Additional Case Details

The Case Additional Information dialogCase Additional Information dialog is typically used to enter details related to workers' compensation cases. The dialog has two tabs: HCFA and UB. The tabs correspond to industry standard claim forms used for both paper and electronic billing.

The tabs contain some common fields. Where there are fields in common, the information users enter in one tab is automatically transferred to the other tab. For example, if you enter an Accident Date on the UB tab, that information automatically populates in the Accident Date field on the HCFA tab.

Accessing the Case Additional Information dialog

• From the Demographics moduleFrom the Demographics module

  1. Double-click the name of a case in the Cases sectionCases section of the Demographics screen.

     

  2. The Cases dialog appears.

  3. Click Additional Information to open the Case additional Information dialog box.

• From the CDM moduleFrom the CDM module
  1. Click Procedures under the Operative Sheet Bar heading or the Pre-Operative Sheet Bar heading.
  2. In the Procedures Performed section click Additional case info. The Additional Case Details dialog appears.

   

Fields on the tabs

To learn more about the fields listed below, click the links. Complete the fields that are appropriate to the specific case.

UB Tab

• Admission HourAdmission Hour

  1. • The hour, based on a 24-hour clock, that the patient was admitted to the facility. This field is tied to the Admission Date/Time field in the CDM module.

     • Entering the time in either field will auto populate/adjust the time displayed in the other.

     • This field is referenced on UB-04 paper claims as FL 13.

• TypeType

  • Enter the Priority (Type) of Admission/Visit in this field.

  • This field is tied to the Type field in the Clinical Documentation Management (CDM) module.  Entering a value in either field will auto populate/adjust the value displayed in the other.  

  • A default Type can be sent in Administration > Preference > Preference Editor > Clinical Documentation Management > Default admission data

  • This field is referenced on UB-04 paper claims as FL 14.   

  • This field is also often referenced in state mandatory reporting files.

• SourceSource

  1. • Enter the Point of Origin for admission or Visit in this field. 

     • This field is tied to the Source field in the Clinical Documentation Management (CDM) module.  Entering a value in either field will auto populate/adjust the value displayed in the other.   

     • A default Source can be sent in Administration > Preference > Preference Editor > Clinical Documentation Management > Default admission data.   This field is often referenced in state mandatory reporting files.

     • This field is referenced on UB-04 paper claims as FL 15.

• Discharge HourDischarge Hour

  1. • The hour, based on a 24 hour clock, that the patient was discharged by the facility. 

     • Discharge Hour can also be recorded in the CDM module. Entering a value in either field will auto populate/adjust the value displayed in the other.   

     • This information is referenced on UB-04 paper claims as FL 16.

• Patient StatusPatient Status

  1. • Enter the code that indicates the patient’s disposition or discharge status at the ending date of service for the period of care. 

     • Patient status can also be recorded in the CDM module. Entering a value in either field will auto populate/adjust the value displayed in the other. 

     • This information is referenced on UB-04 paper claims as FL 17.  

• Auto AccidentAuto Accident

  Select this check box to indicate the claim involves an auto accident.

• Other AccidentOther Accident

  Select this check box to indicate the claim involves an  accident other than an auto accident.

• Work RelatedWork Related

  Select this check box to indicate the claim involves an accident related to employment.

• EmergencyEmergency

  Select this check box to indicate the patient was seen in the Emergency Department.

• Accident DateAccident Date

  • If you selected either Auto Accident or Other Accident, use this field to record the date the accident took place.

  • Accident Date is report on the UB-04 with the applicable Occurrence Code and Date FL 31 – 34.

   

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

• Accident StateAccident State

  • If you selected either Auto Accident or Other Accident, use this field to record the state in which the accident took place.

  • This field is referenced on UB-04 paper claims as FL 29.

   

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

• PregnantPregnant

  Select this check box to indicate the patient is pregnant.

• PI Document Control #PI Document Control #
  1. • Enter the internal Control Number (ICN) or document control number (DCN) assigned to the original bill by the health plan when required by the Primary payor.
     • This field is referenced on UB-04 paper claims as FL 64 a.

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

• Original Ref #Original Ref #

  Used in the case of a resubmitted claim to denote the original claim number.

• SI Document Control #SI Document Control #
  1. • Enter the internal Control Number (ICN) or document control number (DCN) assigned to the original bill by the health plan when required by the Secondary payor.
     • This field is referenced on UB-04 paper claims as FL 64 b.

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

   

• Resubmission CodeResubmission Code

  Used in the case of a resubmitted claim.

• TI Document Control #TI Document Control #
  1. • Enter the internal Control Number (ICN) or document control number (DCN) assigned to the original bill by the health plan when required by the Tertiary payor.
     • This field is referenced on UB-04 paper claims as FL 64 c.

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

• Condition CodesCondition Codes
  1. • Situational fields that contain codes to identify conditions that may affect payer processing of the bill.
     • Click on the plus sign icon to add a code. Use the minus sign icon to remove a code.
     • This field is referenced on UB-04 paper claims as FL 18 - 28.

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

   

   

• Occurrence Code & Date InformationOccurrence Code & Date Information
  1. • Enter the occurrence code and associated date that define a significant event related to the bill that may affect payer processing.
     • This field is referenced on UB-04 paper claims as FL 31 a,b – 34 a,b.

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

   

• ECI CodesECI Codes

  • Used to record the ICD diagnosis code pertaining to external cause of injuries, poisoning, or adverse effect for accident-related situations.

  • These codes are often included in state mandatory reporting.

  • This field is referenced on UB-04 paper claims as FL 72 a-c.

• Reason CodesReason Codes

  1. • This field is used to report the patient’s reason for the visit at the time of registration. 

     • Reason codes are often included in state mandatory reporting.

     • This field is referenced on UB-04 paper claims as FL 70 a-c.

• Value Code & Amount InformationValue Code & Amount Information
  1. • Used to record codes and the related dollar amounts or values that are necessary to process the claim by the payor.

     • This field is referenced on UB-04 paper claims as FL 39 a-d – 41a-d.

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

   

• Occurrence Span Code & Date InformationOccurrence Span Code & Date Information
  1. • This field is used to identify the span codes and dates of events that relate to payment of the claim.  The codes identify an occurrence that happened over a period of time.  Enter a code, the beginning (from) date and the ending (through) date associated to the occurrence.
     • This field is referenced on UB-04 paper claims as FL 35 - 36.

  NOTE: Information entered in this field will be applied at the claim level if entered prior to posting charges.  Once charges have been posted, add or edit information from the Charge Entry Screen, using the Additional Information button. See Charge.

   

• Claim Supplemental InformationClaim Supplemental Information

  • Used to identify supplemental reports such as a plan of treatment or certified test report.

  • Select a Report Type Code from the drop down list or click Alt + D in the field to access the dictionary to add a new Report Type Code.

  • Select the Transmission Code in the same manner. CMS generates a Control Number that you can enter here to ensure all reports are matched to the correct claim.

  • This information is specific to HCFA-1500 and EMC (electronic medical claims) only and does not print on a paper UB-04 form.

• Claim Note InformationClaim Note Information
  1. • Similar to the Claim Supplemental information field, this field is used to include additional information related to the claim.  Select the Note Reference Code from the drop down menu and enter text in the Description field.
     • This information is specific to HCFA-1500 and EMC (electronic medical claims) only and does not print on a paper UB-04 form.

   

HCFA tab

• Case NameCase Name

  The Case Name defaults into this field, but you can change it by typing over the default in this free text field. This will update the Case Name in all areas of the system.

• Date of ServiceDate of Service

  The Date of Service defaults into this field and cannot be edited here.

• StatusStatus

  The current status of the case defaults into this field and is not editable.

• Case PhysicianCase Physician

  • The Case Physician defaults into this field. You can change the Case Physician using this field's drop down list.

  • Changing the Case Physician in this field will also update the Case Physician field on the Case Details dialogCase Details dialog.

    

• Referring PhysicianReferring Physician

  • The Referring Physician defaults into this field.

  • You can change the Referring Physician using this field's drop down list.

  • Changing the Referring Physician in this field will also update the Referring Physician field on the Case Details dialogCase Details dialog.

    

• Diagnosis Information: Quick CodeDiagnosis Information: Quick Code

  Any diagnosis codes entered in Scheduling auto populate in this field.  

  To add or change diagnosis codes

  1. Enter a Quick Code for each additional diagnosis either using the drop-drop list in this field or by using Hot Keys [Alt + D] to access the dictionary. To change a diagnosis code, select the correct code from the drop-down list.

     • If you are working on AmkaiOffice, Version 3.16x, a total of 9 unique diagnosis codes can be referenced here.  The system will display a warning if you attempt to add the same code twice.

     • If, however, you are working on AmkaiOffice, Version 3.17b or greater, up to 18 codes can be referenced here.

  2. To add any lines needed for additional diagnoses, click the plus sign icon.

  3. To remove a blank line, select the line and click the minus sign icon.

  4. Use the up and down arrows to change the position of diagnoses.

  5. Codes entered here will also flow to the Financial Management module.  

• Disability StatusDisability Status

  Select the appropriate radio button to indicate whether the disability is None (default), Partial, or Full.

• Auto AccidentAuto Accident

  • Select this check box to indicate the claim involves an auto accident.

  • This field is referenced on HCFA-1500 paper claims as FL 10b.

• Other AccidentOther Accident

  • Select this check box to indicate the claim involves an  accident other than an auto accident.

  • This field is referenced on HCFA-1500 paper claims as FL 10c.

• Work RelatedWork Related

  • Select this check box to indicate the claim involves an accident related to employment.

  • This field is referenced on HCFA-1500 paper claims as FL 10a.

• EmergencyEmergency

  • Select this check box to indicate the claim is related to an emergency.

  • This field is referenced on HCFA-1500 paper claims as FL 24c.

   

• Accident DateAccident Date

  • If you selected either Auto Accident or Other Accident, use this field to record the date the accident took place.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with appropriate qualifier)

• Accident StateAccident State

  • If you selected either Auto Accident or Other Accident, use this field to record the state in which the accident took place.

  • This field is referenced on HCFA-1500 paper claims as HCFA-1500 FL 10b.

  • When processing claims, the system will display an error if an Auto Accident Date is entered without an Accident State being referenced.

• EPSDT Indicator and Reason CodeEPSDT Indicator and Reason Code

  • If the claim is related to Early & Periodic Screening, Diagnosis, and Treatment, select the Yes radio button and enter the appropriate code in the Reason Code field.

  • This field is referenced on HCFA-1500 paper claims as FL 24h.

• Family Planning Indicator and Reason CodeFamily Planning Indicator and Reason Code
  • If the claim is related to Family Planning, select the Yes radio button and enter the appropriate code in the Reason Code field.
  • This field is referenced on HCFA-1500 paper claims as FL 24h.
• PregnantPregnant

  • Select this check box to indicate the patient is pregnant.

  • This field will also update the Pregnant field located on the Case Details dialog.

• First OccurrenceFirst Occurrence

  • Use this field to record the date of illness, injury or pregnancy (LMP, or Last Missed Period).

  • This field is referenced on HCFA-1500 paper claims as FL 14 (with appropriate qualifier).

• Similar SymptomsSimilar Symptoms

  • Use this field to record the date the patient had the same or similar symptoms.

  • This field is referenced on HCFA-1500 paper claims as HCFA-1500 FL 15 (with appropriate qualifier).

• Date Last SeenDate Last Seen

  • Use this field to record the date the patient had last been seen in the facility.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Last X-Ray DateLast X-Ray Date

  • Used to record the date of last x-ray when the claim involves spinal manipulation.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Acute Manifestation DateAcute Manifestation Date

  • Used to record the date on which an acute condition manifested for a claim involving spinal manipulation where the payer is Medicare.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Spinal Manipulation CodeSpinal Manipulation Code

  Used to record patient condition code when spinal manipulation is involved.

• Spinal Condition CodeSpinal Condition Code

  Used to record patient condition code when the claim is related to the spine.

• Original Ref #Original Ref #

  • Used in the case of a resubmitted claim to denote the original claim number.

  • This field is referenced on HCFA-1500 paper claims as FL 22.

• Resubmission CodeResubmission Code

  • Used in the case of a resubmitted claim.

  • This field is referenced on HCFA-1500 paper claims as FL 22.

• Svc Auth ExceptionSvc Auth Exception

  Use this field to record the Medicaid service authorization exception code.

• First ContactFirst Contact

  • Used to record the date the patient first made contact with your facility regarding this date of service.

  • This field is referenced on HCFA-1500 paper claims as FL15 (with applicable qualifier).

• Auth Return to WorkAuth Return to Work

  Used to record the date the patient is authorized to return to work.

• Last WorkedLast Worked

  Used to record the last day the patient worked.

• Last Menstrual PeriodLast Menstrual Period

  • Used to record the date of the first day of a female patient's last menstrual period.

  • This field is referenced on HCFA-1500 paper claims as FL 14(with applicable qualifier).

   

• Initial TreatmentInitial Treatment

  • Used to record the date the patient first received treatment related to this claim.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Disability From and ThruDisability From and Thru

  • Use these fields to record the beginning date the patient was unable to work and the ending date of that period of inability to work.

  • This field is referenced on HCFA-1500 paper claims as FL 16.

• Hospitalization From and ThruHospitalization From and Thru

  • Use these fields to record the admission and discharge dates of an inpatient stay associated to services on the claim.

  • This field is referenced on HCFA-1500 paper claims as FL 18.

• Assumed CareAssumed Care

  • Required on Medicare claims for situations where providers share post-operative care (global surgery claims). Assumed Care Date is the date care was assumed by another provider during post-operative care. See Medicare guidelines for further explanation of this date.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Relinquished CareRelinquished Care

  • Required on Medicare claims for situations where providers share post-operative care (global surgery claims). Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of this date.

  • This field is referenced on HCFA-1500 paper claims as FL 15 (with applicable qualifier).

• Case Narrative InformationCase Narrative Information

  Free text field with limited character capacity.

• Claim Supplemental InformationClaim Supplemental Information

  • Used to identify supplemental reports such as a plan of treatment or certified test report. Select a Report Type Code from the drop down list or click Alt + D in the field to access the dictionary to add a new Report Type Code. Select the Transmission Code in the same manner. CMS (Centers for Medicare & Medicaid Services) generates a Control Number that you can enter here to ensure all reports are matched to the correct claim.

  • This field is referenced on HCFA-1500 paper claims as FL 19.

• Claim Note InformationClaim Note Information
  • Similar to the Claim Supplemental information field, this field is used to include additional information related to the claim. 
  • Select the Note Reference Code from the drop down menu and enter text in the Description field.

 

©2024 Surgical Information Systems. All Rights Reserved.