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1 SHARP REES STEALY MEDICAL GROUP/SHARP HEALTHCARE Billing and Claim Payment Procedures December 2008 December 2008 of 93Ģ CONTENTS PREFACE 3 CLAIMS SCANNING 4 THE CMS 1500 CLAIM FORM 5 COMPLETION OF CMS 1450 FORM REQUIRED DATA 57 EDI REPORTS 60 ICD-9-CM DIAGNOSTIC CODES 64 CPT PROCEDURE CODE DEFINITTION 65 CLAIMS EDITING SYSTEM 66 MODIFIERS AND PAYMENT RULES 67 ELIGIBILITY-CALIFORNIA HEALTH & SAFETY CODE BALANCE BILLING 70 DUPLICATE BILLING 70 TRACER CLAIMS 71 PROOF OF TIMELY FILING TIPS 71 AB 1455 TIME LIMITS AND MEASUREMENTS 72 MEDICAL RECORD DOCUMENTATION 77 PROVIDER DISPUTE RESOLUTION 79 OVERPAYMENTS 81 PUBLICATIONS 82 FRAUD AND ABUSE 84 WHERE TO FIND THE ANSWERS 85 APPENDIX A: THE INTERNET APPENDIX B: FORM APPENDIX C: PLACE OF SERVICE CODES APPENDIX D: GLOSSARY OF TERMS December 2008 of 93ģ PREFACE This billing guide is intended to serve as a useful guide to facilitate billing and understand claim payment The guidelines set forth in this manual are industry standard guidelines from Medicare, AMA and specialty associations.