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Change Makes Sense – Part II
By Marianne Harper

Just as you thought you had it down pat and realized that filing dental procedures with medical carriers wasn’t really so difficult, I have to report that there is going to be a change. "Change" – the very word can strike fear in us. There is one thing in life, and in dentistry, that is a constant and that is change. So let’s make the most of this and work through the process. You will see that there is nothing to fear.

Medical claims have been printed on CMS-1500 forms for the past fifteen years. The form is actually called CMS-1500 (12/90). We are all aware of the many changes that have taken place in medicine in that time period. Add to that the requirements of HIPAA and you will, no doubt, realize that the manner in which we will be asked to communicate with insurance carriers through a claim form will have to be revised.

The new form is still be referred to as CMS-1500 but the update name is CMS-1500 (08/05). The primary impetus for the revision is HIPAA. As I am sure you are aware, all medical providers will be required to report their NPI (National Provider Identifier) on all claim forms. In order to accommodate for the HIPAA requirements, the form has to provide fields for entering this information. There are also some other changes that can make filing a little easier and I will discuss these toward the end of the article.

You may ask what the timeline is on this change. According to Ingenixonline, ‘as of January 2, 2007 all Health plans, clearinghouses and other information support vendors will be ready to handle and accept the revised form". Between that date and March 30, 2007, all providers will be allowed to file on either form as there will be a dual acceptability period. Effective with April 2, 2007, the older claim form will be discontinued and all claims will have to be reported on the revised form. Do not assume that the old form can be used if you are submitting a claim after that date but with a date of service prior to April 2, 2007. Resubmitted claims must be filed on the revised claim form. The only exception to these rules is for small health plans. They will be required to accept the revised form no later than May 23, 2008.

In addition to entering the provider’s NPI, you will also need to provide a referring provider’s ID number including the ID Qualifier. Your staff should obtain these numbers when the referral is made.

With the current version of CMS-1500 (12/90), providers have been entering either PINs (Provider Identification Numbers), UPINs Unique Physician Identification Numbers, OSCARs (Online Survey Certification & Reporting System numbers) or NSCs (National Supplier Clearinghouse numbers). They are commonly referred to as legacy identifiers. The CMS-1500 (08/05) has been revised to accommodate the NPIs, and the major change is that there are split provider ID fields. The split field is required to enable the reporting of the NPI and/or the legacy identifiers during the dual acceptability period.

Let’s look at the individual changes on the form:

  • Field 17 – The old form required the name of the referring physician with the referring physician’s ID number listed in 17a. The new field 17 still requires the name of the referring or ordering provider but 17a has been split in half length-wise and shaded while 17b is a new field in the lower half of field 17. Prior to May 23, 2007, either the legacy ID number can be placed in 17a, the NPI can be placed in 17b, or both can be entered. After that date, only 17b (the unshaded area) is to be used.
  • Field 24 - Field 24i and 24j on the old form have been changed. The revised form also has the area split length-wise with the top half shaded. 24i is titled ID Qualifier and this must be completed. As with field 17, the upper shaded area can be used until May 23, 2007 to provide for the rendering provider’s ID qualifier and legacy number. After that date, do not use the shaded section and only report the rendering provider’s NPI in the unshaded section.
  • Fields 32 and 33 – The revisions in these fields will allow for more detailed information on where services were rendered and where the provider of the service is located if different from where the service was performed (e.g. home health). You will still need to enter the provider’s or supplier’s billing name, address, and zip code. The telephone number needs to be placed at the top of the box with the area code in the parentheses. ID numbers and NPIs can be reported in field 32a and 32b. Providers of service will need to identify the supplier’s NPI when billing for purchased diagnostic tests. Field 33 also has the shaded and unshaded sections used for reporting the billing provider’s information. Again, the legacy number is entered in the shaded field 33a and/or the NPI in the unshaded field 33b until May 23, 2007 when only the NPI is required.

To simplify this process, just keep in mind the basic formula for these fields:

  • Shaded fields are for legacy numbers and unshaded fields are for NPIs.
  • Between October 1, 2006 and May 23, 2007 – either or both can be reported. After that date – only place NPIs in unshaded areas.

Let us now explore the other changes of which some will not even affect how you will fill out the form. They are as follows:

  • The barcode and words "PLEASE DO NOT STAPLE IN THIS AREA" were removed. There are other revisions to the form header but they are not significant enough to mention.
  • Field 1 - Tricare has been placed above Champus.
  • Field 21 – This field is still used for ICD-9 (diagnosis) codes. What has changed is the length of the lines after the decimal. These lines were extended to accommodate four bytes. Diagnosis codes are updated every year. The codes are becoming more complex with the result that many of the codes now have several digits beyond the decimal.
  • Field 24 – There are four significant changes to this field.
    1. The areas that are used to report procedure codes have been split length-wise with a shaded area at the top. This area will eventually be used to provide supplemental information. Do not use this area to report extra procedures.
    2. Field 24c used to be titled "type of service". EMG, that had been the heading for 24i, is now the title for 24c.
    3. Field 24d will still be used for CPT/HCPCS codes. The modifier area has changed and now allows for four sets of two bytes. This eliminates the need to split modifiers between multiple lines.
    4. Field 24e has had a change of name. It used to be titled "Diagnosis Code". It has now been changed to "Diagnosis Pointer". Nothing has changed in how to use this field; it just has a more accurate title.

Be advised that there are no grace periods after the May 23, 2007 effective date for NPI reporting. Claims filed without this information will be rejected and the rejection code will most likely be 16 that states "claim/service lacks information that is needed for adjudication" along with the rejection code that specifies the missing information.
If you do not already have your NPI, you can learn more about it and how to obtain it by visiting http://www.cms.hhs.gov/NationalProvidentStand/ on the CMS web site.

If you would like to see the changes made to the CMS-1500 form, they can be viewed at the National Uniform Claim Committee’s web site. You will be able to view the new form and get information on suppliers.

Now that you have this information, you will be able to file medical claims correctly once the changes become effective. You will be serving your patients’ needs by helping them obtain additional benefits from their health insurance plan for their medically necessary dental procedures. This can result in greater case acceptance for you.

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