Uniform Claim Editor. A Guide to Accurate 1500 Professional Claim Submission

Transcription

1 Uniform Claim Editor A Guide to Accurate 1500 Professional Claim Submission March 2013

2 Publisher s Notice The Uniform Claim Editor is designed to be an accurate and authoritative source regarding coding and every reasonable effort has been made to ensure accuracy and completeness of the content. However, Optum makes no guarantee, warranty, or representation that this publication is accurate, complete or without errors. It is understood that Optum is not rendering any legal or other professional services or advice in this publication and that Optum bears no liability for any results or consequences that may arise from the use of this book. Acknowledgments Mike Grambo, Product Manager Karen Schmidt, BSN, Technical irector Stacy Perry, Manager, esktop Publishing Lisa Singley, Project Manager Regina Magnani, RHIT, Clinical/Technical Editor Trudy Whitehead, CPC-H, CMAS, Clinical/Technical Editor Hope M. unn, Senior esktop Publishing Specialist Katie Russell, esktop Publishing Specialist Kate Holden, Editor American Medical Association Notice CPT 2013 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. Our Commitment to Accuracy Optum is committed to producing accurate and reliable materials. To report corrections, please visit or accuracy@optum.com. You can also reach customer service by calling , option 1. Copyright 2014 OptumInsight's, Inc. About the Technical Editors Regina Magnani, RHIT Ms. Magnani has more than 30 years of experience in the health care industry in both health information management and patient financial services. Her areas of expertise include facility revenue cycle management, patient financial services, CPT/HCPCS and IC-9-CM coding, the outpatient prospective payment system (OPPS), and chargemaster development and maintenance. She is an active member of the Healthcare Financial Management Association (HFMA), the American Health Information Management Association (AHIMA), and the American Association of Healthcare Administrative Management (AAHAM). Trudy Whitehead, CPC-H, CMAS Ms. Whitehead has more than 25 years of experience in hospital and physician coding and reimbursement. Recently she developed an APC review system for the postpayment review of Medicare FFS APC claims, including workflow, training, and development of an instruction manual as director of ambulatory review systems. She has conducted hospital and insurance bill auditing, managed facility claims processing and claims negotiations, developed outpatient repricer and rules engines, performed hospital chargemaster reviews, and worked on software development. Ms. Whitehead is a member of the American Academy of Professional Coders (AAPC) and the American Association of Medical Audit Specialists (AAMAS). Made in the USA ISBN

3 Contents IC-9-CM to IC-10 Transition... 1 How to Use the Uniform Claim Editor... 3 Introduction P... 4 Trading Partner Agreements and Requirements... 5 ifferences Between the 837P and 1500 Formats... 5 Time Limit for Filing Medicare Claims... 6 Item Number Unlabeled Carrier Block... 7 Unlabeled Item Carrier Block... 7 Item Numbers 1 13: Patient and Insured Information... 9 Item Number 1. Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other... 9 Item Number 1a. Insured s I Number...10 Item Number 2. Patient s Name...12 Item Number 3. Patient s Birth ate, Sex...13 Item Number 4. Insured s Name...14 Item Number 5. Patient s Address...16 Item Number 6. Patient Relationship to Insured...18 Item Number 7. Insured s Address...19 Item Number 8. Reserved for NUCC Use...20 Item Number 9. Other Insured s Name...21 Item Number 9a. Other Insured s Policy or Group Number...22 Item Numbers 9b and 9c. Reserved for NUCC Use...22 Item Number 9d. Insurance Plan Name or Program...23 Item Numbers 10a-10c. Is Patient s Condition Related To: Employment, Auto Accident, or Other Accident...24 Item Number 10d. Claim Codes...27 Item Number 11. Insured s Policy, Group, or FECA Number...29 Item Number 11a. Insured s ate of Birth, Sex...34 Item Number 11b. Other Claim I...35 Item Number 11c. Insurance Plan Name or Program Name...36 Item Number 11d. Is There Another Health Benefit Plan?...37 Item Number 12. Patient s or Authorized Person s Signature Release of Information...37 Item Number 13. Insured s or Authorized Person s Signature Payment Authorization...39 Item Numbers 14 33: Physician or Supplier Information Item Number 14. ate of Current Illness, Injury, Pregnancy (LMP)...41 Item Number 15. Other ate...42 Item Number 16. ates Patient Unable to Work in Current Occupation...44 Item Number 17. Name of Referring Provider or Other Source...45 Item Number 17a and 17b. Other I Number and National Provider Identifier...49 Item Number 18. Hospitalization ates Related to Current Services...50 Item Number 19. Additional Claim Information...51 Item Number 20. Outside Lab? $Charges...56 Item Number 21. iagnosis or Nature of Illness or Injury OptumInsight, Inc. i

4 Contents Uniform Claim Editor Item Number 22. Resubmission and/or Original Reference Number Item Number 23. Prior Authorization Number Item Number 24. Supplemental Information Item Number 24A. ate(s) of Service [lines 1 6] Item Number 24B. Place of Service [lines 1 6] Item Number 24C. EMC (Emergency) [lines 1 6] Item Number 24. Procedures, Services, or Supplies [lines 1 6] Item Number 24E. iagnosis Pointer [lines 1 6] Item Number 24F. $Charges [lines 1 6] Item Number 24G. ays or Units [lines 1 6] Item Number 24H. EPST/Family Plan [lines 1 6] Item Number 24I. I Qualifier [lines 1 6] Item Number 24J. Rendering Provider I # [lines 1 6] Item Number 25. Federal Tax I Number Item Number 26. Patient s Account No Item Number 27. Accept Assignment? Item Number 28. Total Charge Item Number 29. Amount Paid Item Number 30. Reserved for NUCC Use Item Number 31. Signature of Physician or Supplier Including egrees or Credentials Item Numbers 32, 32A, and 32B. Service Facility Location Information Item Numbers 33, 33A, and 33B. Billing Provider Information Appendix A: Modifiers for Other Than Facility Use Appendix B: Place of Service Codes Appendix C. Type of Service Codes Appendix. Specialty Codes Appendix E. State Abbreviation and Country Abbreviations Appendix F. Medically Unlikely Edits for Practitioner Services Appendix G. Taxonomy Codes for Selected Providers Appendix H. CMS Not Otherwise Classified Codes for Medicare Editing, Jurisdictions, and their MPFS Status Code Appendix I. Claim Adjustment Reason Codes Appendix J. Remittance Advice Remarks Codes Appendix K. Medicare Coverage for Selected Services ii 2014 OptumInsight, Inc.

5 Item Numbers 14 33: Physician or Supplier Information Uniform Claim Editor Item Number 24G. ays or Units [lines 1 6] This field is the number of days corresponding to the dates entered in Item 24A or the number units as defined in CPT or HCPCS Level II coding manual(s) P Loop (837P only) 2400 Item or data element number and name Unit or basis for measure Unit amount Item 24Gays or units Unit or basis for measurement code and quantity SV103 SV104 Status Required Required Length units or basis for measure 2 AN Length unit amount 3 N 8 N Repeatable Once per line Once per service line A=alphabetic character N=numeric character AN=alphanumeric character Both formats: Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Both formats: This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. 1500: Enter numbers left-justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point. Both formats: Anesthesia services must be reported as minutes. Units may be reported for anesthesia services only when the code description includes a time period (such as daily management ). 1500: Enter numbers right-justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point. 837P, version 5010: SV103 identifies the type of units being reported in SV104 with one of the following: Coding Structure MJ Minutes UN Units 837P, version 5010: Field allows a decimal point in SV104. The field length of eight digits does not include the decimal point. If a decimal is used, the maximum number of digits allowed to the right of the decimal is three. 837P, version 5010: Anesthesia services must be reported as minutes. Units may be reported for anesthesia services only when the code description includes a time period (such as daily management ). 837P, version 5010: According to the implementation guide, anesthesia time is counted from the moment the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the A AMB ME L LAB M MAM X PHY RUG refers to version X222A OptumInsight, Inc.

6 Uniform Claim Editor Item Numbers 14 33: Physician or Supplier Information A A A patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. Both formats: Report the number of units based on the CPT or HCPCS code description reported in Item 24d of that service line. Both formats: Ambulance mileage is reported for loaded mileage only. Report all medically necessary mileage, including the mileage subject to a rural adjustment, in a single line item. Air mileage must be reported in whole numbers of loaded statute miles flown. (Medicare Claims Processing Manual, Pub , chapter 15, section ) Both formats: Report ambulance ground mileage as fractional units for trips totaling up to 100 covered miles. When reporting fractional mileage, suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage. The decimal must be used in the appropriate place (e.g., 99.9). For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., miles should be reported as 999). For trips totaling less than one mile, enter a 0 before the decimal (e.g., 0.9). (Medicare Claims Processing Manual, Pub , chapter 15, section ) Both formats: For mileage HCPCS code billed on a Form CMS-1500 or ANSI X12N 837P only, contractors shall automatically default to 0.1 units when the total mileage units are missing in Item 24G. (Medicare Claims Processing Manual, Pub , chapter 15, section ) Both formats: When reporting drugs, biologicals, or radiopharmaceuticals that require HCPCS Level II codes, units are entered in multiples of the units shown in the HCPCS narrative description. When the NC is required, units are entered in multiples of the units shown in the NC label description. If the units provided exceed the size of the units field or require more characters to report than there are spaces available in the format, repeat the HCPCS or NC code on multiple lines until all units can be reported. (Medicare Claims Processing Manual, Pub , chapter 17, section 70) Both formats: For rental ME items, including oxygen equipment, report a separate line for each month. One month of service equals a unit of 1. (Medicare Claims Processing Manual, Pub , chapter 20, section 130.6) Both formats: For oxygen contents (HCPCS codes E0441, E0442, E0443, and E0444), report the number of feet or pounds as described by the HCPCS Level II code. (Medicare Claims Processing Manual, Pub , chapter 20, section 150) Both formats: CMS has added a category of edits to the CCI edit file, the medically unlikely edits (MUE), which establish maximum daily allowable units of service. The edits are applied to the services provided to the same patient, for the same CPT or HCPCS code, on the same date of service, when billed by the same provider. Edits are based on both medically reasonable expectations and anatomical considerations. (For more information about MUEs, go to the CMS website at An automatic denial will occur for any units of any line item billed with units greater than the allowable, for claims billed to the carrier. There are separate MUE files for practitioner services and ME supplier services, as well as hospital outpatient department services. An appeals process will be allowed for those claim line items that are denied. Services denied due to these edits cannot be billed to the patient, nor can an ABN be used to assign financial responsibility to the patient. A AMB ME L LAB M MAM X PHY RUG 2014 OptumInsight, Inc refers to version X222A1 75

7 Item Numbers 14 33: Physician or Supplier Information Uniform Claim Editor Both formats: A carrier claim will be returned as unprocessable if it does not indicate at least one day or unit in Item 24G. The carrier may program the system to automatically default to one unit when the information in this item is missing. (Medicare Claims Processing Manual, Pub , chapter 1, section ) Both formats: The units reported for rehabilitation services must be based on the procedure code or service reported in Item 24d. Units are reported based on the number of times the procedure, as described by the HCPCS code definition, is performed. For HCPCS codes that do not define a specific time frame for the procedure, use 1 in the units field. Both formats: CMS is imposing edits based on the units of service for therapy services. The following codes may be billed, when covered, only at or below the number of units indicated in the table per treatment day. When units over the stated limit are billed, the units that exceed the limit shall be denied as medically unnecessary. enied claims may be appealed, and an ABN may be appropriate to notify the patient of liability (Medicare Claims Processing Manual, Pub , chap. 5, sec and 30). The following edits are to be applied: CPT/ HCPCS Level II escription Timed or Untimed PT Allowed units OT Allowed units SLP Allowed units Speech/hearing Untimed NA evaluation Oral speech device eval Untimed NA Ex for speech device rx, Timed NA 1hr Motion Untimed fluoroscopy/swallow Endoscope swallow test Untimed (fees) Laryngoscopic sensory Untimed test Fees w/laryngeal sense Untimed test Limb muscle testing, Untimed manual Limb muscle testing, Untimed manual evelopmental test, Untimed limb evelopmental test, Untimed extend PT evaluation Untimed NA PT re-evaluation Untimed NA OT evaluation Untimed NA OT re-evaluation Untimed NA *Physician or nonphysician practitioner (NPP) Physician/NPP * NOT under Therapy POC A AMB ME L LAB M MAM X PHY RUG refers to version X222A OptumInsight, Inc.

8 Uniform Claim Editor Item Numbers 14 33: Physician or Supplier Information The allowed units may be billed no more than once per provider, per discipline, per date of service, per patient. A zero (0) in the units column indicates that the code may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP). When physicians or NPP bill always therapy codes, they must follow the policies of the type of therapy they are providing, among them using a plan of care and billing with the appropriate therapy modifier (GP, GO, GN). The allowed units in the table that apply for PT, OT, or SLP depend on the plan of care. A physician or NPP cannot bill an always therapy code unless the service is provided under a therapy plan of care. Both formats: Therapy providers report the code for the time actually spent delivering the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted in determining treatment time. The time counted is the time the patient is treated. o not bill for services performed for less than eight minutes. The expectation is that the provider s time for each unit will average 15 minutes. It does not imply that any minute until the eighth should be excluded from the total count. The beginning and ending times of the treatment should be recorded in the patient s medical record along with a note describing the treatment. If more than one CPT code is billed during the calendar day, the total number of units reported is limited to the total treatment time. For example, if treatment for CPT code lasts 24 minutes and treatment for CPT code lasts 23 minutes, the total time reported is 47 minutes. Only three units of service can be reported. Two units are allocated to CPT code and one unit to code (Medicare Claims Processing Manual, Pub , chap. 5, sec and 30) Both formats: For MEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For MEPOS products supplied as refills to the original order, suppliers must contact the patient no sooner than 14 calendar days before the delivery date to confirm that the refilled item remains reasonable and necessary and that existing supplies are approaching exhaustion, and to ascertain whether there are any changes or modifications to the order. (Medicare Program Integrity Manual, Pub , chap. 5, sec ) Both formats: Units reported for MEPOS should correspond to the physician orders for usage and frequency and to actual supplies delivered, and must be justified by medical record documentation. No more than a one month's supply of dressings may be provided at one time, unless documentation substantiates the necessity of greater quantities. For example, if the order is for a composite dressing to be changed every other day, 10 units are reported for one month. Both formats: Review LCs for limitations on size, amounts, and/or frequency of usage, all of which can affect units reported. A AMB ME L LAB M MAM X PHY RUG 2014 OptumInsight, Inc refers to version X222A1 77