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CRCS Chapter 4

Hospital and Clinic Billing

Clean Claim Will pass CWF edits, is processed electronically, and does not require further contact or evidence
Incomplete Claim Claim missing required information
Invalid Claim Claim contains complete and necessary information, but the information is illogical or incorrect
Unprocessable A claim considered incomplete or invalid due to missing claim form data elements
Non-standard A claim that has extraneous attachments in lieu of data entered correctly in the claim form
1 calendar year Deadline to file a Medicare claim for services
Code edits Examine a record for the correct use of ICD-9-CM codes
Coverage edits Examine the type of patient and the procedures performed to determine if the services were covered
Clinical edits Examine the clinical consistency of procedural and diagnostic information to determine if it is clinically reasonable
NCCI Medicare's National Correct Coding Initiative promotes correct coding methodologies and strives to eliminate improper coding.
Data Mailer A system-generated, free-form statement that is used to communicate the status of a patient's account and/or to bill the patient for an unpaid amount remaining on the account
Medicare Summary Notice (MSN) A statement to the payee and/or beneficiary reflecting services received, charges submitted, charges allowed, amount for which the beneficiary is responsible, and the amount that was paid to the provider or beneficiary.
Itemized Statement Provides a complete listing or detailed account of every service posted to a patient account to include the date of service, descrition of service, service code, charge amounts, and totals.
CMS 1500 form the equivalent electronic transaction is the 5010A1, formerly the 837P
Field locators 1-17 Provider and patient information
Field locator 38 Responsible party name and address
Field locator 29 Accident State
Field locators 18-28 Condition codes
Field locators 35-36 Occurance Span Codes and Dates
Field locator 67 Principal Diagnosis Code
Field locator 69 Admitting Diagnosis
Field locator 51 Health Plan Identifier Number
Field locators 42-49 Revenue descriptions, codes, and charges
Field locator 58 Insured's name
$1216.00 per spell of illness Part A current year inpatient deductible, days 1 through 60
$304.00 per day Part A coinsurance, days 61 through 90
$608.00 per day Part A lifetime reserve, days 91 through 150
$0 per benefit period Part A SNF care, days 1 through 20
$152.00 per day Part A SNF care, days 21 through 100
$0.00 Part A, home health care
Coinsurance (20% Medicare-approved amount) Part A, DME
$147.00 per year, then 20% of Medicare-approved amount Part B, Medical and other services
First 3 pints per year, then 20% of the Medicare-approved amount Part B, Blood
Diabetes Screening Test 2 screening tests per year with pre-diagnosis, 1 screening per year if tested but not diagnosed
Health Maintenance Organization (HMO) Members must generally get healthcare from providers in the plan's network
Preferred Provider Organization (PPO) members can see any doctor or provider that accepts Medicare and they don't need a referral to see a specialist
Private Fee-for-Service Plans allow members to got to any provider that accepts the plan's terms. The private company decides how much it will pay and how much members pay for services
Special Needs Plans limit all or most of their membership to people in some long term care facitities, and who are eligible for Medicare and Medicaid.
Medicare Medical Savings Accounts there are two parts, one part is Medicare Advantage Plan with a high deductible and the other part is a Medical Savings Account into which Medicare deposits money that people cand use to pay healthcare costs
Condition Code 02 Condition is Employment Related
Condition Code 21 Billing for Denial
Condition Code 40 Same Day Transfer
Field Locators 31-34 Occurrence Codes and Dates
Occurrence Code 01 Auto Accident
Occurrence Code 11 Date of Onset of Symptoms/Illness
Occurrence Code 18 Date of Patient/Beneficiary Retirement
Field Locators 39-41 Value Codes and Amounts
Value Code 01 Most Common Semi-Private Rate
Value Code 12 Working Aged Beneficiary/Spouse with EGHP
Value Code 13 ESRD Beneficiary in a Medicare Coordination Period with an EGHP
Rev Code 250 Pharmacy
Rev Code 300 Lab
Rev Code 450 Emergency Room
Created by: DRangel78