Create Patient Claims
To create patient claims, select a Patient, then click the Create Claims tab.
To navigate the Claim entry screen, use the Tab key. The cursor will start at the Claim Entry Date field and will logically progress to each field as the Tab key is pressed.
Claim Information
When the claim screen is loaded, many of the fields may already be populated. Based on the patient demographics, these fields include:
· Rendering Provider
· Referring Provider
· Primary Payer
· Secondary Payer
· Facility
· Diagnosis
· Prior authorization number
If the patient demographic has not defined these fields, then you’ll need to select them each time a claim is created.
At a minimum, you should define the payers for each patient. When a new claim is created, the payer will be set to the Primary Payer. If the patient has Secondary, the secondary payer will be shown but MDC will initially send the claim to the Primary payer. After a primary payment or adjustment is applied to the claim, MDC will prompt you to send the claim to Secondary. If you click ‘Yes’, the ‘Send claim to’ option will be set on the Secondary Payer. See payments and adjustments for more information.
Navigating the Claim Screen
The claim screen is designed so that the cursor logically flows from one point to the next. Always use the Tab key on your keyboard to move the cursor from one point to the next.
Claim Entry Date: Enter the correct Claim Entry Date then press the Tab key. As soon as the cursor moves away from the Claim Entry Date, the Service Dates will automatically be set to the same date. This action will only occur the first time the cursor moves from the claim entry date. That is, if you move the cursor back to the Claim Entry date field, the Service Dates will not automatically receive the new date.
Provider: The Cursor moves to the Physician Field. If there is only one Physician in this practice, or if this Patient has a Primary Physician defined, then this field will already be selected. Otherwise, select the correct rendering provider.
Diagnosis: The cursor moves to the Diagnosis field. Enter the diagnosis codes for this claim. Up to four codes can be entered. Press the Enter key to retrieve a list of all diagnosis codes in your database. You can just type the first few characters of the code. MDC will automatically suggest the closest match and/or will scroll the popup list to the diagnosis code that’s been selected.
Service Date: The cursor moves to the Service Dates. Enter the appropriate service dates for this claim. Click for information on entering dates.
Procedure: The cursor moves to the Procedure field. Enter the appropriate procedure code for this claim. Press the Enter key to retrieve a list of all procedure codes in your database. You can just type the first few characters of the code. MDC will automatically suggest the closest match and/or will scroll the popup list to the procedure code that’s been selected.
Modifiers: The cursor moves to the Modifier field. Enter the modifiers for this line. If you need to enter multiple modifiers, separate the modifiers with a ‘-‘ character. For example, if there are 3 modifiers and they are 25, 50, and 01, enter the modifier as 25-50-01.
Modifiers can be inserted automatically if you have defined a modifier with the CPT code. See the section on creating Procedure codes. The modifier will be inserted immediately after the cursor leaves the Procedure field. This automatic action only occurs if the cursor has not already been in the modifier field. Once the cursor is moved to the modifier field, the automatic entry of the modifier is killed for that service line. If you use the Tab key to navigate to each field you will be assured that the cursor enters the procedure and modifier fields in the correct order.
Charge: The cursor moves to the Charge. Enter the appropriate charge for this procedure. This field can be automatically filled in by defining the correct charge for the selected procedure code. See Procedure codes for more information on defining the standard charge.
Units: The Cursor moves to the Units field. Enter the correct units. The Extended field will multiply the procedure charge and the units. The extended field is the field that will be transmitted to the claim form.
Regarding the Units calculation, you can turn on an option that will disable the automatic multiplication of the charge and the units. See the Edit Menu - Preference – HCFA Settings. When this option is turned on, you can optionally mark each claim service line so that the units are not considered when computing the extended amount.
When the option is on, you’ll notice another checkbox field (FX) in the claim entry section. Click the FX check box to fix the extended amount so that it is always equal to the Charge regardless of the number of units.
Fractional Units: If your claim requires fractional units, then you must use the FX button. For example if the number of units is 1.2 then you’ll need to click the FX button and manually enter the total charge in the charge field.
The cursor moves to the ‘T’ field. This field represents the ‘Type of Service’. This field is not transmitted to the claim form. There are a few internal uses of this field.
· X – disables the showing of this CPT on the claim form
· 9 – Type of service for counseling or professional services. When type of service code is ‘9’, box 32b and box 33b will use the secondary identification number for the selected payer. This rule will take precedence over any other rules for box 32b and box 33b.
After all procedures have been entered, click the Record Claim button.
|
CMS Form Information |
Field |
|
Entry Date |
Box 12, Box 31 |
|
Diagnosis |
Box 21 |
|
From/To Dates |
Box 24A |
|
Procedure |
Box 24D |
|
Mod (Modifiers) |
Box 24D |
|
Extended (Charge * Units) |
Box 24F |
|
TOS (Type of Service) |
N/A |
|
DX (Diagnosis Pointers) |
Box 24E |
|
Physician |
Box 31 |
|
Referring Physician |
Box 17 |
|
Facility |
Box 32 |
|
Admitted/Discharge Dates |
Box 18a, Box 18b |
|
Notes |
Box 19 |
|
Prior Authorization Number |
Box 23 |
|
Place of Service Code |
Box 24B |
Additional Claim data can be entered by clicking the arrow key to the right of the diagnosis pointer check boxes. If your screen resolution allows, this additional information will always be viewable.
|
CMS Form Information |
Field |
|
Patient Condition |
Box 10 |
|
Dates unable to work |
Box 16a, Box 16b |
|
Outside Lab / Charge |
Box 20 |
|
Assign |
Box 27 |
|
EMG |
Box 24C (n/a) |
|
EPSDT |
Box 24H |
|
Provider ID |
Box 24J** |
|
Current Illness |
Box 14* |
|
Similar Illness |
Box 15 |
* Box 14 will be automatically set to the earliest date found in the service date fields (Box 24A).
** You can manually type data in this field, however if you leave the field blank, MDC will automatically insert the correct data based on how you have setup this payer. Typically, this field will show the rendering provider NPI. You can also set up MDC so that you can select the rendering provider from a drop list. See the HCFA Settings screen. You may need this option if you have multiple rendering providers on the same claim.
All other Claim data is retrieved from the Patient Demographic database.
Patient Copay
If the Patient has made a Copay, you can apply this payment immediately with the claim. Enter the copay amount. If the copay check box is enabled, this means that this patients’ demographic has a copay defined. Just click the check box to automatically insert the copay. The copay will be recorded in the patient register as a Patient payment. The payment will be applied to the first line item of the claim form.
HCFA to be eFiled or Printed (Batch Processing)
Before recording the claim, you can check the HCFA to be eFiled/Printed button. This button is automatically checked if the claim is being sent to an insurance company. When this box is checked, the claim will be placed into a print queue so that it can be printed at a later time. You have the option of printing the claim immediately by clicking the Print Claim Form button.
When you print the claim form directly from this screen, the claim will print exactly as shown. This is useful if you need to print a claim form after it has been filed and after you have applied payments or adjustments. Normally, when a payment or adjustment is applied to a line item, that line item will no longer print on the claim form (unless the claim is being sent to secondary). Also, box 29 and box 30 will indicate payments and claim balance after a payment or adjustment is applied. This will be the case when you print claim forms from the Claims Print Queue. However, if you print the claim form directly from the claim screen, the claim will ‘print clean’ and print exactly as shown.
Deleting a Patient Claim
To delete a patient claim, select the claim using the Previous/Next buttons, then click the Edit Menu – Delete button. You cannot delete a claim if payments or adjustments have been applied to the charges on the claim.
Removing a Charge from a Claim
If the claim has multiple charges, and you only want to remove a particular charge, delete the item using the Patient Register.
Editing a Patient Claim
To edit a patient claim, use the Previous/Next buttons to select the claim that you wish to edit. Make the necessary changes then click the Update Claim button.
There are a number of other ways to go directly to a particular patient claim.
1. From the Patient Claims screen, pull down the Claim History list and select the claim
2. From the Patient Register, right click your mouse on a charge line and select Jump to this claim.
3. From the list of claims to print (File – Print Forms – Insurance Claim forms), right click on a claim and select Edit this Claim.
4. From the MDC Home, if the claim is in the print queue, open the Claims to Print tree and select one of the claims in the list. The selected patient/claim will load for review and edit.
When you are editing a claim, the claim number will flash indicating that you are currently editing a claim. When you are creating a new claim, this section of the screen does not flash and simply says ‘NEW CLAIM’.
Displaying Notes on a Claim
Notes on the claim form can be shown in either the shaded area of box 24 or in box 19.
To include notes in box 19, check the box that says ‘Show notes on Claim Form’ and type the notes in the ‘Notes’ section.
To include notes for the service lines in box 24 (shaded), check the box that says ‘SHOW IN BOX24’. In this case the Description for the procedure will be shown in the shaded area of box 24 directly above the service lines. You can change the Description if needed as the claim is being created. See HCFA Settings if you do not see the option to show notes in box 24.
Last Update: 02/20/2008