Claim Information (SAMPLE)

Medicare: 
or ZIP Code: 
Claim ID: 
Claim Date:  ...
Patient Gender: 
Birth Date:  ...
or Age: 
Diagnosis Codes:
1: 
2: 
3: 
4: 
5: 
6: 

Claim Procedures

Line 1  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Line 2  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Line 3  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Line 4  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Line 5  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Line 6  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Line 7  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Line 8  (These lines do not need to correspond with the line #s on your claim form.)
POS: 
Procedure Code:
From: ...
To: ...
Units/Days:
Modifiers:
1: 
2: 
3: 
4: 
Diagnosis Codes:
Primary: 
Secondary 1: 
Secondary 2: 
Secondary 3: 
Tools:

Results:     Ok     Info     Warning     Error   

Claim Level
Error
Usage Validation
Diagnosis not typically reported for males, Code: 628.9
Warning
Usage Validation
Diagnosis should be billed with additional diagnosis code, Code: 573.1, Additional Code: 0748;075;0785
Error
Code Validation
Diagnosis is truncated, Code: 812.0
Line 1  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: J3420  Diagnosis: 266.2  Units/Days: 1
OK
OK
No known issues detected for this Line.
Info
Medical Necessity
Valid medical necessity
Line 2  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: 20600  Diagnosis: 266.2  Units/Days: 1
OK
OK
No known issues detected for this Line.
Info
Medical Necessity
Valid medical necessity
Line 3  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: 99396  Diagnosis: V70.0  Units/Days: 1
Error
Medical Necessity
Never covered procedure according to coverage decision - Source: 2011 Physician Fee Schedule #2011 MPFSDB
Error
Usage Validation
E/M procedure must be billed with modifier 25 when billed on same date as significant procedure, Code: 99396
Error
Usage Validation
Procedure not typically reported outside of custom age range, Code: 99396
Line 4  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: 64483  Diagnosis: 573.1  Units/Days: 1
Error
Correct Coding
CCI: 64483 is component of 20600, override modifier not found
Error
Correct Coding
CCI: 64483 is mutually exclusive of 62311, override modifier not found
Error
Usage Validation
Diagnosis is secondary only, Code: 573.1
Warning
Medical Necessity
Procedure has warning in coverage decision, "COVERED 3 INJECTIONS PER 60 DAYS.DO NOT REPORT IN CONJUNCTION WITH 77003." - Source: Blocks and Destruction of Somatic and Sympathetic Nerves #J3 CB2006.02 R3
Warning
Medical Necessity
Procedure has frequency restrictions in coverage decision, Frequency:3,60,D - Source: Blocks and Destruction of Somatic and Sympathetic Nerves #J3 CB2006.02 R3
Line 5  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: 62311  Diagnosis: 812.0  Units/Days: 1
Error
Correct Coding
CCI: 62311 is component of 20600, override modifier not found
Warning
Medical Necessity
Procedure has warning in coverage decision, "COVERED FOR A SERIES OF 3 INJECTIONS WITHIN 6 MONTH PERIOD." - Source: Injection of Spinal Canal #J3 CB2006.52 R6
Warning
Medical Necessity
Procedure has frequency restrictions in coverage decision, Frequency:3,6,M - Source: Injection of Spinal Canal #J3 CB2006.52 R6
Error
Medical Necessity
Procedure not covered for diagnoses according to coverage decision - Source: Injection of Spinal Canal #J3 CB2006.52 R6
Line 6  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: 11201  Diagnosis: 628.9  Units/Days: 2
Error
MUE Validation
Units greater than MUE maximum for procedure, Code: 11201
Warning
Medical Necessity
Procedure has warning in coverage decision, "REMOVAL OF BENIGN SKIN LESIONS COVERED WHEN ONE OR MORE OF THE FOLLOWING IS PRESENT: BLEEDING, INTENSE ITCHING, PAIN, INFLAMMATION, OBSTRUCTS ORIFICE, CLINICALLY RESTRICTS VISION, UNCERTAINTY AS TO LIKELY DIAGNOSIS, SUBJECT TO RECURRENT PHYSICAL TRAUMA. ICD-9 DX 701.1 SHOULD BE USED TO INDICATE SYMPTOMATIC, PAINFUL, AND/OR INFLAMED LESIONS ONLY. WHEN USING DX 701.4 OR 702.11 REFER TO DOCUMENTATION REQUIREMENTS SECTION FOR QUALIFYING CRITERIA. DX 238.2 SHOULD BE USED TO INDICATE KERATOACANTHOMA; SOME CONDITIONS REQUIRE SECONDARY DX V49.89 FOR COVERAGE." - Source: Skin Lesion Removal (Includes AK and Excludes MOHS) #J3 CB2006.93 R6
Error
Medical Necessity
Procedure not covered for diagnoses according to coverage decision - Source: Skin Lesion Removal (Includes AK and Excludes MOHS) #J3 CB2006.93 R6
Error
Usage Validation
Add-on procedure is missing base procedure, Code: 11201
Line 7  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: A0429  Diagnosis: 573.1  Units/Days: 1
Error
Usage Validation
Diagnosis is secondary only, Code: 573.1
Warning
Medical Necessity
Procedure is identified as permissive - Source: Ambulance Fee Schedule - Medical Conditions List and Instructions #Transmittal 1185, CR 5442
Error
Medical Necessity
Procedure not covered for diagnoses according to coverage decision - Source: Ambulance Fee Schedule - Medical Conditions List and Instructions #Transmittal 1185, CR 5442
Line 8  (These lines do not need to correspond with the line #s on your claim form.)
      Date: 01/01/2011  POS: 11  Procedure: 90799  Diagnosis: 573.1  Units/Days: 1
Error
Code Validation
Invalid procedure for dates of service, Code: 90799 - Effective Date: 01/01/1990 Termination Date: 12/31/2005
Error
Usage Validation
Diagnosis is secondary only, Code: 573.1
Info
Medical Necessity
Valid medical necessity