Miles, Times, Units, Services (MTUS) Indicator Field of CMS 1500

Miles/Times/Units/Services (MTUS)

Miles/Times/Units/Services (MTUS) count and MTUS indicator fields are on Part B Physician/Supplier Claims. These fields are documented in the CMS National Claims History Data Dictionary.

Standard systems are to put MTUS count and MTUS indicators on all claims at the line item level.
The purpose of the MTUS Count Field on the line item is to document additional information reflecting certain volumes related to indicators. In most cases, the value in this field will be the same as in the Service Count Field on the line item; however, for services such as anesthesia the field values will differ. In this case, the service count field will likely contain a value of 1 for the occurrence of the surgery while the MTUS Count Field will contain the actual time units that the anesthesiologist spent with the patient in 15 minute increments or a fraction thereof.

Signature of provider - Box 31 CMS 1500

Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.

CMS 1500 Box 13 - patient Singnature on file

The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.

The presence of or lack of a signature or “signature on file” in this field will be indicated as such to any downstream Coordination of Benefits trading partners (supplemental insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. Medicare has no control over how supplemental claims are processed, so it is important that providers accurately address this field as it may affect supplemental payments to providers and/or their patients.

KIDNEY DISEASE PROGRAM BILLING - how to fill HCFA

CMS-1500  KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS

CMS 1500 BLOCK TO BLOCK BILLING INSTRUCTIONS

Providers must use the CMS-1500 form to bill the Program. The CMS-1500 forms are available from the Government Printing Office, the American Medical Association, major medical oriented printing firms, or visit: (http://www.cms.hhs.gov/providers/edi/cms1500.pdf)

For Kidney Disease claims processing, THE TOP RIGHT SIDE OF THE CMS-1500 MUST BE BLANK. Notes, comments, addresses or any other notations in this area of the form will result in the claim being returned unprocessed.

The following fields MUST be completed on the CMS-1500:


Block 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Enter the patient’s (recipient’s) name as it appears on the Kidney Disease Program card.

CMS-1500 KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS

CLAIM SUBMISSION CHECKLIST

Prior to submitting your claims to the Kidney Disease Program, use the following checklist:
�� Is your copy legible? Did you type or print your form? Although not required, typing the form will speed up the process.
�� Did you follow the Billing Instructions?
�� Do you have the correct address for submitting your claims? Correct address for submission is listed on page 1 of these billing instructions.


CLAIM TROUBLESHOOTING

This section provides information about the most common billing errors encountered when
providers submit claims to the Kidney Disease Program. Preventing errors on the claim is
the most efficient way to ensure that your claims are paid in a timely manner.


Claims commonly reject for the following reasons:1. The appropriate provider and/or recipient identification is missing or inaccurate.

�� Verify that the 6 digit Kidney Disease Program Patient Identification number is entered in Block 10D. This ID number must be entered or claim will reject for invalid KDP recipient.

�� Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.

�� Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.

completing CMS 1500 instruction - Field 1 - 13

Tips for Completing the CMS-1500 Claim Form

Member Information (Fields 1-13)

Field Number : 1
Field Description : Coverage
Data Type : Optional
Instructions : Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).

Field Number : 1a
Field Description : Insured's ID number
Data Type : Required
Instructions : List the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.

Field Number : 2
Field Description : Patient's name
Data Type : Required
Instructions :  Enter the patient's last name, first name, and middle initial, if any.
NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.

Field Number :  3
Field Description : Patient's birth date and gender
Data Type : Required
Instructions : Enter the patient's birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.



Field Number : 4

Medical billing CMS 1500 - hint & tips to complete claim

Required Fields – Professional Claims - CMS1500 (08-05)

CMS1500 FL #            Description of Information Required

1a Patient’s ID Number
2 Patient’s Name, as it appears on identification card
3 Patient’s Date of Birth (mm/dd/ccyy) and Sex
4 Subscriber’s Name—if same as patient, enter SAME.
5 Patient’s address—if different from subscriber’s, complete item 7
9-9d Other insurance information—if applicable. DOB must be in mm/dd/ccyy format.
10a-c If services are related to patient’s employment, auto accident or other accident, please complete. Otherwise leave blank.
11a-c Subscriber’s Insurance Group Number, Subscriber’s DOB (mm/dd/ccyy), Subscriber’s Sex
11d “Yes/No”—If “yes”, complete Item 9.
14 Date of onset of current illness or injury. (Use LMP for pregnancy)
17 Name of referring physician—required for lab and radiology claims only
17a Shaded area—Legacy qualifier / legacy number of referring physician (legacy qualifiers—1G for UPIN; G2 for MHP ID; 1C for PIN)
17b NPI of referring physician

Date format of CMS 1500

Providers and suppliers must report 8-digit dates in all date of birth fields (items 3, 9b, and 11a), and either 6-digit or 8-digit dates in all other date fields (items 11b, 12, 14, 16, 18, 19, 24a, and 31).


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. For instance, a provider of service or supplier will not be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a 6-digit date for item 24a. The same applies to providers of service and suppliers who choose to submit 6-digit dates too. Items 12 and 31 are exempt from this requirement.

Legend                                    Description
MM                                    Month (e.g., December = 12)
DD                                        Day (e.g., Dec15 = 15)
YY                                  2 position Year (e.g., 1998 = 98)
CCYY                            4 position Year (e.g., 1998 = 1998)

Tips for Completing the CMS-1500 Claim Form - Field 14 -33

Provider of Service or Supplier Information (Fields 14-33)

Field Number : 14
Field Description : Date of current illness, injury or pregnancy
Data Type : Not required
Instructions : Not applicable.

CMS-1500 KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS

INTRODUCTION

These billing instructions have been prepared to provide proper procedures and instructions for
the Kidney Disease Program providers who use the CMS-1500 (08-05) form.

BILLING INFORMATION

Providers must bill on the CMS-1500 claim form. Claims can be submitted in any quantity and
at any time within the filing limitation.

Filing Statutes: Claims must be received within 6 months of the date of service. The following
statutes are in addition to the initial claim submission.

• 3 months from the date of any intermediary payment, i.e., Medicare, other third party insurance (Must include copy of EOB.)

PROCEDURES FOR SUBMITTING HARDCOPY MEDICARE CLAIMS

Billing a CMS-1500 with a Medicare EOMB:

On the Medicare EOMB, each individual claim is generally designated by two horizontal lines. Therefore, you should complete one CMS-1500 form per set of horizontal lines.
• When billing Medical Assistance, the information on the CMS-1500 must be identical to the information that is between the two horizontal lines on the Medicare EOMB.
o Dates of service must match
o Procedure codes must match
o Amount(s) on line #24F of the CMS-1500 must match the “amount billed” on the EOMB.

• Each CMS-1500 claim must be totaled with accompanying EOB attached.

• When submitting your Medicare claims for payment, the writing should be legible. In addition, when attaching a copy of the Medicare EOMB make sure it is clear and that the entire EOMB, including the information on the top and the glossary is included on the copy. In order for KDP to pay for co-insurance and deductibles, the CMS-1500 and the Medicare EOMB must be submitted.

Claims should be sent to the original claims address:
Kidney Disease Program
201 W. Preston Street, SS3
Baltimore, MD 21203

The Program will not accept computer-generated reports from the provider’s office as proof of timely filing. The only documentation that will be accepted is a remittance advice, Medicare/Third-party EOB, and/or a returned date stamped claim from the Program.

All claims should be mailed to the following address:

Department of Health and Mental Hygiene
Kidney Disease Program
201 W. Preston Street, Room SS3
Baltimore, MD 21201 

Single carrier TPR codes

Single carrier TPR codes

UD Service under deductible
NC Service not covered by insurance policy
PN Patient not covered by insurance policy
IC Insurance coverage canceled/terminated
IL Insurance lapsed or not in effect on date of service
IP Insurance payment went to policyholder

Box 17 - 23 - How to file the claim - CMS 1500

Middle section of CMS 1500 form

Box 17a - Optional

Referring Provider Number

�� Enter the six (6)-or nine (9)-digit DHS provider number of the referring provider.
�� Beginning 12/09/2008, newly enrolled providers will have a 9-digit provider number.
�� This may be required if the client has a Primary Care Manager (PCM) or the service requires a referral (e.g., Physical Therapy, Occupational Therapy or Speech Therapy).

Where to enter NDC number and anesthsia service in CMS 1500

Supplemental Information

* More than one supplemental item can be reported.
* Enter the first qualifier and number/code/information.
* After the first item, enter three blank spaces and then the next qualifier and number/code /information.
* The following three slides are examples of different types of supplemental information.

How to enter supplemental information on BOX 24

Supplemental Information

Box 24A - 24H

�� DMAP accepts the following types of supplemental information that can be entered in the shaded line across box 24A through box 24H:

• Anesthesia duration in hours and/or minutes with start and end times
• Narrative description of unspecified codes
• National Drug Codes for drugs
• Vendor Product Number
• Health Care Uniform Code, formerly Universal Product Code
• Contract rate

�� The following qualifiers are to be used when reporting these services:

Qualifier                     Description
7                                 Anesthesia
ZZ                              Narrative description of unspecified codes
VP                              Vendor Product Number
OZ                             Health Care Uniform Code
CTR                          Contract rate
N4                             National Drug Code, also use the following:
F2                              International unit
GR                             Gram
ML                            Milliliter
UN                            Unit 

CMS 1500 - points to remember

Claim form billing instructions - CMS 1500

Overview


This step-by-step presentation is intended to provide information to assist those who bill the Division of Medical Assistance Programs (DMAP) for Medicaid services complete the 08/05 CMS 1500 billing form correctly the first time. If applicable, this presentation is to be used in conjunction with General Rules, provider guidelines and supplemental information.