HI215 Unit 4 Claim Form Exercise Example

One Knee MRI, Two Claims, Five Planted Errors: A Unit 4 Claim Form Exercise Routing the Hospital's Technical Work and the Radiologist's Reading to Separate Forms, Then Correcting the Institutional Claim Field by Field

[Student Name]

Purdue University Global

HI215: Reimbursement Methodologies

Unit 4 Claim Form Exercise

[Instructor Name]

[Date]

The patient, the hospital, the radiologist and the claim are composite; the form fields, codes and sources cited are real.

Scenario

Patient: composite adult, Medicare Part B. Order: left knee MRI without contrast for suspected meniscal tear, from an orthopedic surgeon. Service: performed in the hospital's outpatient imaging department on April 9. Report: dictated and signed by the radiologist on April 9, impression of a medial meniscus tear involving its posterior portion, left knee.

Routing

1. Hospital technical component: the scanner, technologist, room and supplies. Billed by the hospital on the institutional claim, the electronic version of the UB-04, under the outpatient prospective payment system.

2. Radiologist professional component: interpretation and report. Billed by the radiology group on the professional claim, the electronic version of the CMS-1500, with modifier 26, which identifies the professional component.

One encounter produces two claims because two entities provided two parts of the service, each billing under its own payment system. Instructions for completing both forms are set out in Medicare's claims processing manual, for institutional claims (Centers for Medicare & Medicaid Services [CMS], 2024a) and for professional claims (Centers for Medicare & Medicaid Services, 2024b).

Corrections to the Institutional Claim

Each item gives the form locator, the value as submitted, the corrected value and the source.

1. Form locator 4, type of bill: submitted 111, a hospital inpatient claim. Corrected: 131, hospital outpatient. Source: registration, which shows an outpatient encounter.

2. Form locator 42, revenue code: submitted 0350, computed tomography. Corrected: 0614, magnetic resonance imaging, other. Source: the department's charge description master line for the MRI performed.

3. Form locator 44, procedure code: submitted 73721-26. Corrected: 73721 with no modifier, since the hospital bills the technical service and modifier 26 belongs only on the radiologist's claim. Source: the order and the technologist's log, which confirm a lower extremity joint MRI without contrast.

4. Form locator 45, service date: submitted April 2, the date the order was written. Corrected: April 9, the date of the scan. Source: the technologist's log and the report date.

5. Form locator 67, principal diagnosis: submitted M25.561, pain in right knee. Corrected: the left knee code supported by the order and the signed report. Source: the order's indication and the radiologist's impression. Laterality must match the documented side, and the official coding guidelines tie code assignment to the provider's documentation (National Center for Health Statistics [NCHS], 2025).

Two of the five errors, the bill type and the modifier, came from confusing the hospital's claim with the radiologist's, which is exactly the confusion the routing table exists to prevent.

The Professional Claim, Briefly

Item 24D: 73721-26. Item 24B, place of service: 22, on-campus outpatient hospital. Item 17: the ordering orthopedic surgeon as referring provider, with his national provider identifier. Item 32: the hospital's imaging department as the service facility. Diagnosis: the same left knee code as the hospital's claim.

Working From the Source Packet

The exercise depends on a habit more than on knowledge of the forms: every value on a claim should trace to a document in the record, and the person correcting a claim should be able to name that document. The packet for this case held four sources: the registration record, which settles the type of encounter and the patient's coverage; the physician's order, which states the procedure requested, the side and the reason; the technologist's log, which records what was actually done and when; and the radiologist's signed report, which records what was found. When two sources disagree, the later clinical document usually governs, because it reflects what happened rather than what was planned. Here the order and the report agreed on the left knee, which made the right knee code on the claim an error rather than a judgment call. Had the report described a different study than the order requested, the claim would follow the report and the order would be clarified with the ordering physician before billing. Working this way makes a claim auditable: an auditor who asks where any value came from receives an answer in one sentence, and the billing office never has to reconstruct its reasoning months later.

Why the Errors Matter

An inpatient bill type on an outpatient service would be rejected or routed to the wrong payment system. The CT revenue code would mismatch the MRI procedure code and fail payer edits. The 26 modifier on the facility claim would signal a professional service the hospital did not provide. The wrong date would fail to match the radiologist's claim. A right knee code on a left knee scan would undermine medical necessity and any later review. Each error sits in a different field but has the same cause: the value was not taken from the source document.

References

Centers for Medicare & Medicaid Services. (2024a). Medicare claims processing manual, Chapter 25: Completing and processing the Form CMS-1450 data set.

Centers for Medicare & Medicaid Services. (2024b). Medicare claims processing manual, Chapter 26: Completing and processing Form CMS-1500 data set.

National Center for Health Statistics. (2025). ICD-10-CM official guidelines for coding and reporting FY 2025. Centers for Disease Control and Prevention.