Cms150 Case Study

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You would have all of the patient's demographics.
Guarantor information, assignment of benefits form. Employment, Primary insurance, secondary insurance information.
Physician name, address, NPI number,
Diagnosis, procedures and ICD 10-CM, CPT, or HCPCS, Modifiers, codes.
Super bills, if you work in physician's office, that would give you what the physicians charged for the encounter.

Compare and contrast the information for the CMS1500 and the UB04:
The CMS1500 is an outpatient billing form it is used in a physician's office, emergency room encounters.
“The form was developed by the Centers for Medicare and Medicaid Services (CMS) to facilitate the process of billing by easily arranging diagnoses and services provided that were necessary to treat patients”.

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Need accurate coding, billing, all of the patient information, Member ID correct primary insurance and secondary insurance, additional forms if medical necessity.
Prompt reimbursement of charges form needs to be in within 30 days.

Discuss how reimbursement differs for inpatient versus outpatient, what is it based on? Three basic reimbursement methods are used for inpatient hospital services:
1. Prospective payment system was initiated by Medicare, which established payment rates to hospitals prospectively, which means before services are rendered.
2. Fee for service is the oldest method for which actual charges rendered to the patient are paid if found to be medically necessary. This is based on the diagnosis as related to the treatment rendered the patient.
3. Per Diem this pays a fixed rate per day for all services performed or provided by the hospital facility. Outpatient reimbursement:
1. Ambulatory Payment Classification (APC) the services associated with a specific procedure or visit are bundled in the APC

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