Data Elements Required on Claim for Monthly Capitation

140.3 - Data Elements Required on Claim for Monthly Capitation Payment (Rev. 10236, Issued: 07-31-2020, Effective: 08-31-2020, Implementation: 08-31-2020) On Form CMS-1500 A. Elements 1 through 13 of the Form CMS-1500 are completed in accordance with the regular instructions B. Elements 14 through 20 of the Form CMS-1500 are omitted. C. Element 32 must contain the name and address of the facility involved with the patient’s maintenance care or training, and 32a must contain the facility NPI. D. Element 21 must show the diagnosis. Indicate in Element 19 whether the patient is in training for self-dialysis. E. Element 24A must show the dates of service during the month that are included in the MCP. The period includes the full calendar month the MCP physician or practitioner was responsible for the beneficiary's ESRD related care. For the first month the beneficiary begins dialysis treatments, the first date the dialysis treatments begin through the end of the calendar month should be used as the dates of service. For outpatient ESRD-related services furnished for less than a full month, per day as discussed in 140.2 (e.g. transient patients, partial month due to hospitalization, transplant, or death), the first and last date the physician or practitioner was responsible for the beneficiary’s ESRD-related care during the month should be used as the dates of service. Non-continuous dates should be billed on separate claim lines, (e.g. 1/1/08 – 1/7/08 and 1/20/08 – 1/31/08). A separate monthly claim should be submitted when the duration of ESRD-related services, per day, overlaps two different months as discussed in 140.21 (e.g. August 15 - September 7). F. The remainder of the Form CMS-1500 is completed in accordance with the general instructions. On ASC X12 Professional Format Instructions for completing the ASC X12 837 professional claim format are in the related implementation guide, available on the official Washington Publishing Company website.