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CRCS Chapter 4
Hospital and Clinic Billing
Term | Definition |
---|---|
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 |