Using the Medicare Claims Processing Manual: Facility Guide

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Written by Katherine Zheng, PhD, BSN Content Writer, IntelyCare
An administrator, nurse, and physician take a look at the Medicare Claims Processing Manual.

Medicare billing requires a comprehensive understanding of federal guidelines, which can feel like a daunting expectation without the right resources. To ease the process, the Center for Medicare and Medicaid Services (CMS) published the official Medicare Claims Processing Manual as an all-in-one guide for healthcare staff and administrators submitting claims.

If you’re looking at this manual for the first time but don’t know where to start, we’ve got you covered. This facility guide will walk you through all the fundamentals, from navigating the manual to pinpointing relevant information that clarifies your billing questions.

What Is the Medicare Claims Processing Manual?

The CMS Claims Processing Manual is part of the Internet-Only Manual (IOM) repository, which provides access to comprehensive information about CMS-administered programming. This manual in particular details all federal rules, guidelines, and procedures that healthcare professionals and administrators should know in order to submit Medicare claims correctly.

What’s Inside the Manual?

In total, the manual is broken up into 39 chapters, each one covering a specific topic about Medicare claims. In addition to a few overviews, the chapters are broken up by the type of facility or service to be billed. For example, the first five chapters are outlined as follows:

  • Chapter 1 – General Billing Requirements
  • Chapter 1 Crosswalk
  • Chapter 2 – Admission and Registration Requirements
  • Chapter 2 Crosswalk
  • Chapter 3 – Inpatient Hospital Billing
  • Chapter 3 Crosswalk
  • Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS)
  • Chapter 4 Crosswalk
  • Chapter 5 – Part B Outpatient Rehabilitation and CORF/OPT Services
  • Chapter 5 Crosswalk

In between Chapters, you will also notice a Chapter Crosswalk that brings you to an outline of the contents inside each chapter. However, clicking on a chapter directly will also bring you right to its table of contents, which hyperlinks to specific subsections.

Some of the more specific topics covered in the manual include:

  • Instructions on how to submit different types of claims
  • Information on ICD-10 and CPT coding practices
  • Guidelines on how Medicare reimburses facilities
  • Definitions of the different types of billing claims
  • Details on maintaining HIPAA compliance with claims

How to Navigate the Manual

The claims processing manual can be found directly on the CMS online repository. There is a lot of information in the manual, so it’s helpful to develop a systematic process for searching through it. Here are some basic steps you can follow to find sections that are relevant to you.

  1. Visit the CMS IOM repository
  2. Use the Filter On function to search for “Medicare Claims Processing Manual”
  3. Click on the manual’s publication number: 100-04
  4. Scroll down the list of chapters
  5. Click the chapter title most relevant to your question
  6. Scroll down the subsection list
  7. Click on a subsection title to jump to that corresponding information

General Tips:

  • Chapter 1 is a good place to get an overview of billing requirements if this is your first time visiting the manual.
  • Have a specific claims-related topic in mind so that you can easily scan for keywords in the chapter and subsection titles.
  • If multiple chapters might cover your topic, start with the earlier chapters because they will likely provide more basic context referencing later chapters as needed.
  • Reading the introduction section of a subsection first can give you a good overview before you dive into more specific information.

Medicare Claims Processing Manual: Usage Examples

The exact way you go about navigating the manual will depend on the type of information you need. To provide more context, we can take a look at a few examples of how you would use the manual in practice.

Example 1: HIPAA Standards for Electronic Claims

Let’s say you’re a healthcare facility leader wondering if your electronic claims process is HIPAA compliant. This information would likely be in a chapter detailing the basic requirements for submitting claims. With this in mind, Medicare Claims Processing Manual: Chapter 1General Billing Requirements may be a good place to start.

Upon selecting this Chapter, you’ll see the following subsections (truncated for this example):

  • 01 – Foreword
    • 01.1 Remittance Advice Coding Used in this Manual
  • 02 – Formats for Submitting Claims to Medicare
    • 02.1 – Electronic Submission Requirements
      • 02.1.1 – HIPAA Standards for Claims
      • 02.1.2 – Where to Purchase HIPAA Standard Implementation Guides

In these first two subsections, it already looks like there’s information that could answer your question in 02.1 – Electronic Submission Requirements. Clicking on this title will bring you to information providing an overview on HIPAA requirements for electronic claims.

Here, you’ll see a general overview of the HIPAA standards and implementation guides that facilities are expected to adhere to, including:

  • ASC X12 Standards for Electronic Data Interchange Technical Report Type 3
  • Telecommunication Standard Implementation Guide
  • Batch Standard Implementation Guide, National Council for Prescription Drug Programs

Below this list, you’ll also see a reference to Chapter 24 – General EDI and EDI Support Requirements, Electronic Claims, and Mandatory Electronic Filing of Medicare Claims, which you now know to read in order to get more information about the above standards.

Example 2: Billing for Services Under Medicare Part B

For this next example, let’s say you’re a healthcare professional seeking clarification on how to bill for inpatient services under Medicare Part B. Looking at the chapters, Medicare Claims Processing Manual: Chapter 4Part B Hospital (Including Inpatient Hospital Part B and OPPS) seems most relevant. This particular chapter has quite a long list of subsections and unlike the previous example, you’re not sure if the right information will be in the first few subsections.

This is a scenario where it’s helpful to have a more targeted topic in mind. For instance, you may want to specifically figure out how to bill for a stent placement. You can scroll down the subsections to look for these keywords, or use the search function (“Control F” on PC and “Command F” on Mac) to search for the word “stent”.

When you search the word “stent”, the first subsection you’re brought to is 61.5 – Billing for Intracoronary Stent Placement. Clicking this subsection will bring you to introductory guidelines for stent coverage followed by a list of updated CPT codes.

Looking for More Guidance on Medicare Billing?

Now that you’ve learned how to use the Medicare Claims Processing Manual, you may be seeking other resources to facilitate claim submissions at your facility. Sign up for IntelyCare’s free newsletter to read other easy-to-understand guides designed to help you streamline your billing process.