With 33 items and multiple subfields completing the CMS-1500 claim form is challenging. As per recent study done by leading PMS software, it costs an average of $6.50 to file a claim, $25 to resubmit a rejected claim, and $37 to correct and resubmit a denied claim. More rejections and denials you have to deal with, the lower your profit margin will be. While mistakes can happen at any point while filling out and submitting the form, there are few mistakes that most often trip up in the billing process.
First thing you want to make sure that you are using the most recent version of the CMS-1500 form. You have to make sure that you’re using the most recent version since the form is updated regularly. You can get most updated copy from your practice management software.
You have to use the diagnosis code that describes the patient's diagnosis, symptom, complaint, or condition. Always code to the highest level of specificity. If the diagnosis is not known, use a sign or symptom rather than ‘possible’ or ‘rule out’ for outpatient services.
• F43.20: Adjustment disorder, unspecified
• F43.21: Adjustment disorder with depressed mood
• F43.22: Adjustment disorder with anxiety
• F43.23: Adjustment disorder with mixed anxiety and depressed mood
• F43.24: Adjustment disorder with disturbance of conduct
• F43.25: Adjustment disorder with mixed disturbance of emotions and conduct
• F43.29: Adjustment disorder with other symptoms
Using unspecified codes might get the current claim paid but it will not support a more serious level of acuity in risk-based contracts.
Using inaccurate CPT code/s is a common for mistakes, especially when it comes to timed codes. There are chances if you use same codes frequently, you might be relying on the same few codes, resulting in over-billing (if a session was shorter than usual) or under-billing (if you provided additional billable services). While using new CPT codes reading long description would be helpful. The short descriptions don’t always provide all the information you need in order to identify whether a code is the right one to use.
If you are not using accurate CPT codes, it might seem as if you’re trying to commit fraud to increase reimbursement. Unbundling, upcoding, and using incorrect modifiers are ways to misuse codes. Unbundling refers to billing for two services separately when a single code is available that accurately describes the services. Upcoding on other side describes using an inaccurate code with a higher reimbursement rate. It might happen when a therapist spends significantly less time than normal in a session but uses a 45-minute service code.
Even if you file a claim correctly, the payer may deny it if you didn’t submit it in the timeframe required. Most private payers give you as much as a year to file a claim, but others insist on a 6-month or 90-day timeframe. To avoid running into problems with payers denying based on late filing, it’s a good idea to bill within 30 days. This will ensure you keep a regular cash flow as well as meet submission deadlines.
Any missing patient information may be cause for a denial, the most common missing items are patient name, patient sex, insured’s name, patient’s address, patient’s relationship, insured’s address, dates of service, and ICD-10 code. Asking clients to update their information twice a year, and reviewing each claim to ensure you’ve filled all the fields will help prevent this mistake.
Don’t forget to include complete service provider information in the claim. Item 24I requires you to select the type of provider identification number you’ll be entering i.e. a state license number, provider UPIN number, provider commercial number, or provider taxonomy. Then, in the bottom portion of the form, you’ll enter your provider NPI. The NPI tells the payer who provided the service, and the taxonomy code communicates what kind of provider you are. Also be sure to include the complete address in the subfields of item 32.
We are catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders.