Coding for HIPAA: How to Report Professional Claims / Edition 1

Coding for HIPAA: How to Report Professional Claims / Edition 1

by Jean Narcisi
Pub. Date:
American Medical Association


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Coding for HIPAA: How to Report Professional Claims / Edition 1

This resource takes readers from the paper-based world of health care claims and gives them the data content knowledge necessary for reporting claims in the HIPAA environment. It examines the CMS 1500 claim form in detail, gives a brief overview of the electronic transactions standards mandated by the secretary of the Department of Health and Human Services, and primarily addresses the non-medical code sets required under HIPAA, including place of service, claim adjustment reason, provider taxonomy, and remittance remark. This book provides a comprehensive education on particular elements not found in other HIPAA publications, particularly the reporting of the specialty of the practitioner providing the service using the appropriate provider taxonomy code on an electronic form. Insurance companies are requiring these codes more frequently.

Product Details

ISBN-13: 9781579475505
Publisher: American Medical Association
Publication date: 02/01/2004
Pages: 350
Product dimensions: 8.50(w) x 11.00(h) x 0.80(d)

Table of Contents

Contents About the Author
CHAPTER 1 Introduction
History of the 1500 Health Care Claim Form
The National Uniform Claim Committee
Designated Standards Maintenance Organizations
Hospital Billing Form
Transition from Paper Forms to Electronic Data Interchange
Accredited Standards Committee
Parts of an Electronic Data Interchange Document
Electronic Data Interchange and Beyond
CHAPTER 2 Overview of HIPAA
Adopting Uniform Transaction Standards
Implementation Plan
Standards Adoption Process
Public and Private Sector Input into the Standards-Development Process
Implementation Schedule
Status of Final Rules
Who Must Comply
Transmissions That Must Comply
HIPAA Implementation Guides
Health Care Claim or Equivalent Encounter Information Implementation Guide
Health Care Payment and Remittance Advice Implementation Guide
Enrollment and Disenrollment in a Health Plan Implementation Guide
Health Plan Premium Payments Implementation Guide
Standard for Referral Certification and Authorization Implementation Guide
Health Care Claim Status Implementation Guide
Eligibility for a Health Plan Implementation Guide
Coordination of Benefits Implementation Guide
When the Standards Become Effective
Other HIPAA Administrative Simplification Requirements
Privacy Requirements
Security Requirements
National Identifier Requirements
Medical Code Sets
Local Code Sets
Nonmedical Code Sets
CHAPTER 4 Health Care Provider Taxonomy Code Set
Code Maintenance
Level I: Provider Type
Level II: Classification
Level III: Area of Specialization
The Provider Taxonomy Code List
Coding Nonindividuals
Coding Referring Providers
Using the Provider Taxonomy Codes
Health Care Provider Taxonomy Codes with Same or Similar Specializations
The Provider Taxonomy Code List Version 3.1, October 2003
CHAPTER 5 Claim Adjustment Reason Code Set
Claim Adjustment Group Code
Explanation of the Term Adjusted
Claim Adjustment Reason Code Set
CHAPTER 6 Remittance Advice Remark Codes
CHAPTER 7 Claim Status Codes
Claim Status Category Codes
Claim Status Code Set
CHAPTER 8 Place-of-Service Codes for Professional Claims
CHAPTER 9 National Uniform Claim Committee Data Set
CHAPTER 10 National Uniform Claim Committee CMS-1500 Claim Form Instructions
CMS-1500 Instructions
Carrier Block
Items 1-13: Patient and Insured Information
Item 1. Medicare Medicaid CHAMPUS CHAMVA Group Health Plan FECA Blk Lung Other
Item 2. Patient's Name
Item 3. Patient's Birth Date, Sex
Contents v Item 4. Insured's Name
Item 5. Patient's Address
Item 6. Patient Relationship to Insured
Item 7. Insured's Address?
Item 8. Patient Status
Item 9. Other Insured's Name
Items 10a-10c. Is Patient’s Condition Related to . . .
Item 10d. Reserved for Local Use
Item 11. Insured's Policy, Group, or FECA Number
Item 12. Patient's or Authorized Person's Signature
Item 13. Insured's or Authorized Person's Signature
Items 14-33: Physician or Supplier Information
Item 14. Date of Current Illness, Injury, Pregnancy
Item 15. If Patient Has Had Same or Similar Illness
Item 16. Dates Patient Unable to Work in Current Occupation
Item 17. Name of Referring Physician or Other Source
Item 18. Hospitalization Dates Related to Current Services
Item 19. Reserved for Local Use
Item 20. Outside Lab Charges
Item 21. Diagnosis or Nature of Illness or Injury
Item 22. Medicaid Resubmission
Item 23. Prior Authorization Number
Item 24a. Date(s) of Service
Item 24b. Place of Service
Item 24c. Type of Service
Item 24d. Procedures, Services, or Supplies
Item 24e. Diagnosis Code
Item 24f. Charges
Item 24g. Days or Units
Item 24h. EPSDT/Family Plan
Item 24i. EMG
Item 24j. COB
Item 24k. Reserved for Local Use
Item 25. Federal Tax ID Number
Item 26. Patient's Account No
Item 27. Accept Assignment?
Item 28. Total Charge
Item 29. Amount Paid
Item 30. Balance Due
Item 31. Signature of Physician or Supplier Including Degrees or Credentials
Item 32. Name and Address of Facility Where Services Were Rendered
Item 33. Physician's, Supplier's Billing Name, Address, Zip Code, and Phone #

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