Understanding Hospital Billing and Coding Chapter 10

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Review: Claim Forms

The CMS-1450 (UB-04) is a summary of the hospital visit and charges incurred. Where is information required to complete the claim form pulled from?

The patient's account and the hospital data file

Patient diagnosis information is reported in which of the following sections on the CMS-1500 claim form?

Blocks 14 to 23

Health Care Common Procedure Coding System (HCPCS) Level I and II codes describing hospital outpatient services are reported on the CMS-1450 (UB-04) in what form locator (FL)?

FL 44

Which section of the CMS-1450 (UB-04) is used to provide information about charges submitted on the claim form?

FL 42-49

The definitions included in the Uniform Hospital Discharge Data Set (UHDDS) can be used to determine which codes should be reported. Item 12 of UHDDS states that all significant procedures are to be reported and defines a significant procedure as one that:

requires specialized training.

Two methods of claim form submission are manual and electronic transmission, which are transmitted through:

electronic data interchange (EDI).

In accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations, standard formats for electronic transactions have been adopted. The adopted standard formats were developed by the American National Standards Institute (ANSI). The standard transaction format for the CMS-1450 (UB-04) is:

Version 5010

Examples of significant procedures include:

infusions

The process by which a claim form is scanned and data on the claim are transferred into a computer system.

Optical scanning

A form completed by providers for the purpose of submitting charges for medical services and supplies to various third-party payers such as insurance companies and government programs.

Insurance claim form

The admitting diagnosis code describes the condition, sign, symptom, illness, injury, disease, or other reason why the patient was admitted and it is entered in this field.

FL 69

The difference between CMS-1500 and CMS-1450 (UB-04) is that CMS-1500 is used to submit charges for physician and outpatient services. How many fields does this form contain and what is the field called?

33 blocks

The principal and other diagnosis code(s) and present on admission (POA) indicator are reported in which FLs on the CMS-1450 (UB-04)?

FL 67 A-Q

What type of procedure code is recorded in FL 74 a-e on a claim for date of service October 1, 2013?

ICD-9-CM Volume III

Which of the following procedures is a significant procedure?

Surgery

Disadvantages of this claim submission method are that claims can be lost and there is no tracking.

Electronic health record transfer

The insurance company that is responsible to pay the claim, after the primary and secondary payers have issued a payment determination.

tertiary payer

T/F The purpose of claim forms is to submit charges for medical services and supplies to various third-party payers for reimbursement.

True

T/F The CMS-1450 (UB-04) is used to submit facility charges for ambulatory surgery and inpatient services.

True

T/F Third-party reimbursement for medical services and/or supplies is determined on the basis of information reported on the claim form.

True

T/F Hospitals use the CMS-1500 to report professional and inpatient services.

False

T/F HCPCS codes are reported in FL 42 and ICD-9-CM Volume III codes are reported in FL 74 a-e.

True

The standard unique health identifier for health care providers, to use in filing and processing health care claims and other transactions, is called _____________ __________________________.

National Provider Identifier (NPI)

T/F The purpose of a claim form is to submit charges to a patient.

False: The claim form is used to submit charges to payers for reimbursement.

T/F Manual claim submission is more efficient than electronic claim submission.

False: Electronic claim submission is more efficient.

T/F CMS-1500 is used to submit non-institutional charges to a payer for reimbursement.

True

T/F The CMS-1450 (UB-04) has 33 fields.

False: The CMS-1450 (UB-04) has 81 fields.

T/F Claim form completion instructions vary by payer.

True

The _________ ______ ________ _________ _________ ______ ________ coding system is used to record services, procedures, and items in FL 44.

Health Care Common Procedure Coding System (HCPCS)

A patient's written permission for the payer to send payment to the provider is called the
_______________._______________._______________..

assignment of benefits

The condition determined after study is the __________________ diagnosis.

principle

Item 12 of UHDDS states that all __________________ _______________ are to be reported in FL 74 a-e and defines a significant procedure as one that is surgical in nature, or carries a procedural risk, or carries an anesthetic
risk, or requires special training.

significant procedures

The procedure performed for definitive treatment of the principal diagnosis is called the_____________ procedure

principal

The __________________ claim form is utilized by institutional providers to submit hospital facility charges for services, procedures, and items to payers for reimbursement.

CMS-1450 (UB-04)

The ____________ acronym represents the coding system used today to report patient conditions and significant procedures.

ICD-9-CM

In accordance with HIPAA provisions, the _________ _______________ coding system will replace the ICD-9-CM coding system effective_________________.

ICD-10-CM, OCTOBER 1, 2014.

Inpatient claims require the reporting of a __________ ____ ___________ ____ indicator for principal and other conditions.

Present on admission (POA)

The CMS-1450 (UB-04) contains 81 fields referred to as _______________.

form locators (FL)

The field used to record four-digit codes used to categorize services, procedures, and items.

FL 42

The field used to record the principal procedure.

FL 74

The field used to report the standard abbreviated description of revenue codes.

FL 43

The fields used to report he principal and other diagnoses.

FL 67 (A-Q)

The field used to record the HCPCS Level I and HCPCS Level II Medicare National code.

FL 44

The _______ ______is reported in FL 42 on the CMS-1450 (UB-04) to describe the category of services as defined by the National Uniform Billing Committee (NUBC).

four-digit, service

The admitting diagnosis code describes the condition, sign, symptom, illness, injury, disease, or other reason why the patient was admitted and it is entered in this field.

FL 69

The insurance company that is responsible to pay the claim, after the primary and secondary payers have issued a payment determination.

tertiary payer

The standard unique health identifier for health care providers, to use in filing and processing health care claims and other transactions, is called _____________ __________________________.

National Provider Identifier (NPI)

Hospitals are not required to bill Medicare for __________ inpatient services if the service is performed during a _______________inpatient stay.

noncovered, covered

Blocks 24A to 24J on this claim form are used to record charge information regarding the date of service, type of service, place of service, procedure code, days or units, and charges.

CMS-1500

Disadvantages of this claim submission method are that claims can be lost and there is no tracking.

Electronic health record transfer

The CMS-1450 (UB-04) is a summary of the hospital visit and charges incurred. Where is information required to complete the claim form pulled from?

The patient's account and the hospital data file

The difference between CMS-1500 and CMS-1450 (UB-04) is that CMS-1500 is used to submit charges for physician and outpatient services. How many fields does this form contain and what is the field called?

33 blocks

The process by which a claim form is scanned and data on the claim are transferred into a computer system.

Optical scanning

A written authorization from a patient for the payer to forward benefits for services directly to the provider.

Assignment of benefits

The provider who is responsible for the patient's care during the inpatient hospital stay.

Attending physician

An organization that reformats claim data received from providers to meet compatibility
specifications for submission to various payers.

Clearinghouse

Claim form used by institutionalproviders to submit hospital facility charges for services, procedures, and items to payers for reimbursement.

CMS-1450 (UB-04)

Claim form used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement.

CMS-1500

The process of sending data from one computer to another by telephone line or cable.

Electronic data interchange (EDI)

A claim that is transmitted through electronic data interchange (EDI).

Electronic media claim (EMC)

Form locator (FL)

A term used to describe each data field
on the CMS-1450 (UB-04).

Insurance claim form

A form completed by providers for the purpose of submitting charges for medical services and supplies to various third-party payers such as insurance companies and government programs.

Medical record number (MRN)

A number assigned to a patient's medical record by the facility (hospital). The medical record number is also referred to as the health
record number (HRN).

National Provider Identifier (NPI)

The standard unique health identifier for health care providers required
for filing and processing health care claims and other transactions. The NPI is issued through the National Provider System (NPS) that was developed by CMS.

National Uniform Billing Committee (NUBC)

A committee formed by the American Hospital Association in 1975 to develop a single billing form and a standard data set that could be used nationally by institutional providers. Today, the role of the NUBC is to maintain the integrity of the CMS-1450 (UB-04) data set.

North American Industry Classification System (NAICS) code

The unique code assigned to each business within the United States. The NAICS code classifies the business, and it is used for statistical purposes by various agencies in the United States.

Optical scanning

A process whereby the claim form is scanned and data on the claim are transferred into a computer system.

Paper claim

A claim that is typed or computer generated on paper and sent by mail.

Patient control number (PCN)

A unique number assigned by the hospital to identify the patient account for the claim.

Provider

An individual or entity, such as a doctor or hospital, that provides medical services and/or supplies to patients.

Reimbursement

The payment received from a third-party payer for services rendered to patients by the provider.

Revenue code

A four-digit numeric code developed and maintained by the National Uniform Billing Committee (NUBC) to categorize like services and items.

State Uniform Billing Committees (SUBC)

Committees that are responsible for the oversight of state-specific
CMS-1450 (UB-04) billing requirements.

Tax identification number (TIN)

A number assigned to the facility by the Internal Revenue Service for tax reporting purposes. TIN is also referred to as the employer
identification number (EIN).

Tertiary payer

Refers to the insurance company that is responsible to pay the claim, after the primary and secondary payers have issued a payment determination.

Timely filing

Refers to the period of time that claims have to be filed within, such as 90 days. Timely filing is generally calculated from the date of service.

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