Flashcards › Fordney Chap 7/17 Mod F Set A

A federal violation occurs in a Medicare case if "signature on file" is stated on the CMS 1500 claim form but records do not include this. True this is a Federal violation Medicaid and workers comp have adopted the use of the CMS 1500 in all states. False, not all states have adopted the form A photocopy of the CMS 1500 claim form that is processed by the insurance carrier using scanning equipment is not acceptable. True, companies using scanning equipment cannot scan photocopies A paper claim is one that is submitted on paper, then optically scanned and converted to electronic form by insurance companies. True, this is considered a paper claim An insurance company may send a copy service to the Drs office to copy pt records. True, with proper identification and documentation Most major insurance companies accept the CMS 1500 except TRICARE and the Blue Plans False, TRICARE and the Blue Plans both use CMS 1500 You should allow the pt to submit his/her own claim forms to the insurance company. False, most pts do not have the knowledge to submit correctly If several services are being billed on the same insurance form, you may 'ditto' dates on each line of service below the first line. False, symbols are not allowed on claim forms List all services on the insurance claim form, including 'no charge' services False, do not list no charge services According to OCR (Optical Character Recognition) guidelines, all information on the CMS 1500 claim form should be typed in upper case True, all information should be capitalized The health insurance claim form CMS 1500 is known as the Universal claim form An insurance claim form that contains no staples or highlighted areas and on which the bar code area has not been deformed is called: A physically clean form An insurance claim submitted with errors is referred to as a dirty claim What is the protocol to follow on receiving a request for an attending physicians statement from an insurance company? Request a fee from the insurance company before sending the attending physicians statement If you receive a request, accompanied with the correct authorization, asking to abstract medical info from a pts medical record you should send only the information requested Office visits may be grouped on the insurance claim form if each visit... is consecutive, uses the same procedure code, and results in the same fee OCR is the acronym for optical character recognition OCR (Optical Character Recognition) guidelines for the CMS 1500 claim form state it should not be photocopied because it cannot be scanned. To conform to CMS 1500 OCR guidelines do not fold when mailing, do not use symbols with data, do not strike over errors when making a correction on an insurance claim for. The CMS 1500 claim form is divided into which two major sections Patient and physician information If a claim form is denied or rejected because it is missing the place of service code you should verify that the place of service is correct for the submitted procedure codes and fill in the correct service code. If the insurance claim form was submitted to the secondary instead of the primary insurance company you should obtain data from pt during the first office visit on which company is the primary insurer. If the patients name and the insureds name are entered as the same when the pt is a dependent Ck for Sr, Jr, correct DOB and verify the insured. If a claim is rejected because the the pts insurance number is incorrect proofread numbers from the source documents If a claim is returned because it has the incorrect modifier verify and submit valid modifiers with the correct procedure codes for which they are valid. If a claim comes back stating the operative report is missing... submit all attachments with pts name and insurance id number. If a claim is returned because a procedure code is invalid refer to the current procedure codebooks and verify the coding system used by the insurance company. When a claim is rejected due to missing diagnostic codes refer to an updated diagnostic codebook and review the pt record. When the claim is returned because the total amounts do not equal itemized amounts charged total all charges on each claim, recheck the math, and verify the amounts with the pt account. If claims come back because there are duplicate dates of service verify the pts medical record that all dates of service are listed and accurate. Because of the diversity in reimbursement methods, it is very important that the insurance billing specialist have basic knowledge of insurance programs True, Billing Specialists should have an understanding of all forms of reimbursement Emergency Department charges are billed along with the inpatient stay on the CMS 1500 claim False, ER charges are billed seperately When admitted as a worker's compensation case, the pt will not have an insurance card True, workers comp claimants do not have an insurance card. The insurance office uses ICD-9-CM Volumes 1, 2, and 3 to code diagnoses and procedures False (Volume 3 is strictly Surgical) A pt has a right to request an itemized bill from a hospital stay with no cost to the pt Yes, pt always has the right to request itemized billing On the UB-04 claim form, the pts date of birth should be entered using 6 digits in block 14. False (8 digit format) On the UB-04 claim form, in block 17, code 20 (expired) is used to indicate the pts status True (Code 20 means deceased) The DRG (Diagnosis Related Grouping) is assigned using an automated system called the DRG (Diagnosis Related Group) selector. False, this is not an automated classification The purpose of the DRG (Diagnosis Related Group)-based system is to hold down rising health care costs. True, the system helps minimize medical costs The grouper differentiates between chronic and acute conditions False, there is no such differentiation in the DRG When criteria are used by the review agency for admission screening, this is referred to as AEP (Appropriateness Evaluation Protocols) One of the criterion that needs to be met to certify severity of illnes (SI) in an admission is active uncontrolled bleeding One criterion that is used to meet the intensity of service (IS) in an admission is administration and monitoring of intravenous medications A patient is considered an inpatient to the hospital on admission for an overnight stay When a pt with a managed care program is admitted for an emergency to a hospital, the program needs to be notified in 48 hours The rule stating that when a pt receives out pt services within 72 hours of admission, then all out pt services are combined with inpt services and become part of the diagnostic related group rate for admission", is called The 72 hour rule What organization is responsible for admission review, readmission review, procedure review, day and cost outlier review, DRG validation, and transfer review? QIO (Quality Improvement Organization) The significant reason a pt is admitted to the hospital is coded using the Principle Diagnosis Classifications of surgical and nonsurgical procedures and miscellaneous therapeutic and diagnostic procedures are found in ICD-9-CM Volume 3 Insurance Handbook for the Medical Office