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Part 1 Filing 3 rd Party Claims. Addressing: The CMS-1500 Form & Its Electronic Equivalent Diagnosis Coding. Disclaimers. This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD.
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Part 1Filing 3rd Party Claims Addressing: The CMS-1500 Form & Its Electronic Equivalent Diagnosis Coding
Disclaimers This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD. To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free. It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.
Disclaimer • The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services. • The Nebraska Optometric Association, and its presenters, agents, consultants and staff makeno representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.
Filing Claims – Info provided • Who (patient & insured) • Why (diagnosis) • What (service provided) • When (date provided) • How Much (fees) • Where (provided) • By Whom (provider)
Filing Claims –Format Used • Medical Insurance Claims • Electronic • Generally filed through a Clearinghouse • Must use HIPAA 5010 Format • Paper • CMS-1500 paper form (less than 10 FTE employees) • Routine Care Claims • Proprietary paper forms • CMS-1500 paper form • Internet direct filing
CMS-1500 to Electronic Claims Crosswalk • Claim information based on CMS-1500 Claim Form • For those who file electronically, there is a WPS source that explains where to insert the CMS-1500 data items into which electronic claim data loop. • This is referred to as the CMS-1500 Electronic Claim Crosswalk, and can be found at • http://www.wpsic.com/edi/pdf/npi_1500_crosswalk.pdf
TOP OF CMS-1500 Patient Authorization to Pay to Provider (So Dr. can accept assignment)
BOTTOM CMS-1500 Qualifying Information Example: Date assumed + date relinquished post-op care + # Post-op care days.
BOTTOM CMS-1500 Diagnosis Data MORE TO COME ON THIS AREA….
BOTTOM CMS-1500 Service & Materials Supplied MORE TO COME ON THIS AREA….
Medicare Provider Manual Billing InstructionsIncluding what data in which box • CMS Medicare Claims Processing Manual Website – (chapter 26)http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf
Medicare Provider Manual Billing InstructionsIncluding what data in which box
Medicaid Provider Manual Billing InstructionsWhat data in which box • Payments section: • http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-03.pdf • Form CMS-1500 Instructions • http://www.hhs.state.ne.us/reg/appx/471-000-65.pdf
Routine Care Claims • Companies may still use proprietary claim forms (or on-line via Internet) • Patient & Insured demographics • Policy data • Service provided • Diagnosis (refractive ICD-9-CM) • Materials provided
Diagnosis Codes • Don’t write “cataracts” or “presbyopia” • Instead, use a standard code • ICD-9-CM is standard resource for diagnosis codes • ICD-10-CM is coming soon, codes are completely different.
Diagnosis Codes 1st look up in alphabetical listing
Diagnosis Codes • An ICD-9-CM code for every eye disorders • Cataract, senile: 366.10 • E-codes for external causes • E960.0 due to unarmed fight • V-codes for other situations • V58.69 observation due to use of toxic medication • Routine Care Claims • Use ICD-9-CM Refractive codes
Diagnosis Codes • ICD-9-CM is soon to be replaced by ICD-10-CM • Completely different diagnosis coding system • More comprehensive • Defines disorders more explicitly • Required on all claim by October, 2013? (2014?) • Quick Reference Guide at http://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf • More information at http://www.cms.gov/ICD10/01_Overview.asp#TopOfPage
Thank You for Listening We hope this information has been helpful. Thank you for listening! See our NOA Website for more 3rd Party Educational Videos. 3rd Party Services Nebraska Optometric Association