CMS-1500 claims data reporting requirements

We must capture certain data to meet Center for Medicare & Medicaid Services (CMS) encounter-reporting requirements. Refer to CMS-1500 (08/05) Required Fields (PDF) for field designations when reviewing the following requirements.

CMS holds physicians responsible for the accuracy of the information coded on a claim or bill. Kaiser Permanente Medicare Advantage claims are subject to all Medicare billing requirements. In addition, they must include the data elements outlined below.

Note: CMS prohibits defined-network plans from changing information on provider claims. Kaiser Permanente must return your claim for correction if the claim has missing, incomplete, or incorrect data, which could delay your payment.

You must be able to support any data on a claim with documentation from the member's medical record:

• If the interpreting physician has confirmed a diagnosis based on test results, they should document and code that diagnosis. You may report the signs and symptoms that prompted the order as additional diagnoses if they are unrelated to the confirmed diagnosis.
• If the diagnostic test is normal or does not provide a diagnosis, the interpreting physician should code the signs or symptoms that prompted the order for the study.
• If the results of the diagnostic test are normal or do not provide a diagnosis and the referring physician's diagnosis included words that indicated uncertainty, the interpreting physician should report the signs or symptoms that prompted the study. Do not code the referring diagnosis in this instance.
• When a diagnostic test is ordered in the absence of signs or symptoms, the interpreting physician should report the reason for the test (for example, screening) as the primary ICD-10-CM diagnosis code. The results of the test may be coded as additional diagnoses.
• The interpreting physician may report unrelated and coexisting conditions or diagnoses as additional diagnoses.

Modifiers

Use the following modifiers in the situations as indicated.

Modifier 25

Append only to Evaluation and Management (E/M) codes.

Modifier GW

Use with CPT codes when services are not related to a hospice patient's terminal condition. (Medicare B News, Issued Jan. 27, 2006)

Modifier GV

Use after each procedure code billed by a hospice attending physician to indicate "Attending physician not employed or paid under agreement by the patient's hospice provider" when billing the services furnished for the treatment and management of a hospice patient's terminal condition.

Modifier Q5

Use when a member of a physician group provides a service related to a hospice patient's terminal illness on behalf of another group member who is the designated attending physician for that patient.

Modifier Q6

Use if a locum tenens or another physician who is not a member of the group provides a service. The designated attending physician would bill using this modifier.

In the above instances, the designated attending physician would bill using modifier GV in conjunction with either modifier Q5 or Q6.

Modifier AT

Use when providing acute spinal manipulation for a Medicare patient. Billing without this modifier indicates the service is maintenance therapy.

Home health and hospice

You must have a home health or hospice agency National Provider Identifier (NPI) in field 23 if you bill with the Care Plan Oversight code (CPT-4 code 99375).

When submitting a claim using any of the above modifiers, the hospice-elected attending physician's NPI must be used on the claim or the claim will be denied. If our software detects unbundled services, we will return your claims for correction and resubmission because CMS will not allow us to modify claims. We cannot add the correct bundled code for these services.

Durable medical equipment

You must have referring provider's National Provider Identifier (NPI) in form locator 17b on the CMS 1500.