There are many important details that are entered on a CMS 1500 claim form for a patient’s services that were rendered by a provider. Information added to the claim form is electronically captured within the practice management system and electronic health record that is used by the medical office. Medical coders and reimbursement specialists are gatekeepers for ensuring that information that will ultimately be billed to the patient’s insurance is accurate and timely.
Investigate components of a CMS 1500 claim form and how it is used for billing purposes.
Include the following aspects in the discussion:
· Explain at least three blocks of the CMS 1500 claim form and the information each block should contain.
· Identify the differences between clean and dirty claims.
· Discuss at least one ramification that could result if a claim is not error-free.
Block 21 (Diagnosis Codes): This block contains the patient's diagnosis or condition codes, specified using the International Classification of Diseases (ICD) system. A medical coder selects these codes to justify the medical necessity of the services provided. The codes in this block must accurately reflect the patient's symptoms and diagnoses to support the billing codes for the services rendered.
Block 24a-g (Service Line Details): This series of blocks provides a detailed breakdown of the services rendered on a specific date. It includes the date of service (Block 24a), the place of service (Block 24b), the type of service (Block 24c), the procedure code (Block 24d), the charges for the service (Block 24f), and the number of units (Block 24g). This is the core of the claim, as it itemizes what the provider is billing for.
Sample Answer
The CMS 1500 Claim Form
The CMS 1500 claim form is the standard paper form used by non-institutional providers (like physicians and therapists) to bill for services. Although most claims are now submitted electronically, the electronic 837P format is based on the same information captured in the CMS 1500 form. Medical coders and reimbursement specialists are responsible for ensuring every detail is accurate to facilitate proper payment.
Key Blocks and Their Information
Block 1a (Insured's I.D. Number): This block requires the patient's unique insurance identification number. This number is essential for the payer (insurance company) to correctly identify the policyholder and verify coverage for the services rendered. Without the correct ID, the claim will be rejected as the insurance company won't be able to match the patient to a policy.