UHB Chapter 10

Understand Hospital Billing and Coding
Principal Procedure
The procedure performed for definitive treatment of the principal diagnosis, or the procedure that is most closely related to the principal diagnosis is the:
Attending physician information is recorded in FL 50-66 on the CMS-1450(UB-04).
Insured Unique Identifier
What number is assigned by the insurance company or government program to identify the individual who is covered under the plan and reported in FL 60 on the CMS-1450(UB-04)?
Carry high procedural or anesthetic risk
Significant procedures are those that:
Procedure code information is recorded on the CMS-1450(UB-04) Section 1, FL 1 and 5.
Reimbursement is determined based on the information reported on the claim form.
What is the relationship between the claim form and reimbursement?
External cause of the injury or illness
Identify what E codes are used to describe
Direct transmission and through a clearinghouse.
Two ways that the electronic claims process can be accomplished are:
The CMS-1500 is used to submit facility charges to a payer for reimbursement.
Section 1 FL 8 (B), 9 (A-E)
What section and fields on the CMS-1450(UB-04) are used to record the patient name and address?
An insurance claim form is used by providers to submit charges for medical services and supplies to various third-party payers
Value Codes
Two-digit alphanumeric codes are recorded n FL 39-41 on the CMS-1450(UB-04) are called:
Computer templates are used to define all the information required on the claim for the payer, and specific payer edits may also be programmed on templates.
FL 81 of the CMS 1450(UB-04) to report additional condition or occurrence codes describing more information.
FL 67-86 on the CMS-1450(UB-04) are used to record diagnosis codes that describe te admitting diagnosis, principal and other diagnosis, external cause of injury(of the condition for which the patient is admitted), and the principal and other procedures.
Treatment authorization code
A payer provides an authorization number that is reported on the claim when services are authorized. The number is recorded on the CMS-1450(UB-04) in FL 63 and is called a(n):
The coding systems used in FL 44 are HCPCS Level 11 National codes, and ICD-9-CM Volume 111.
The purpose of a claim form is to submit charges to a patient.
Claim form completion instructions vary by the payer.
The need for various versions of software or a clearinghouse to submit a claim.
Disadvantages of electronic claim submission include:
FL 42-49
Charge capture data are gathered during the patient visit and used to print a detailed itemized statement and to complete which form locators on the claim form?
Optical scanning replaces te process of having to input data manually from the claim form into a computer system.
Scanning has improved claim processing in the following ways:
Manual claim submission is more efficient than electronic claim submission.
FL 8-41 on the CMS-1450(UB-04) is used to record information regarding the facility, when the patient was admitted and discharged, the patient's name and address, as well as other information regarding the patient visit.
Optical Scanning
The term used to describe the process in which a claim form is scanned and data on the claim are transferred into a computerized system.
A claim form used to submit charges for inpatient services.
The term used to describe the payment received for rendering services and supplies to a patient.
An individual or entity that provides medical services and supplies to patients.
Paper claim and electronic media claim (EMC)
Two ways a claim form can be submitted.