Tools of the Trade

Lesson 2, Step 5

Claim Form

A document that requests reimbursement, completed and sent to insurance companies

Common Insurance Forms

CMS-1500 and UB-04

CMS-1500

A standard claim form used by providers to request payment for their services

Who is responsible for maintaining the CMS-1500 claim form?

NUCC (National Uniform Claim Committee)

UB-04

A claim form used in hospitals and inpatient settings

Diagnosis

What the provider finds is wrong with the patient (Ex: High blood pressure)

Procedure

Anything the provider does to determine the diagnosis (Ex: A blood pressure check is used to determine high blood pressure)

CPT Codes

Contains codes the describe procedures completed (Ex: The code 87635 means a Covid-19 test was preformed)

CPT Category I

Include the “regular” codes found in the six main sections of the book, these are all 5-digit numeric codes

CPT Category II

A special collection of codes only used by providers to track their performance. Insurance companies DO NOT use these codes to determine reimbursement

CPT Category III

Temporary codes. If these codes are not approved to be moved onto the Category I list within 5 years, they will be removed from the book

This group developed HCPCS (Level II) codes

The Centers for Medicare and Medicaid Services (CMS)

HCPCS (Level II) Codes

These codes are 5-digit and alphanumeric. They code for procedures the CPT does not cover including drugs, medical equipment, ambulance services, and prosthetics

ICD-10-CM

The system that determines diagnostic codes for both inpatient and outpatient

ICD-10-CM codes consist of how many characters?

3-7, and a decimal is ALWAYS placed after the third character (Ex: F53.0 is Postpartum Depression)

ICD-10-PCS

Separate from the ICD-10-CM! It’s a seven character, alphanumeric code. (Ex: 0DTJ4ZZ is Removal of Appendix)