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Master Core Curriculum

Master Core Curriculum. Part B Basic Module 5 Basics of Billing & Reimbursement. Learning Outcomes. At the end of this module, participants will be able to: properly complete the top and bottom portions of the claim form

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Master Core Curriculum

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  1. Master Core Curriculum Part B Basic Module 5 Basics of Billing & Reimbursement

  2. Learning Outcomes At the end of this module, participants will be able to: • properly complete the top and bottom portions of the claim form • understand Comprehensive Error Rate Testing Program (CERT) and the impact of incorrect claim filing • identify common claim form completion and submission errors • explain the differences between Medigap and crossover insurance processes • independently research and avoid common claim filing errors • explain elements of the paper and electronic remittance advice notices

  3. CMS Claims Filing Requirement • Provider of service must file claim if: • It is a covered service, or • Patient requests that claim be filed • May not charge for preparing and filing claim

  4. Time Limitations for Filing Medicare Claims • Claims may be filed for dates of service (DOS) in current year, preceding year, and last quarter of prior year • If claim filed more than 12 months from DOS: • assigned claims: 10% payment reduction • nonassigned claims: referral to CMS

  5. Methods of Claim Submission • Electronic Media Claims (EMC) • Paperless claim • Most cost-effective form of claim submission • Most claims should be filed electronically based on HIPAA requirements • Free billing software available • Paper Claim Form • Standard CMS-1500 form • Paper claims must be submitted as originals • Photocopied claims are not accepted

  6. CMS-1500 Instructions: Beneficiary Information • Item 1, Medicare • Item 1a, Health Insurance Claim Number (HICN) • Item 2, Patient’s Name • Item 3, Date of Birth, Gender • Item 5, Patient’s Address

  7. CMS-1500 Instructions: Medicare Secondary Payer (MSP) Information • Item 4, If MSP, Name of Insured • Medicare primary, leave blank • Item 6, If MSP, Patient Relationship • Item 7, If MSP, Insured’s Address • Item 8, Check marital status and if employed or student • Item 10, Accident (Y/N)

  8. CMS-1500 Instructions: MSP Information • Item 11 • MANDATORY • “Good faith effort” • MSP Questionnaire • Part A - Mandatory; Part B - Voluntary • Ask Questions; Provider makes determination • Medicare Secondary or Primary? • Coordination of Benefits (COB) Contractor-1.800.999.1118

  9. CMS-1500 Instructions: Medigap Information • Reported in Items 9-9d • Medicare Supplement Policy • Only reported by participating providers • Patient must assign Medigap benefits • Report Insured Name, Medigap, Policy Number, DOB, M/F

  10. CMS-1500 Instructions: Medigap Authorization • Item 13 • Beneficiary authorization by: • Patient signing Item 13 of CMS-1500, or • Statement of “Patient Request for Payment On file” • Medigap insurer must be named • good until or unless patient changes/voids

  11. CMS-1500 Instructions: Beneficiary Signature • Item 12 • Signature of patient or authorized representative • Release of medical information and payment of benefits (assigned) • Patient may sign individual claims, or • Statement of Signature on File - “Patient Request for Payment on File”

  12. CMS-1500 Instructions: Medicaid Entitlement • Item 10d • If patient entitled to Medicaid • Report Medicaid number preceded by “MCD” • If not entitled to Medicaid • Leave Blank

  13. CMS-1500 Instructions: Physician/ Supplier Information • Item 14, Date of current illness, injury, or pregnancy • Initiation of treatment plan (chiropractor) • Item 15, Not required by Medicare • Item 16, Date patient became unable to work, if employed

  14. CMS-1500 Instructions: Ordering/ Referring Provider Name • Item 17 • Required when provider requests items or services, or • Referrals • Consultations • Orders non-physician services • Clinical labs • Diagnostic tests • Pharmaceutical services • Durable Medical Equipment (DME)

  15. CMS-1500 Instructions: Ordering/ Referring Provider UPIN • Item 17a • Unique Physician Identification Number

  16. CMS-1500 Instructions: Items 18 & 19 • Item 18, Hospitalization Dates • Item 19 or EMC Narrative/Notepad • Independent PT/OT - Date Last Seen and UPIN of attending physician • X-ray date (chiropractor) • Not Otherwise Classified (NOC) drug - Name and dosage • NOC code - Narrative • Modifier 99 definitive information • Global surgery • split post-op • assumed and relinquished care dates

  17. CMS-1500 Instructions: Purchased Diagnostic Tests • Item 20 • Used to indicate purchase of technical component of diagnostic tests • Indicate “Yes” and purchase price

  18. Diagnosis Codes • Item 21, report • Minimum of one ICD-9 code • Maximum of four ICD-9 codes • Electronic claims may submit up to 8 ICD-9 codes • Item 24E • Enter diagnosis code reference number as shown in Item 21 to relate procedures performed to primary diagnosis • Enter only one primary reference number per line • 1,2,3, OR 4

  19. CMS-1500 Instructions: Items 22 & 23 • Item 22 • Leave blank • Not required by Medicare • Item 23, report • QIO Authorization Number • Investigational Device Exemption Number • HHA Provider Number - 6 digits • CLIA Number - 10 digits • Substituting physician UPIN, when reporting locum tenens or reciprocal billing arrangements

  20. CMS-1500 Instructions: Items 24A-C • 24A, Date of Service • MM/DD/CCYY format • Span dates if consecutive days • 24B, Place of Service • 2 digit numeric • If other than “12”, complete Item 32 • 24C, Type of Service • Leave blank • Not required by Medicare

  21. CMS-1500 Instructions: Item 24D • Report procedures, services, and supplies • HCPCS Level I (CPT) or II codes • Report modifier, if appropriate • Unlisted procedure code • requires narrative in Item 19 • EMC – use narrative field

  22. CMS-1500 Instructions: Items 24F-K • 24F, Charge for each service • 24G,Number of days/units • May use multiple units only when • Consecutive days are spanned (Hospital visits) • Not subject to multiple surgery guidelines • Dosages • Anesthesia - Elapsed time (minutes) • 24H, 24I, 24J, Leave blank, not required by Medicare • 24K, PIN of performing provider If member of a group practice

  23. CMS-1500 Instructions: Items 25 & 26 • Item 25, Employee ID Number (EIN) or Social Security Number (SSN) • EIN mandatory for Medigap crossover • Item 26, Patient account number (optional)

  24. CMS-1500 Instructions: Item 27 • Choose Assigned/Nonassigned • Mandatory assignment guidelines • Clinical Lab • Dual Eligibility • Participating Physicians • Non-physician practitioners (NPPs) • Ambulatory Surgical Center (ASC) • Drugs and Biologicals • Ambulance

  25. CMS-1500 Instructions: Items 28-30 • Item 28, Total of all charges • Item 29, Amount paid by PATIENT for COVERED SERVICES • Item 30, Balance due • Leave blank, not required by Medicare

  26. CMS-1500 Instructions: Item 31 • Provider or Representative Signature • Written, stamped, typed, or computer printed • Date

  27. CMS-1500 Instructions: Item 32 • Facility name and address, including zip code • Required if POS other than home (12) • Mammography certification #

  28. CMS-1500 Instructions: Item 33 • Item 33 • Provider of Service billing name, address, and telephone number • Provider Identification Number (PIN)

  29. Comprehensive Error Rate Testing Program (CERT) • Comprehensive Error Rate Testing Program (CERT) • Goal is to improve processing and medical decision making involved with payment of Medicare claims, and reduce the claims error rate • CMS contracts with Independent contractors who • Select a random sample of claims processed • Follow claims until adjudicated • Compare contractor’s final claims decision with its own

  30. CERT Process • Includes monthly audit of randomly selected claims (200 claims per contractor) • Did provider bill correctly? • Did Carrier process correctly?

  31. CERT Process • CERT Documentation Contractor (CDC) requests documentation from providers to determine if payment or denial was correct. • If the provider does not return requested documentation: • Claim denied • Payment recouped • Errors reported to Carrier for possible progressive corrective action

  32. Documentation • Provider should respond timely to CDC’s request for documentation • It is the provider’s responsibility to supply all documentation upon request • Documentation should: • Support medical necessity • Reflect that item or service was actually rendered • Represent services billed to Medicare

  33. How CERT Benefits Providers • CMS uses error rate data to determine need for changes to regulations. • Provider errors help to shape contractors’ educational efforts. • CERT protects the Medicare trust fund.

  34. Additional CERT Information • CMS website page for the CERT program www.cms.hhs.gov/cert

  35. Claim Submission Errors • Errors or omissions within the claim form itself • Incorrect entry of billing/ data information results in claim denials • Omissions generally indicate that required fields were left blank

  36. Common Billing Errors • Beneficiary Name/ Health Insurance Claim Number/ Gender • Billing/ Performing Provider Information • Diagnosis Error • Procedure Code/ Modifier Error • Place of Service (POS) • Unique Physician Identification Number (UPIN) • CLIA Error

  37. Resolutions • Omissions generally indicate that required fields were left blank • Refer to CMS claim filing instructions • Incorrect entry of billing/ data information may result in errors • Verify that all codes, modifiers, patient and physician identifiers were entered correctly • Verify that all procedure codes, modifiers, and diagnosis codes are valid for the date of service billed • Details of rejected claims are included in provider’s RA/ ERA

  38. Crossover • Three types of crossover • Complementary • Medicaid • Medigap

  39. Complementary Crossover • Supplemental insurers (trading partners) contract with Medicare • They supply eligibility information • Crossover for both assigned & nonassigned claims • Weekly transfer of information • MA18 on Remittance Advice indicates crossover occurred

  40. Medicaid Crossover • Similar to complementary crossover • Mandatory assignment for dual-eligibles • Eligibility file received from State Medicaid Agency • Item 10d must be completed • MA07 on Remittance Advice indicates crossover to Medicaid

  41. Medigap Crossover • Private health insurance plans that supplement Medicare • Fill in some “gaps” in Medicare coverage • Crossover based on information submitted on claim (Items 9-9d) • The word “Medigap” or an abbreviation (MG or MGAP) in Item 9a • Other Carrier Name & Address (OCNA) in Item 9d • Beneficiary authorization in Item 13 • Must be participating physician/supplier

  42. Remittance Advice (RA) Notice • Standardized payment report issued to Medicare providers • RA can be broken down into four parts • Mailing address and provider identification • Claim level information • Total remittance information • Claims Adjustment Reason Codes, Remittance Advice Remark Codes, and Medicare Outpatient Adjudication (MOA) code definitions

  43. Section One • Section One contains: • Mailing address and provider identification information • Number of pages in MRN • Date of RA • Check Number • Provider bulletin with important messages

  44. Section Two • Section Two provides claim level information such as: • Patient information • Name • HICN • Account number • Services billed & how items were adjudicated • DOS • POS • CPT/ HCPCS codes & modifiers • Allowed amount, paid amount, contractual obligation amount

  45. Section Two • Individual Claim totals • Patient responsibility • Billed amounts • Allowed amounts • Provider Paid amounts

  46. Section Three • Section Three contains RA total information such as: • Claims reported on RA • Billed amount • Allowed amount • Deductible applied • Coinsurance amount • Provider paid amount • Amount of check

  47. Section Four • Section Four of the RA contains descriptors for: • Group codes • Identify financial responsibility • Reason codes • Used in combination with group codes • Remark codes • Specific remarks for line items • Usually used for denials • MOA codes • Contain information for entire claim

  48. Reason Codes and Medicare-Specific Remark Codes • Remittance Advice Remark Code Committee reviews • requests for new Remittance Advice Remark Codes • requests for modifications to existing codes • To view current list of codes or request changes to existing codes: http://www.wpc-edi.com/codes/

  49. Electronic Remittance Advice (ERA) • Electronic version of RA • Some software packages offer automatic posting to patient accounts from ERA • Technical requirements and Implementation Guide available at: http://www.wpc-edi.com/HIPAA

  50. Chapter Review Slide • Review question 1….What is the length of time a provider has in which to submit a claim to Medicare? • Review question 2…. What is the goal of the CERT program? • Review Question 3…. What is the difference between Medigap and complementary crossover?

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