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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

HCFA Boxes - Step by Step

NOTE - For my assistant's services, make sure to change Box 25, Box 32 and Box 33.

These are my notes from the general guidelines for Completion of the HCFA-1500 Claim Form

BLOCK 1 - (Almost) Always Group Health Plan - Exception is COBRA plans??? which are Other?

BLOCK 1A INSURED'S I.D. NUMBER - Subscriber Iq

BLOCK 2 PATIENT'S NAME - Enter the patient's last name, first name, and middle initial, if any, exactly as shown on the patient's Medicare card.  For services for the baby within the first 30 days (typically covered under mother's plan), can put LastName (BABY), First Name MI

BLOCK 3 PATIENT'S BIRTH DATE AND SEX - Enter the patient's birth date (MMDDCCYY) and sex.

BLOCK 4 INSURED'S NAME - can be "SAME"

BLOCK 5 PATIENT'S ADDRESS - If the patient has an unlisted telephone number or does not have a telephone number, enter 000-000-0000.

BLOCK 6 PATIENT RELATIONSHIP TO INSURED

BLOCK 7 INSURED'S ADDRESS - can be "SAME" or empty if BLOCK 4 is "SAME"

BLOCK 8 PATIENT STATUS - straightforward

BLOCK 9 OTHER INSURED'S NAME - for Medigap policy, (Almost) Always Blank
All sub-blocks also left blank.

BLOCK 10A THROUGH 10C IS PATIENT'S CONDITION RELATED TO: - straightforward

BLOCK 10D RESERVED FOR LOCAL USE - for Medicaid (MCD) policy, (Almost) Always Blank

BLOCK 11 INSURED'S POLICY, GROUP OR FECA NUMBER - REQUIRED -

Completion of blocks 11B-C are conditional for insurance information primary to Medicare.
I THINK this means that if Medicare isn't involved, then these can be left blank, but not sure.

BLOCK 11A INSURED'S DATE OF BIRTH - Enter the insured's birth date (MMDDCCYY) and sex, if different from block 3.

BLOCK 11B EMPLOYER'S NAME OR SCHOOL NAME - Can be left blank if Medicare not involved.

BLOCK 11C INSURANCE PLAN NAME OR PROGRAM NAME - Can be left blank if Medicare not involved.

BLOCK 11D IS THERE ANOTHER HEALTH BENEFIT PLAN - straightforward

BLOCK 12 PATIENT OR AUTHORIZED PERSON'S SIGNATURE - can use "SIGNATURE ON FILE" without a date. [NOTE - many people seem to think it's essential that the dates in BLOCK 12 and BLOCK 31 be the same, and they seem to be the date the form was completed.  Not sure why.]

BLOCK 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE - Can be left blank if Medigap not involved and insured SAME as patient???

BLOCK 14 DATE OF CURRENT ILLNESS - Enter the six - digit LMP date (MMDDYY) and then LMP in the space on the right of the box.

BLOCKS 15-19 - Leave blank

BLOCK 19 RESERVED FOR LOCAL USE - This is where you might enter "Planning Homebirth" or "Homebirth" for the 659.8? codes.
For longer narratives, you can attach a separate sheet of paper.

Unlisted Drug Codes
Enter the drug's name and dosage when submitting a claim for a "not otherwise classified" (NOC) drugs.

Unlisted procedure code or not otherwise classified (NOC) codes
Enter a coherent description of an unlisted procedure code or not otherwise classified (NOC) code or a "not otherwise classified" (NOC) code if one can be given within the confines of this box. Otherwise an attachment must be submitted with the claim.

Modifier 99
Enter all applicable modifiers when modifier 99 (multiple modifiers) is entered in block 24d. If modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a modifier 99 should be listed as follows: 1= (mod), where the number 1 represents the line item and "mod" represents all modifiers applicable to the referenced line item.

BLOCK 20 OUTSIDE LAB - "Check "No"

BLOCK 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Enter the patient's diagnosis/condition. All physicians must use an ICD-9-CM diagnosis code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition).

All narrative diagnosis codes must be submitted on an attachment.
The International Classification of Diseases, Clinical Modification (ICD-9-CM) is the coding system which must be used.

BLOCKS 22-23 - Leave blank

BLOCK 24A DATES OF SERVICE

Enter the six or eight - digit date (MMDDYY) (MMDDCCYY) for each procedure, service, or supply. When "from" and "to" dates are shown for a series of identical services, enter the number of days or units in column G; only report a range by month, do not combine months in a range date.

Completion of this field is required for all claims; all lines of service.

When you're billing Standby Services for your assistant to the baby, you can omit the FROM date if it occurred before the date of the baby's birth, because otherwise, their system will choke on it.

BLOCK 24B PLACE OF SERVICE

BLOCK 24C TYPE OF SERVICE - Leave blank

BLOCK 24D PROCEDURES, SERVICES, OR SUPPLIES

Enter the procedures, services or supplies using the HCFA Common Procedure Coding System (HCPCS). When applicable, show the correct HCPCS modifiers with the HCPCS code.

Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in block 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim.

BLOCK 24E DIAGNOSIS CODE

Enter the diagnosis code reference number as shown in block 21, to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; either a 1, or a 2, or a 3, or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnoses in block 21. [Everyone I know uses multiple diagnoses per line item!]

BLOCK 24F ($) CHARGES - straightforward, except that for multiple units, you put the total here, i.e. # units times charge per unit

BLOCK 24G DAYS OR UNITS - This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered. - If you use more than 1 units, you put the multiplied charge in Block 24F, e.g. if you have 4 units of 99355 at $180, then you would put $720 in Block 24F.
    * For units of portable contents only (i.e., no stationary gas or liquid system used) round to the nearest five feet or one liquid pound, respectively.

Completion of this field is required for all claims; (all lines of service).

BLOCK 24H EPSDT FAMILY PLANNING - Leave blank

BLOCK 24I EMG - Leave blank

BLOCK 24J COB - Leave blank

BLOCK 24K RESERVED FOR LOCAL USE - Leave blank for solo practice

BLOCK 25 FEDERAL TAX ID NUMBER - straightforward

BLOCK 26 PATIENT'S ACCOUNT NUMBER - straightforward and OPTIONAL - use the same one for mother and baby, to avoid confusion

BLOCK 27 ACCEPT ASSIGNMENT - Can be left blank if Medigap not involved.

BLOCK 28 TOTAL CHARGE - Required

BLOCK 29 AMOUNT PAID - Required (i.e., amount paid or "$0.00")

BLOCK 30 BALANCE DUE - Can be left blank?

BLOCK 31 SIGNATURE OF THE PROVIDER OF SERVICE AND (OR) SUPPLIER INCLUDING DEGREE OR CREDENTIALS

Enter the signature of the provider of service and (or) supplier, or his representative, and the six - digit date (MMDDYY) the form was signed.

Completion of this field is required for all claims.

Not sure whether this is really necessary - can be "SIGNATURE ON FILE", but what about date?

BLOCK 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED - if other than home or office.  MUST complete this if care was provided in a hospital setting, e.g. labor support or transports!  Otherwise, probably best left blank.

BLOCK 33 PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER
Enter the physician's individual/group or or supplier's billing name, address (physical location, NO P.O. Boxes), ZIP code, and telephone number.
Individual Provider - Enter the carrier assigned PIN# preceded by the two alpha characters (Not the HCFA assigned UPIN) for the performing physician or supplier who is not a member of a group practice.