All 1500 Boxes and where they pull from

 The drchrono system will pull data from a patient’s chart to populate CMS 1500 forms. The following is a guide identifying which fields the data will be pulled from. 

Essential Background Information 

For an individual appointment, you can generate a CMS 1500 form by clicking on the appointment and going to the “Billing” tab at the top. In the top right corner of this window, we can click “Other Forms” and select the first option, HCFA/1500.

Figure 0

Screen_Shot_2017-12-20_at_3.55.24_PM.png

The CMS 1500 will update dynamically based on the “Payment Profile” field.

Figure 1

Screen_Shot_2018-03-14_at_1.04.00_PM.png

This will direct the system to pull data from the corresponding Insurance item under the “Insurances tab” under the “Demographics” section in the patient chart:

Figure 2

fig_2.png

(Please note that alongside “Insurances” there are various blue “tabs,” one of which is labelled “Demographics.” I will refer to this item as the “Demographics tab,” which exists within the Demographics section.)

1500 items:

Carrier Block - Under Account > Account Settings > Billing > HCFA/CMS-1500, the first checkbox says “Payer Address.” If this box is checked, the Carrier Block will pull address data from the insurance information in the patient chart. 

Box 1 - The checkbox will update based on which payer is selected in “Insurance Company” in the patient chart. Box 1a will pull data from the “Insurance ID Number.”

Figure 3

fig3.png

Box 2 - Data pulls from First Name and Last Name fields, found under “Important” tab in the patient chart. 

Box 3 - Data pulls from “Patient Date of birth” and “Patient Sex” fields, found under Demographics tab in the patient chart. 

Box 4 - In Figure 3, there is a checkbox called “Subscriber is the Patient.” If this is selected, nothing will appear in Box 4. If it is de-selected, “Subscriber” fields will appear below “Primary Insurance Notes” on the page, allowing you to enter subscriber information.

Figure 4

fig4.png

Box 5 - Address information is found in the Demographics tab. Relevant fields are “Street Address,” “Zip Code,” “City,” “State” 

Phone number pulls from the “Important” tab. (The system will prioritize the “Cell Phone” field, then the “Home Phone” field, then the “Office Phone” field.) 

Box 6 - Pulls from “Patient relationship to the Subscriber” in the “Insurances” tab (Figure 4) 

Box 7 -  Subscriber address information, as shown in Figure 4, comes from the “Insurances” tab. Relevant fields are “Subscriber Address,” “Subscriber Zip Code,” “Subscriber City,” “Subscriber State” 

Box 8 - this box is reserved for NUCC use 

Box 9 - If there is information under Secondary Insurance for the patient, this box will display the Subscriber’s name. 

9a - displays whatever information is entered under “Insurance Group #” in the Secondary Insurance under the “Insurances” tab. 

9b - this box is outdated and reserved for NUCC use 

9c - WORKER’S COMP - displays data from Employer under the “Demographics” tab. 

9d - displays whatever information is entered under “Insurance Company” in the Secondary Insurance under the “Insurances” tab. 

Box 10 - Items A, B, C in this Box will update automatically based on the “Payment Profile” of the appointment (figure 1) but can be manually edited using the Yes/No fields dedicated for this item:

Figure 5 - Click on the Appointment, then go to the Billing tab

fig5.png

Auto Accident - Go to the Insurances section (Figure 3), click Auto Accident, and look for "Auto accident state of occurrence"

10d - this box is reserved for NUCC use 

Box 11 - The information here pulls from the “Insurance group number” field in the Primary Insurance under the “Insurances” tab. 

11a - Pulls from “Patient Date of Birth” in Demographics if the patient is the subscriber. If not, Subscriber DOB is used

11b - this box is reserved for NUCC use 

11c - Depending on the relevant insurance information for the appointment, this box will display what is in “Insurance Company” for Primary or Secondary Insurance, “Auto Accident Company” for Auto Accident, or “Insurance Provider” for Worker’s Comp 

11d - This box will be marked as “Yes” if the Primary Insurance is being used and there is data under Secondary Insurance 

Box 12 - Under the Demographics tab, the second to last item is “Signature On File.” If “Consent on File” is selected in this field, the box will display “Signature on File.” The date will auto-populate when the 1500 is generated. 

Please note that this field will automatically update to "Consent On File" if the patient has signed the HIPAA Data Use Agreement when checking in on the Check In app or onpatient.com 

Box 13 - For Auto Accident, if you de-select the checkbox “Claim representative is the insurer” in the Insurances tab and enter data for the Claim Representative in the subsequent fields, this Box will display “Signature on File.” 

Box 14 - This box pulls from the Onset Date fields shown in Figure 5. 

Box 15 - This box pulls from the Other Date fields shown in Figure 5.

(These two items can also be edited in the Insurances tab, under Primary Insurance, below the HCFA Options header) 

Box 16 - Currently drchrono does not support filling out Box 16, as it is not required for claims. 

Box 17 - This box pulls from information found in the Demographics tab, under “Referring Doctor.” The fields “Referring Dr. First Name” and “Referring Dr. Last Name” will be used, and the identifier DN will be applied. If no information is available under “Referring Doctor,” information found under “Ordering Doctor” will be used instead, and the identifier DK will be applied.

17a - This item pulls from the fields “Referring Dr. Qualifier” and “Referring Dr. Number” under “Referring Doctor.” The identifiers for this item are as follows, and come from the selection in “Referring Dr. Qualifier:” 

0B State License Number
1G Provider UPIN Number
G2 Provider Commercial Number 

17b - This item pulls from “Referring Dr. NPI Number,” or if no Referring Dr. data is  present, “Ordering Dr. NPI Number.”

Supervising provider information can be shown by marking off “Display the claim's supervising provider in box 17.” (Figure 6) This option can be found in Account Settings > Billing. Selecting this option will cause box 17 to pull data from the supervising provider’s information, once a supervisor is selected in the Appointment details. Relevant information for that supervising provider is “First Name,” “Last Name,” and “Rendering Provider NPI” - this information will be pulled from that provider’s drchrono Account Settings.

 

Figure 6 - Go to Account > Account Settings > Medical Billing

fig6.png


***Please note that Box 17 will not update if the demographics of the patient chart are updated AFTER the appointment is scheduled.***

If you need to update this box after the appointment is scheduled, we need to get to the “Billing Details” of an appointment. Access this screen by clicking “Billing Details” next to the “Other Forms” button we use to generate 1500s (see Figure 0) For the items in Box 17, click on the pencil icon next to “Providers” (Figure 7, Red Box)

Figure 7 - Billing Details

fig7.png



Box 18 -  Data can be entered in this box only if the Place of Service is 21 or 22. (See Box 24b / Figure 9 for information on how to edit Place of Service.) If the appointment is scheduled in an office using Place of Service 21 or 22, “Hospitalization Info” will appear in Billing Details (Figure 7, Orange Box) 

Box 19 - This box pulls from Billing Details, on the “EDI Billing Note” This text box is fully customizable and allows for manual entry of anything you need. (Figure 7, Yellow Box) 

Box 20 - Box 20 will be updated to Yes if there is anything entered into the “Purchased Serv Provider” field (Figure 7, Green Box), which can be edited by clicking the corresponding pencil icon.

The last item in the box which comes up is “Charge Amount,” where a charge for using outside labs can be added. 

Box 21 - Any ICD codes applied to the appointment will display here in the order they are entered. The “ICD Ind.” will also update with a “9” or “0” to represent if ICD-9 or ICD-10 is being used. 

Box 22 - This box pulls from the “Claim Type” and “ID of original claim” fields found in Billing Details. (Figure 7, Light Blue Box). If “Re-submission” is selected, bill frequency code 7 will be used, whereas if “Void claim” is selected, code 8 will be used. 

Box 23 - In Billing Details, the field “Payer pre-auth #” (Figure 7, Blue Box) can be edited to fill in this box.

(This item will also be shown under Appointment > Billing as “Pre Authorization Approval #”. Note that Box 18 and 19 can also be edited here.) 

Box 24 - This Box will display procedure codes associated with the appointment 

Box 24a - The dates of service for each individual code. By default, the From and To date will display the date of the appointment. If further specification is needed for each code, you can go to Billing Details and modify the “Service Date” field.

Figure 8 - Billing Details, Coding section

fig8.png

Box 24b - Place of Service will pull from the Office Details of the office in which the appointment was scheduled. This item can be specified on a per-office basis by going to Account > Offices, and clicking “Edit” on the office you wish to specify. On the resulting “Edit Office” page, click on the blue “Billing” tab (See Figure 9). The second item on this screen is “Facility Code.” By default, it will be 11 - Office, but it can be changed to anything you need.

 

Figure 9 - Go to Account > Offices > Edit > Billing tab

fig9.png

 

Box 24c - In the appointment’s Billing Details, the item immediately below “ID of Original Claim”  is labelled “Emergency Service” (Figure 7, Purple Box). If Yes is selected, a “Y” will display in Box 24c. 

Box 24d - This box will display the code identifier for any CPT or HCPCS codes attached to the appointment, and corresponding modifiers for these codes. 

Box 24e - This box will display any Diagnosis Pointers entered for any codes in lowercase letters. The letters correspond to diagnosis codes entered in box 21. 

Box 24f - Any charges entered in the “Price” box will display in Box 24f. Base prices will be multiplied by values entered in the “Quantity/Minutes” field for each code. 

Box 24g - This box will display the value entered in “Quantity/Minutes” for each code. 

Box 24h - This box pulls from the “EPSDT Services” field in the patient chart, in the Demographics tab. This field is applied on a per-patient basis. 

Box 24l - This box will remain static with the NPI identifier 

Box 24j - This box will display the NPI of whichever provider is attached to this appointment. The provider can specify their NPI number by going to Account > Account Settings > Billing (Figure 6), and entering data into the “Rendering Provider NPI” field.

 

Shaded Areas of Box 24 - NDC codes attached to the appointment and corresponding data will display in the shaded area above each line item.

 

Box 25 - By default, this box will display data that is entered in the “Practice Tax ID” field found in Account > Account Settings > Billing. However, as shown in Figure 6, there is a checkbox which reads “Mark the SSN checkbox instead of the EIN checkbox in Box 25.” If there is an SSN on file for your drchrono account, you will see that displayed in Box 25 when that checkbox is checked. 

  • If you check off the checkbox and Box 25 does not update accordingly, this means that we at drchrono do not have your SSN on file. To resolve this, please contact support by submitting a ticket at drchrono.com/help 

Box 26 - The Patient Account number in this box is automatically generated from the drchrono system. 

Box 27 - This box can be updated on a per-payer basis by going to Billing > Insurance set up, and deselecting the “Accept Assignment” box.

Figure 10 - Billing > Insurance Set Up > “Edit” Icon

fig10.PNG

Please note that in Figure 10, many of the items previously discussed can be overwritten on a per-payer basis.

Box 28 - This box will calculate the sum total of charges in box 24f. 

Box 29 - This box will update as patient payments are logged into the system, only if Box 27 is marked as “No.” Patient payments can be logged in Appointment Details > Billing. 

Box 30 - This field is reserved for NUCC use and will not populate data in drchrono. 

Box 31 - This box will pull data from fields under Account Settings > Profile for your drchrono account. Make sure that the account has the correct “First Name” and  “Last Name” fields entered here.

  • Under Account Settings > Billing (Figure 6) there is a checkbox which allows a user to toggle between writing out the full first name, or only using the first initial.  
  • The date in Box 31 will display whatever date the 1500 form was generated on. 

Box 32 - All of the information entered in this Box can be edited by going to Account > Offices, and clicking the “Edit” pencil icon for the office in which the appointment was scheduled.

The relevant fields are: “Office Name,” “Address,” “City,” “State,” and “Zip Code” 

Box 32a - By default, this box will display whatever data is on file for “Rendering Provider NPI,” found in Account Settings > Billing (Figure 6).

However, other information can be displayed here, by going to Account > Offices, clicking “Edit,” and then going to the blue “Billing” tab (Figure 9). The checkbox “Use facility NPI number in box 32a of CMS 1500 form” will allow data from the “Facility NPI number” field to display in box 32a.

Box 32b - By default, this box will not populate with data, but in Billing > Insurance Set Up (Figure 9), for each payer, there is a checkbox under “Edit Payer” which reads: “Send facility provider number.” If checked, data from the “Facility provider number” field (Figure 9) will display in Box 32b. 

Box 33 - By default, this box will populate based on what is entered in the “Practice Official Name” field, found in Account Settings > Billing (Figure 6). Further down on that page, however, there is a checkbox for “Box 33” which would allow you to use the doctor’s name instead. 

  • The Address and Phone number items will pull from Account > Offices, under the Basic tab on the Edit Office screen. If you click on the Billing tab (Figure 9), you will find a checkbox which states “Use alternate pay to address for HCFA.” Checking this box allows you to enter alternate data, which will then be displayed in Box 33.

Box 33a - By default this box will pull from the Billing NPI number in Account Settings > Billing (Figure 6), but this item can be overwritten in Account > Offices > Edit > Billing by entering data in the “Billing NPI number” (Figure 9)


Box 33b - By default, this box will not populate with data, but in the “Edit Payer” screen (Figure 10), the “Group Provider #” field can be used to populate data into this box.



For an in-depth explanation of the content of each box as it exists outside of drchrono, please use this guide as a reference: 

http://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02-v5.pdf

 

Was this article helpful?
0 out of 0 found this helpful
Have more questions? Submit a request

Comments

Powered by Zendesk