when the patient has an insurance primary to Medicare and the patient is the insured?

A

SAME

52
Q

Line 24B is for place of service. Where can the place of service codes be found?

A

Front of CPT book

53
Q

FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span codes and dates. When is this section completed?

A

Only for inpatient services. DO NOT complete on outpatient claims

54
Q

When entering the patients name on the CMS 1500 form, what punctuation should be used?

A

Commas: last name, first name, middle initial

55
Q

On the CMS 1500 claim form, which item number identifies the prior authorization or referral number?

A

Item 23 - can also place CLIA # here.

56
Q

Who can electronic claims be submitted to?

A

provider directly to the payer or to a clearing house

57
Q

How many digits should be entered in the DOB fields (items 3, 9b, and 11a)?

A

8-digit dates

58
Q

How many digits should be entered in the non DOB date fields? (items 11b, 12, 14, 16, 18, 19, 24a and 31)

A

either 6 or 8-digit dates — they must ALL be 6 digits or ALL be 8 digits
Items 12 & 31 are exempt from the requirement

59
Q

What is an item on the electronic format of CMS1500?

A

Loop = Item

60
Q

What goes in Item 5 on the CMS 1500?

A

Patients address
-NO punctuation
-permanent address not temporary (ex: at college)

61
Q

What goes in Item 7 on the CMS 1500?

A

Insureds address
- SAME if pt is subscriber
- workers comp = employer address

62
Q

The following goes in which box on the CMS 1500 form?
Claim codes
- claim codes to identify additional information about the patients condition
- condition codes approved for use in this box: abortion, sterilization, and workers comp

A

Item 10d on the CMS 1500 form

63
Q

What item number does the policy group or FECA number go in?

A

Item 11 – if item 4 is completed, you MUST include a group or FECA number

64
Q

For work related injures, where of you enter the dates the patient is unable to work on a CMS 1500 form?

A

Item 16

65
Q

What goes in item 17 on a CMS 1500 form? Item 17ab?

A

referring (DN), ordering provider (DK), or supervising physician (DQ)
IF the service or item was ordered or referred by a physician
17ab = NPI

66
Q

On Item 17 of the CMS 1500 form, what order do you enter the providers in when you have multiple providers involved?

A
  1. Referring provider (DN)
  2. Ordering provider (DK)
  3. Supervising provider (DQ)
67
Q

On the CMS 1500 form, where can you enter additional claim information?

A

Item 19
-NOC drugs
- more than 4 modifiers on a line (mod 99 on the line item)
- PWK = paperwork

68
Q

On the CMS 1500 form, where would you check off “yes” to indicate billing for purchased services?

A

Item 20: outside lab

69
Q

What item number does the patient diagnosis/condition go in?

A

Item 21
- no decimals
-proper sequence
- ICD indicator

70
Q

In what item number do you use to enter resubmission codes when resubmitting claims?

A

Item 22 - enter resubmission code and original reference/claim #

71
Q

what goes in Item 23 on CMS 1500 form?

A

Authorization #, CLIA

72
Q

What goes in Item 24, 24b, 24c, 24e, 24g, and 24h on the CMS 1500?

A

Item 24 - contains 6 service lines
Item 24b - Place of Service
Item 24c - EMG: E for emergency (medicaid); not all payers require. other payers Y or N
Item 24e - DX Pointer (dx code assignment)
Item 24g - Days/units
Item 24h - EPSDT Family Planning (Medicaid: Y or N)

73
Q

What is another name for the UB-04 claim form used to report facility services?

A

CMS 1450

74
Q

On the UB-04 form, where do you enter Billing Provider name, address and phone number? Billing providers pay to name, and address?

A

FL 1
FL2 - optional; billing providers pay to name and address

75
Q

On the UB-04 form, what goes in FL 3a and FL 3b?

A

FL 3a = patient control number (financial records)
FL 3b = MRN (assigned by the facility)

76
Q

What is a four digit alphanumeric code that gives three specific pieces of information after a leading Zero? Where does it go?
CMS ignores the leading Zero.

A

FL4 - Type of Bill

77
Q

What is the Code Structure for when selecting the type of bill?

A

1st - zero (ignored by CMS)
2nd - type of facility (1st to CMS)
3rd - classification (clinics only)(2nd to CMS)
4th - frequency - definition (3rd to CMS)

78
Q

On the UB-04 form, where does the Federal Tax number go?

A

FL5

79
Q

Where can you find the period the statement covers on a UB-04 form?

A

FL 6

80
Q

On the UB-04 form, where does the patient name, ID #, address, DOB and sex go?

A

FL 8 - pt name and ID #
FL 9 - patient address
FL 10 - DOB
FL 11 sex

81
Q

On the UB-04 form, FL 12 - Admission/start of care date is required for what?

A

Inpatient, HH, Hospice and outpatient rehab/facility

82
Q

On the UB-04 form, which FL are not used?

A

FL 7, 29, 30, 37, 38, 49
FL 52abc, 57, 68,71, 75, - not used

83
Q

On the UB-04, which FL are not required?

A

FL13 - Admission hour
FL16 - Discharge hour
FL 55abc

84
Q

On the UB-04 form, where does a provider enter the code indicating the source for the referral for the admission or visit?

A

FL15 point of origin for admission or visit
(ex: ER before pt was referred to transferred to inpatient)

85
Q

On the UB-04 form, where do you enter the Priority type of admission and patient discharge status (2)?

A

FL 14 - priority type
FL 17 - patient discharge status

86
Q

On the UB-04 form, where does the provider enter the corresponding code to describe any conditions or events that apply to the billing period?

A

FL 18-28 Condition codes
entered in ascending order; beginning with # then letters

87
Q

On the UB-04 form, what goes in FL 31, 32, 33, and 34?

A

Occurrence codes and dates.
codes and dates defining specific events related to the billing period
code =2 alphanumeric digits
dates = 6 digits

88
Q

On the UB-04 form, when occurrence code 04 accident employment related is entered, what does that indicate and where must you include a value code?

A

04 indicates a workers comp claim
include value code in FL 39-41 = another payer involved

89
Q

Which FLs are required for inpatient claims only?

A

FL35 and 36 - occurrence SPAN code and dates
** not the same as FL 31-34 occurrence codes and dates
FL 69 - admitting dx
FL 74 - Principal procedure code and date
FL 74A-E - when other procedure codes and dates must be reported

90
Q

On the UB-04 form, where are value codes and amounts entered?

A

FL 39, 40, 41
codes related to money or unit amounts

91
Q

On the UB-04 form, where is the revenue code and revenue description entered?

A

FL 42 - revenue code
FL 43 revenue discription/medicaid drug rebate

92
Q

On the UB-04 form, where do you enter the following?
1. HCPCS/Rates/ HIPPS Rate Codes
2. Service Date
3. Units
4. Total Charges
5. Non covered charges

A
  1. FL 44
  2. FL 45
  3. FL 46
  4. FL 47
  5. FL 48
93
Q

On the UB-04 form, where is the following entered?
1. payer ID
2. health plan ID

A
  1. FL50abc
  2. FL51abc
94
Q

On the UB-04 form, where do you enter the following?
1. release of information indicator
2. prior payments
3. billing provider NPI

A
  1. FL52abc
  2. Fl 54abc
  3. Fl 56
95
Q

On the UB-04 form, where is the following entered?
1.Insureds name
2. relationship to insured
3. Member ID #
4. Group name
5. group #

A
  1. FL 58abc - Insureds name
  2. FL 59abc - relationship to insured
    3.FL 60abc - Member ID #
  3. FL 61abc - Group name
  4. FL 62abc - group #
96
Q

On the UB-04 form, where can you find the Authorization code?

A

FL 63abc

97
Q

On the UB-04 form, where can you find the DCN placed by the payer?

A

FL64abc

98
Q

On the UB-04 form, where do you enter the ICD indicator?

A

FL 66

99
Q

On the UB-04 form, where do you enter the Attending Provider name and NPI when claim/encounter contains any services other than non scheduled transportation services?

A

FL76

100
Q

On the UB-04 form, which 3 Secondary Identifier Qualifiers are used in FL 77, FL 78, & FL 79?

A

0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number

FL77 - Operating Provider Number and ID (Required: surgical procedure code is on Claim)

FL 78 & 79 - Other Provider Name and ID

101
Q

On the UB-04 form, 3 Secondary Identifier Qualifiers are used on which FLs?

A

FL 77 - operating provider ID (required for Surgical Codes)
FL 78 & 79 - Other Provider Name and ID
FL 80 - Remarks ( MC is secondary due to WC, liability or EGHP)
FL81 - Code-Code FL. (additional codes)

102
Q

When billing on CMS 1500, Item 14, what do the qualifiers 431 & 484 represent?

A

Qualifiers :
431: Onset of Current Sx or Illness
484: LMP

103
Q

When billing on CMS 1500, Item 14 or 15, Which qualifier is used to identify the dates of the Initial Treatment?

A

454 - Initial Treatment

104
Q

When billing on CMS 1500, Item 14 or 15, What does the qualifier 439 represent?

A

439 - Accident

105
Q

When billing on CMS 1500, Item 14 or 15, What do the qualifiers 455 and 471 represent?

A

455 - Last X-ray
471 - Prescription

106
Q

When billing on CMS 1500, Item 14 or 15, Which qualifiers are used to represent the Start Date (Assumed Care) and the Report End (Relinquished Care)?

A

090 - Start Date (Assumed Care)
091 - Report End (Relinquished Care)

107
Q

When billing on CMS 1500, Item 14 or 15, What qualifier is used to represent the date of the First Visit or Consultation? Latest Visit or Consultation?

A

444 - First Visit or Consultation
304 - Latest visit or consultation

108
Q

When billing on CMS 1500, Item 14 or 15, What qualifier is used to represent the date of Acute Manifestation of a Chronic Condition?

A

453 - Acute manifestation of a chronic condition

109
Q

On the CMS 1500 and UB-04 Claim Forms, what does the qualifier 0B identify?

A

0B = State License Number

110
Q

On the CMS 1500 and UB-04 Claim Forms, what does the qualifier 1G identify?

A

1G = Provider UPIN Number

111
Q

On the CMS 1500 and UB-04 Claim Forms, what does the qualifier G2 identify?

A

G2 = Provider Commercial Number

112
Q

On the CMS 1500 and UB-04 Claim Forms, which provider can the qualifier LU: Location Number ONLY be used for?

A

Supervising Provider

113
Q

What are Condition Codes used for on the UB-04 claim form?

A

Used to indicate an inpatient service is reported on an outpatient claim. ( numerical order)
ex: code 44 - inpatient services order but upon review services did not meet inpatient criteria and claim submitted as outpatient

114
Q

FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span codes and dates. When is this section completed?

A

Only for Inpatient Services

115
Q

On the UB-04 claim form, FL 10 is used to record the patient’s birthdate. If the birthdate is unknown, what information is entered?

A

eight zeros

116
Q

Which form locator(s) on the UB-04 claim form reports the main reason for the encounter?

A

FL 67 - principal dx code

117
Q

When is Item 7 completed?

A

only when Item 4 is completed. (subscriber is not pt)

118
Q

On the UB-04 claim form, what is entered in FL 50A when Medicare is determined to be the primary payer?

A

Medicare
FL50A-C - payer identification

119
Q

If a patient has insurance primary to Medicare, which Items must be completed in addition to Item 11?

A

Items 4, 6, 7, and 11a-11c

120
Q

In Item 4 of the CMS-1500 claim form, what is entered on a Medicare claim when the patient has an insurance primary to Medicare and the patient is the insured?

A

SAME

Billing (14 decks)

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