The CMS 1500 and the UB04 are two types of claims forms used to submit charges for reimbursement. The UB04 (also called CMS 1450) is mainly used for facility claims, such as hospitals, surgery centers, and nursing homes. They cover both inpatient and outpatient charges, along with any associated with diagnostics, supplies, and lab work. This forms shows the “resources used” by the facility. When this form is submitted electronically, it is called the 837-I, with the “I” standing for Institutional. The 1500 is used for professional billing, again both inpatient and outpatient. This form shows the skills and services of the doctors and specialists. When the 1500 is submitted electronically, it is called the 837-P, the “P” standing for Professional in this case. When dating the services,
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This distinction will also play into the reimbursement that is received. CMS has now released a “Two midnight rule” meaning that you must be admitted for 2 consecutive midnights in order to be considered inpatient. Each inpatient will be placed into a Medicare severity diagnosis-related group, which will in turn affect how much the hospital will receive back. This is seen as an average of what others that fall into this group cost, and how the insurance will pay back. They will rarely pay over what others get for the same MS-DRG, even if additional services were done. Outpatient reimbursement however is done by the actual services and testing provided. Everything basically boils down to this- insurance companies want to pay back the bare minimum. All of these rules end up helping them more than they do the doctors, facilities, or patients. However, there is no way people could afford most of their healthcare without insurance, so we must follow their payment
This distinction will also play into the reimbursement that is received. CMS has now released a “Two midnight rule” meaning that you must be admitted for 2 consecutive midnights in order to be considered inpatient. Each inpatient will be placed into a Medicare severity diagnosis-related group, which will in turn affect how much the hospital will receive back. This is seen as an average of what others that fall into this group cost, and how the insurance will pay back. They will rarely pay over what others get for the same MS-DRG, even if additional services were done. Outpatient reimbursement however is done by the actual services and testing provided. Everything basically boils down to this- insurance companies want to pay back the bare minimum. All of these rules end up helping them more than they do the doctors, facilities, or patients. However, there is no way people could afford most of their healthcare without insurance, so we must follow their payment