Go into the patient's
file, go to the case screen, on the right hand side towards the top you will
see an edit comments button. Click on this button. Towards the middle you will see
a comment box for CMS forms. Anything typed in this box will print in
Note:
3/26/14 and above, the Medicare/Medicaid
tab is now the Dates/Specialty/CMS tab
Note: Cond |
Medicare/Medicaid tab; Sublexation level box also
will print in
Note – For DC in MO (for one) prts XR for
X-ray and will pull x-ray date on the Medicare/Medicaid tab. (Date can be added
to HCFA comments on case screen if needed) (get XR in box 19 even if no x-ray
date; can change degree type to “None” to remove for paper or PrtCap. If doing ANSI, also enter 111N00000X in taxonomy code override box on PINs tab.)
Note – For DC, on HCFA form, will pull x-ray date on the
Medicare/Medicaid tab. (May also print ‘XRAYS AVAIL’).
Note – For DC, on 2/12 HCFA form: ‘the last x-ray date for chiropractor services (if an
x-ray, rather than a physical examination was the method used to demonstrate
the subluxation).’ [Otherwise it looks like box 19 is not used for Chiro except
for the last x-ray date]. (see ch.26 of billing manual pgs
12&13).
Note – For PT in NY and NJ, box 19 is turned off for paper & PrtCap. (Change degree type to ‘None’ if you need box 19).
Note – For PT in TX, box 19 will have ‘LAST SEEN ON MM/DD/CCYY’
(Date from Cond | Date/Specialty/CMS … Last seen by supv.
Physician 8 digit date & can’t be changed). 11/16/18
and above: ‘LAST SEEN ON MM/DD/YY’ 6 digit date.
Instructions: Please refer to the most
current instructions from the public or private payer regarding the use of
this field. Some payers ask for certain identifiers in this field. If
identifiers are reported in this field, enter the appropriate qualifiers
describing the identifier. Do not enter a space, hyphen, or other separator
between the qualifier code and the number. (For Medicare, see ‘Medicare Claims
Processing Manual, Chapter 26 - Completing and Processing Form CMS-1500 Data
Set’)
When reporting a second item of data, enter three blank spaces
and then the next qualifier and
number/code/information.
___________________________________________________________________________________
The NUCC defines the
following qualifiers used in 5010A1:
0B State License Number
1G Provider UPIN Number
G2 Provider Commercial Number
LU Location Number (This qualifier is used for
Supervising Provider only.)
N5 Provider Plan Network Identification
Number<
SY Social Security Number (The social security
number may not be used for Medicare.)
X5 State Industrial Accident Provider Number
ZZ Provider Taxonomy
(The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain
the qualifier for the 1500 Claim Form.)
The above list contains both provider
identifiers, as well as the provider taxonomy code. The provider identifiers
are assigned to the provider either by a specific payer or by a third party in
order to uniquely identify the provider. The taxonomy code is designated by the
provider in order to identify his/her provider type, classification, and/or
area of specialization. Both, provider identifiers and provider taxonomy may be
used in this field.
When reporting a second
item of data, enter three blank spaces and then the next qualifier and
number/code/information.
FOR WORKERS’
COMPENSATION:
NEW YORK WORKERS COMPENSATION
You must be running a 1/16/2020 revised date or greater. During CMS-1500 generation, ECLIPSE determines that this is a NY WCB claim by verifying ALL of the following criteria:
1. Payment source for the primary payer is set to WC.
2. Condition work related box is checked.
3. NY is the current provider’s state.
4. Condition screen data was saved at some point (regardless of whether proper fields were filled out).
If the above criteria are met, ECLIPSE will automatically populate Box 19 with the WCB Rating Code and SCB Authorization. This can be entered in the condition screen and then clicking on the PI/Comp/State tab. Click on the WC button and you will see a space for both.
When reporting
Supplemental Claim Information: Use the qualifier PWK for data, followed by
the appropriate Report Type Code, the appropriate Transmission Type Code, then
the Attachment Control Number. Do not enter spaces between qualifiers and data.
The NUCC defines the following qualifiers used in 5010A1:
REPORT
TYPE CODES
03 Report Justifying Treatment Beyond
Utilization
04 Drugs Administered
05 Treatment Diagnosis
06 Initial Assessment
07 Functional Goals
08 Plan of Treatment
09 Progress Report
10 Continued Treatment
11 Chemical Analysis
13 Certified Test Report
15 Justification for Admission
21 Recovery Plan
A3 Allergies/Sensitivities Document
A4 Autopsy Report
AM Ambulance Certification
AS Admission Summary
B2 Prescription
B3 Physician Order
B4 Referral Form
BR Benchmark Testing Results
BS Baseline
BT Blanket Test Results
CB Chiropractic Justification
CK Consent Form(s)
CT Certification
D2 Drug Profile Document
DA Dental Models
DB Durable Medical Equipment Prescription
DG Diagnostic Report
DJ Discharge Monitoring Report
DS Discharge Summary
EB Explanation of Benefits (Coordination
of Benefits or Medicare Secondary Payor)
HC Health Certificate
HR Health Clinic Records
I5 Immunization Record
IR
LA Laboratory Results
M1 Medical Record Attachment
MT Models
NN Nursing Notes
OC Oxygen Content Averaging Report
OD Orders and Treatments Document
OE Objective Physical Examination (including
vital signs) Document
OX Oxygen Therapy Certification
OZ Support Data for Claim
P4 Pathology Report
P5 Patient Medical History Document
PE Parenteral or Enteral Certification
PN Physical Therapy Notes
PQ Paramedical Results
PY Physician’s Report
PZ Physical Therapy Certification
RB Radiology Films
RR Radiology Reports
RT Report of Tests and Analysis Report
RX Renewable Oxygen Content Averaging Report
SG Symptoms Document
V5 Death Notification
XP Photographs
TRANSMISSION
TYPE CODES
AA Available on Request at Provider Site
BM By Mail
Example:
PWK03AA12363545465
Providers and suppliers have the option of entering either a 6 or
8-digit date in items 11b, 14, 16, 18, 19, or 24a. However, if a provider of service
or supplier chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19, or
24a, he or she must enter 8-digit dates for all these fields. [Uncheck both
boxes on the printed claims options tab for 6-digit dates.] [Any hand written
dates MUST be in 6-digit format]