Directions for a CMS 672

Also referred to as HCFA Form 672, CMS 672 is a form used by the Centers for Medicare and Medicaid Services. It is used primarily when billing for care services provided in long-term care facilities such as a nursing home. Used to document the census and conditions of patients, the CMS 672 should be filled out by an employee of the facility in which a patient is currently receiving care, and then submitted to the insurance company along with the insurance claim.

Things You'll Need

• CMS Form 672

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Instructions

• 1

  Enter the medical facility's provider number in the labeled space at the top of the page.

• 2

  Enter the appropriate responses in boxes F75 to F78 as they relate to the facility. Box F75 is for the number of residents in the facility who have Medicare as their primary insurance payer. Box F76 is for the number of residents who have Medicaid as their primary payer. Box F77 is for the total number of patients who do not have either Medicare or Medicaid. Box F78 is for the total number of residents, which should be equal to F75 plus F76 and F77.

• 3

  Fill in responses for questions F79 to F93, which have to do with the patient's ability to perform his own activities of daily living (ADLs). ADLs include bathing, dressing, feeding, walking and using the toilet.

• 4

  Respond to questions F94 to F99 regarding the patient's toilet use and incontinence.

• 5

  Respond to questions F100 to F107 regarding specific details about the patient's mobility and use of ambulatory aides such as walkers, canes and wheelchairs.

• 6

  Answer questions F108 to F114 regarding the patient's current mental state.

• 7

  Enter the appropriate responses for questions F115 to F118 about the integrity of the patient's skin.

• 8

  Respond to questions F119 to F132, which relate to any special care that the patient requires.

• 9

  Fill in F133 to F139 regarding the patient's current medications.

• 10

  Answer the remaining questions, F140 to F145, regarding other special patient characteristics. Leave F146, F147 and F148 blank.

• 11

  Submit CMS 672 for payment to the claims submissions address given by the patient's insurance company. This can be done electronically or by mail.