TMA asked the Texas Department of Insurance (TDI) for its interpretation of the correct way to complete clean CMS-1500 claim forms in the following three scenarios involving blocks 14 and 15.
Block 14 - Date of current illness, injury, or pregnancy
Block 15 - First date of previous, same, or similar illness
1. Most claims contain more than one ICD-9 diagnosis code in block 21, as the form allows up to four diagnoses per claim. When those diagnoses are for unrelated conditions, neither the statute nor the regulation provides guidance as to which diagnosis code, and its related dates, is correct and most appropriate for blocks 14 and 15 of the claim in question.
SCENARIO: A patient with chronic conditions makes quarterly visits to the physician. During each encounter, the physician evaluates all conditions, such as diabetes, hypertension, and chronic obstructive pulmonary disease. The medical office can submit only one claim form because there is only one charge, the office visit. The regulations are not clear as to which diagnosis should be the basis for completing blocks 14 and 15.
2. Physicians who do not have direct patient contact or the opportunity to question patients (e.g., pathologists, radiologists, anesthesiologists, and clinical laboratories) have no way to obtain the information required for blocks 14 and 15.
SCENARIO: A cardiologist who only reads inpatient electrocardiograms (EKGs) never actually sees patients and must depend upon the hospital patient records for insurance billing information, which is usually limited to the information on the patient's insurance card. This physician performs hundreds of these services within any given week. Under the current rules, the physician is required to complete blocks 14 and 15, even though he or she may not have access to the necessary information.
3. Preventive medicine procedures are services performed absent any signs or symptoms.
SCENARIO: A physician performs a preventive medicine procedure such as a routine physical, flu shot, cancer screening, or well-woman exam. No "illness or injury" date exists to be reported on the claim form, yet the fields are required.
According to TDI, physicians must complete blocks 14 and 15 - unless the contract between the physician and health carrier states otherwise - even when (1) patients present with multiple conditions that may have begun on different dates; (2) physicians or their staff do not have direct contact with the patient; or (3) patients receive preventive services absent any symptoms or signs of illness. Physicians should ascertain whether their contracts, claims filing manuals, claims filing instructions, or clean claim element notices provide instructions regarding how to fill in blocks 14 and 15 under these scenarios. Absent such direction, says TDI, physicians must rely on patient information presented at the time of the office visit, test, or treatment.
- When a patient presents with multiple conditions that may have begun on different dates, the physician may list the onset date of the primary condition that initiated the visit or treatment.
- Physicians who do not have direct access to the patient may use information from medical records to complete blocks 14 and 15. For example, the cardiologist reading the EKG should have access to the chart and be able to obtain the necessary information. Or, the technician performing the EKG could ask the patient for this information and note it in the patient's medical record. If a specialist or technician is unable to obtain this information from either direct contact with the patient or the patient's medical record, the physician may enter the date of the test or procedure that he or she is evaluating.
- When the physician provides preventive care and no illness is discerned, he or she may list the date of the service to complete blocks 14 and 15.
Go to the TMA Web site for additional information on how to file a clean claim. If you have questions about completing the CMS-1500 form, contact the TMA Knowledge Center at (800) 880-7955 or knowledge[at]texmed[dot]org .
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