eSignature Medical Claim Made Easy

Form dental

hi I'm Becky Gerber owner and lead instructor here at Academy of dental practice careers as you know billing medically necessary dental procedures to a patient's medical insurance carrier is becoming a necessity in today's market here at atpc we have designed a video that is intended to teach you how to fill out the current CMS 1500 medical claim form section by section we are using a simple sleep apnea case study as our example now before we get started it is our assumption that you already have the required documentation needed to proceed with submitting the claim first of all make sure to have your codebook this is the one I use the ndas medical dental coding and fee guide sixth edition it is available at Med fees.com if you prefer looking up codes online here is a valuable resource icd-10 datacom and finally if you want to look up the average UCR fees for your zip code you can go to Fair health consumer org the software that I prefer to use for generating a medical claim form is from speedy soft you can find that at speedy soft usa.com I like it because it is reasonably priced and easy to use plus it integrates well with most medical clearinghouses now that we're ready let's get started for our simulated sleep apnea case study we are going to be using a patient named Willard P patient please remember this is for example only and we at a DPC highly recommend that you look up your own icd-10 and CPT codes Willard P patient came in with a chief complaint of fatigue headaches and dry mouth when waking up in the morning he had a sleep study done on January 15 2016 and the results were negative the doctor did an assessment of the patient and advised the patient in order to correct the condition he would need a sleep apnea appliance at this point you at the front desk ask mister patient for his medical insurance identification card for the purposes of this video I have cut the current CMS 1500 medical claim form into three sections the first section is numbered 1 through 13 and then above the solid red line in the upper right corner we have the place for the name and address of the medical insurance carrier please notice that the third line is left blank and that is for a suite number if applicable box 1 is marked other because we are using PP O insurance boxes 2 3 & 5 are for the patient's name date of birth gender address and phone number box 1a is for the ID of the patient or the person that has the insurance and in this case it is the patient and that number is found on the medical insurance identification card box 4 is the name of the person with the insurance and box 6 is patient relationship to insured which is in this case self and then box 7 is the insurance address and phone number box 11 is for the group number or policy number and that again is found on the ID card and then box 11 a is for the date of birth of the person with the insurance and their gender and then box 11 C is for the insurance plans name and that is petco which happens to be the name of the employer box 10 is asking if the patient's condition is related to an employment accident and auto accident or another accident and for the purposes of this example we are marking know in each box box 12 is the release of information and the SOF is the acronym for signature on file and either is acceptable sof or signature on file and then the date box 13 is the assignment of benefits so sof again for signature on file and when that is signed that means that the provider will receive the insurance check the middle section is boxes 14 through 23 in box 14 we put the date that the patient noticed the symptoms or the date when the problem was diagnosed by either the doctor or the dentist we also have a qualifier to put in the next box and in this case we are going to put 4 3 1 which designates this information in box 17 we enter a qualifier for a provider and we have d n for referring provider d k for ordering provider and DQ for supervising provider we will be putting in DN in our box 17 if you need further information on filling out the CMS 1500 medical claim form you can visit one of websites SF HP org or la care org and both websites have very detailed information on how to fill out that claim form here's box 14 and we put in the date of current illness and then the qualifier of four three one which is designating that September 1st 2016 is when the illness was diagnosed or when the patient had the onset of the illness but 17 is for the referring providers name and and credentials so Wayne Johnson MD and then just before his name we have DN which means referring provider in 17 B we have the referring providers NPI number in box 19 we put what documents we have available and for a sleep apnea appliance we need a letter of medical necessity a sleep study and clinical notes or the initial assessment and when we put something in box 19 we need to put pwk which stands for paperwork and then a number or a set of letters so in this case pwk 13 AAA available upon request at the providers site so I'll explain that when we get to box 19 and I'll explain it a little further then we have box 20 and that is where we put the lab fee if in fact the insurance carrier considers a sleep apnea appliance a DME which out stands for durable medical equipment if the insurance carrier considers a sleep apnea appliance DME then we can now put the lab fee in box 20 and all the lab fee in our example it's 165 dollars once we have done that we can now drop down to box 32 at the bottom of the claim form and we put the name of the lab their address and their tax ID number or their NPI number here's box 19 and we put w pw k 13 AAA and then that is paperwork sleep study available upon request and then the next one is pw k DB AAA which is paperwork durable medical equipment available upon request and then pw k py AAA which is paperwork physicians report available upon request next to that is box 20 and we mark outside lab yes because the insurance company considers this a DME or durable medical equipment we then put the lab charge and that was a hundred and sixty-five dollars and only the lab fee in box 23 we put the prior authorization number and that is the claim number or the call number that we received when we called for authorization in box 21 we put the icd-10 for diagnosis codes and these are the five codes that we will be using for this example claim Music when we put the diagnosis codes in the boxes box a through e we list them in order of severity so the g47 decimal point 3 3 is first it's the most severe and then the g47 decimal 3 zero is second and then so on above the d box we actually have the ICD indicator and we have zero for that and that means that we are using icd-10 codes the cpt procedure codes that we'll be using on this claim re0 4 8 6 and 9 9 2 4 2 so we will be working with boxes 24 a through 24 J and if you need any further procedure codes CPT codes or icd-10 codes you can look at the website icd-10 datacom and that's very good but the 99 242 is the equivalent of the dental codes for the clinical oral evaluations and the 0 for 8 6 is the sleep apnea appliance here it is on the claim form with 24 a we put the date of service and the from in the to the month day and year and then 24 B is the place of service which will always be 11 for the office and then 24 D we have the code number for the exam 992 for two and then the code number for the sleep apnea appliance easy row for 8 6 now we're going to talk about modifiers and a modifier is a code that modifies the original CPT code so with the exam code we are going to be using the modifier 25 which states that the treatment is provided on the same day as the exam and that's provided that the exam has not been billed in the past then we'll use the modifier and you for the code easy row 486 and that designates that this is a new appliance for box 24 e we are going to put in diagnosis pointers and diagnosis pointers are listing the icd-10 codes in order of severity so in the first box for the exam code we're going to be listing ABCD and then in the second box of 24 e we will be listing ABC for the second procedure and here it is under modifiers 25 for the exam code and nu for the sleep apnea appliance and then the diagnosis pointers ABCD and then ABC inbox 24 F we put the charges for the services and then box 24 G how many we did for instance if we did one sleep apnea appliance we put one now this is for example only if we did two sleep apnea appliances in box G we would put two and that number would then be multiplied by 3800 and we would come up with 7600 and that would be the number that goes in box F for the fee for the sleep apnea appliance because we did two in box 24j we have the rendering providers NPI number and then we drop down to box 25 and that is the tax ID number of the during provider box 27 is the assignment of benefits we click yes we accept the assignment of benefits and then box 28 is the total charge now back in box 25 we are also letting the insurance company know if this is the social security number or the tax ID number at the bottom box 31 is the signature of the provider and signature on file or SOF is acceptable and the date and then box 32 as we discussed earlier is the name of the lab that fabricated the sleep apnea appliance and their address and their NPI number and their social security number and then finally box 33 which is the name address telephone number and NPI number of the rendering provider if you need to know more about documentation or medical billing for dental procedures we have an introductory medical dental insurance billing & Kross coding course online at ADP CED u-20 comm we also have a one-day hands-on class and our San Diego training facility you can visit dental practice careers comm for more information and as always here's to you and your success