Common Errors on CMS-1500 (Version 02/12) Claim Form: Implementation Date 04/01/2014

Helpful Hints to Improve Claim Processing

• Use a Legible Font – Use a size 10 or 12 font in Courier New style, making sure information is properly aligned on the form.
• Remove all Staples – Remove all staples, paper clips, or binder clips from claims and attachments. These items may prevent the scanner from properly imaging the claim and corresponding attachments as well as slow down their processing.
• Remove all Sticky Notes and Stickers – Sticky notes and stickers are often used to convey additional information but often cover information needed for the processing of the claim resulting in additional processing time. Avoid using sticky notes and stickers. Any additional information about the claim should be included on an attachment.
• Don’t Highlight Information – Although highlighting information is intended to make elements on a claim stand out, it has the reverse affect. When scanned, this information cannot be processed as it appears to be blacked out. Do not use highlighters on paper claims.
• Refrain from Extraneous Information – Extraneous information on the claim adds additional time to the processing of a claim. Extraneous information can include but is not limited to: descriptions after a diagnosis code, descriptions after a procedure code, any stamped information such as “Corrected Claim” in Item 24, addresses in the margins around the claim form, circling information or using an arrow to indicate important information. 
• Use the Correct Mailing Address – Using the address that is appropriate for the claim will assist in timely processing. Mailing the claim to the incorrect address can cause delays in processing or possible denials. If Part B, DME, and/or Part A claims need to be submitted, do not submit them in the same envelope. Include only one type of claim per envelope.

View the “CMS-1500 Form Version 02/12 Completion Tips” webpage at med.noridianmedicare.com/web/jeb/topics/claim-submission/cms-1500-claim-form-completion-tips for Item visuals and completion details about the following.

• Item 17 – Name of Referring Provider or Other Source
• Item 21 – Diagnosis or Nature of Illness or Injury
• Item 24E – Diagnosis Pointer

Courtesy of Noridian

New CMS-1500 Claim Form Must Be Submitted on April 1, 2014

The CMS-1500 claim form has been updated for ICD-10. Form Version 02/12 will replace the CMS-1500 claim form, 08/05, effective for claims received on/after April 1, 2014.
Below are key dates for compliance with the claim submission rules:

• Medicare began accepting claims on the revised form, version 02/12, on January 6, 2014;
• Medicare will continue to accept claims on the old form, version 08/05, through March 31, 2014;
• On April 1, 2014, Medicare will only accept paper claims on the revised CMS-1500 claim form, version 02/12; and
• On and after April 1, 2014, Medicare will no longer accept claims on the old CMS-1500 claim form, version 08/05.

The grace period for providers to transition to the new form expires on April 1, 2014. Providers need to plan ahead to ensure that claims submitted on the "old" 08/05 claim form mailed or sent via a courier service reach the Noridian offices located in Fargo, ND by March 31, 2014. Claims on the "old" claim form received on/after April 1, 2014 will not be processed. Providers will receive a letter stating that the incorrect form was submitted and that they will need to submit the claims on the current, 02/12 version of the paper claim form.
Note: Updating the print layout for the new claim form will require fairly significant adjustments. The revised form, version 02/12, has a number of revisions which require changes to the print layout for proper data alignment.
Those most notable changes to the 02/12 claim form are for Items 17, 21 and 24E.
Item 17 must have a qualifier entered to the left of the dotted vertical line in Item 17 to indicate the type of provider being reported in this field, as outlined below:

• DN - Referring Provider
• DK - Ordering Provider (this is the appropriate qualifier for DME claims)
• DQ - Supervising Provider

Item 21 now allows for 12 diagnosis codes, rather than 4 and the diagnosis pointers have changed from 1-4 to A-L. In addition, the diagnosis codes are now read left to right, rather than up and down.
Item 24E now requires the corresponding alphabetic, rather than numeric, diagnosis pointer. See Item 21.
Providers are encouraged to start their claim form transition now, by updating your print layouts and obtaining the new claim form for testing. Proper preparation and testing will ensure your ability to properly submit claims on the new form by April 1, 2014.
For more information, see the following:

• CMS Medicare Learning Network (MLN) Matters (MM) 8509 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8509.pdf 

• CMS-1500 Instructions for 02/12 Version at https://med.noridianmedicare.com/web/jeb/topics/claim-submission/instructions

Last Updated Feb 06, 2014

CMS 1500 Claim Form Instructions: Revised for Form Version 02/12

MLN Matters® Number: MM8509
Related Change Request (CR) #: CR 8509
Related CR Release Date: December 27, 2013
Effective Date: January 6, 2014
Related CR Transmittal #: R2842CP
Implementation Date: January 6, 2014
Provider Types Affected

 This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare contractors (carriers, A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME/MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
This change request (CR) 8509 revises the current CMS 1500 claim form instructions to reflect the revised CMS 1500 claim form, version 02/12.
Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with claims received on and after April 1, 2014:

• Medicare will begin accepting claims on the revised form, 02/12, on January 6, 2014;
• Medicare will continue to accept claims on the old form, 08/05, through March 31, 2014;
• On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500 claim form, 02/12; and
• On and after April 1, 2014, Medicare will no longer accept claims on the old CMS 1500 claim form, 08/05.

Make sure that your billing staff are aware of these instructions for the revised form version 02/12.

Background
The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.
The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

• DN - Referring Provider
• DK - Ordering Provider
• DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.
The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be sent electronically unless certain exceptions are met. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper. Medicare requires that the paper format for professional and supplier paper claims be the CMS 1500 claim form. Medicare therefore supports the implementation of the CMS 1500 claim form and its revisions for use by its professional providers and suppliers meeting an ASCA exception. More information about ASCA exceptions can be found in Chapter 24 of the "Medicare Claims Processing Manual" which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c24.pdf  on the Centers for Medicare & Medicaid Services (CMS) website.

Additional Information
The official instruction, CR 8509 issued to your MAC regarding this change may be viewed at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2842CP.pdf  on the CMS website. CR 8509 contains the instructions for completing the revised CMS 1500 claim form (02/12), which will become part of Chapter 26 in the "Medicare Claims Processing Manual" (Pub. 100-04).

Last Updated Jan 29, 2014

New CMS-1500 Medi-Cal (California Medicaid) Guide for Use Beginning January 6, 2014

Medi-Cal has created a New CMS-1500 Medi-Cal Guide to show providers the fields that have changed on the new 02/12 version of the CMS-1500 claim form. Information submitted in the fields will be the same as information submitted previously on the old 08/05 version of the claim form.

Providers can refer to the CMS-1500 Completion or CMS-1500 Completion for Vision Care section in the appropriate Part 2 provider manual for claim completion instructions by field number. Side-by-side comparisons of the current and upcoming claim fields are available in the New CMS-1500 Medi-Cal Guide, which can be downloaded from the new Claim Form Updates page of the Medi-Cal website.

Old and New Claim Versions: Dates of Use
Beginning January 6, 2014, the Medi-Cal claims processing system will be able to accept and process the new 02/12 version of the CMS-1500. The old 08/05 version of the CMS-1500 will continue to be accepted and processed also, but only for three months, through March 31, 2014. Beginning April 1, 2014, only claims submitted on the 02/12 version will be accepted and processed.

Provider Manual Update Plan
The CMS-1500 claim form has been revised to accommodate the ICD indicator that will be required on claims in 2014 with the ICD-10-CM code rollout. Rather than update the entire provider manual to announce claim updates and then next year release the manual pages again with ICD-10 information, Medi-Cal has determined to approach provider manual updates as follows:

• To serve the immediate need for claim completion instructions, the CMS-1500 Completion and CMS-1500 Completion for Vision Care manual sections will be updated. The sections are slated for release in the December 2013 Medi-Cal Update bulletins. A set of instructions for completing the new 02/12 version of the CMS-1500 will be added at the front of each section. The older 08/05 instructions will be retained at the back of the section.
• Claim field names in the provider manual will continue as they appear on the 08/05 version of the CMS-1500. For example, Reserved for Local Use field (Box 19) will be retained and not changed to Additional Claim Information field (Box 19) until later in 2014.
• Billing examples will be retained, as is, in the 08/05 version of the CMS-1500.
• If it is determined that claim instructions must be updated before ICD-10-related manual pages are released in 2014, an analysis will be performed to decide if select manual pages should be updated and released.

The above cost-saving approach will allow several hundred manual sections to be updated only once.

Courtesy of: http://files.medi-cal.ca.gov/pubsdoco/Claims/Articles/claims_21966.asp?utm_source=iContact&utm_medium=email&utm_campaign=Medi-Cal%20NewsFlash&utm_content=21966

Six ICD-10 Questions for Your Medical Claims Clearinghouse

By Lucien W. Roberts courtesy of Physicians Practice

It's September, and you've been busy since February preparing for ICD-10. No? Well, fortunately you still have 12 months to get ready. One key partner in your preparations should be your medical claims clearinghouse.

One of the things I learned from the HIPAA 5010 transition was that it hurt cash flow in way too many practices. I had the chance to observe two practices that had the same practice management system, the same payers, but different clearinghouses. One practice was a month down on cash flow well into the spring; the other had no cash flow disruption at all.

A very few clearinghouses made the 5010 transition seamless for practices; accepting both 4010- and 5010-formatted claims and then converting them, as necessary, on a payer-by-payer basis.  I never appreciated the value of a reliable clearinghouse partner until the 5010 transition.

So how does that lesson apply to the ICD-10 transition? As with 5010, your practice's cash flow will be at risk during the ICD-10 transition. Here are six questions to ask your clearinghouse as you prepare your practice for ICD-10.

1. Our practice suffered a disruption of cash flow during the 5010 transition. What will you do differently with ICD-10 to prevent a repeat performance?

(This is an optional question for practices that suffered during the 5010 transition. If you do not like the answer you get, consider moving to a clearinghouse whose 5010 performance was stronger.)

2. Would you please run a report of claims rejections and denials by ICD-9 code?

(And while you're at it, please provide guidance on how to prevent these errors.)

3. Would you run a similar report by payer?

(Such a report will give you a good basis for meeting with your key payers and discussing their ICD-10 conversion plans.)

4. Please run a report that identifies the "generic" codes each provider uses regularly.

(Generic ICD-9 codes (like 250.00 for Type II diabetes) are most likely to be denied by payers going forward. These codes should be your first priority as you commence ICD-9 to ICD-10 mapping.)

5. Could you share advice on mapping my superbill from ICD-9 to ICD-10?

(Coding remains each provider's responsibility. However, your clearinghouse may be helpful in this critical exercise.)

6. Could you share the progress of your discussions with my practice management vendor and my payers? When can we start sending test claims?

(Mapping from ICD-9 to ICD-10 is not an exact code-for-code proposition. Prudent practices will map — test — refine — test — refine their coding well before they submit their first real ICD-10 claim on Oct. 1, 2014.)

Post ICD-10 performance evaluation

TK Software of Carmel, Ind., is one clearinghouse whose clients were unaffected by the 5010 transition. TK Software's managing partner, Matt Behringer, shared their post-ICD-10 plans: "A post ICD-10 performance evaluation is critical," Behringer says. "Your clearinghouse should be able to create reports that show encounters, dollars billed, dollars rejected, and/or denied [claims] per day for each provider, pre- and post-ICD-10."

I agree. Ongoing cash flow in an ICD-10 world will require diligence and corrective education in the days and months following Oct. 1, 2014. A reliable clearinghouse partner helps, but it remains incumbent upon practices to begin their ICD-10 preparations now.

Article by: Lucien W. Roberts, III, MHA, FACMPE, is a consultant and a former practice administrator. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He can be reached at Lucien.roberts@yahoo.com.

Article courtesy of http://www.physicianspractice.com/icd-10/six-icd-10-questions-your-medical-claims-clearinghouse?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19092013

Unlisted Procedure and Not Otherwise Classified Codes: Noridian

Processing Changes: Effective 9/16/13, items requiring an invoice must follow the below criteria. Faxes will only be reviewed for PWK processing.
When billing for a service or procedure, select the CPT, HCPCS, or drug code that accurately identifies the service or procedure performed. If no such code exists, then report the service or procedure using the appropriate "unlisted procedure code or Not Otherwise Classified (NOC) code (which often end in 99). Noridian will not correctly code unlisted codes when a valid code is available.

Correct Coding Guidelines

• It is the responsibility of the provider to ensure all information required to process unlisted procedure codes or (NOC) codes is included on the CMS-1500 form or the electronic media claim (EMC) when the claim is submitted.
• If required information is missing, the code will be denied or deemed unprocessable.
• Descriptions of the unlisted procedure codes include, but are not limited to, narratives, trip notes for ambulance claims, etc.
• Enter a concise description of the services rendered in Item 19 on the CMS-1500 claim form. If the description does not fit in Item 19, an attachment describing the services must be submitted for providers who submit paper claims.
• When submitting attachments (e.g., operative report, office notes, invoices) to support the unlisted code billed, unless it is immediately evident, identify the unlisted procedure with a written description, or by underlining or marking the billed service on the attachments. Highlighters should not be used as this obliterates the text and is not visible after the document is photocopied or scanned.
• The electronic equivalent for Item 19 on EMC submissions will hold up to 80 characters for the concise statement and should be enough space to describe the unlisted procedure code.

Unclassified Drug Billing

The following unclassified drug codes should be used only when a more specific code is unavailable:

• J3490 Unclassified drugs
• J3590 UNCLASSIFIED BIOLOGICS
• J9999 Not otherwise classified, anti-neoplastic drug

When submitting a claim using one of the codes listed above, enter the drug name and dosage in Item 19 on the CMS 1500-claim form or the electronic equivalent. Pricing will be based on the information entered in these fields. The quantity-billed field must be entered as one (1).

Compound Drug Billing Exception

An exception to the unclassified drug code instruction above is the billing of compound drugs (often prepared by special pharmacies), which should be billed as outlined in the companion articles published simultaneously with this article:

• Compounded Drugs Reimbursement Billing Revised – November 2011
• Infusion Drugs Reimbursement Billing Revised – November 2011

If there is a valid J-code for the drug billed, the unlisted code will not be correctly coded by Noridian. The unlisted code will be denied as a billing error. Medicare payment will be based on the information submitted. If the required information is not submitted, any unlisted procedure or service will be denied as unprocessable.
Source: Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 26, Section

Courtesy of Noridian https://www.noridianmedicare.com/je/docs/unlisted_procedure_and_not_otherwise_classified_codes.html

JE Medicare Part B Processing Changes Using CPT Modifier 52-Reduced Services - Effective September 16, 2013

Noridian has identified a claim processing difference between contractors .This notification is to make all Part B providers served by Jurisdiction E (JE) aware of this difference. 
Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. A concise statement that explains the nature of the reduced service along with any other supporting documentation the provider deems relevant. The concise statement may appear on the operative report but, it must be clearly identified. This statement may be entered in the electronic documentation field or submitted via the fax attachment process. For paper claims, this documentation must be submitted as an attachment to the CMS-1500 claim form. Services that are submitted with CPT modifier 52 that do not include a concise statement will be rejected as 'unprocessable' and must be resubmitted as new claims
Noridian requires the provider to determine the charge amount, reduce normal fee by percentage of service not provided e.g., if 75% of normal service provided, reduce amount billed by 25% Medicare reimburses lower of actual charge or fee schedule allowance.

Example: Provider performs 75% of service and appends modifier 52
Medicare Physician Fee Schedule (MPFS) allowed amount	$300
Reduced Billed Amount ($300 x 75%)	$225

• Reflect statement “reduced services” in Item 19 (narrative or electronic equivalent)
• Documentation reflecting “reduction” reason retained in patient’s medical record
• Do not confuse with “terminated procedure” modifier 53
• Never use with evaluation and management or anesthesia codes

Appeals

• When submitting the Redetermination request include:
•  A separate, concise statement explaining the necessity for allowable reduction
•  An operative report or chart notes

Example

• Performed on one eye; unilateral
• Do not use RT or LT

Treatment Description	CPT/Modifier
Fundus photography with interpretation/report; bilateral	92250 52

"New" CMS-1500: WCMS-1500CS-12 Date of Implimentation Unknown (as of August 2013)

1500 Health Insurance Claim Form Change Log 6/17/2013 
The following is the list of changes between the 1500 Claim Form 08/05 version and the 02/12 version.

 

Header: The barcode was removed.

Header: The language “PLEASE DO NOT STAPLE IN THIS AREA” was removed from the left-hand side.

Header: The rectangle with “1500” was added in black ink to the left-hand side.

Header: The title “HEALTH INSURANCE CLAIM FORM” was moved from the lower, right-hand side to the left-hand side.

Header: The language “APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05” was added to the left-hand side.

Header: The language “TEST VERSION – NOT FOR OFFICIAL USE” was added to the right-hand side. This language will be removed when the form is approved by OMB.

Box 1: “TRICARE” was added above “CHAMPUS”.

Box 1: Under CHAMPVA, “VA File #” was changed to “Member ID#”.

Box 17a: The box was split in half length-wise.

Box 17a: This area was shaded. This box will accommodate other ID numbers.

Box 17a: Two vertical lines were added. This field will accommodate a two byte qualifier for other ID numbers.

Box 17b: This field was added.

Box 17b: Two vertical lines were added with the “NPI” label. This field will accommodate the NPI number.

Box 21: The lines after the decimal point in items 1, 2, 3, and 4 were extended to accommodate four bytes.

Box 24: The line with the alpha indicators was removed. The alpha indicators were moved next to the respective titles in the title fields.

Box 24: The line numbers to the left of Box 24 were increased in size and centered with each line.

Box 24: Each of the six lines were split length-wise and shading was added to the top portion of each line. This area is to be used for the reporting of supplemental information.

Box 24: Vertical line separators on each of the six lines have been removed from the shaded area,               except for the lines before Boxes 24I and 24J.

Box 24C: “Type of Service” was removed. This field is now titled “EMG”.

Box 24D: The field became wider by three bytes.

Box 24D: Shading was added vertically between “CPT/HCPCS” and “MODIFIER”.

Box 24D: Vertical lines were added in the unshaded “MODIFIER” section to accommodate four                  sets of two bytes.

Box 24E: The title was changed from “DIAGNOSIS CODE” to “DIAGNOSIS POINTER”.

Box 24E: The field was decreased by three bytes.

Box 24G: This field was increased by one byte.

Box 24H: This field was decreased by one byte.

Box 24I: The title was changed from “EMG” to “ID. QUAL.”.

Box 24I: A horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field.

Box 24I: The label “NPI” was added in the unshaded portion of the field.

Box 24J: The title was changed from “COB” to “RENDERING PROVIDER ID. #”. 1500 Claim                            Form Change Log – 11/29/05

Box 24J: A dotted horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field. The NPI number is to be reported in the unshaded field. An other ID number can be reported in the shaded field.

Box 24K: This field, “RESERVED FOR LOCAL USE”, was removed.

Box 32: Boxes 32a and 32b were added at the bottom.

Box 32a: This field was added to accommodate reporting of the NPI number and is indicated by the shaded label of “NPI”.

Box 32b: This shaded field was added to accommodate the reporting of other ID numbers.

Box 33: Parentheses were added after the title to indicate the location for reporting the telephone number.

Box 33: Boxes 33a and 33b were added at the bottom.

Box 33a: The title of this field was changed from “PIN#” to “a.”.

Box 33a: A shaded label of NPI was added to the box to indicate the reporting of the NPI number.

Box 33b: The title was changed from “GRP#” to “b.” to accommodate the reporting of other ID numbers.

Box 33b: The field was shaded.

Footer: The language “NUCC Instruction Manual available at: www.nucc.org” was added to the left-hand side.

Footer: The OMB approval numbers were removed and the language “OMB APPROVAL                 PENDING” was added. The numbers will be added after approval has been received by OMB.

Back: The following language was added in the last line at the bottom of the form: “This address     is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM  FORMS TO THIS ADDRESS.”

 

Courtesy of HMBA

CMS 1500 claim form instructions

The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies. Please contact your Medicaid State Agency for more details.
The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form. CMS does not supply the form to providers for claim submission. In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).
The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form. The majority of paper claims sent to carriers and DMERCs are scanned using Optical Character Recognition (OCR) technology. This scanning technology allows for the data contents contained on the form to be read while the actual form fields, headings, and lines remain invisible to the scanner. Photocopies cannot be scanned and therefore are not accepted by all carriers and DMERCs.
You can find Medicare CMS-1500 completion and coding instructions, as well as the print specifications in Chapter 26 of the Medicare Claims Processing Manual (Pub.100-04).

The NUCC has developed a 1500 Reference Instruction Manual detailing how to complete the claim form. The purpose of this manual is to help standardize nationally the manner in which the form is being completed.

The current version of the instructions (v 9.0) was released in July 2013.
• Version 9.0 7/13

Courtesy of: http://www.nucc.org/index.php?option=com_content&view=article&id=33&Itemid=114