Billing Manual Final Version
Content
MEDICAL BILLING & CODING PROCESS MANUAL
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Table of Contents
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Understanding Healthcare in US
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Health Care in U.S.
Medical care in the United States is generally very high quality. The government closely monitors medically oriented businesses and institutions. Hospitals, clinics, medical schools, and pharmaceutical companies must comply with government standards. Doctors, nurses and other medical personnel must be licensed, and becoming a medical specialist frequently entails fifteen years or more of rigorous schooling and training. The high level of technology available in the U.S. contributes to quality care, and the average hospital contains millions of dollars worth of state-of-the-art equipment. Medical and health care is big business. Hospitals and medical schools also spend substantial amounts on research, knowing that new techniques and discoveries will bring them prestige, patients, and money, while benefiting many people. The result for consumers is ever improving quality and effectiveness of medical care, but at the same time expensive care. When seeking any kind of medical assistance in the United States, there are few free services, and most care is expensive. Unlike other countries, there is little government sponsored health care here, except for those over 65 years of age (Medicare), or for the poor (Medicaid). The insurance industry is a major influence in the business of staying well or regaining one's good health. Obtaining some type of health insurance coverage to protect one self and their family is very smart, but expect it to be a significant monthly expense.
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Medical Emergency
In an emergency, the first thing to remember is "911". This is the telephone number to call from anywhere in the United States for immediate, skilled medical attention. While it is wise to have other important numbers regarding medical assistance (individual’s personal doctor, poison control center, etc.) near telephone, in a genuine emergency it is imperative to dial 911 first. In such situations, time is the most important factor in preventing damage or even loss of life. The operator handling your "911" call will immediately dispense the necessary help, both in terms of sending an ambulance and in routing individual’s call to a counselor who will guide through the situation until the ambulance arrives. Emergency medicine in the U.S. is very high quality. Ambulance attendants, or paramedics, are highly trained in dealing with trauma and making split-second decisions that save lives. And many hospitals are equipped with trauma centers whose single purpose is handling emergency situations, including emergency surgery. In an emergency, individual will begin to receive treatment immediately and will be taken to the facility that can best handle the situation, whether it is a trauma center, a burn treatment center, a cardiac treatment center (heart attacks), a children's hospital or a general hospital. If an individual is conscious, or if there is a family member or a friend with the individual, they will be asked for the name of patient’s doctor, who will be summoned to the hospital to which patient is taken.
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It is important to keep in mind that while emergency care in the U.S. is excellent, it is also expensive. There will be a fee for the ambulance, the emergency room, any medications administered, the services of doctors involved and any tests or special procedures involved. It is important never to hesitate when there is a genuine emergency but these services are not intended for situations where a call to your doctor or a visit to a walk-in clinic would be sufficient. An additional note about "911" This number is also used in police emergencies, and therefore is not limited to medical situations. Any time an individual is in serious danger, witness an accident or a crime in progress, this number is called.
Why Health Insurance is needed?
The United States does not have socialized medical care. If a person does not have health insurance coverage, he / she have to pay for health care out of their own finances at the time of service. This can run into many thousands of dollars for serious illnesses One buy’s health insurance for the same reason one buy’s other kinds of insurance, to protect one self financially. With health insurance, an individual and their family are protected in case of any medical care that could be very expensive. One cannot predict what his medical bills would be. In a good year, costs may be low but if he becomes ill, medical bills could be very high. If he has insurance, many of medical costs are covered by a third-party payer, not by the individual. A
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third-party payer can be an insurance company or, in some cases, it can be the employer. Many people in the United States are enrolled in some sort of managed care plan. This is an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), point-of-service (POS) plans and fee-for-service plans. Individuals enrolled in health care plans pay a monthly or quarterly fee as insurance for the time when they will need medical attention. At the time when a service is provided, the health insurance organization pays part or the entire fee, minimizing the amount an individual have to pay at the time of service. Choosing the right insurance plan that best meets financial circumstances will depend on information like, whether an individual is married or single, have children or no children. Definitions of the health insurance terms used are included in the section called Understanding Health Insurance Terms.
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What are the various types of Health Insurance Coverage?
The two main ways that people obtain health coverage are by paying into a group or buying individual insurance.
Group Health Plans Individual Insurance Plans
Group Insurance Plans
Most Americans get health insurance through their jobs or are covered because a family member has insurance at work. This is called group insurance. Group insurance is generally the least expensive kind. In many cases, the employer pays part or all of the cost. Some employers offer only one health insurance plan. Some offer a choice of plans a fee-for-service plan, a Health Maintenance Organization (HMO), or a Preferred Provider Organization (PPO), for example. Employers with 25 or more workers are required by Federal law to offer employees the chance to enroll in an HMO. What happens if an individual or his family member leaves the job? He will lose employersupported group coverage. It may be possible to keep the same policy, but he will have to pay for it himself. This will certainly cost him more than group coverage for the same, or less, protection. A Federal law makes it possible for most people to continue their group health coverage for a period of time called COBRA (for the Consolidated Omnibus Budget Reconciliation Act of 1985), the law requires that if an individual work’s for a business of 20 or more employees and leave the job or are laid off, he can continue to get health
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coverage for at least 18 months. He will be charged a higher premium than when he was working. He / she also will be eligible to get insurance under COBRA if their spouse was covered but now he /she is widowed or divorced. If an individual was covered under his parents group plan while he was in school, he can also continue in the plan for up to 18 months under COBRA until the individual find a job that offers individual health insurance. Not all employers offer health insurance. Individual might find this to be the case with his job, especially if he work’s for a small business or work part-time. If the employer does not offer health insurance, he might be able to get group insurance through membership in a labor union, professional association, club, or other organization.
Individual Insurance Plans
If the employer does not offer group insurance, or if the insurance offered is very limited, one can buy an individual policy. One can get fee-for-service, HMO, or PPO protection. But an individual should compare the options and shop carefully because coverage and costs vary from company to company. Individual plans may not offer benefits as broad as those in group plans
What Types of Insurance Plans Are There?
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Managed Care: An Explanation
You will hear the term "managed care" quite a lot in the United States. It is a way for insurers to help control costs. Managed care influences how much health care an individual use. Almost all plans have some sort of managed care program to help control costs. For example, if an individual need to go to the hospital, one form of managed care requires that he receive approval from his insurance company before he is admitted to make sure that the hospitalization is needed. If he goes to the hospital without this approval, he may not be covered for the hospital bill.
Fee-for-Service Plans
This is the traditional kind of health care policy. Insurance companies pay fees for the services provided to the insured people covered by the policy. This type of health insurance offers the most choices of doctors and hospitals. An individual can choose any doctor he wishes and change doctors any time. He can go to any hospital in any part of the country. With fee-for-service, the insurer only pays for part of doctor and hospital bills. Individual’s pay a monthly fee, called a premium. A certain amount of money each year, known as the deductible, is paid for by the individual before the insurance payments begin. In a typical plan, the deductible might be $250 for each person in a family, with a family deductible of $500 when at least two people in the family have reached the individual deductible. The deductible requirement applies each year of the policy. Also, not all health
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expenses have count toward the deductible. Only those covered by the policy do. Individuals need to check the insurance policy to find out which ones are covered. After individual has paid deductible amount for the year, he would share the bill with the insurance company. For example, individual might pay 20 percent while the insurer pays 80 percent. Individual’s portion is called "coinsurance". To receive payment for fee-for-service claims, individual may have to fill out forms and send them to insurer. Sometimes doctor's office will do this for Insured. Individual also need to keep receipts for drugs and other medical costs and is responsible for keeping track of his own medical expenses. There are limits as to how much an insurance company will pay for a claim if both individual and his spouse file for it under two different group insurance plans. A coordination of benefit clause usually limits benefits under two plans to no more than 100 percent of the claim. Most fee-for-service plans have a "cap," the most individual will have to pay for medical bills in any one year. He reaches the cap when out-of-pocket expenses (for deductible and coinsurance) total a certain amount. It may be as low as $1,000 or as high as $5,000. The insurance company then pays the full amount in excess of the cap for the items listed in policy. The cap does not include what individual pay for monthly premium. Some services are limited or not covered at all. Insured need to check on preventive health care coverage such as immunizations and well-child care.
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There are two kinds of fee-for-service coverage basic and major medical. Basic protection pays toward the costs of a hospital room and care while patient is in the hospital. It covers some hospital services and supplies, such as x-rays and prescribed medicine. Basic coverage also pays toward the cost of surgery, whether it is performed in or out of the hospital, and for some doctor visits. Major medical insurance takes over where insured basic coverage leaves off. It covers the cost of long, high-cost illnesses or injuries. Some policies combine basic and major medical coverage into one plan. This is sometimes called a "Comprehensive Plan." Insured need to check whether his policy covers both kinds of protection.
Health Maintenance Organizations (HMOs)
Health maintenance organizations are prepaid health plans. As an HMO member, insured pay a monthly premium. In exchange, the HMO
provides comprehensive care for the insured & his family, including doctors' visits, hospital stays, emergency care, surgery, laboratory
(lab) tests, x-rays, and therapy. The HMO arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, patient choices of doctors and hospitals are limited to those that have agreements with the HMO to provide care. However, exceptions are made in emergencies or when medically necessary.
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There may be a small co-payment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Individual total medical costs will likely be lower and more predictable in an HMO than with fee-for-service insurance. Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure patient get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of services covered varies in HMOs, so it is important to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis. Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor's office or hospital. However, in an HMO individual may have to wait longer for an appointment than he would with a fee-for-service plan. In some HMOs, doctors are salaried and they all have offices in an HMO building at one or more locations in individual’s community as part of a prepaid group practice. In others, independent groups of doctors contract with the HMO to take care of patients. These are called individual practice associations (IPAs) and they are made up of private physicians in private offices who agree to care for HMO members. Individual select a doctor from a list of participating physicians that make up the IPA network. If an individual is thinking of switching into an IPA-type of HMO, he needs to check whether doctor participates in the plan.
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In almost all HMOs, individuals are either assigned or choose one doctor to serve as patient’s primary care doctor. This doctor monitors health and provides most of patient’s medical care, referring to specialists and other health care professionals as needed. Patient usually cannot see a specialist without a referral from primary care doctor who is expected to manage the care received by the patient. This is one way that HMOs can limit patient’s choice. In HMO’s there is another part called capitation which is like an agreement between the insurance and the provider. In brief let us see what it is.
Capitation
Many HMO plans and some PPO plans are considering capitated. When a plan is capitated the doctor and treatment center receives a monthly payment from insurance company based on the number of enrollees. The monthly payment may be varying due to increase or decrease and the treatment centers are paid more than the individual doctors. When a doctor or treatment center treats a capitated patient, we go through the charge entry process, but none of the claims are mailed. This is because under a capitated plan, since the doctors and treatment centers are paid monthly regardless if they treat a patient. When they do treat a patient. They can not bill the insurance company for the services rendered. If a claim is accidentally issued to the insurance company, they automatically deny the claim as a provider with a capitated plan, and you hope that none of the enrollees ever became patients
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Point-of-Service Plans (POS)
Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If patient refer themselves to a provider outside the network and the service is covered by the plan then patient will have to pay coinsurance.
Preferred Provider Organizations (PPOs)
The preferred provider organization is a combination of traditional fee-for-service and an HMO. Like an HMO, there are a limited number of doctors and hospitals to choose from. When patient use those providers (sometimes called "preferred" providers, other times called "network" providers), most of his medical bills are covered. When patient goes to doctors in the PPO, he presents a card and do not have to fill out forms. Usually there is a small co-payment for each visit. For some services, patient may have to pay a deductible and coinsurance. As with an HMO, a PPO requires that patient choose a primary care doctor to monitor his health care. Most PPOs cover preventive care. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.
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In a PPO, patient can use doctors who are not part of the plan and still receive some coverage. At these times, patient will pay a larger portion of the bill himself (and also fill out the claims forms). Some people like this option because even if their doctor is not a part of the network, it means they do not have to change doctors to join a PPO.
Features of different Insurance Plans
Whether insured is opting for traditional indemnity fee-for-service plans (FFS), health maintenance organizations (HMOs), point of service plans (POS), and preferred provider organizations (PPO). Each plan has its own features to consider before making a choice.
FFS, Also Called Traditional Indemnity
FFS coverage offers flexibility in exchange for higher out-of-pocket expenses, more paperwork, and higher premiums. FFS advantages: Individual may choose your own doctors and hospitals. Individual may visit any specialist without getting permission from a primary care physician. FFS disadvantages: There's typically a deductible (anywhere from $500 to $1,500) before the insurance company starts paying claims, and then doctors are reimbursed about 80 percent of the bill while patient pick up the remaining 20 percent.
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FFS plans pay only for "reasonable and customary" medical expenses. If patient’s doctor charges more than the average for the area, patient will have to pay the difference.
HMO
HMOs are the least expensive, but also the least flexible of all the health insurance plans. They are geared more toward members of a group seeking health insurance.
HMO advantages: They offer their customers low co-payments, minimal paperwork, and coverage for many preventive-care and health-improvement programs. HMO disadvantages: Individual must choose a primary care physician, also known as a PCP. HMOs require that individual see only network doctors or they won't pay. Individual must get a referral from your PCP to see a specialist.
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POS
POS plans are more flexible than HMOs, but they also require patient to select a PCP.
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POS advantages: Depending on patient insurance company's rules, he may choose to visit a doctor outside the network and still receive coverage — but the amount covered will be substantially less than if patient went to a physician within the network.
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These plans tend to offer more preventive care and well-being services, such as workshops on smoking cessation and discounts to health clubs.
POS disadvantages: Individual must choose a PCP. While individual may choose to see a physician outside the network, if he did not receive permission from PCP, individual is likely to wind up submitting the bills himself and receiving only a nominal reimbursement — if any.
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PPO
PPOs give policyholders a financial incentive — reasonable co-payments (also called co-pays) — to stay within the group's network of practitioners. PPO advantages: The standard co-payment is $10 for a routine office visit during regular hours.
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Individual may go to any specialist without permission, as long as the doctor participates in the network.
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PPO disadvantages: If individual see an out-of-network doctor, he may have to pay the entire bill himself, and then submit it for reimbursement.
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Individual may have to pay a deductible if he chooses to go outside the network, or pay the difference between what network doctors vs. out-ofnetwork doctor’s charge.
Types of Insurance
MEDICARE
Medicare is the federal (national) health insurance program for Americans age 65 and older and for certain disabled Americans. If individual is eligible for Social Security or Railroad Retirement benefits and are age 65, he and his spouse automatically qualify for Medicare. Medicare has two parts hospital insurance, known as Part A, and supplementary medical insurance, known as Part B, which provides payments for doctors and related services and supplies ordered by the doctor. If individual is eligible for Medicare, Part A is free, but insured must pay a premium for Part B. Medicare will pay for many of insured health care expenses, but not all of them. In particular, Medicare does not cover most nursing home care, long-term care services in the home, or prescription drugs. There are also special rules on when Medicare pays patient’s bills that apply if patient have employer group health
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insurance coverage through his own job or the employment of a spouse. Medicare usually operates on a fee-for-service basis. Some people who are covered by Medicare buy private insurance, called "Medigap" policies, to pay the medical bills that Medicare doesn't cover. Some Medigap policies cover Medicare's deductibles; most pay the coinsurance amount. Some also pay for health services not covered by Medicare. There are 10 standard plans from which individual can choose (some States may have fewer than 10.) If an individual buy a Medigap policy, he should make sure that he does not purchase more than one.
MEDICARE PART A
Medicare Part A is also known as Hospital Insurance (HI). The intermediary determines payment to Part A facilities for covered items and services provided by the facility. The following services are covered in Part A, • • • • Inpatient Hospital Care. Inpatient Care in a Skilled Nursing Facility (SNF). Home Health Care. Hospice Care.
The services and coverage limitations for each of Medicare Part A Care: Part A services and coverage for Inpatient Hospital Care: Covered Services for Inpatient Hospital Care:
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• • • • • • • • •
Semi private room All meals, including special diets Regular Nursing services Costs of special care units Blood transfusions Lab tests Medical supplies such as splints and casts Use of appliances such as wheelchairs X-rays and other radiology services, including radiation therapy, billed by
the Hospital. • • Operating and recovery room costs Rehabilitation services, such as physical therapy, occupational therapy and
speech pathology therapy. Non-covered Services for Inpatient Hospital Care: • • • Private duty Nurses Personal convenience items Any extra charges for a private room unless medically necessary.
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Benefit Period for Inpatient Hospital Care: Benefit period begins when the first day (not on the previous benefit period) on which an eligible patient is furnished inpatient hospital or extended care services by a qualified provider. The benefit period with the close of a period of 60
consecutive days (after the date of discharge from the facility) during which the patient was neither an inpatient hospital nor a Skilled Nursing Facility (SNF). Eligible Benefits for Inpatient Hospital Care: A patient is eligible for 90 days of hospital care in a benefit period, as long as medical necessity for the admission and the number of days has been proven. The patient also has a lifetime reserve of 60 days, which could be used once the 90 days have been exhausted. Once the reserve days have been used, they are not replenished. Part A services and coverage for Inpatient Care in a Skilled Nursing Facility (SNF): Covered Medicare Part A SNF services include the following: • • • • • Semi-private room All meals, including special diets Regular Nursing services Physical/occupational therapy and speech-language pathology services Drugs furnished during stay
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• • •
Blood transfusions Medical supplies such as splints and casts Use of appliances such as wheelchairs
Non-Covered Medicare Part A SNF services include the following: • • • • Private duty Nurses Personal convenience items Any extra charges for a private room unless medically necessary Any services not provided by the facility and included in its bill.
Duration of Care: Benefit period – A benefit period begins with the first day (not in a previous benefit period) on which an eligible patient is furnished inpatient hospital or extended care services by a qualified provider. The benefit period ends with the close of a period of 60 consecutive days (after the date of discharge from the facility) during which the patient was neither an inpatient of a hospital nor an inpatient of a Skilled Nursing Facility (SNF). Eligible benefits – A patient is eligible for 100 days of care in a SNF during a benefit period, as long as medical necessity for the admission and the number of days has been proven. Part A services and coverage for Inpatient Care in a Home Health Care:
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Covered Medicare Part A home health care services include the following: • • • • • • • Part-time or intermittent skilled nursing care and home health aid services Physical therapy Speech-language pathology services Occupational therapy Medical social services Medical supplies Durable medical equipment (DME)
Non-covered Medicare Part A Home Health Care services include the following: • • • • • 24-hour-a-day nursing care at home Drugs and biologicals Meals delivered to the patient’s home Homemaker services Blood transfusion.
Duration of Care: Eligibility requirements – The eligibility requirements for home health services are:
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The patient must be homebound The home health services must be provided under a plan of care established and approved by a physician
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The patient must be under the care of a physician The patient needs skilled nursing care on an intermittent basis or has a continued need for physical/occupational therapy or speech-language pathology services
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The Home Health Agency (HHA) must be acting upon a physician certification that is part of the plan of care and the agency must meet certain qualification requirements to be certified under the Medicare program.
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Part A services and coverage for Inpatient Care in a Hospice Care: Covered Medicare Part A Hospice care services include the following: • • • • • • • • • Nursing services Doctors services Drugs, including outpatient drugs for pain relief and symptom management Physical/Occupational therapy and speech-language pathology services Home health aide and homemaker services Medical social services Medical supplies and appliances Short-term inpatient care, including respite care Counseling
Non-covered Medicare Part A Hospice Care services include the following: • Treatment other than for pain relief and symptom management of a terminal illness • Regular Medicare can usually help pay for treatment not related to the terminal illness.
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Duration of care: Eligibility requirements – Provided to patients terminally ill with a life expectancy of six months or less who elect to forego traditional medical treatment for the terminal illness and elect to receive only limited (hospice) care. Eligible Benefits – A patient may elect to receive Medicare coverage of four election periods of hospice care. The periods consist of two 90-day periods, one 30-day period and an unlimited fourth extension period.
MEDICARE PART B
Medicare Part B is also known as Supplemental Medical Insurance (SMI). Medicare part B typically thought of as insurance for physician services (in both hospital & non-hospital settings). physician services Medicare Part B coverage: • • • • • Physician Services Non-Physician Services Diagnostic Tests Durable Medical Equipment Ambulance Transportation However, Medicare Part B also covers certain non-
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PHYSICIAN SERVICES
Definition of physician services – For Medicare purposes, a physician is described as a doctor of medicine; doctor of osteopathy; doctor of dental surgery or dental medicine; a chiropractor; a doctor of podiatry or surgical chiropody; or a doctor of optometry legally authorized to practice by a state in which s/he performs this function. Scope of Physician Services – The services performed by a physician within the above definition are subject to any limitations imposed by CMS 1500, the state licensing agency or the local Medicare contractor on the scope of practice. If any limitations are placed on the scope of practice, Medicare will only cover items or services within the limitation. For example, Medicare limits reimbursement for
chiropractors for only spinal manipulation, as long as coverage requirements are met – based on the scope and limitation of the medical license. Requirements for coverage of physician services – In order for a physician service to be potentially covered under Medicare, it must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Covered Medicare Part B physician services include, but are not limited to, the following: • Diagnostic tests and procedures that are part of treatment
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• • • • •
X-rays Medical and surgical services, including anesthesia Drugs and biologicals that cannot be self-administered Physical/occupational therapy and speech-language pathology services Treatment of mental illness.
Non-covered services – Situations in which an item or service would not be covered under Medicare Part B include, but are not limited to the following: • • Program exclusions, as designated by CMS 1500 Medical devices or biologicals which have not been approved by the food and drug administration. • Items and services which are determined to be investigational in nature.
NON-PHYSICIAN SERVICES
In addition to physician services, Medicare Part B also reimburses covered items and services from various non-physician providers. These non-physician providers include the following types: • • • Certified Registered Nurse Anesthetist (CRNA) Certified Nurse Midwife (CNM) Clinical Psychologist (CP)
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• • • • •
Clinical Social Worker (CSW) Physician Assistant (PA) Independent Billing Audiologists Independent Billing Psychologists Independent Practicing independent Physical, occupational and speech therapists
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Nurse practitioner and Clinical Nurse Specialist in collaboration with a physician
Scope of Non-Physician services – The services performed by the above listed nonphysicians are subject to any limitations imposed by CMS 1500, the state licensing agency or the local Medicare contractor on the scope of practice. If any limitations are placed on the scope of practice, Medicare will only cover items or services within the limitation. For example, Medicare limits reimbursement for clinical
psychologists or clinical social workers to services involving treatment of mental illness, as long as coverage requirements are met – based on the scope and limitation of the medical license. Requirements for coverage of non-physician services – In order for a nonphysician service to be potentially covered under Medicare, it must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.
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Covered Medicare Part B non-physician services include, but are not limited to, the following: • • • • • • Diagnostic tests and procedures that are part of treatment X-rays Anesthesia Administration of drugs and biological’s that cannot be self-administered Physical/occupational therapy and speech-language pathology services Treatment of mental illness
Non-covered services – Situations in which an item or service would not be covered under Medicare Part B include, but are not limited to the following: • • Program exclusions, as designated by CMS 1500 Medical devices or biologicals which have not been approved by the Food and Drug Administrations • Items and services which are determined to be investigational in nature
Note: All service(s) which are related to a non-covered item or service is /are also not covered service(s) under the Medicare Program.
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Non-covered Medicare Part B non-physician services include, but are not limited to, the following: • • • Acupuncture Hearing aids Personal comfort items
Note: The local Medicare contractor has the ability and authority to designate an item or service as non-covered for their service area or jurisdiction. For a
complete list of all non-covered items or services for your state, you should contact your local Medicare contractor. Diagnostic Procedures Diagnostic procedures can be performed in a variety of places, such as independent laboratories, Independent Diagnostic Testing Facilities (IDTF),
outpatient x-ray and testing facilities and inpatient hospitals (interpretation only). Keep in mind Diagnostic tests, as with all other services your provide must meet the regular coverage requirements in order for Medicare to make payment. They are the item or service must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. For most diagnostic tests, Medicare contractors develop a list of
diagnoses for which payment will only be allowed. If a claim for a diagnostic test is received and the indicated diagnosis is not on the list of covered diagnosis codes, then Medicare will deny the service as not being medically reasonable and
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necessary. For a list of diagnostic tests and applicable covered diagnosis codes, please contact your local Medicare contractor. Diagnostic Tests Covered diagnostic tests include, but are not limited to the following: • • • • • • • • • • • • X-ray (diagnostic radiology) Magnetic resonance imaging (MRI) Cat scans Diagnostic ultrasound procedures Nuclear medicine Nuclear imaging procedures Organ or disease-oriented panels Drug screens Clinical pathology consultations Individual blood chemistry tests Immunology Transfusion medicine
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•
Surgical pathology
Durable Medical Equipment (DME) include, but are not limited to the following: • • • • • • • Wheelchairs Commode chairs Oxygen equipment Walkers Hospital beds Canes Nebulizers
Non-covered DME include, but are not limited to the following: • • Personal convenience items Bathroom or safety equipment
Duration of care: Claims for DME are processed by regional contractors (DMERC). You should
contact your local DMERC for further information regarding duration of care.
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Note: All DME must be prescribed by a physician. Ambulance Transportation In order for Medicare to reimburse ambulance transportation, several coverage requirements must be met. limited to the following: • The ambulance service must be medically necessary and reasonable. To These coverage requirements include, but are not
meet medical necessity, the patient’s condition must be such that use of any other method of transportation is contraindicated. In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individuals health, whether or not such other transportation is actually available, no Medicare payment may be made for the ambulance service. To meet the
medical reasonableness, the patients diagnosis must warrant ambulance services. The diagnosis requirement still needs to be met, even though the patient’s condition may contraindicate the use of other means of transportation. • The ambulance vehicle and crew must meet Medicare requirements. The average
Medicare covers ambulance transportation either by land or air. requirements for air ambulance are stricter than land transportation.
Duration of care:
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There is no limit to the number of ambulance transports, as long as medical necessity and reasonableness has been determined and proven.
MEDICARE PART C
Medicare Part C coverage includes: • • Part A Medicare Coverage Part B Medicare Coverage
In addition, Part C coverage includes: • • • • • Preventive Care Prescription Drugs Eyeglasses Dental Care Hearing Aids
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What is hospice? Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is given by a public agency or private company approved by Medicare. It is for all age groups, including children, adults, and the elderly during their final stages of life. The goal of hospice is to care for the patient and their family, and not to cure the patient illness. If a patient qualifies for hospice care, he/she gets medical and support services, including nursing care, medical social services, doctor services, counseling, & homemaker services. In many cases, the patient and their family can stay together in the comfort of their home. Depending on the patient’s condition, they may have hospice care in a hospice facility, hospital, or nursing home. Who is eligible for Medicare Hospice Benefits? Hospice care is covered under Medicare Part A (Hospital insurance). A patient is eligible for Medicare hospice benefits when: • • Patient is eligible for Medicare Part A (Hospital Insurance); Patients doctor and the hospice medical director certify that a patient is
terminally ill and probably have less than six months to live; • Patient signs a statement for choosing hospice care instead of routine
Medicare covered benefits for terminal illness;
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How does hospice work? Patient’s doctor and the hospice will work with the patient and their family to set up a plan of care that meets patient’s needs. For a hospice patient, there is a team of people that will help take care of the patient. They are: • • • • • • Patient’s family A doctor A nurse Clergy or other counselors A social worker Trained volunteers
Volunteers are trained to help with every day tasks, such as shopping and personal care services, like bathing and dressing. Speech, physical, and
occupational therapists and other persons who are trained to give care are also there when required. A Family member or other person who cares for the patient will be there every day and members of the hospice team will make regular visits. A nurse and a doctor are on-call 24 hours a day, 7 days a week to give the patient and their family the
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support and care when needed. If a patient should need care in hospital for illness, the hospice team will help arrange the stay.’ Even though a doctor is a part of the hospice team, patient can choose to use his/her regular doctor, who is not a part of the hospice to get care. The hospice will work closely with the patient’s regular doctor to give the care that a patient needs. What does Medicare covers? Medicare covers these hospice services and pays nearly all of their costs: • • • • • • • • • • Doctor services Nursing care Medical equipment (such as a wheelchairs or walkers) Medical supplies (such as bandages and catheters) Drugs for symptom control and pain relief Short-term care in the hospital including respite care Home health aide and homemaker services Physical and occupational therapy Speech therapy Social workers services
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• •
Dietary counseling Counseling to help you and your family with grief and loss
The patient, only have to pay part of the cost for outpatient drugs and inpatient respite cares. What is respite care? Respite care is care given to a hospice patient by another caregiver so that the usual caregiver can rest. As a hospice patient, you may have one person that takes care of you every day. That person might be a family member. Sometimes they need someone to take care of you for a short time while they do other things that need to be done. During a period of respite care, you will be cared for in a Medicare approved facility, such as a hospice facility, hospital or nursing home. What is not covered? The care that you get for your terminal illness must be from a hospice. When you choose hospice care, Medicare will not pay for: • Treatment to cure your terminal illness.
As a hospice patient, you can get comfort care to help you cope with your illness not cure it. Comfort care includes drugs for symptom control and pain relief, pain relief, physical care, and counseling and other hospice services. Hospice uses medicine, equipment, and supplies to make you as comfortable and pain-free as possible. Medicare will not pay for treatment to cure your illness. You should talk
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with your illness; you should talk with your doctor if you are thinking about potential treatment to cure your illness. As a hospice care and go back to your regular doctor health plan. • Care from another hospice that was not set up by your hospice.
You must get hospice care from the hospice provider you chose. You can get hospice care from another hospice provider, unless you change your hospice provider. • Care from another provider that is the same care that you must get from
your hospice. Your hospice team must give all care that you get for your terminal illness. You cannot get the same type of care from a different provider unless you change your hospice provider. What will I have to pay for hospice care? Medicare pays the hospice for your hospice care. You will have to pay: No more that $5 for each prescription drug and other similar products” The hospice can charge up to $5 for each prescription for outpatient drugs or other similar products for pain relief and symptom control. 5% of the Medicare payment amount for inpatient respite care For example, if Medicare pays $100 per day for inpatient respite care, you will pay $5 per day. You can stay in a Medicare – approved hospital or nursing home up to 5 days each
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time you get respite care. There is no limit to the number of times you can get respite care The amount you pay for respite care can change each year. Can I keep my Medicare health plan? Yes. You should use your Medicare health plan (like the Original Medicare Plan or a Medicare managed care plan) to get care for any health problems that are not related to your terminal illness. You may be able to get this care from your own doctor who is not a part of the hospice, or from the hospice doctor. When you use your Medicare health plan, you must pay the deductible and coinsurance amounts (if you have the Original Medicare Plan), or the copayment (if you have a Medicare managed care plan). • Important information about Medicare Supplemental Insurance:
If you are in the Original Medicare Plan, you may have a medicare Supplemental Insurance or “Medigap” policy. Your Medigap policy still helps to cover the costs for the care of health problems that are not related to your terminal illness. How long can I get hospice care? You can get hospice care as long as your doctor certifies that you are terminally ill and probably have less than six months to live. Even if you live longer than six months, you can get hospice care as long as your doctor recertifies that you are terminally ill. Hospice care is given in periods of care. As a hospice patient, you can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods. At
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the start of each period of care, your doctor must certify that you are terminally ill in order for you to continue getting hospice care. A period of care starts the day you begin to get hospice care. It ends when your 90 or 60-day period is up. If your doctor re-certifies that you are terminally ill, your care continues through another period of care. As a hospice patient, why would I stop getting hospice care? Sometimes a terminally ill patient’s health improves or their illness goes into remission. If that happens, your doctor may feel that you no longer need hospice care and will not re-certify you at that time. Also, as a hospice patient you always have the right to stop getting hospice care, for whatever reason. If you stop your hospice care, you will get your health care from your Medicare health plan, (like the Original Medicare Plan or a Medicare managed care plan). If you are eligible, you can go back to hospice care at any time. As a hospice patient, you always have the right to stop getting hospice care and go back to your regular doctor or health plan.
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MEDICAID
The Medicaid Program provides medical assistance for certain individuals and families with low incomes and resources. Medicaid eligibility is limited to individuals who fall into specific categories. Although the Federal government establishes general guidelines for the program, the Medicaid program
requirements are actually established by each State Medicaid eligibility is limited to individuals who fall into specified categories. The federal statute identifies over 25 different eligibility categories for which federal funds are available. These categories can be classified in to five broad coverage groups:
• • • • •
Children; Pregnant Women; Adults in Families with Dependent children; individuals with disabilities; and individuals 65 or over
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BLUE CROSS BLUE SHIELD PLANS
Blue Cross plans were founded originally to cover hospital expenses. Blue shield plans were originally established primarily to cover physician services. In most areas, Blue cross and blue shield plans are a single corporation. In other areas, they are separate organizations and in some case even compete with each other. A person becomes a member by entering into a contract with the local Blue cross and/or Blue shield plan and by paying regular dues. The person becomes a subscriber not a policyholder and retains a certificate not a policy, that tells him what to expect from the contract when medical services are required. When the BCBS plans serve as a Medicare contractor (Medicare HMO), the Blue Cross staff within the plan handle Medicare Part A as the fiscal intermediary and the Blue shield staff within the plan handle Medicare Part B as the carrier.
Types of Blue Cross and Blue Shield contracts
There are two basic types of blue cross and blue shield contracts: -
•
Service Benefit Contracts - Offered by all BCBS plans that offer physician participation agreements. The contract provides the covered services themselves, rather than reimbursing the subscriber for some or all of the expenses incurred in obtaining covered services. Through physician participation agreements, a blue cross or blue shield plan secures the performance of service benefits (i.e. covered services) on behalf of its subscribers.
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•
Indemnity Benefit – contracts cover some or all of the actual expenses of providing covered services but not more than the actual charges for a specific service. An indemnity benefit contract makes not promise to cover the full fee. A professional provider may bill the subscriber an amount in excess of the Plan’s benefit allowance. The subscriber is responsible for any difference between the plan’s allowance and the professional provider’s bill.
TRICARE (CHAMPUS)
Tricare is the Managed healthcare program for Active Duty service members and retirees and their families. Tricare formerly CHAMPUS is the Managed care program for DoD beneficiaries. Through the 3 tricare programs Standard, Extra and Prime, Military Treatment Facilities MTF and Civilian providers work as partners to help control the overall cost of healthcare. TRICARE is administered by regional Managed care Contractors to provide you with an appropriate balance of cost, access and quality. The TRICARE programs are available to family members of active duty military service members and also to military retirees and their dependents. These dependents include spouses, unmarried children under age 21, unmarried children who are full-time students under age 23 and stepchildren adopted by the sponsor. Those who are eligible must be listed in the Defense Department's worldwide, computerized database DEERS (Defense Enrollment Eligibility Reporting System). The following are not eligible for TRICARE benefits: • People age 65 or older who are eligible for Medicare (with some exceptions)
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• •
Parents and parents-in-law of active duty service members or retirees People who are eligible for health benefits under CHAMPVA (Civilian Health
and Medical Program of the Department of Veterans Affairs) The Defense Enrollment Eligibility Reporting System (DEERS) is a military database that lists everyone who is eligible for TRICARE benefits. Make sure your DEERS record is up-to-date. This will help us process your claims quickly and accurately.
RAILROAD MEDICARE
The Railroad Retirement Board’s mission is to administer retirement/survivor and unemployment/sickness insurance benefit programs for railroad workers and their families under the Railroad Retirement Act and the Railroad Unemployment Insurance Act. These programs provide income protection during old age and in the event of disability, death or temporary unemployment and sickness. The Railroad Retirement Board also administers aspects of the Medicare program and has administrative responsibilities under the Social Security Act and the Internal Revenue Code. The ID format is one or two alpha’s followed by 8 numeric. Medicare - Blue Cross and Blue Shield Plans have served as partners to the federal government in administering the Medicare program since its inception in 1966. Blue Plans helped design the original infrastructure for tracking and processing Medicare payments. Today, the Blue System collectively is the largest single processor of Medicare claims - handling more than 90 percent of claims
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from hospitals and institutions (Part A) and nearly 60 percent of claims from physicians and other health care practitioners (Part B). National Accounts – This is a program that covers the employees of a company that has offices, plans and people in several states and whose employees travel a great deal or change location frequently. The Identification number on the subscriber’s card indicates this is a National account. Claims are filed and paid by the local plan where the treatment was rendered.
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DISABILITY INSURANCE
Disability insurance replaces incomes which individual lose if he has a long-term illness or injury and cannot work. This is an important type of coverage for working-age people to consider. Disability insurance does not cover the cost of rehabilitation if an individual is injured. Some employers offer group disability insurance and this may be one of the benefits where individual work. Or the individual might be eligible for some government-sponsored programs that provide disability benefits. Many different kinds of individual policies are also available.
WORKMEN’S COMPENSATION INSURANCE
This insurance policy protects the insured party from legal liabilities against injury or death of any of his employees who is a "workman" as defined by the Workmen's Compensation Act. Workers hurts on-the-job are protected by workers’ compensation employees. With rare exceptions, Oregon has a "no fault" system, which means both workers and employers are protected from the time and expense of determining who caused an on-the-job accident. It is the workers responsibility, however, to prove that an injury or disease is job related rather than substantially related to a diagnosed pre-existing condition. insurance. Oregon law requires employers to insure their
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This insurance policy is necessary for every employer since it indemnifies him against his legal liability as an "employer" towards accidental or fatal injuries sustained by his work men during work. The actual cost of workers’ compensation insurance coverage is paid totally by employers to the insurance company the employer selects. The amount the employer pays depends primarily upon a worker’s job. A hazardous job costs more to insure than a less hazardous job. For example, a roofing company may pay $14.31 for workers’ compensation insurance for every $100 earned by each of its roofers, but just 18 cents for every $100 earned by its bookkeeper. On extra payment of premium, medical, surgical and hospitalization expenses including transportation costs are also covered. Liabilities that may arise owing to diseases mentioned in Section III (C) of Workmen's Compensation Act during the course of employment are also covered.
Some common things regarding Workers CompensationA worker's paycheck shows a deduction for "workers’ compensation." What is this for? The payroll deduction is the Department of Consumer and Business Services’ cents-per-hour assessment. Both workers and employers are assessed equal amounts for each hour the employee works. The money is collected by the Department of Revenue and is passed on to the Department of Consumer and Business Services (DCBS) -- the state agency that oversees the Oregon workers’ compensation system. The assessment goes to special funds the DCBS
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administers and is used to provide incentives to rehire injured workers and to ensure that benefits paid to injured workers and workers’ beneficiaries keep pace with the cost of living. Why do employers care about on-the-job injuries, if insurance covers those injuries? Employer’s care for several reasons: No employer wants to see anyone get sick, hurt or injured on-the-job. Employers don’t want to lose valuable, trained employees. The most valuable resource a business has is the people who work there. Injuries cause rates to increase. Individuals may have to pay more for car insurance if they are in an automobile accident. Similarly, employers may have to pay more for insurance or may even have coverage canceled, if there are too many injuries in the workplace. There are many indirect costs associated with accidents. For example, there may be lost production time and damage to machinery, which are costs not covered by insurance.
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What are workers supposed to do if they are hurt on-the-job? They should report their injury to their employers or supervisors immediately. They will help their workers get appropriate medical treatment, if necessary. The worker and employer must then file a workers’ compensation claim for benefits if the worker sees a doctor for medical treatment or missed time from work. The claim is filed by completing a Report of Occupational Injury or Disease (Form 801) available from the employer. Workers must complete page 2, then give the form to the employer who will complete page 1. The employer will send both pages to the insurance company. If the worker is in the hospital or cannot complete the form due to injury, the employer can send it to the insurer without the worker’s signature. The employer should give the worker a copy of the completed form. Workers should be sure to tell their doctors that the injury happened on the job and the name of the company that insures the employer. The doctor is required to file a report and will ask the worker to sign a portion of the form. If the employer is enrolled in a managed care organization (MCO) service area, he or she provides the worker with a list of doctors who are authorized to treat injured workers under the contract. A worker’s family doctor or authorized nurse practitioner may also be permitted to treat by the MCO. Employers will provide workers with additional information, if necessary.
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What kinds of injuries or illnesses qualify for workers’ compensation benefits? Generally, any injury that occurs while working (or illness due to work) that requires the worker to see a doctor or results in disability or death may qualify for workers’ compensation benefits. An injury could be traumatic (caused by an accident), cumulative (caused by repetitive motion) or an occupational disease (such as loss of hearing). A doctor must be able to verify that there is objective medical evidence showing that an injury or disease exists and that work exposure was the major cause. How does a worker get benefits when hurt on-the-job? If SAIF is the employer’s workers' compensation insurance company, we will begin evaluating the claim as soon as it is received. We will notify the worker and employer in writing when the claim has been accepted or denied. A claim number will be assigned to the claim. A claims adjuster may contact the worker by telephone or in writing to ask questions about the claim. Workers should have their claim number with them when they complete any forms, see the doctor or call SAIF. Having the claim number available will also help workers get their questions answered quickly.
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What does "deferred" mean? It means the claim has not been accepted or denied. No decision has been made yet. A claim is considered to be "deferred" while it is being evaluated. While a claim is deferred (and also when a claim is accepted), workers will receive wage replacement benefits, if the doctor states that the worker cannot work, and the worker is unable to work for more than three days. These benefits will not be paid if the claim is denied within 14 days of the day the injury was reported to the employer. Who pays for medical expenses if the claim is deferred? No one should pay for medical expenses while the claim is in a deferred status. If SAIF accepts the claim, we will pay for medical care related to the claim. If the claim is denied, the worker or the worker’s private health insurance carrier will be responsible for medical expenses. However, as of January 1, 2002, a claim that is denied and is on appeal will be processed by the health insurance company, provided the worker has coverage. However, if there is a balance remaining, the medical provider can bill the workers compensation carrier, who will pay up to the fee schedule for certain types of medical services prescribed to reduce pain, diagnose the condition or prevent disability. If the claim denial is ultimately upheld, the amount paid to the medical provider can be held as an overpayment and deducted from future workers’ compensation benefits with the same insurer.
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By law, if the worker is receiving medical care in Oregon, the doctor may not seek payment from the worker for the medical treatment related to the claim during the time the claim is being evaluated or if the claim is accepted. It is also important to know that during the time the claim is being evaluated (deferred), SAIF will not make payment for any medication the doctor may prescribe or for any other expenses such as transportation costs for visits to the doctor’s office. Workers should keep receipts for these expenses, as they will be paid by SAIF, in addition to related medical bills, if the worker’s claim is accepted. If SAIF sends a worker for an evaluation during this "deferred" period, we will reimburse expenses to attend the appointment(s). How do workers get reimbursed for prescriptions that they pay for? Workers may send their prescription receipts to their claims adjusters for reimbursement. Pharmacies can direct bill SAIF for most future prescriptions. Workers may contact us to verify whether a pharmacy participates in our pharmacy program. When will the worker receive a wage replacement check? If SAIF has received notification of the injury, the initial check will be mailed no later than 14 days from the date the worker informed the employer of the injury or became unable to work because of the injury, unless the claim is denied by the 14th day. Subsequent checks are mailed about every two weeks. An attending physician or authorized nurse practitioner must authorize these benefits.
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How long do wage replacement checks continue? The wage replacement benefit checks will continue until one of the following occurs: The worker returns to regular work; The worker’s doctor releases him/her to return to regular work; or The doctor approves a written offer of modified work by the employer, but the worker refuses to take it, and the wage offered is equal to or greater than the wage at injury. The worker returns to modified work and receives the equivalent of a regular wage. The claim is closed. SAIF may ask the worker to verify earnings after returning to modified work to ensure that he/she is receiving the correct amount of wage replacement. A prompt response will ensure there is no interruption in benefits. What is the amount of the wage replacement check? In most cases, the check will be for two-thirds of the worker’s weekly wage up to a maximum. For dates of injury on or after January 1, 2002, the maximum is 133% of the Oregon average weekly wage. There is usually a deduction for the three-day wait that is not paid in the first check.
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Why is there a three-day wait? The three-day wait is required by state law and acts as a form of "deductible." If the worker’s physician authorizes temporary total disability for 14 consecutive days or if the worker is hospitalized as an inpatient during the first period of disability, wage replacement benefits are paid back to the first day the worker missed work. How much is the maximum compensation? Wage replacement checks will generally be equal to two-thirds of the worker’s weekly wage, up to the maximum that is 133% of Oregon’s average weekly wage. (If your date of injury is prior to January 1, 2002, your maximum is 100% of the Oregon average weekly wage.) This maximum is calculated annually using figures from the state Employment Department. The minimum for any injured worker is $50 per week or 90 percent of the worker’s weekly wage, whichever is less. When will the claim be accepted or denied? A claim is evaluated and accepted or denied as quickly as possible. Sometimes your adjuster may need additional medical information or must request an investigation. This may cause a delay in the decision to accept or deny a claim. By law, insurers have 60 days from the time your employer knew of the injury to make this decision. (If your date of injury is prior to January 1, 2002 we have up to 90 days.)
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What are the worker's responsibilities if a claim is denied? The worker has 60 days to appeal a denial. If a claim is denied and that denial becomes final, the worker will be responsible for payment of all medical bills. The worker may bill his/her private health insurance company for medical treatment if the claim is denied by sending a copy of the denial to them. According to Oregon workers’ compensation law, it is up to the injured worker to prove that an injury occurred on-the-job or that an illness was due to job-related factors. Workers who file a workers’ compensation claim for an injury that they know occurred off-the-job or attempt to collect wage replacement and benefits for one job while failing to report earnings at another may be committing fraud and could be prosecuted. For dates of injury after January 1, 2002, some medical benefits may be paid while the claim is on appeal. Contact your adjuster if you need more information on these benefits. What are the worker's responsibilities if a claim is accepted? A SAIF claims adjuster is available to assist the worker with his/ her claim. Workers should be sure to ask questions if they don’t understand something or receive any forms or letters that are confusing. Workers should also keep their claims adjusters up to date on their recovery progress. The adjuster is there to help. It is the worker’s responsibility to do all he/she can to return to work. Workers should cooperate fully with those who are helping to return them to work. They
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should keep their medical appointments and follow their doctor’s instructions and treatment plan. They should avoid any activities that will slow or stop recovery. It is important for workers to keep their employers informed about their condition. Employers need to know what the worker’s doctor reports after each medical visit. When the doctor releases the worker for work, the worker must contact the employer immediately. Workers should be sure to obtain a written copy of the work release to give to the employer. What happens to the worker’s job if he/she can’t work? The intent of the workers’ compensation system is to help injured workers get back to work. Workers have a responsibility to make every effort to return to work once they are able. Employers may also ask an injured worker to return to a different job while they are healing. Studies show that most injured workers recover more quickly when they can return to the workplace. If the worker is unable to return to his/her old job and has a permanent disability, he/she may be eligible for the Preferred Worker Program that provides financial incentives to employers who hire injured workers with permanent disabilities. The Department of Consumer and Business Services will notify workers if they are eligible or they can contact the Department directly at 1-800-445-3948 to inquire about this program.
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Will the worker get retrained? Retraining is one of the last options exercised to get an injured worker back to work. In most cases, re-employment depends upon the worker’s existing skills and physical capabilities. If a worker believes his/her injury will prevent him/her from returning to any employment he/she has held in the past, the worker should contact SAIF to review eligibility for vocational benefits. Why do insurers send out all that paperwork inquiring about a worker’s medical and work history? This information is needed to ensure that the benefits the worker receives are appropriate and to determine his/her eligibility for vocational assistance or permanent partial disability. Who should a worker call if he/she has questions about workers’ compensation? Employers can certainly help answer questions workers may have. Any worker who has filed a claim with SAIF should contact us at 1-800-285-8525. They can also call the Department of Consumer and Business Services Injured Workers' Hotline at 1-800-452-0288 or the Ombudsman for Injured Workers at 1-800-9271271.
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HOSPITAL INDEMNITY INSURANCE
This insurance offers limited coverage. It pays a fixed amount for each day, up to a maximum number of days. An individual may use it for medical or other expenses. Usually, the amount the individual receive will be less than the cost of a hospital stay. Some hospital indemnity policies will pay the specified daily amount even if patient has other health insurance. Others may coordinate benefits, so that the money patient /insured receive is not equal / more than 100 percent of the hospital bill.
LONG-TERM CARE INSURANCE
Long-term care insurance is designed to cover the costs of nursing home care, which can be several thousand dollars each month. Long-term care is usually not covered by health insurance except in a very limited way. Medicare covers very few long-term care expenses. There are many plans and they vary in costs and services covered, each with its own limits
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Understanding Health Insurance Terms
Coinsurance
The amount patient / insured is required to pay for medical care in a fee-for-service plan, after deductible have been met. as a The coinsurance For rate is usually if the
expressed
percentage.
example,
insurance company pays 80 percent of the claim, patient / insured pay 20 percent.
Coordination of Benefits
It is a system to eliminate duplication of benefits, when an individual is covered under more than one group plans. Benefits under the two plans usually are limited to no more than 100 percent of the claim.
Co-payment
It is another way of sharing medical costs. Here Individuals pay a flat fee every time he receives medical service. (For example, $5 is paid for every visit to the doctor). The insurance company pays the rest.
Covered Expenses
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Most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures the insurer agrees to pay for. They are listed in the policy. Customary Fee Most insurance plans will pay only what they call a reasonable and customary fee for a particular service. If patient’s doctor charges $1,000 for a hernia repair while most doctors in that area charge only $600, patient will be billed for the $400 difference. This is in addition to the deductible and coinsurance which patient is expected to pay. Deductible The amount of money insured must pay each year to cover medical care expenses before insurance policy starts paying. Exclusions Specific conditions or circumstances for which the policy will not provide benefits.
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HMO (Health Maintenance Organization)
Prepaid health plans. Insured pay a monthly premium and the HMO covers doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, xrays, and therapy. Insured must use the doctors and hospitals designated by the HMO.
Managed Care
Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care. Maximum Out-of-Pocket Expenses The most money insured will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
PPO (Preferred Provider Organization)
A combination of traditional fee-for-service and HMO. When patient use the doctors and hospitals that are part of the PPO, he can have a larger part of medical bills covered. Patient can use other doctors, but at a higher cost. Pre-existing Condition A health problem that existed before the date insurance became effective. Premium
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The amount which insured or his employer pays in exchange for insurance coverage. Primary Care Doctor Usually patient’s first contact for health care. This is often a family physician or internist, but some women use their gynecologist. A primary care doctor monitors health and diagnoses and treats minor health
problems, and refers the patient to specialists if another level of care is needed. In many plans, care by specialists is only paid for if the patient is referred by primary care doctor. An HMO or a POS plan will provide a list of doctors from which patient will choose primary care doctor (usually a family physician, internists, obstetriciangynecologist, or pediatrician). This could mean patient might have to choose a new primary care doctor if his current one does not belong to the plan. PPOs allow members to use primary care doctors outside the PPO network (at a higher cost). Indemnity plans allow any doctor to be used.
Provider Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care is called an provider. Third-Party Payer Any payer for health care services other than the patient / insured. This can be an insurance company, an HMO, a PPO, or the Federal Government.
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MEDICAL BILLING – AN INTRODUCTION
What Is Medical Billing?
Medical billing is better described as full medical practice management and a doctor's key to getting paid. Full medical practice management," meaning that billing office handle all the bookkeeping and
accounting functions for their doctor-clients, including patient statements, recording
payments, preparing financial reports, and even consulting the physicians on issues such as how to negotiate contracts with the growing number of managed care companies such as HMOs and PPOs that are trying to reign in doctors' fees.
Medical billing involves preparation of medical bills on behalf of the doctor for the treatments performed on the patients. The work also involves sending the
medical bills to the respective insurance company with whom the patient is a beneficiary. The billing department also collects the money from the insurance
company on behalf of the doctors. The insurance company pays for the treatments billed by the billing office.
The Medical Billing industry is a subsidiary of the Health care industry. Medical Billing is the financial-data management of a physician or a group of physicians’ practices. This means maintaining all of the physician’s non-medical records and keeping track of and collecting all money due to him.
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What are the basic differences between US & Indian medical payment collections?
To understand “Medical Billing”, it is important to first understand the difference between medical payment collections in India as opposed to the collections policies in the U.S. There are two basic differences 1. The first difference is that few people in India have a medical insurance
policy. They pay their medical fee out of their pockets immediately after their visit to the doctor. On the other hand, a large percentage of the American population had Medical Insurance Policies to cover their medical bills. In addition, most physicians extend credit. In short, insurance companies pay most medical bills, and they do this, at an extended period from the date of treatment. 2. Even if a person has a medical insurance policy in India, and if his policy
covers his treatment, he has to pay the medical bill out of his pocket at the time of his treatment. His insurance company then later reimburses him. In the U.S, the patient undergoes his treatment, gives all relevant information regarding his insurance policy or policies at the physician’s office and leaves. According to American law, it is the physician’s responsibility to collect the money from the government insurance programs. Most physicians take the responsibility of collecting payments due from the private insurance companies also as an added service to their patients.
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The client of a Billing Office may be one physician, a group of physicians working in the same hospital practicing different specialties (Ophthalmology, Anesthesia, etc.) or a group of physicians practicing the same specialty.
Why Physicians go for Medical Billing Companies to do billing?
America has more than 3000 insurance companies, each with a number of plans. This posed a problem to the physicians. Every insurance company required the medical claims filed to them according to their own rules and formats. Also, when physicians sent out claims to these insurance companies the explanation of the diagnosis and the treatment, necessary to every claim, were voluminous and time consuming. The forms and codes developed by Center for Medicare and Medicaid Services (CMS – formerly known as HealthCare Financing Administration CMS) reduced the volume of the information to be transferred to the insurance companies but the volume was still considerable and required skill and time. The medical treatment performed still had to be encoded. These codes, with the patients’ demographic information, still had to be entered into specific medical billing software’s. This process was again time consuming and the extra personnel and infrastructure meant extra costs. They could not handle the volume and turned to specialist billing offices for assistance. It was easier for a physician to source their non-medical, accounting work to a billing office so that he could concentrate on his practice. Thus the medical billing office became an intermediary between the physician and the insurance companies.
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The billing office collects information relevant to the patients’ treatment from the physicians’ office. Using these codes and forms, the billing office bills the insurance companies and patients on behalf of the physicians. Until recently, medical billing was usually done by typing out and mailing claims to various insurance companies. Now the objective of the medical billing industry is to offer fast, efficient, and error-free claims processing using computers to log and transmit claims to the insurance companies.
What is a Claim?
A claim is a request made to the insurance company, by the billing office on behalf of the insured person or the physician, for reimbursement of services rendered by the physician. A claim is sent out on standardized forms that contain information regarding the patient, his insurance coverage, the physician, the diagnosis and the treatment. A claim is either mailed or electronically transmitted to an insurance company. In a small family practice or suburban clinic this task may be simple and assigned to the medical assistant or nurse but in bigger practices and clinics this is the medical biller's job! When a physician treats a patient, the doctor’s office must file an insurance claim to get paid. This claim is usually filed on paper and sent by mail. These paper claims are notoriously slow, often taking 60-90 days or more for the doctor to get paid. Now, these claims can be processed electronically, saving healthcare provider’s time and money. With electronic claims processing, payment time is drastically reduced to just 7 to 21 days on average. This dramatic improvement in cash flow
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is exactly why medical billing is in such demand. Physicians are constantly seeking remedies to their medical billing difficulties.
A brief study on working of Medical billers?
Medical billers and coders usually work forty regular office hours from Monday through Friday on a desk in the billing office or billing department of the professional healthcare office. They must know the different methods of billing patients, understand various collection methods, ethical and legal implications have a good working knowledge of medical terminology, anatomy, medical billing and claims form completion, and coding. They also must understand database management, spreadsheets, electronic mail, and possess state-of-the-art word processing and accounting skills, be proficient in bookkeeping, and be able to type at a speed of at least 45 words-per-minute. The work area of medical billers and coders usually is in a separate area away from the patients and public eye. However, even though they are not involved in the actual process of doctors and healthcare professionals providing medical care they need to possess excellent customer service skills when it comes to making contact with clients, insurance companies, and often patients. Medical billers must know how to explain charges, deal with criticism, give and receive feedback, be assertive, and communicate effectively without becoming confused as the person is asking questions. Patients can quickly become frustrated when trying to deal with healthcare providers and bills over the phone.
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While an increasing amount of patient care is being funded through HMO (Health Managed Organizations) related insurance, where the patient makes a small copayment at the time of service and the doctor bills the managed care company for the balance, a number of patients still need to make arrangements to pay for their medical services over a period of time. Part of the medical biller and coder's job is to contact some of these patients from time to time regarding a past due bill. Incoming calls from patients who have questions regarding a bill are also directed to the medical billers office. The way s/he communicates over the phone can make or break business relationships. Other specialties closely related to the medical billing profession are: • • • • • • • • • • Medical Coders/Coding Specialists Patient Account Representatives Electronic Claims Processors Billing Coordinators Reimbursement Specialists Claims Assistant Professionals Medical Claims Analysts Medical Claims Processors Medical Claims Reviewers Medical Collectors
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What are the various departments in an Indian billing office?
Billing office is a link between the Doctor and the insurance company. The billing office in India has four departments put together, they are: 1. Scanning Department 2. Charge Entry Department 3. Cash Department 4. Accounts receivable department 5. Quality Department
Scanning Department
This department is responsible for collecting the data scanned from the US billing office. The US office in turn receives the data from the physician’s office,
insurance companies, and patients. The data received in US is scanned to back office in India. The data sent to us involves the details of the patients and
treatments taken at the hospitals. (Patient Demographic & charge sheets). These data are handled by the charge entry department. The second form of data is the data sent to us by the insurance companies. The data contains the benefit paid to the respective patient’s by the insurance companies and this data is handled by the cash department. The third form of data is called the regular mails and this comes from the insurance companies and this is handled by the accounts receivables.
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The scanning department receives and allocates all the data received by them to the respective departments.
Charge Entry Department
This department is responsible for registering the patients in the system before entering the charges. Each type of ailment or disease has a unique diagnosis code called ICD-9 code (International Classification of Diseases 9th Edition Clinical Modification) and each type of ailment requires different modes of treatment procedures. The procedures involved in the treatments are noted by unique codes called the CPT (Current Procedural Terminology). code (Procedure code) The charge sheets notify the various treatments performed on a patient. The
charge entry department enters these procedures into the respective patient account. These details are collected and entered by the billing office and the
copies of these claims are sent to the insurance companies. The mode of sending the claims to the insurance companies can be by mail or by electronic transmission. Insurance companies take on an average time period of 30 days to process the claims. Patient Demographics & charge entry is the first step of the billing process and an error here will prompt errors in the subsequent steps. In some cases this error can be discovered only after the claims reach the insurance carriers. This will
result in lost accounts receivables time. Hence utmost care should be taken while entries are being made.
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Cash Department
This department is responsible for entering the cash details into a particular account. The check and the explanation of benefits (EOB) are sent to us by the insurance companies. Check contains the providers or group name, amount paid and the insurance company’s name. EOB contains the detailed description of the payments made for the type of procedures involved in the treatment. In case of a denial, an EOB alone is sent and it explains which charge has been denied and for what reason. payment. EOB will be used to verify any discrepancies from the expected
When a claim has been processed and paid, the amount paid will have to be applied to the amount charged for individual patient’s treatment in the Medical billing software. This makes it possible for the billing office to track the payments received from different angles. Some examples of how a billing office would want to track the payments received are: a) All insurance payments for a doctor or a group b) All patient payments for the doctor or group c) Total payments made for all patients or any group of patients (grouped by insurance company, date etc) d) Payment made for any specific treatment for a patient e) Payments made by an individual patient or insurance company
f) All payments made for one particular treatment that the physician renders.
(total revenue earned from heart operations alone for an cardiologist)
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Cash posting or the correct application of payments to their respective charges in the medical billing software is very important as any wrong posting may result in wrong accounting. If there are any mistakes in posting, the reports that are run to assess a physician’s practice or judge the billing office’s performance will be incorrect. EOB’s are the only hard copy evidence the billing office have to check how the
insurance company had processed the claims sent to them and it has to be filed carefully for future references.
Accounts Receivables Department
This department has to check for the steady inflow of money from the insurance company. The main motive of this department is to collect money for all the
treatments taken by the patients. Usually the turn around period for the payment by the insurance company is 30 – 45 days. Once the limit is exceeded AR
department has to make an enquiry for the delay. There are various reasons for the delay like: a) Correct details may not have been provided to the insurance companies. b) Claims were sent correctly but Insurance Company may not have received the claims. c) The checks issued might have been sent to the wrong address. d) The insurance company may delay the payments if they have a backlog and they would inform us by a letter that they have received the claims and would be making the payments shortly.
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AR department acts as a hub around which other departments have to revolve. This department can gather & update lot of billing information which is required to settle a claim. There are instances where insurance company does not make a 100% payment and we would have received a low payment, in such case AR analyst have to work on such claims & settle the claim. The Medical billing software is capable of running reports that pull out claims that are unpaid for greater than 30 days. These are calling aging reports and show pending payments in slots such as 0 – 30 days, 31-60 days and 61-90 days. Claims filed within the last 30 days will find themselves in the first slot (0-30days). Claims that are more than 30 days but less than 60 days old will be found in the 31-60 days slot. A glance at this report will show the AR personnel the claims that need to be followed up on with the insurance company. Claims will be followed up over the telephone or by written correspondence. It
would be necessary to find out why the claims are yet to be paid and what needs to be done to have these claims paid. The delay and denials will be corrected by the billing office in coordination with the physician’s office and the insurance carriers. The same applies when patient billing statements are sent out. The
patient is given 3-4 weeks to pay the bill and if the payment is not received with in that time, the billing office will follow up with the patient. Communication is very important between the three departments. There will be a number of circumstances where these departments will have to work with each other to troubleshoot problem claims. Only good coordination between these
departments will assure correct and quick payments from both the insurance companies and the patients.
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Quality Department
Quality in Health care business can be defined in two words first “
Accuracy “ ( Defect free transaction ) where in data captured in the software is accurate with the information received, this will also enable the claim to be paid within the given time period. Next comes “Timely Response i.e., work received
has to be completed within the stipulated time period as agreed with the client. In the competitive world of Healthcare BPO Environment today, Quality Process plays a vital role to ensure that a clean claim is being transmitted/forwarded to the Insurance carrier. Quality check is done based on General rules and specific rules given by the client from time to time. Quality check is maintained in all departments of Medical Billing by laying down rules for each department and thereby arresting the errors to minimum level. In the absence of correct checks and balances, companies can run the risk of jeopardizing their relationship with customers through the inability to provide continuously good service.
The project is initiated with formal identification of the Project Manager, allocation of project resources, and overall establishment of the project environment and preparation of Project Development and Quality Plan. Continuous Project
monitoring is done through various levels of quality reviews. The project manager ensures a smooth interaction with the customer through e-mails, teleconferences and Weekly Progress Reports.
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Quality Check List
Demos: Patient Details: 1. 2. 3. 4. 5. 6. 7. Patient Account Number. Patient Name: Last name, First name Middle Initial Patient DOB: MM/DD/YYYY Patient SSN: 9 Digits Numeric Patient Sex: Male/Female Patient Marital Status: Married/Single/Others Patient Address: Physical Address/Mailing Address City, State, Zip Code 8. Patient Ph#: 10 digits 9. Employer Details.
Guarantor Details: 1. 2. 3. Guarantor Name. Guarantor Address Guarantor Phone#.
Insurance Details: Primary Insurance: 1. 2. 3. Plan Name. Insurance Address Policy Number
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4. 5. 6.
Group Number Subscriber Relationship code
Secondary/ Tertiary same details need to be checked.
Charges: 1. 2. 3. 4. 5. 6. 7. 8. 9. Date of Service (From Date; To Date) Place of Service Facility Referring Doctor Provider Procedure Modifiers Diagnosis Units
10. Billed Amount
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What are the problems faced by US providers or physicians?
Constantly US physicians face the problems of insurance coding & payment reimbursement on their insurance claims. Optimizing reimbursement is like trying to piece together a puzzle with a lot of pieces. Not only is there a lot of complexity, but change is continuously occurring. important factors, few are outlined below. 1. Providers are using invalid, obsolete or deleted codes while submitting claims to respective insurance carriers. 2. The code and fees may be okay, but providers may be losing charge information, missing super bill fees or billing insurance carriers wrongly or irregularly. 3. The practice is not well-informed about current coding and billing issues. 4. The practice doesn't have and/or doesn't follow written policies and procedures which support the billing, coding and collections processes. 5. Not participating in Medicare may allow providers to bill higher fees to patients, but this may not be in the best interests of their practices. 6. Poor understanding of how insurance carriers work and ineffective strategies and systems for dealing with them. 7. The practice is not using forms and documents which are current. In general, the basic tools needed by health care providers for optimizing reimbursement are: 1. A thorough understanding of the billing process and related terminology. There are a number of
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2. Procedure coding and diagnostic expertise.
3. A well-designed super bill. 4. A fee schedule based on relative values.
5. Current and accurate forms and documents.
6. Current reference materials (such as code books).
7. Written policies and procedures covering billing guidelines.
What is the normal work flow process in Medical billing?
The following brief outline would give the workflow process from the time a patient is seen by a physician. 1. The doctor sees the patient. Demographics, super bills/charge sheets,
insurance verification data and a copy of the insurance card i.e. all the information pertaining to the patient is sent to the Billing office. 2. Billing office scans the source documents and saves the image file to an FTP
site or on to their server under pre-determined directory paths. 3. Scanning department retrieves the files and prints them and ties up with
the control log for number of files and pages. (This process is absent if a billing office opts for data entry thru electronic source documents) 4. Illegible /missing documents are identified and a mail is sent to the Billing
office for rescanning. 5. Documents are batched, numbered and sent to the appropriate departments
for action 6. Coding and pre-coding of the super bill/charge sheet and demographics for
insurance, doctors, modifiers, CPT and diagnosis are done wherever required.
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7.
The claims data entry operator creates a charge, according to the billing
rules pertaining to the specific carriers and locations .All charges are accomplished within the agreed turnaround time with the client. 8. Charges are checked for accuracy and again verified by audit department
for accuracy and compliance with rules.
9.
Claims are filed and information sent to the Transmission department. the electronic media. Once claims are transmitted electronically,
Transmission department prepares a list of claims that go out on paper and through confirmation reports are obtained and filed after verification. Paper claims are printed and attachments done, if necessary, stuffed into envelopes and sent to the US for postage and mailing. Transmission rejections are analyzed and appropriate corrective action is taken.
10.
Cash Application team receives the cash files and the deposit control log is
prepared. This helps to reconcile the deposits at the end of each month. During cash application overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Also underpayments/denials are highlighted for further research by the denied claims team. 11. All denied codes in the EOB’s or Explanation of Benefits received are
researched by the rejected/denied claims group, which will determine the reason for denial, and appropriate action is initiated for resolving the issue. This group also researches the regular mail received from the insurance companies and appropriate actions are taken on the refund request, newsletters, rejection reports etc. 12. AR analysts are the key to any group. They record the processing time of
each insurance companies and identify all claims falling above the processing time.
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Then the claims are researched for completeness and accuracy and insurance carriers are called if required. AR analysts are responsible for the cash collection and resolving all problems to enable the account to have clean AR.
13.
Insurance calling team initiates calls to the insurance companies to establish
reasons for non-payment of the claims. All reasons are passed on to the Analysts for resolution. Calling team works during the American Time zones. 14. Patient calling team calls up the patients to confirm receipt of bill and when
they are going to pay. Based on client’s approvals budget plans and discounts for immediate payments are also undertaken. Below chart will clearly demonstrate the actual flow of medical billing process. Process starts right from the stage of patient demographic entry at the physician’s office by the patients.
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PD & Charges from Facility I
PD & Charges from Facility II
PD & Charges from Facility III
PD & Charges from Facility IV
PD & Charge sheets received from all four facilities are received, batched & Scanned to Back Office
All the Scanned documents are received, checked with Scan logs and forwarded to respective entry departments
Patient Demographics and Charges are entered as per rules
Patient Demographics & Charges are coded in Coding Department
Entered demographics & Charges are quality checked based on entry guidelines.
Entries are updated and Claims are filed to Insurance Carriers
Paper Claims Submiss ion
Claims are sent to Insurance Carriers via U.S Mail After 45 Days
Electronic Claims Submission
Claims are sent to Insurance Carriers via Clearing house
A
If a claim is still outstanding, calls are placed to Insurance Carriers to check status of the claims
After 30 Days
B
Claim Paid
Claim Not In System
Low paid Claim
Claim Denied
Claim Pended
Cash posting
Claims needs to be resubmitted after proper verification
Analyst needs to review each situation and take appropriate actions to settle claims
If secondary or tertiary Insurance available, submit claims If Claim needs to be submitted in paper
Appeals
Client Assistance
Adjustments If Claims needs to be submitted electronically
Other actions
A
B
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MEDICAL BILLING FLOW CHART
Front Office Provider
Medical transcription
Patient
Medical Coding
Billing office in U.S
Billing office in India
Eligibility Verification Clearing House Patient registration & Charge entry Cash Posting A/R Department Insurance Company
Preliminary screening
Conversion in to ins. Specific format
Dispatch
Communication of Decision
Claim Adjudicatio n
Pre-edit/Audit
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MEDICAL CODING
What is Medical Coding?
Every Healthcare Provider that delivers a Service receives money for these services by filing a claim with patient’s Health Insurance Carrier. This is also referred as an encounter. An encounter is defined as “a face to face contact between a healthcare professional and an eligible beneficiary.”
Codes exist for all types of encounters, services, tests, treatments, and procedures provided in a Medical office, clinic or hospital. Even patient complaints such as headaches, upset Stomach, etc have codes which consist of a set of numbers and a combination of set of numbers. The Combination of these codes tells the payer what was wrong with patient and what service was performed. This makes it easier to handle these claims and identify the provider on a predetermined basis.
Reason for the Visit /Encounter – Diagnosis Code
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Service rendered - Procedure Code
Coding Systems
The two major coding systems are
1. International Classification of Diseases – Clinical Modification – 9th Revision
(ICD-9-CM) 2. Current Procedural Terminology (CPT)
CPT and ICD-9-CM are not the only coding systems. Here are few more coding systems that are used to code a variety of coding information:
1. CDT-3 codes 2. ABC codes 3. SNOMED codes 4. NDC codes 5. Home Healthcare (saba) codes 6. DRG systems.
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ICD coding system
ICD (International Classification of Disease) is a coding system for which the first edition was published in 1900, and it is being revised at approximately 10-year intervals. The most recent version is ICD-10, which was published in 1992. WHO is responsible for its maintenance. In US, the coding is still based on ICD-9-CM, which contains more detailed codes. ICD consists of a core classification of three-digit codes, which are the minimum requirement for reporting the reason for the encounter. An optional fourth digit provides an additional level of detail. At all levels, the numbers 0 to 7 are used for further detail, whereas the number 8 is reserved for all other cases and the number 9 is reserved for unspecified coding. The basic ICD is meant to be used for coding diagnostic terms, but ICD-9 as well as ICD-10 also contains a set of expansions for other families of medical terms. For instance, ICD-9also contains a list of codes starting with the letter “V” for reasons for encounter or other factors that are related to someone’s health status. A list of codes starting with the letter “E” is used to code external causes of death. The nomenclature of the morphology of neoplasms is coded by the “M” list. The disease codes of both ICD-9 and ICD-10 are grouped into chapters. For example, in ICD-9, infectious and parasitic diseases are coded with the three-digit codes 001 to 139, and in ICD-10 the codes are renumbered and extended as codes starting with the letters A or B; for tuberculosis the three-digit codes 010 to 018 are used in ICD-9, and the codes A16 to A19 are used in ICD-10. The four-
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digit levels and optional five-digit levels enable the encoder to provide more detail. Table below gives examples of some codes in the ICD-9 system.
Example of a Four-Digit Code Level in ICD-9 and the Five-Digit Code Level as Extended by the ICD-9-CM Code Disease 001 - 139 Infectious and parasitic diseases 001 - 009 Infectious diseases of the digestive tract 003 Other Salmonella Infections - 003.0 Salmonella gastroenteritis 003.1 Salmonella Septicemia 003.2 Localized Salmonella Infections 003.20 Localized Salmonella Infection, 003.21 003.22 003.23 003.24 003.29 Unspecified Salmonella Meningitis Salmonella Pneumonia Salmonella Arthritis Salmonella Osteomyelitis Other Localized Salmonella Infections Other Specified
003.8
Salmonella
-
003.9
Infections Salmonella Infections, Unspecified
The U.S. National Center for Health Statistics published a set of clinical modifications to ICD9, known as ICD-9-CM. It is fully compatible with ICD-9, but it contains an extra level of detail where needed. In addition, ICD-9-CM contains a volume III on medical procedures. CPT Coding System
Current Procedural Terminology (CPT), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an
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effective means for reliable nationwide communication among physicians, patients, and third parties.
The American Medical Association (AMA) first developed and published CPT in 1966. The first edition helped encourage the use of standard terms and descriptors to document procedures in the medical record; helped communicate accurate information on procedures and services to agencies concerned with insurance claims; provided the basis for a computer-oriented system to evaluate operative procedures; and contributed basic information for actuarial and statistical purposes. The first edition of the CPT code book contained primarily surgical procedures, with limited sections on medicine, radiology, and laboratory procedures. The second edition was published in 1970, and presented an expanded work of terms and codes to designate diagnostic and therapeutic procedures in surgery, medicine, and the specialties. At that time, five-digit coding was introduced,
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replacing the former four-digit classification. Another significant change was a listing of procedures relating to internal medicine. In the mid- to late 1970s, the third and fourth editions of the CPT code were introduced. The fourth edition, published in 1977, represented significant updates in medical technology, and a procedure of periodic updating was introduced to keep pace with the rapidly changing medical environment. In 1983, the CPT code was adopted as part of the HealthCare Common Procedure Coding System (HCPCS) (Formerly called as HealthCare Financing Administration's (HCFA) Common Procedure Coding System). With this adoption, CMS mandated the use of HCPCS to report services for Part B of the Medicare Program. In October 1986, CMS also required State Medicaid agencies to use HCPCS in the Medicaid Management Information System. In July 1987, as part of the Omnibus Budget Reconciliation Act, CMS mandated the use of CPT for reporting outpatient hospital surgical procedures. Today, in addition to use in federal programs (Medicare and Medicaid), CPT is used extensively throughout the United States as the preferred work of coding and describing health care services
Tools of the Trade
1. CPT Book – Procedural Coding Medical services provided by physicians are identified using the AMA Current Procedure Terminology or CPT codes. The AMA CPT book provides descriptors for each of the 8,000 codes listed. Frequently there are additional instructions for code use in
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each section of the book. These CPT rules should be followed when choosing the correct code to describe the service provided
2. ICD-9-CM - Medical Diagnosis Coding The ICD-9-CM coding system contains three "volumes" of coding information although the volumes come in one book. Volume 1 contains the diagnosis codes that every provider needs for billing. index of Volume 1. Volume 2 is an alphabetical
Outpatient diagnostic or treatment centers, like
physician offices, need only Volumes 1 and 2. Thus, books that contain only Volumes 1 and 2 are often referred to as physician, office, or outpatient editions. Volume 3 contains procedure codes, not diagnosis codes. Volume 3 codes are used for billing inpatient hospital stays in the DRG system so books that contain Volume 3 are called hospital, payer, or inpatient editions
3. HCPCS – CPT Level II codes HCPCS Level II codes are used to bill Medicare for supplies, materials, injections, DME, rehab, and other services.
4. NCCI Manual
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National Correct Coding Initiative guide will help us code our service for reimbursement in compliance with CMS’s policies to prevent claim rejection, delays, and audits.
Coding department functions
1. Charge sheets that must be coded are, upon receipt by the billing account, forwarded to the coding department for diagnosis and CPT coding.
2. Medical coders code the diagnosis description given in the charge sheets according to established guidelines, using the ICD-9-CM (International
Classification of Diseases, Revision 9, Clinical Modification, and Volumes 1 & 2) diagnosis coding system and CPT/HCPCS codes according to the procedure performed.. The published diagnosis/CPT coding rules under the ICD-9-CM/CPT coding system are observed.
3. Codes are selected strictly based on documentation provided by the client,
and to the highest specificity as indicated in the submitted documents. When documentation is insufficient or unclear, the charges are returned to the client for clarifications.
4. Coding policies and guidelines, if any, established by the client, the coding
supervisor, or insurer are followed wherever applicable during the process of
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coding.
5. When coders identify procedure coding or other errors in the charge information given to them, such errors are corrected with an explanatory note written on the concerned charge sheet. If the coding department decides that the errors are of such a type that will require client authorization or clarification, then such authorization or clarification is obtained from the client by the concerned billing account.
6. When a coder finds that the information on the charge sheet is insufficient to select the appropriate diagnosis or procedure code, the coder writes a note in the charge sheet stating what additional information is needed to supply the code.
7. When a given diagnosis code is not in the list of covered diagnosis codes listed in the state Medicare carrier’s LMRP (Local Medical Review Policy), the coder will code the diagnosis as documented and write “Not in LMRP” in the charge sheet. A policy can be arrived on handling denials by the operation team and client can be alerted on the same.
8. Coders, where ever possible, advise billing departments on the appropriateness of the diagnosis codes and procedure codes documented in a charge sheet, toward ensuring accurate health care claim submission.
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9. Coders should not alter codes or change information documented in the charge sheet, or any other medical document, unless authorized by the client, except when there are definite errors, such as typographical errors. No attempt will be made to alter the procedure or diagnosis documented by the physician or medical service provider. (See also point 6 above)
10.
Upon completion of coding, the coded charge sheets are forwarded to the charge entry department of the respective billing account.
11.
The work of new coders who join the department will be fully audited before file submission, until such time the coders gain the required level of accuracy.
12. A hundred percent audit of all coding work can be conducted during project
transition, until such time the coders gain the required experience and accuracy levels.
13.
Account specific coding policies, if applicable, will be documented
Coding guidelines
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Use all codes necessary to completely code all diseases and procedures, including underlying diseases. Refer all medical records of patients treated for multiple trauma and patients hospitalized over thirty days to the coding supervisor to verify selection of principal diagnosis before abstracting. E codes are used whenever appropriate to identify external codes.
2. Consult the following sources to identify all diagnoses and procedures requiring coding and to increase the accuracy and specificity of coding. Face Sheet-code diagnoses and complications appearing on the face sheet. Progress Notes-Scan to detect complications and/or secondary diagnoses for which the patient was treated and/or procedures performed. History and Physical-scan to identify any additional conditions; such as history of cancer or a pacemaker in situ. coded. Discharge Summary-read if available and compare listed diagnoses with face sheet. Code diagnoses and procedures listed on discharge These conditions should be
summary but not specified on face sheet.. Operative Reports-scan to identify additional procedures requiring coding. Consult previous medical records in patients admitted for follow-up of neoplasm to determine the primary and secondary sites.
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X-ray and laboratory-use reports as guides to identify diagnoses (e.g. types of infections) or more detail (e.g. type of fractures). Physician’s Orders-scan to detect treatment for unlisted diagnoses-the administration of insulin, antibiotics, and sulfonamides may indicate treatment of diabetes, respiratory or urinary infections which should be confirmed by checking other medical record forms.
3. Code incomplete face sheets by reviewing the above items. Record codes assigned in pencil on the fact sheet. Request supervisor’s assistance if difficulty is encountered in identifying codable data by scanning record. Call physician for diagnostic information only if instructed to do so by supervisor.
4. Exercise discretion in coding diagnostic conditions not identified on the face sheet or discharge summary. Query physician on the deficiency report if the coding question influences Identification of most specific code.. Review all alcohol/drug abuse cases to confirm prior to coding.
5. Process special diagnostic coding situations as follows:
V codes are used to identify encounters for reasons other than illness or injury. V codes are used as principal diagnoses for newborn admissions
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(V30.0-V37.0), Chemotherapy session (V58.0), Radiotherapy session (V58.1), Removal of fixation devices (V54.0), and Attention to Artificial openings (V55). For inpatient coding, avoid the use of V codes as the principal diagnosis where a diagnosis of a condition can be made. V codes are used in outpatient coding when a person who is not currently ill obtains health services for a specific purpose, such as, to act as a donor, or when a circumstance influences the person’s health status but is not in itself a current illness or injury. Patients receiving
preoperative evaluations receive a code from category V72.8. Avoid using codes that lack specificity. These vague codes should not be used if it is possible to obtain the information required to assign a more specific code. Inpatient coding requires that signs and symptoms are coded when a specific diagnosis cannot be made or when the etiology of a sign or symptom is unknown. Do not code symptoms if the etiology is known and the symptom is usually present with a specific disease process. Example: Do not code convulsions with the diagnosis of epilepsy. Outpatient coding requires that diagnoses documented as “probable, suspected, questionable, rule out or working”, should not be coded. Code the condition for that visit, i.e., signs or symptoms or abnormal test results. Chronic conditions may be coded as many times as the patient receives treatment.
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Code abnormal laboratory tests only when noted on the face sheet by the attending physician. When there are more diagnoses for a hospitalization, acute conditions take precedence over chronic and at least one comorbid condition or complication should be included in the diagnoses which may be submitted to Medicare. All complications and comorbitities should be
reported for calculating severity of illness.
6. Sequence
diagnoses
and
procedures
according
to
the
“Guidelines
for
Sequencing and Designating Principal Diagnosis and Principal Procedure Codes.”
Essentials of accurate coding
1. Identify all main terms or procedures included in the diagnostic/procedural statements(s). 2. Locate each main term/procedure in the Alphabetical Index. A main term may be followed by a series of terms in parentheses. The presence or
absence of these parenthetical terms in the diagnosis has no effect upon the selection of the code listed for the main term. 3. Refer to any sub terms indented under the main term. These sub terms for individual line entries and describe essential differences by site, etiology or clinical type.
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4. Follow cross reference instructions if the needed code is not located under the first main entry consulted. 5. Verify code selected from the Index in the Tabular List. 6. Read and be guided by any instructional terms in the Tabular List. 7. Fourth and fifth digit sub classification codes must be used where provided. 8. Continue coding diagnostic and procedural statements until all of the component elements are fully identified. This instruction applies even when no “use” statement appears. 9. Use both codes when a specific condition is stated as both acute (or sub acute) and chronic and the Alphabetic Index provides unique codes at the third, fourth, or fifth digit level. 10. The term hypertensive means “due to”, but the presence of words such as “and or with hypertension” does not imply causality. 11. If the cause of a sign or symptom is specified in the diagnosis, code the cause but do not assign a code for the sign or symptom. 12. For inpatient coding, when a diagnosis statement consists of a symptom followed by comparative or contrasting diagnoses, assign codes for the symptom as well as for the diagnoses. When coding outpatient
services, do not code diagnoses documented as “probable, suspected, questionable, rule out or working diagnosis”. Code the condition
necessitating that visit, such as signs or symptoms, abnormal test, or other reasons.
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13.
Do not confuse V codes which provide for classifying the reason for visit with procedure codes documenting the performance of a procedure.
14.
V codes are found in the Alphabetic Index under references such as Admission, Examination, History of, Problem, Observation, Status,
Screening, Aftercare, etc. 15. When an endoscopic approach is utilized to accomplish another procedure (such as biopsy, excision of lesion or removal of foreign body), assign codes for both the endoscopy and the procedure unless the code books contain instructions to the contrary or the code identifies the endoscopic/laparoscopic approach. 16. No procedure code is assigned if an incision was not made. Code
canceled surgeries to V64.1, V64.2 and V64.3. use code V64.1 if a closed fracture reduction was attempted but not accomplished. 17. Consult the Alphabetical Index first to code neoplasm in order to determine whether a specific histological type of neoplasm has been assigned a specific code. 18. Do not assign the code for primary malignancy or unspecified site if the primary site of the malignancy is no longer present. Instead, identify the previous primary site by assigning the appropriate code in category V10 “Personal history of malignant neoplasm.” 19. Cancer “metastatic from” a site should be interpreted as primary of that site and cancer described as “metastatic to” a site should be interpreted as secondary of that site.
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20.
If no site is stated in the diagnosis but he morphologic type is identified as metastatic, code as primary site unknown and also assign the code for secondary neoplasm or unspecified site.
21. 22.
Code fractures as closed unless they are specified as open. Code only the most severe degree of burn when different degrees of burns occur at the same site.
23.
Assign separate codes for multiple injuries unless the coding books contain instructions to the contrary or sufficient information is not available to assign separate codes.
24.
Poisoning by drugs includes drugs given in error, suicide and homicide, adverse effects of medicines taken in combination with alcohol, or taking a prescribed drug in combination with self prescribed drugs.
25.
Adverse
reactions
to
correct
substances
properly
administered
include: allergic reaction, hypersensitivity, intoxication, etc. The poisoning codes 960-979 are never used to identify adverse reactions to correct substances properly administered. 26. Complications of medical and surgical care are located in the Alphabetical; Index under Complication or the name of the condition. 27. The causes or residual illnesses or injuries are located in the Alphabetical Index under Late Effect. 28. When the late effect of an illness or injury is coded in the main classification, the E code assignment must also be one for late effect.
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MEDICAL BILLING – PATIENT DEMOGRAPHICS
Patient demographics – an overview
•
What is Patient Demographics and what does it contain?
Patient Demographics sheet contains all the basic demographic information about an individual or patient. Patient demographics ( PD ) include Patient name, Date of birth, Address, Phone number, Doctor information, Social security number (SSN) and Sex. Patient Demographic also contains Guarantors or emergency
contact information, Health insurance information. Each piece of information is important because correct and quality entry of such information will directly impact physician’s monthly revenue. This sheet is also called as face sheet of a charge or claim.
A good patient demographic form is the key to obtaining accurate information which is required for claim submission. Providing as much information as possible will reduce the insurance company’s need to contact billing office. Avoiding unnecessary contact will reduce the costs of claims processing and delay in payments. Obtaining all the required demographic information will often determine how willing the patient is to complete the form. If the request is firm and
professional without being offensive, we have great chances of getting the information’s which we need to settle a claim.
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Ideally a patient’s insurance coverage should be verified before any service is rendered with the common exception of emergency treatment. shouldn’t apply exclusively to new patients. This policy
Established patients may have
changed employers, gotten married or divorced or are no longer covered by the policy which was in effect during their last visit. Photocopy of insurance cards is always a help.
•
How Patient demographics originate and reach us?
Patient Demographic sheets also known as face sheet are distributed to patients when they visit physician’s office for treatment. Before the services are rendered, front office staff ensures that patient demographic sheets are filled in by the patient or some one in patient’s family. This process ensures that all necessary patient’s demographic information are gathered accurately which would facilitate in timely reimbursement of physicians charges. In most of the physician’s front office, copies of insurance identification card are also taken. This is to ensure that all the information’s available in insurance identification card are captured. Insurance ID card contains very valuable information which would be very helpful in settling the claim.
These patient demographics are batched together at physician’s office and are forwarded to our office for patient demographics entry.
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•
For our easy understanding now let us see each of the information found in patient demographics. Information found in patient demographics have been
classified into five major headings. They are:
I.
II.
Patient Information. Patient Employer Information. Patient Guarantor Information. Physician Information. Insurance Information.
III. IV. V.
I. Patient Information
This segment in face sheet consists of basic demographic information. They are: 1. Account # 2. Patient Name 3. Patient Sex 4. Patient Date of Birth 5. Marital Status 6. Patient Address 7. Patient phone number
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Each patient record is assigned a patient account number. This is how a patient is identified in the system. Before filing any claim we would need to obtain clear,
accurate information from the patients. A good patient information sheet is the key to this aspect of claims submission. Let us now see few more things about items listed below.
1. Account Number [Visit Number]: In case of a New Patient this field in almost
all the Medical Billing software’s is updated automatically. In cases where it does not get updated automatically the billing office enters the Medical Record Number/Account Hospital/Provider. In case of an Established Patient the Billing Office runs a query to search for the patient record with the help of the Medical Record Number/Account Number or using the Last Name or using the Date of Birth of the patient. If the software has a Visit Number concept then a new visit with the same Account number and the next visit number is created if not then the same Account is edited with the new details as on the Encounter Form. This number is for the internal purpose of the Billing Office and the Hospitals. This field is usually in numeric format but may differ from software to software. This number does not form part of the CMS-1500 claim form. Example: Account #: 24584951, 3205215 … Account # and Visit #: 24584951-01, 24584951-02 … Number as on the Encounter Form submitted by the
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2. Patient Name: This field is entered in the Last Name, First Name Middle Initial
format. However in some software’s this field is split as Last Name First Name and Middle Initial fields. The patient name may also contain title (Junior, Senior, I, II, III …) and suffix (M.D. …) this information also needs to be entered along with the name. The title must be entered with the last name and the suffix should be entered with the first name or after the middle initial. The Name on the Encounter Form may not be given in above said format but still it should be entered as per the Billing Software specifications. Checking the spelling of patient name is a very important step. Simple errors such as transposition of letters or misspelled names can result in denial or suspension of the claim. Patient name is printed in the 2nd field of the CMS1500 form in Last Name, First Name Middle Initial format. Example: Patient Name: Jones, Brenda K; Brenda K Jones; Miller John Jr.; …
3. Date of Birth: This field contains the Date of Birth of the patient. It is entered
in the MM/DD/YYYY or MMDDYYYY as per the Billing Software specification. This field is printed in the 3rd field of the CMS-1500 claim form in MM DD YY format. If Date of Birth detail is not available then generic DOB format have to be entered i.e., 01/01/1901. Example: Date of Birth: 02/12/1979; 02/12/79; 02-Dec-1979 …
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4. Sex: This field contains the Gender of the patients. i.e., M for Male, F for
Female, and U for Unknown when the gender of the patient is not specified on the patient encounter Form. This field is printed in the 3rd field of the CMS-1500 claim form along with the Date of the Birth. Example: Sex: Male; Female; M; F.
5. Social Security Number: This field contains a 9 digit number which is allotted
to the patient by the Social Security Administration. If SSN is missing from patient encounter form then this field is usually left blank or any 9 digit dummy number (000-00-0000/999-99-9999) is entered as per the Billing Software specifications. Example: SSN: 245-19-0124; 245190124
i.
When did Social Security start?
The Social Security Act was signed by President Franklin Roosevelt on August 14, 1935. Taxes were collected for the first time in January 1937 and the first onetime, lump-sum payments were made that same month. Regular ongoing monthly benefits started in January 1940.
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ii. What is the origin of the term ‘Social Security’?
The term was first used in the U.S. by Abraham Epstein in connection with his group, the American Association for Social Security. Originally, the Social Security Act of 1935 was named the Economic Security Act, but this title was changed during Congressional consideration of the bill. Under the 1935 law, Social Security only paid retirement benefits to the primary worker. A 1939 change in the law added survivor’s benefits and benefits for the retiree's spouse and children. In 1956 disability benefits were added.
iii. Who assigns the SSNs and how many SSNs have been assigned?
Social Security numbers are assigned by Social Security Administration. SSNs were first issued in November 1936. By December 1, 2002 more than 418 million numbers had been assigned.
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iv. Is it true that Social Security was originally just a retirement program?
Yes. Under the 1935 law, Social Security only paid retirement benefits to the primary worker. A 1939 change in the law added survivor’s benefits and benefits for the retiree's spouse and children. In 1956 disability benefits were added.
v. Is Social Security just a program for the elderly and disabled?
Social Security is not just a program for the elderly and disabled. Survivors of deceased workers and the families of retired or disabled workers also qualify for benefits. In fact, about 3.8 million children are currently receiving such benefits and 9 out of 10 would be eligible to receive benefits if a parent retires, becomes disabled, or dies. They need a Social Security number (SSN) before they can receive benefits. The SSN is also needed for reasons not connected with Social Security benefits. For example, to be claimed as a dependent on a tax return, to open a bank account and buy Savings Bonds, your child needs an SSN.
vi. Is there any significance to the numbers assigned in the Social Security Number?
The digits in the Social Security number allow for the orderly assignment of numbers. The number is divided into three parts: the area, group, and serial
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numbers. The first three (3) digits (area) of a person's social security number are determined by the ZIP Code of the mailing address shown on the application for a social security number. Generally, numbers were assigned beginning in the northeast and moving westward. So people on the east coast have the lowest numbers and those on the west coast have the highest numbers. The remaining six digits in the number are more or less randomly assigned and were organized to facilitate the early manual bookkeeping operations associated with the creation of Social Security in the 1930s.
Within each area, the group number (middle two (2) digits) range from 01 to 99 but are not assigned in consecutive order. For administrative reasons, group numbers issued first consist of the Odd numbers from 01 through 09 and then Even numbers from 10 through 98, within each area number allocated to a State. After all numbers in group 98 of a particular area have been issued, the Even Groups 02 through 08 are used, followed by Odd Groups 11 through 99.
Within each group, the serial numbers (last four (4) digits) run consecutively from 0001 through 9999.
vii. Are Social Security Numbers re-assigned after a person dies?
SSA does not reissue SSNs after someone dies. When someone dies their number is simply removed from the active files and is not reused. In theory, the time might come someday when SSA would need to consider "recycling" numbers in
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this way--but not for a long time to come. SSA does not have to face reissuing numbers since the 9-digit Social Security number allows about 1 billion possible combinations, and to date SSA have issued a little over 400 million numbers.
viii.
How can one get a different Social Security number assigned to
himself?
Generally, an individual is assigned only one Social Security number (SSN) which is used to record the individual’s earnings for future benefit purposes and to keep track of benefits paid under that number. However, under certain circumstances, SSA may assign an individual a new (different) SSN. When they assign a new number, the original number is not voided or deleted. For integrity reasons, they cross-refer in the records all the numbers assigned to the same individual.
SSA can assign new SSN in the following situations, provided all of the documentation requirements are met:
• Sequential SSN are assigned to members of the same family
• Certain scrambled earnings situations • Certain wrong number cases • Religious or cultural objection to certain numbers/digits in the SSN • Misuse by a third party of the number holder’s SSN and the number holder has been disadvantaged by that particular misuse
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• Harassment, abuse or life endangerment situations (including domestic violence)
To apply for a new (different) SSN, you need to complete Form SS-5 (Application for a Social Security Card)
You will also need to submit evidence age, identity, and U.S. citizenship or lawful alien status. Form SS-5 explains what documents will satisfy these requirements. You will also need to submit evidence to support your need for a new number.
If you are age 18 or over, you must submit your request for a new SSN in person at your local Social Security office.
ix. When
did
Social
Security
cards
bear
the
legend
"NOT
FOR
IDENTIFICATION"?
The first Social Security cards were issued starting in 1936; they did not have this legend. Beginning with the sixth design version of the card, issued starting in 1946, SSA added a legend to the bottom of the card reading “FOR SOCIAL SECURITY PURPOSES -- NOT FOR IDENTIFICATION”. This legend was removed as part of the design changes for the 18th version of the card, issued beginning in 1972. The legend has not been on any new cards issued since 1972.
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x. How to get a Social Security number for my baby? The easiest way to apply for a baby's Social Security number (SSN) is at the hospital. Both parents’ Social Security numbers are required when applying for a baby’s SSN. When a parent requests a Social Security number (SSN) for his/her newborn as part of the birth registration process in the hospital, the State Vital Statistics Office forwards to the Social Security Administration (SSA) data we need to assign an SSN to the child and issue a card. This is known as the Enumeration at Birth (EAB) process. Once SSA receives the data, the process of assigning the number and issuing the card is the same as if the application were taken in a Social Security office. In most States, the birth registration process is electronic. Hospitals submit birth registration information through local registrars to the State, where the
information is entered into an automated database. In most States this process is completed and EAB data is sent to the Social Security Administration within 60 days of birth. EAB is a good service for most parents who have no immediate need for their child's SSN because they do not have to submit an application and evidentiary documents to a Social Security office.
xi. What types of Social Security cards does SSA issue?
SSA issues three types of Social Security cards depending on an individual's citizen or non-citizen status and whether or not a non-citizen is authorized by the Department of Homeland Security (DHS) to work in the United States.
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The first type of card shows the individual's name and Social Security number only. This is the card most people have and reflects the fact that the holder can work in the U.S. without restriction. SSA issues this card to: - U.S. citizens, or - Non-citizens who are lawfully admitted to the U.S. for permanent residence, or who have permission from the Department of Homeland Security (DHS) record to work permanently in the U.S., such as refugees, asylees and citizens of Compact of Free Association countries.
The second type of card bears, in addition to the individual's name and Social Security number, the legend, "NOT VALID FOR EMPLOYMENT". SSA issues this card to non-citizens who: - don't have DHS permission to work, but are receiving a federally-funded benefit; or - are legally in the U.S. and don't have DHS permission to work but, are subject to a state or local law which requires him or her to provide a SSN to get general assistance benefits or a State driver's license for which all other requirements have been met.
The third type of card bears, in addition to the individual's name and Social Security number, the legend, "VALID FOR WORK ONLY WITH INS (or DHS) AUTHORIZATION". SSA issues this card to people who have DHS permission to work temporarily in the U.S. If you’re a non-citizen, SSA must verify your documents with DHS before SSA issues a SSN card. SSA will issue the card within two days of receiving
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verification from DHS. Most of the time, they can quickly verify your documents online with DHS. If DHS can’t verify your documents online, it may take several weeks or up to three months to respond to Social Security's request.
xii. Which Social Security numbers are invalid (impossible)? An invalid (or impossible) Social Security number (SSN) is one which has not yet been assigned. The SSN is divided as follows: the area number (first three digits), group number (fourth and fifth digits), and serial number (last four digits). To determine if an SSN is invalid consider the following:
•
No SSN with an area number in the 800 or 900 series, or "000" area number, have been assigned.
•
No SSN with an area number above 728 have been assigned in the 700 series, except for 729 through 733 and 764 through 772.
•
No SSN with a "00" group number or "0000" serial number have been assigned.
•
No SSN with an area number of "666" have been or will be assigned.
xiii.
Is it legal to laminate your Social Security card?
SSA discourages the lamination of Social Security number (SSN) cards because lamination would prevent detection of certain security features. To deter potential fraud and misuse involving SSN, SSA currently issues SSN cards that are both counterfeit-resistant and tamper-resistant. (For example, the card contains a
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marbleized light blue security tint on the front, with the words "Social Security" in white; intaglio printing in some areas on the front of the card; and yellow, pink, and blue planchets--small discs--on both sides). SSA cannot guarantee the validity of a laminated card. You may, however, cover the card with plastic or other material if the material could be removed without damaging the card.
SSA would also recommend that as a security precaution, you carry your Social Security card only when you expect to need it, for example, to show to an employer or other third party.
xiv.
Is there any charge for replacing a Social Security card?
Social Security does not charge a fee for either an original or replacement Social Security card. A replacement card can be a duplicate card (one with the same name and number) or a corrected card (one with different name but the same number).
xv. Can metal or plastic versions of Social Security cards be used? The official verification of your Social Security number is the card issued by the Social Security Administration. Third parties who request your Social Security card as verification of your number will want to see the card SSA issues. Although Social Security has no authority to prevent use of metal or plastic replicas of Social Security cards, SSA considers them an unauthorized use of the Social Security number and discourages their use.
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xvi.
Can Social Security number be canceled?
No. When someone has applied for and been assigned a Social Security number (SSN) based on a validly signed application, the Social Security Administration (SSA) may not cancel or destroy that record. The Privacy Act of 1974 authorizes agencies to maintain in their records any information about an individual that is relevant and necessary to accomplish a purpose of the agency that is required by law. SSA is required by law to establish and maintain records of wages and selfemployment income for each individual whose work is covered under the program. The SSN is considered relevant and necessary for that record keeping purpose. Consequently, valid SSN are permanently part of SSA's records.
6. Marital Status: This field contains the Marital Status of the patient. It is
usually entered as ‘S’ for Single, ‘M’ for Married, ‘D’ for Divorced, ‘W’ for Widow/Widower, ‘X’ for Separated and ‘O’ for Others. It marital status is missing from patient encounter form, we need to enter ‘O’ in the marital status field. This field is printed in the 8th field of the CMS-1500 claim form. Example: Marital Status: Single; Married; Divorced; Widow …
7. Address: Patient’s address is split into 5 different fields. It is usually entered
as Address1 (PO Box#/Door#/Appt. #), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. This field can not be left blank. Patient address is a
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important field to file a claim & send patient statement. Following are the general abbreviations found in patient encounter forms:
a) Apt. # - Apartment number b) Ave. Avenue number
c) Blvd. - Boulevard d) Ste. e) Dr. - Suite/Street - Drive
This field is printed in the 5th field of the CMS-1500 claim form. Example: Address: 1067 Orange Grove Blvd. Apt. # 194 Los Angeles, CA 90001
8. Patient Phone Number: This field contains the contact number of the patient
including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code, and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. This field is printed in the 5th field of the CMS-1500 claim form along with the address. Example: Phone Number: 626-843-2846; (626)357-5496 …
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II.Patient Employer information
This segment in the face sheet contains employer information of the patient. The entry person needs to enter this information if available in face sheet. Employer information is a must for worker’s comp claims. Non-worker’s comp claims do not require employer name to process claims but it is advisable to update employer information during entry. Following information’s are found in this segment 1. Employer Code 2. Employer Name 3. Employer Address & Phone # 4. Designation/Occupation 5. Contact Person
1. Employer Code: This field is used in most of the Billing Software’s to reduce
the time of PD entry. The Names and Addresses of the major Employers are stored in the Employer database with a unique code assigned to each employer. Hence it is enough to just enter the code and skip to the next block. Example: Employer Code: IBM; A0012; MS024 …
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2. Employer Name: This field contains the name of the patients Employer. If the
patient is a Student or Not Employed or Retired then it can be entered as Student or Not employed or Retired in this field. This field is printed in the 11b field of the CMS-1500 claim form. Example: Employer: Verizon Wireless; Microsoft Corp.; SUN Microsystems …
3. Employer Address: The address of the patients Employer is split into 5
different fields. It is usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. Example: Address: PO Box 1954 Los Angeles, CA 90001-1954
4. Employer Phone Number (Ext No.): This field contains the contact number
of the patients Employer including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. Some software’s may also require you to enter the Extension number if given on the encounter form. Example: 818-245-7849 [5478]; (818)-245-7849 …
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III. Patient Guarantor Information
This segment in face sheet consists of guarantor or emergency contact information. They are:
1. Guarantor Account # 2. Guarantor Name 3. Guarantor Address 4. Guarantor phone # 5. Guarantor/patient relationship 6. Guarantor employer & SSN This block is mostly entered only in the case of the patient being a minor or if the patient is not responsible for the payment. This information is for the internal purpose of the Billing Office and the Hospitals for the purpose of Emergency Contact or follow-up of pending balances and hence does not form part of the CMS-1500 claim form.
1. Guarantor Account #: This field is used to enter the guarantor account #. If
the guarantor is already stored in the database then the stored information can be pulled up using this number. This information is not part of the encounter form. The account number of the guarantor is pulled using search engine.
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Example: 245818A; 6252315; 421154; …
2. Guarantor Name: This field is entered in the Last Name, First Name Middle
Initial format. However in some software’s this field is split as Last Name First Name and Middle Initial fields. The guarantor name may also contain title (Junior, Senior, I, II, III …) and suffix (M.D. …) this information also needs to be entered along with the name. The title must be entered with the last name and the suffix should be entered with the first name or after the middle initial. The Name on the Encounter Form may not be given in above said format but still it should be entered as per the Billing Software specifications. Example: Joseph Warowes Sr.; Warowes, Virginia E M.D …
3. Relationship: This field contains the relationship of the Guarantor with the
patient, such as Spouse, Parent, Others etc. Example: Relationship: Spouse; Parent; Grand Parent …
4. Address: The address of the Guarantor is split into 5 different fields. It is
usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. Example: 102 West 35th Street Heathsville, GA 65418
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5. Phone Number: This field contains the contact number of the Guarantor
including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. Example: (517)373-1820; 517-374-5857 …
6. Guarantor
Employer:
This
field
contains
the
guarantor’s
employer
information. Basically the guarantor’s employer name, address, and contact details are entered here.
7. Emergency Contact: This field is used to enter the Emergency Contact details
of the patients relative or next of kin. Contact information such as Name, Address Phone # and relation to the patient are entered here.
IV. Physician Information
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This segment contains the following information.
1. Admitting physician code: The physician responsible for admission of a
patient to a hospital or other inpatient health facility. Some facilities have all admitting decisions made by a single physician (typically a rotating responsibility), called an admitting physician. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. This field is optional; if the Admitting physician info is not given it can be left blank. This field does not form part of the CMS-1500 claim form. Example: Adm. Phy.: Mileski MD, William
2. Attending or Rendering physician code: The physician rendering the major
portion of care or having primary responsibility for the care of the patient's major condition or diagnosis. In other words the doctor or supplier who actually renders the service (also referred to as a "rendering physician"). All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. The Name of the rendering physician is printed in the 33rd field along with the Address and Phone #. The rendering physician’s Federal tax ID stored in the database is automatically printed in the 25th field of the CMS-1500 claim form.
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Example: Att. Phy.: Pendridge MD, Dayton
3. Referring Physician/Primary Care physician code: The physician who has
sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is called a referring Physician or Primary Care Physician (PCP). The name of the facility may be reflected in this area if the patient has not identified a unique physician, but has identified a facility. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. The name of the referring physician is printed in the 17th field and the corresponding UPIN stored in the database is printed in the 17a field of the CMS1500 claim form.
V.Insurance Information
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This segment of face sheet contains all active insurance information of the patient. This segment includes primary, secondary, and/or tertiary insurance information. This segment is the most important field in patient demographic
sheet. Information found in this field should always be the updated & correct one. If not, we would be submitting claims to incorrect insurance. Entry persons should always match this information with copy of insurance id cards. (if provided). This will reduce the risk of entering incorrect insurance information. Following information are found in this segment 1. Insurance Code/Name 2. Effective Date 3. Subscribers Name 4. Relationship Code 5. Pre-Certification/Pre-Authorization 6. Referral Number
7. Primary Insurance Group & Policy #
8. Date of Injury/Accident 9. Claim Number Sample Medicare Insurance Card copy:
1.
Insu
rance
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Code/Name: This field is used to enter the insurance code or name of the coverage that the patient has. The insurance code is assigned by the Billing office for its internal purpose to reduce the PD entry time. Each Insurance company’s name, billing address, contact person, etc… are assigned a unique code. The entry person should be very careful while selecting the insurance code and should always verify the billing address with the given card copy or with the billing address given on the encounter form. The Primary insurance name is printed in the 11c field and the Secondary insurance name is printed in the 9d field of the CMS-1500 claim form. Example: Insurance: Medicare, Medicaid, Blue Cross, Blue Shield …
2. Effective Date: This field contains the effective date of coverage. This date
should not be after the Date of Service. The date format is MMDDYYYY. This date is used for the internal purpose of the Billing office and Hospitals. This does not form part of the CMS-1500 claim form. Example: Eff. Date: 7-1-66; 07/01/1976; 07 01 66 …
3. Subscribers Name: This field contains the Subscribers name of the insurance
policy. If the patient is a dependant who is covered under someone else’s policy then the name of the person who pays the premium is entered in this field. If patient is the subscriber then we need to enter the patient name itself. The name is entered in the Last Name, First Name MI format.
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The Primary insurance subscribers name is printed in the 4 th field and the Secondary insurance subscribers name is printed in the 9th field of the CMS-1500 claim form. Example: Subscriber: John Q. Public; Public, John Q …
4. Relationship Code: This field contains the relationship of the subscriber to the
patient. The code is usually 1 – Self, 2 – Spouse, 3 – Parent, 4 – others etc…This field does not form part of the CMS-1500 claim form.
5. Policy ID: This field contains the Policy number given by the insurance
company to the subscriber and the dependants of the policy. This does not have any standard format across the insurance company but each insurance company has a unique format such as for Medicare the policy number is given as SSN + Alpha or Alphanumeric. The policy ID should be entered as given in the scanned card copy or as mentioned on the Encounter form. The Primary insurance ID is printed in the 11th field and the Secondary insurance ID is printed in the 9a field of the CMS-1500 claim form. Example: Policy ID: 123-54-5478A; 215543251W1; 215-47-6491 …
6. Group ID: This field contains the Group ID as given by the insurance company
for the policy. Not all the insurance companies have the Group ID hence if not given then this field can be left blank.
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The Group ID is printed along with the Policy ID on the CMS-1500 claim form.
7. Pre-Auth. / Pre-Cert. Number: Review of "need" for inpatient care or other
care before admission. This refers to a decision made by the payer, Managed Care Organization, or insurance company prior to admission. Most managed care plans require pre-cert. This is a method of controlling and monitoring utilization by evaluating the need for service prior to the service being rendered. The practice of reviewing claims for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. The third party usually reviews the treatment plan, monitoring one or more of the following: patient's eligibility, covered service, amounts payable, application of appropriate deductibles, co-payment factors, and maximums. Under some programs, for instance, pre-determination by the third party is required when covered charges are expected to exceed a certain amount. This number should be attached with the respective claim; otherwise the claim will be rejected. There is no standard format for Auth and Pre-Cert. number across all the insurance companies. Each insurance company has its own unique format of Auth and Pre-Cert. numbers.
8. Referral Number: A Referral number is provided by a PCP (Primary Care
Physician) when he refers a patient to a specialist. Without the Referral number a patient cannot get a specialist’s service if he has a HMO plan. This number is printed on the CMS-1500 claim form or entered in the attached documents as per the Insurance company requirements.
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9. Date of Injury/Accident: This field is used to enter the Date of
Injury/Accident when the claim is filed to Work Comp/Auto Accident insurance. This date is useful for the insurance companies to verify if the coverage was active or not. This date is mentioned in the documents attached while filing the claim.
10. Claim Number: This field is used to enter the Claim number for a particular
claim given by the Work Comp/Auto Accident insurance company. Failing to mention this number on the claim form will result in the rejection of the claim.
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MEDICAL BILLING – PATIENT CHARGES
Patient charges – an overview
•
What are Patient Charges and what does it contain?
Patient charge is nothing but the fees claimed by the physician who rendered the services to the patient. Charges can be either based upon demographic evaluation or a flat fee rate as prescribed by the physician’s office. Each piece of information is important because correct and quality entry of such information will directly impact physician’s monthly revenue. This sheet is also called as face sheet of a charge or claim.
•
How Charge Sheets originate and reach us?
Once patient /spouse completes Pd sheet, patient is then referred to physician in the appointed time. After preliminary investigation physician provides the services required by the patient. In the super-bill, kind of treatment is denoted by procedure code and diagnosis code denotes the nature of illness for which services were administered. Super bills or charge sheets contain information like Date of Service, Kind of Service, Diagnosis Code, Attending Doctor, Modifier details. Super bills are usually completed by physician or their assistant. Sometimes Coding of diagnosis & procedures are done by coding specialists.
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Once Charge sheets are completed, they are batched with PD at physician’s office and are forwarded to our office for charge entry. Mode of transfer of data may vary from client to client. But most preferred mode is thru FTP. Here patient
demographics are scanned & captured as image file. These image files are placed in FTP site. begins. These image scan files are retrieved at our office & charge entry
Information found in patient charge sheet •
For our easy understanding now let us see each of the information found in patient charge sheet 1. Attending Physician 2. Referring Physician 3. Admit Date 4. Date of Service 5. Type of Service 6. Place of Service 7. Prior 10. Diagnosis Code 11.
Authorization Number 8. Modifiers 9. Procedure code
# Of days/ units, 12. Location Details 13. Physician Name, Address, Provider id
1. Attending Physician: Attending physician is also referred as rendering
physician. A physician who renders the service to patients is called
attending or rendering physician. Each Rendering/Attending Physician of a particular facility is assigned a unique code with the Name of the Physician, Address of the Clinic/Facility, PIN (Provider Identification Number), License number, Federal TaxID#.
The Rendering Physician Name, Address, and PIN are printed in the 33rd field and if the Address of the Facility where the service was rendered differs from the Physicians location then that address is printed in the 32 nd
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field and the corresponding Federal Tax ID of the Provider is printed in the 25th field of CMS-1500 form.
2. Referring Physician:
Physician who refers patient to specialists is
called referring Physician or Primary Care Physician (PCP) information is integral to continuity of care, reimbursement and community relations. In simple words, the physician who has sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is known as a Referring Physician. Each Referring Physician is allotted a unique code in the Medical Billing software which stores the Name of the Physician, Address of the Clinic/Facility, UPIN (Unique Physician Identification Number). The Referring Physician Name is printed in the 17th field of the CMS-1500 claim form. The UPIN which is stored along with the code is printed in the 17a field of the CMS-1500 claim form.
3. Admit Date: Admit date refers to the date in which patient was admitted
into the Hospital. For workers compensation Date of Injury (DOI) is very important for processing the claim. For the purpose of determining the date of injury for an occupational disease, the date of injury shall be taken to be the last date of injurious exposure to the hazards of such disease or the date on which the employee first knew or reasonably should have
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known of the condition and its relationship to the employee's employment, whichever is the later.
4. Date of Service: DOS is the date in which services were rendered to
patient by attending physician. In certain cases we have thru date of service and also it will be in the single date format. Standard format for entering DOS is mm/dd/yyyy. admit date. DOS must be greater than or equal to
5. Type of Service:
We need to input the type of service which was Broadly we have two digit TOS codes which
administered to patient.
needs to be entered in block 24C of CMS-1500 form. The type of service defines what type of service it is like radiology, cardiology and etc.
6. Place of Service:
Two digit place of service needs to be entered in
block 24b of CMS-1500 form while submitting claims to insurance carriers. POS can be for inpatient, Outpatient & ER. Health care that you get when you are admitted to a hospital is an inpatient. Medical or surgical care that does not include an overnight hospital stay is an outpatient. Care given for a medical emergency when you believe that your health is in serious danger when every second counts is an Emergency care. This field consists of the place or the location where services were provided to the patient. Location details are printed in block 32 of CMS-1500 form. Where services are
Details like location name, address are printed.
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rendered in patient’s home & physician’s office location details in CMS1500 form can be blank.
7. Preauthorization: An insurance plan requirement in which you or your
primary care physician must notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense. Preauthorization are of two types. 1) Requesting authorization of date of services that have not been previously requested or the request was previously rejected. 2) Requesting authorization for increase or decrease units for previously approved dates of service. In other words, Preauthorization means Insurance is notified in advance about specific procedures. This allows for a review of medical necessity, efficiency, and quality of proposed care. It is also an opportunity to inform patient/physician about benefits, including length-of-stay
guidelines and plan limitations. This will help to understand the costs if patient receive the proposed care.
8. Procedure Code:
Procedure codes are used to indicate the kind of
treatment or service was administered in patient. Utmost care should be given while entering the procedure code. We need to first know what kind of procedure code each insurance accepts to process claims. Healthcare
Common Procedure Coding System (HCPCS) is a coding system that is composed of Level I codes (Current Procedural Terminology (CPT) codes), Level II codes (national codes), and Level III codes (local codes). Level I (CPT) codes are five digit numeric codes that describe procedures and tests.
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CPT codes are developed and maintained by the AMA with annual updates. Level II (national) codes are five digit alpha numeric codes that describe pharmaceuticals, supplies, procedures, tests and services. Level II codes are developed and maintained by CMS with quarterly updates. Level III (local) codes are five digit alpha numeric codes that are being phased out by the fiscal intermediaries. Examples of CPT codes: 85025 – CBC with automated differential 71020 – Chest x-ray 2 views 45378 – Colonoscopy 93501 – Right heart catheterization In other words, this field contains the Code of the procedure done (CPT/HCPCS Code). The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties. All the Procedure codes are stored in a Master database of the Medical Billing software with the description of the code and the dollar amount. This helps the charge entry person to cross verify the procedure before saving the claim. This field is printed in the 24d field and the corresponding dollar amount of the procedure stored in the Medical Billing Software is printed in the 24f field of the CMS-1500 claim form
•
•
•
•
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9.
Modifiers:
A modifier indicates that a service or procedure was altered
by specific circumstances, but not changed in its definition or code. Modifiers are two digit numeric or alpha numeric codes that are appended to the end of CPT/HCPCS codes. Modifiers may be used to indicate that:
•
A service or procedure has both a professional and technical component
• • • • • •
A service or procedure was performed by more than one physician A service or procedure has been increased or reduced Only part of a service was performed An additional service was performed A bilateral procedure was performed more than once Unusual events occurred This field is printed along with the CPT/HCPCS Code in 24d field of the
CMS-1500 Claim Form. A list of the most frequently used CPT (Current Procedural Terminology) modifiers, HCPCS (HealthCare Financing Administration's Common
Procedure Coding System) modifiers, and local modifiers has been compiled for reference.
These modifiers and associated nomenclature emanated from three different sources.
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Physician's Current Procedure Terminology, CPT 1999 was used for the definition of CPT-4 numeric modifiers with one modification. The five digit modifiers identified in the CPT are not included in these definitions since the Medicare program does not recognize reporting modifiers in this format. The HCPCS (Health Care Financing Administration's Common Procedure Coding System) alpha modifiers were developed by the Health Care Financing Administration for use in the Medicare program. Local alpha modifiers were developed by Pennsylvania Blue Shield to address situations not included in CPT-4 or HCPCS. For some of these modifiers, additional clarification (shown as indented text) has been added, as well as examples. Other modifiers are selfexplanatory; no additional comment is provided. Modifiers provide the means by which the reporting provider can indicate a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.
Modifiers may be used to indicate that:
•
a service or procedure has both a professional and technical component
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•
• • • •
a service or procedure was performed by more than one physician a service or procedure has been increased or reduced only part of a service was performed an adjunctive service was performed a bilateral procedure was performed a service or procedure was provided more than once unusual events occurred Anesthesia One of the following modifiers must be reported with anesthesia services to indicate who performed the anesthesia service:
•
•
AA - Anesthesia services performed personally by anesthesiologist AD - Medical supervision by a physician: more than four concurrent anesthesia procedures
•
•
QJ - Medically directed by a physician: two concurrent procedures (for services prior to January 1, 1995)
•
QK - Medically directed by a physician: two, three, or four concurrent procedures (effective for services on or after January 1, 1995)
•
QO - Medically directed by a physician: three concurrent procedures (for services prior to January 1, 1995)
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•
QQ - Medically directed by a physician: four concurrent procedures (for services prior to January 1, 1995)
• • •
QY - Anesthesiologist medically directs one CRNA QX - CRNA service: with medical direction by a physician QZ - CRNA service: without medical direction by a physician
The following modifier is reported in addition to one of the above modifiers to indicate that monitored anesthesia care was provided:
•
QS - Monitored anesthesia care service
Global Surgery The following modifiers are used by physicians to indicate a billed service is not part of a global surgical package and is eligible for separate reimbursement: 24 - Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.
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An excision of a malignant lesion on the left arm is performed in the office on May 10, 1998. The ICD-9-CM diagnosis code reported is 171.2. The postoperative period designated for excision code 11606 is 10 days. The patient returns to the office on May 15, 1998 and is treated for contact dermatitis, ICD-9-CM code 692.0. The physician should report the
appropriate evaluation and management code followed by the 24 modifier, e.g., 9921224. In order for the evaluation and management service to be payable in the post-operative period with the 24 modifier, the diagnosis code supporting the E/M service must be different from the diagnosis code reported for the previously performed surgery. Modifier 24 should not be used for the medical management of a patient by the surgeon following surgery. Medicare recognizes modifier 24 only for the care following a discharge under these circumstances: The care is for immunotherapy management furnished by the transplant surgeon; The care is for critical care (99291, 99292) for a burn or trauma patient under diagnosis codes 800.0-929.9, 940.0-959.9; or
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The
documentation
demonstrates
that
the
visit
occurred
during
a
subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery. 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of thre E/M services on the same date. This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed with the 25 modifier in addition to billing for suturing a scalp wound if a full neurological examination was made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures
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and confirmed allergy and immunization status. In the circumstance when the decision to perform a minor procedure is typically done immediately before the service, (e.g., whether or not sutures are needed to close a wound, whether or not to remove a mole or wart, etc.) it is considered a routine preoperative service and a visit or consultation should not be reported in addition to the procedure. Effective immediately for dates of service on or after January 1, 1997, separate payment may be made for an initial hospital visit (CPT codes 99221-99223), an initial inpatient consultation (CPT codes 99251-99255) and a hospital discharge service (CPT codes 99238 and 99239) when billed by the same physician for the same date as an inpatient dialysis service (CPT code 90935-90947). It is no longer required that these evaluation and management services be unrelated to the treatment of the patient's ESRD in order for payment to be made. However, the 25 modifier must still be reported with these evaluation and management services in order to indicate that they are significant and separately identifiable services. Physicians may request reviews of previously denied services. 57 - Decision for Surgery. An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.
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E/M services on the day before or on the day of major surgery ( 90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment. These E/M services may be billed separately and identified with the 57 modifier. This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period ) unless the purpose of the visit is a decision for major surgery. This modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure. See modifier 25. 58 - Staged Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was planned prospectively at the time of the original procedure. This
circumstance may be reported by adding the modifier 58 to the staged procedure. Note: Medicare policy limits the use of this modifier to staged procedures. The CPT-4 definition of this modifier is broader in scope. This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier 78.
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It would not be appropriate to report this modifier for codes which indicate in the terminology "one or more sessions", e.g., 66761, 67141, 67227. These codes are defined by CPT-4 as consisting of one or more sessions. The relative value units represent the work for the total number of sessions necessary for completion of the procedure. Therefore, subsequent sessions performed within the global period of the initial surgery are included in the global fee. 59 - Distinct Procedural Service: Under certain circumstances, a provider may need to indicate that a procedure or service was independent from the services performed on the same day. See Appendix C (Correct Coding Initiative) for more information regarding the use of modifier 59. 78 - Return to the Operating Room for a Related Procedure During the Postoperative Period: The Physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the 78 modifier to the related procedure. When treatment for complications requires a return trip to the operating room, physicians must bill the CPT-4 code that describes the procedure (s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, e.g., 47999 or 64999. In this situation,
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you must include operative notes with the claim or a narrative description which will allow us to understand the extent of the service performed. The procedure code for the original surgery is not used except when the identical procedure is repeated. An operating room for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit ( unless the patient's condition was so critical there would be insufficient time for transportation to an operating room). A partial colectomy is performed in the hospital on March 1, 1999. The postoperative designation for this procedure (code 44140) is 90 days. On March 15, 1999, the patient is returned to the operating room for a secondary suture of the abdominal wall. This procedure should be reported as 4990078. 79 - Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79.
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A repair of a femoral hernia (49550) is performed on January 5, 1999. The postoperative period designation for this procedure code is 90 days. On February 12, 1999, the same physician performs an appendectomy. The physician should report the appendectomy as 4495079. Surgical 50 - Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier 50to the appropriate five digit code. Report such procedures as a single line item with a unit of 1. For example, when procedure code 19180 (Mastectomy, simple, complete) is performed bilaterally, report the service as 1918050. If a procedure is identified by the terminology as bilateral ( or unilateral or bilateral), do NOT report the procedure code with modifier 50. For example, procedure code 68810 to 68815, (probing of nasolacrimal duct, with or without irrigation, unilateral or bilateral) includes terminology which indicates the procedure is performed either unilaterally or bilaterally. Therefore it's not appropriate to report this modifier with this code. Additionally some procedure codes, i.e., 52000 (Cystourethroscopy,
separate procedure) should NOT be reported with the 50 modifier since anatomy does not permit this procedure to be performed bilaterally.
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51 - Multiple Procedures: When multiple procedures, other than evaluation and management services, are performed on the same day or at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated "add-on" codes (e.g., 22612, 22614). For more information, please reference chapter 22, section 22.1 53 - Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure. Use modifier 53 (discontinued procedure) to report a failed or terminated colonoscopy, or a failed or discontinued procedure. Documentation
describing the circumstances requiring the discontinuation of a procedure should be provided with the claim submission. If this information is NOT included, your claim may be denied.
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Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled f
procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 54 - Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative
management, surgical services may be identified by adding the modifier 54 to the usual procedure code. Services billed with a 54 modifier will be reimbursed at the intraoperative allowance for the surgical procedure. The intraoperative allowance includes the one day preoperative care, the intraoperative service, as well as any inhospital visits that are performed. 55 - Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number.
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This modifier is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient's postoperative care by reporting the
appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. 62 - Two surgeons: Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances the separate services may be identified by adding the modifier 62 to the procedure number used by each surgeon for reporting his services. Under some circumstances the individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and /or the patient's condition.
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If two surgeons, usually with different skills, are required to perform a single surgical procedure, each surgeon bills for the procedure with modifier 62. Co-surgery also refers to single surgical procedures involving two surgeons performing the parts of the procedure simultaneously, e.g., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified by the Health Care Financing Administration. 66 Surgical Team: Under some circumstances, highly complex
procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier 66 to the basic procedure number used for reporting services. Documentation establishing that a surgical team was medically necessary is required for certain services identified by the Health Care Financing Administration. All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing "by report". 73 - Discontinued out-patient hospital/ambulatory surgical center (ASC) procedure prior to the administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when
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provided, and being taken to the room where the procedre is to be preformed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier 73. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical reparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53. 74 - Discontinued out-patient hospital/ambulatory surgical center (ASC) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, incubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier 74. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.
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80 - Assistant Surgeon: Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number (s). This modifier should be reported to identify surgical assistant services performed in a non-teaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare. When the surgical services are performed in a non-teaching setting, report "Non-teaching" in the narrative section of an electronic claim submission, or in Block 24D for paper claims. Note: Please reference Chapter 22 for more information on assistant surgery reporting requirements. 82 - Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number (s). This modifier is used in teaching hospitals if there is no approved training program related to the medical specialty required for the surgical procedure or no qualified resident was available.
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Health Professional Shortage Area (HPSA) These modifiers are used by physicians to indicate the services reported were rendered in a qualified Health Professional Shortage Area (HPSA) and are eligible for the 10% incentive payment.
• •
QB - Physician providing service in a rural HPSA QU - Physician providing service in an urban HPSA
Additional CPT Modifiers 22 - Unusual Procedural Services: When the service(s) provided is greater than what is usually required for the listed procedure, indicate this by adding modifier 22 to the procedure code. A report is also required. For services on the physician fee schedule, modifier 22 is applicable only to those procedure codes for which the global surgery concept applies, whether the procedure code is surgical in nature or not. Supportive documentation, e.g., operative reports, progress notes, order sheets, pathology reports, etc., must be submitted with the claim. Note: Modifier 22 will be removed when reported with procedures that do not have a global surgery period of 0, 10, or 90 days.
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26 - Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. 52 - Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Use modifier 52 (reduced service) to indicate a service or procedure is partially reduced or eliminated at the physician’s election. When you report modifier 52, include office records, test results, operative notes, or hospital records to substantiate the reason for reporting a reduced service. If this information is NOT included, your claim may be denied. Note: Effective January 1, 1999, for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the wellbeing of a patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 76 - Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original
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service. This circumstance may be reported by adding the modifier 76 to the repeated service. Note: When it is medically necessary to repeat a service, the first service should be reported in the usual manner. The repeat service should be reported on the next line with modifier 76 appended to the procedure code. In the event it is medically necessary to repeat a procedure more than twice, report the second line with the 76 modifier and the appropriate number of units in the units field. If a service is repeated more than once, additional documentation should be provided in the narrative field of the claim to support the medical necessity of the repeat services. The patient's medical records must always document the medical necessity of performing repeat procedures and be available to the carrier upon request. 77 - Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated service. 90 - Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier 90 to the usual procedure number. For the Medicare program, this modifier is used by independent clinical laboratories when referring tests to a reference laboratory for analysis.
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91 - Repeat clinical diagnostic laboratory test: In the same course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. (Note: Effective for dates of service 1/1/2000 and after.) 99 - Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure and other applicable modifiers may be listed as part of the description of the service. Note: This modifier should be used by providers submitting claims electronically when it is necessary to report more than two modifiers. In this situation, other applicable modifiers should be reported in the narrative portion of the electronic claim.
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Additional HCPCS Modifiers
• • •
AH - Clinical Psychologist AJ - Clinical Social Worker AM - Physician, team member service EJ - Subsequent claims for a defined course of therapy, e.g., EPO, Sodium Hyaluronate, Infliximab.
•
• • • •
E1 - Upper left, eyelid E2 - Lower left, eyelid E3 - Upper right, eyelid E4 - Lower right, eyelid
Note: These modifiers can be used to specify on which eyelid services were performed. Comprehensive and component code combinations performed on different eyelids are separately payable.
• • •
FA - Left Hand, thumb F1 - Left hand, second digit F2 - Left hand, third digit F3 - Left hand, fourth digit F4 - Left hand, fifth digit F5 - Right hand, thumb F6 - Right hand, second digit F7 - Right hand, third digit F8 - Right hand, fourth digit
•
• • • • •
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•
F9 - Right hand, fifth digit
Note: These modifiers can be used to indicate that rebundled services were performed on different digits. Separate payment will be allowed when column I & II services are performed on different digits. See Appendix C for comprehensive and component code combinations.
•
G6 - ESRD patient for whom less than six dialysis sessions have been provided in a month
•
G7 - Pregnancy resulted from rape or incest or pregnancy certified by physicians as life threatening
•
GA - Beneficiary authorization
Effective for dates of service on and after October 1, 1995, report this modifier to indicate that advance written notice was provided to the beneficiary of the likelihood of denial of a service as being not reasonable and necessary under Medicare guidelines. See chapter 6, page 6-6.1 for example of written notice. GC - This service has been performed in part by a resident under the direction of a teaching physician. GE - This service has been performed by a resident without the presence of a teaching physician under the primary care exception. Note: GE, for this purpose, is for use on all services except ambulance.
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GH - Diagnostic mammogram converted from screening mammogram on the same day GN - Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care GO - Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care GP - Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care GT - Via interactive audio and video telecommunication systems GX - Service not covered by Medicare Note: Effective January 1, 1999, when a beneficiary refuses to have an xray, the claim must be billed using the correct chiropractic HCPCS code (98940, 89841, or 98942) along with the new GX modifier. QA: - FDA investigational device exemption. FDA-approved investigational devices and/or services incident to the use of such devices should be billed using the appropriate HCPCS code and the QA modifier. When billing a service with the QA modifier, you are certifying FDA approval of a clinical trial or the device and that the device was approved at the time the service was rendered.
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The FDA will issue an investigational device exemption (IDE) number that corresponds to each FDA-approved device that has been granted an investigational device exemption. Providers must obtain the investigational device exemption number from the manufacturer supplying the device in the clinical trial. LT - Left side (used to identify procedures performed on the left side of the body) If used to substantiate different body sites, this modifier can exclude services from rebundling. Q1 - Documentation on file for ambulatory or non-ambulatory patients that indicates mycosis/dystrophy of the toenail causing secondary infection and/or pain which results or would result in marked limitation of ambulation and require the professional skills of a provider. Note: This modifier is applied to ambulatory as well as non-ambulatory patients. Documentation that these conditions exist must be maintained in the patient's file. Q3 - Live kidney donor: services associated with postoperative medical complications directly related to the donation. This modifier is effective for services furnished on or after January 1, 1995.
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These postoperative services will be reimbursed at 100% of the allowed charge as required in Section 1881 (d) of the Social Security Act. The following bullets are some reporting notes and tips for submitting kidney donor services: In the event that more than two modifiers are required when reporting postoperative physician services furnished to live kidney donors, it is important that the Q3 modifier is reported in the first modifier position. This is necessary to ensure that these services are reimbursed at 100%. Services are to be reported under the name and HIC number of the recipient of the kidney donation. Procedure code 50320, Donor nephrectomy from living donor, should continue to be reported with the YA modifier to be reimbursed at 100% of the allowed charge.
•
Q4 - Service for ordering/referring physician qualifies as a service exemption for laboratory services
•
Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement
•
• • • •
Q6 - Service furnished by a locum tenant physician Q7 - One Class A Finding Q8 - Two Class B Findings Q9 - One Class B and Two Class C Findings Note: Modifiers Q7, Q8, and Q9 are effective for dates of service on and after October 1, 1995 and are to be used to bill podiatric services.
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•
QP: - Documentation is on file showing that the lab test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes 80002-80019, G0058, G0059 and G0060.
•
QR - Repeat clinical diagnostic laboratory test performed on the same day to obtain subsequent reportable test value(s) (separate
specimens taken in separate encounters.) (This modifier should not be used for dates of service after 12/31/1999. See modifier -91.) • QW - CLIA Waived Tests (Please reference appendix Ha for additional information.) • QY - Medical Direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist. • RT - Right side (used to identify procedures performed on the right side of the body) If used to substantiate different body sites, this modifier can exclude services from rebundling.
•
SF - Second opinion ordered by a Professional Review Organization (PRO) per section 9401, P.L.
•
99-272
(100
%
reimbursement
-
no
Medicare
deductible
or
coinsurance)
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SG - Ambulatory surgical center (ASC) facility service This modifier is only used by the ASC for identifying the facility charge. It should not be reported by the physician when reporting his/her professional service rendered in an ASC.
• •
TA - Left foot, great toe T1 - Left foot, second digit T2 - Left foot, third digit T3 - Left foot, fourth digit T4 - left foot, fifth digit T5 - Right foot, great toe T6 - Right foot, second digit T7 - Right foot, third digit T8 - Right foot, fourth digit T9 - Right foot, fifth digit
•
• • • • • • •
Note: These modifiers can be used to indicate that comprehensive or component code combinations were performed on different digits. Separate payment will be allowed when column I & II services are performed on different digits. See Appendix C (New Correct Coding Combinations). TC - Technical component: Under certain circumstances a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure code number.
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W7 - Kidney Donor (see modifier Q3 for more information) XJ - Course of treatment has ended (radiation therapy) This modifier is used to indicate the course of treatment for radiation therapy has ended. If this modifier is not reported, additional fractions will be denied. YR - Services performed by another provider but billed as services performed "incident to" the personal professional services of the billing physician/non-physician. Beginning January 1, 1997, services provided `incident to' the personal professional services of a physician/non-physician must be billed using the YR modifier. The YR modifier is intended to be attached to all personal professional services performed `incident to' which may be identified by a CPT or HCPCS level I or II code. In general, `incident to' services are services performed by a physician's or non-physician provider's employee, but reported on the claim as if the billing physician or non-physician provider has provided the service. YY - Second surgical opinion (See modifier SF for PRO-ordered services) ZD - Routine non-covered services Services reported with this modifier will be denied as non-covered.
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ZP - No purchased services (*) DO NOT REPORT THIS MODIFIER * Effective with claims received on or after June 23, 1998, do not report the ZP modifier with diagnostic service. If the technical portion of the diagnostic services was NOT purchased block 20 (or electronic equivalent) should be checked “NO”. If the technical portion of the diagnostic service was purchased, blocks 20 and 32 of the CMS 1500 claim form (or electronic equivalent) must be completed to meet purchased service criteria. ZX - Medical necessity for portable Xray suppliers and independent physiological laboratories DO NOT REPORT THIS MODIFIER Note: Providers/Suppliers are required to maintain medical necessity documentation on file. ZZ - Third surgical opinion.
10. Diagnosis Code: Diagnosis code is used to indicate the health problem
that a patient have. The first of these codes is the ICD-9-CM diagnosis code describing the principal diagnosis (i.e. the condition established after study to be chiefly responsible for causing this hospitalization). The remaining codes are the ICD-9-CM diagnosis codes corresponding to additional conditions that coexisted at the time of admission, or developed
subsequently, and which had an effect on the treatment received or the length of stay. Medicare requires physicians to include a complete diagnosis code (or codes) on each claim submitted for payment. The first of these codes is the ICD-9-CM (International Classification of Diseases Ninth
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Revision Clinical Modification) diagnosis code describing the principal diagnosis (i.e. the condition established after study to be chiefly responsible for causing this hospitalization). A Maximum of 4 diagnosis codes can be printed on the CMS-1500 claim form.
This field is printed in the 21st field of the CMS-1500 claim form.
11.
Number of days/Units: This field contains the length of service performed. We need to enter number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service was performed the numerical 1 should be entered.
12. Billed Amount: It is the amount charged by a provider for a specific
service. In other words it is the total charge value of the claim. The billed amount for a specific procedure code is based on the provider.
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MEDICAL BILLING – CASH POSTING
What is Cash Posting?
Cash posting is a process by which the payments received from insurance companies, patients and other entities, towards settlement of claims, applied to the respective claims / patient accounts or other accounts in the billing system. Cash team receives the cash files (Check copy and EOB) and applies the payments in the billing software against the appropriate patient account. During cash posting, overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Also underpayments/denials are informed to the Analysts.
How the cash is generated, received and posted?
The charges submitted to the insurance will be processed payment is made according to the fee schedule. The insurance pays the cash through checks which is deposited in the specified banks date-wise. Each check has its own unique number and date on which the check was issued. The checks along with the claim details are received by the Billing Office in U.S who in turn groups a certain amount together and sends to the billing office here. The details which are received with the checks are known as the EOB (Explanation of Benefits).
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The Billing office in U.S scans the Checks and EOB details to the Billing Office here. The Billing Office here receives the scanned documents as files. The received files are then collected by the cash poster who gives the file reference numbers based on the date on which the file was received. Then the cash poster matches the checks with the EOB details. This process is termed as file sorting or Check matching. Now the file had been sorted and the details are posted in the Software which is called as the Cash Posting.
Electronic Posting
Cash posting can be done either manually or electronically. During manual posting the above said methods are carried on whereas in case of electronic posting the amounts deposited in the bank gets transmitted electronically to the billing office here. The transmitted details are known as Electronic File Transfer i.e. EFT’s. This Eft’s are received by the cash poster with the insurance reference
number. Then the Cash poster retrieves the transmitted details and starts posting the cash electronically. In this posting the amounts that are allotted to the claims get identified by the software itself and the respective amounts are posted, for which the detailed EOB’S will be received later.
Once the posting is over the amount posted in the software is tallied with the amount received. Then a detailed report containing the claim and its posting details are taken which is helpful for any future references.
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General Terms associated with Cash posting and their definitions:
•
Claim: Forms submitted for payment of physician services, other medical
services and supplies provided to Insurance beneficiaries. It is an itemized statement of healthcare services and their costs provided by hospital, physician's office or other healthcare facility. A charge when filed to insurance becomes a claim.
•
Insurance Claim number: It is the number given by the insurance to the claim in order to identify
the claim in case of reference. Some insurance companies address the claim with the help of the claim number. It can be of the combination of any numeric values along with the alphabetical values. It is insurance specific and no general format is there for this. For Example: - 12345ABXCQ78.
•
EOB: It is defined as Explanation of Benefits. This contains the claim details,
the amount paid by the insurance, Co-pay / Co-insurance amount and write-off amount. It also contains the patient name, patient address, patient account number, SSN, insurance name, insurance address, insurance contact numbers and it’s customer care numbers (if any). If insurance does not pay the claim then the reason for which the claim was not paid i.e. the denial reason is also mentioned in
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EOB. In simple words it can be defined as the detailed explanation of the benefits provided by the insurance for the claim. Some insurance like Medicare have their own format of EOB. For Example:EOMB (Explanation of Medicare Benefits) contains a statement detailing the amount of benefits paid or denied for services under the Medicare program.
•
Billed amount: It is the Amount charged for each service performed by the provider.
In other words it is the total charge value of the claim. The billed amount for a specific procedure code is based on the provider. It may vary from place to place. It is not common across all the states.
•
Allowed amount: The maximum reimbursement the member's health policy allows for a
specific service. It is the maximum dollar amount assigned for a procedure based on various pricing mechanisms. Allowed amounts are generally based on the rate specified by the insurance. This amount may be: -a fee negotiated with participating providers. -an allowance established by law. -an amount set on a Fee Schedule of Allowance. For Example:If the billed amount is $100.00 and the insurance allows $80.00 then the allowed amount is $80.00 and the balance $20.00 is the write-off amount.
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Formula: Allowed amount = Amount paid + co-pay / co-insurance + Deductible • Paid amount: It is the amount which the insurance originally pays to the claim. It is the balance of allowed amount – Co-pay / Co-insurance – deductible. The paid amount may be either full or partial. i.e. Full allowed amount being paid or a certain percentage of the allowed amount being paid. For Example:If the billed amount is $100.00 and the insurance allows $80.00 but the payment amount is $60.00. Here $60.00 is the actual amount paid for the claim. Formula: Paid amount = Allowed amount – (Co-pay / Co-insurance + Deductible) • Co-pay: The fixed dollar amount that patient requires to pay as patient’s share each time out of his pocket when a service is rendered. This is paid during the time of the visit. Co-pay ranges from $5.00 to $25.00. Co-pay’s are usually associated with the HMO plan. The Co-pay amount is usually specified in the insurance card copy.
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•
Co-insurance: Co-insurance is the portion or percentage of the cost of covered services to be paid either by insurance or patient. After the primary insurance making payment the balance of the cost covered (Co-insurance) will be sent to secondary insurance if the patient has one or to the patient.
For Example:If the billed amount is $100.00 and the insurance allows @80%. The payment amount is $60.00 then the remaining $20.00 is the co-insurance amount. Formula: Co-insurance = Allowed amount – Paid amount – Write-off amount.
•
Deductible: Deductible is the amount the patient has to pay for his health care
services, whereas only after the patient meets the deductible the health insurance plan starts its coverage. The patient has to meet the Deductibles every year. It is mostly patient responsibility and very rarely another payor pays this amount.
•
Posting Reference Number:
This is the number which is given by the operator to the claims posted in order to keep track of the payment posted details. This is generally given in a specified format as per the client requirement.
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For Example:01.3651.123103 here the 01 refers to the serial number, 3651 refers to the batch number and 123103 refer to the date and the year on which the file was received by us.
•
Offset: This is a kind of an adjustment which is made by the insurance when
excess payments and wrong payments are made. If insurance pays to a claim more than the specified amount or pays incorrectly it asks for a refund or adjusts / offsets the payment against the payment of another claim. This is called as Offset.
For example:Let the total billed amount of two claims is $100.00 each and the specified payment for this is $80.00. The insurance pays $90.00 for the first claim. Here $10.00 is paid in excess. Now while making payment for the second claim the insurance pays $70.00 and sets $10.00 as offset. Now the insurance payment becomes normal as the excess payment had been adjusted off.
•
Refund: This is the process of returning back the excess money paid by the
insurance / patient on request. If payment is received in excess than the specified amount, insurance / patient request for a refund. The process of Refund is usually done as per the client specifications. For example:-
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Let the total billed amount of a claim be $100.00 and the specified payment for this is $80.00. The insurance pays $90.00 for the claim. Here $10.00 is paid in excess. Now the insurance requests for a refund of $10.00 which will be done as per the client specifications.
•
Adjustment: An adjustment is an amount which had been adjusted for some reason
and may be recoverable. It can be an additional payment or correction of records on a previously processed claim. Adjustments are done based on the client instructions. One specific type of adjustment is the write-off.
For Example:Let the billed amount of a claim be $100.00 and the paid amount is given as $70 and $ 30 is given as participating providers adjustment. So this $ 30 has to be adjusted.
•
Write-Off:- It is an amount which cannot be recovered at all. This writeoff is usually done when the insurance payments are made. It is the balance of what the insurance have allowed on a particular charge i.e. Total Billed amount – Allowed amount. The main difference between an adjustment and write-off is that Adjustment may be recovered whereas write-off cannot be recovered at all.
For Example:-
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If the billed amount is $100.00 and the insurance allowed amount is $80.00. The payment amount is $80.00 then the remaining $20.00 is the write-off amount.
•
Denial :
Denial is the technical term used for the non-payment of a claim by the insurance. The insurance usually pays the claim if the details presented to them are sufficient enough for processing. If there is any lack of information then the insurance quotes a reason for which the claim is not considered for payment which is known to be the denial reason. These reasons are found in the EOB. Some insurance like Medicare follow a general set of denial codes which is uniform across all the states. But some commercial insurance follow their own set of reasons codes for the denials which will be clearly mentioned in the EOB. For Example:If the claim has gone to the insurance without the patient date of birth then the insurance will not pay the claim stating a denial reason code to it.
•
Balance Billing:
It is the difference between the billed amount and the amount approved by insurance. Once the claim payment had been made by the primary insurance and if there is any balance pending for the claim then the balance is either sent to the secondary payor or to the patient. If the patient is enrolled with the secondary payor then the balance is billed to it. Generally for secondary billing the claim must be submitted
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along with the primary payor’s EOB. Only then the secondary payor will pay for the claim. In secondary billing primary payor EOB is the most important document. Some insurance like Medicare automatically transfers the pending balance to the secondary payer (Medicare Supplementary) if the patient has any. This procedure is termed as Crossover which reduces the work of the billing office. If the patient is not enrolled with the secondary payor then the balance is billed to the patient. Patient billing cannot be done at all the cases. For certain cases we need the client’s approval for patient billing. Periodic
patient statements are sent to the patient in order to intimate the balance which is pending from patient.
•
Capitation Payment
Specified amount paid periodically to the provider for a group of specified health services, regardless of quantity rendered. This is a method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered. The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. It is a payment system where managed care plans pay the health care providers a fixed amount to care for a patient over a given period. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member.
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MEDICAL BILLING – ACCOUNTS RECEIVABLES
What is Account Receivables?
Receivables are defined as amounts due and expected to be collected by billing / provider’s office for the services provided to individuals. In Medical Billing, receivables are handled by Account Receivables Department. Account Analyst
plays a crucial role in identifying and resolving issues which helps to reduce or clear receivables.
What is the purpose of Claims review & AR Analysis?
The purpose of claim analysis is to identify and resolve medical claims billing and reimbursement issues toward maximizing collections and minimizing accounts receivables. It helps to ensure timely, accurate and final settlement of health insurance claims and patient bills by insurers or patients as appropriate. The scope of claim analysis is applicable to all health insurance claims and patient bills that have not been fully and finally settled by liable party or parties comprising health insurers, patients and others. It is the responsibility of the Accounts Receivables Analyst to ensure that AR is under control & acceptable by industry standards.
What is the scope of AR Department?
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AR Department has to ensure steady inflow of money from the insurance company. The main motive of this department is to collect money for all the Usually the turn around
treatments taken by the patients in a timely fashion.
period for the payment by the insurance company is 30 – 45 days. Once the limit is exceeded AR department has to make an enquiry for the delay. various reasons for the delay like: e) Correct details may not have been provided to the insurance companies. f) Claims were sent correctly but Insurance Company may not have received the claims. g) The checks issued might have been sent to the wrong address. h) The insurance company may delay the payments if they have a backlog and they would inform us by a letter that they have received the claims and would be making the payments shortly. There are
AR department acts as a hub around which other departments revolve.
This
department can gather & update lot of billing information which is required to settle a claim. Account analyst uses various reports available in billing software to identify claims which have not been settled.
The Medical billing software is capable of running reports that pull out claims that are unpaid for greater than 30 days. These are called aging reports and these reports show pending payments in slots such as 0 – 30 days, 31-60 days and 6190 days. Claims filed within the last 30 days will find themselves in the first slot (0-30days). Claims that are more than 30 days but less than 60 days old will be
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found in the 31-60 days slot. A glance at this report will show the AR personnel the claims that need to be followed up on with the insurance company.
Claims will be followed up over the telephone or by written correspondence.
It
would be necessary to find out why the claims are yet to be paid and what needs to be done to have these claims paid. The delay and denials will be corrected by the billing office in coordination with the physician’s office and the insurance carriers. The same applies when patient billing statements are sent out. The
patient is given 3-4 weeks to pay the bill and if the payment is not received with in that time, the billing office will follow up with the patient
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Accounts receivables - calling
Medical accounts receivable follow-up involves following up with entities such as Insurance carriers, Physicians, Hospitals and patients for information required to resolve the pending accounts at the earliest. Calling is a support media for A/R Analyst to close an outstanding account. Calling is done on accounts which are outstanding for more than 40 days and for which no correspondence has been obtained.
Calls are made to the following entities by an AR representative:
Insurance carriers Hospitals Physicians office Patients
Insurance carriers
Calls are made to insurance carriers for the following reasons:
1. Patient eligibility verification
Calls are made to the insurance carrier to confirm on the eligibility of the insured, the type of insurance the subscriber has with the respective insurance and/or the benefits that are covered by the insurance.
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2. Provider enrollment department Calls are made to the insurance carrier to confirm on the provider enrollment details. In order to check whether the provider is participating with the insurance and/or to enroll the provider with the insurance carrier.
3. Claim status Calls are made to insurance company to enquire about the status of a claim that has already been filed to them, but for which there has been no correspondence from the insurance company for over 40 days.
Hospitals
Calls are made to the hospitals to check on the pre-authorization, pre-certification, to confirm on medical records and also to check on patient’s coverage information in case a contact cannot be established with the patient.
Physician’s office
Calls are made to the physician’s office/PCP office to obtain and confirm on the referrals, to confirm on the patient’s coverage information incase a contact cannot be established with the patient.
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Patients
Calls are made to the patient to confirm on the insurance policy details, to obtain and confirm on the patient’s other insurance details or to inform the patient about their responsibility that is due from them to the doctor. Under whose name do we call carriers & patient’s? Calls are made to patients and insurance companies, hospitals, physician’s office under the client’s name. Thus the carriers and patients would have no way of knowing that they are being called from an outside firm, but rather the clients’ in house collections department. Who receives the payment collected by the ar representative? The accounts receivables would be managed under the client’s name, therefore the payments would be made directly to the client account as specified.
Calling – classification
Inbound: Calls that the office receives from patients, insurance carriers etc is termed as inbound. Patients call the billing office to check on the payments and on clarifications when statements are sent to them periodically. Insurance carriers call the billing office when a message is left for them to call us back and/or for clarifications on claims that have been filed with them.
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Outbound: Calls that our office makes to the insurance carriers, patients, hospitals, provider’s office etc are termed as outbound.
Calls are made to insurance carriers to check on patient eligibility, provider enrollment details and/or to check the status of the claim that is filed. Calls are made to the patient to follow-up on the payments, to confirm if the statements sent have been received by them and also to check on their insurance coverage information Calls are made to the hospitals, provider’s office to check on the authorization details.
Abbreviations to update patient notes
Cld TT CPT Dnd DOS PCP Auth# POS EOB EOMB : Called. : Talked to. : Current Procedural Terminology. : Denied. : Date Of Service. : Primary Care Physician. : Authorization number. : Place Of Service. : Explanation of Benefits. : Explanation of Medicare Benefits.
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Chk Pt Proc Clm Diag Ins Pd Amt NIS
: Check. : Patient. : Procedure code. : Claim. : Diagnosis. : Insurance : Paid : Amount : Not in system
Script on how to call insurance for status of a claim
Sample 1 Good morning, this is ……… calling from ………………. (name of the physicians office) to check the status of the claim. (If the rep asks for the provider/ tax id #)…… The Dr’s provider/tax id# is …………. The patient’s ID# id ………………., the patients name is ………………. And the DOS is ………………. For a billed amount of ……………… (If the claim has been paid, ensure all the check points for a paid claim is verified and confirmed.) Thank you for your kind assistance. Have a great day.
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Sample 2 Good morning, this is ……… calling from ………………. (name of the physicians office) to check the status of the claim. (if the rep asks for the provider/ tax id #)…… The Dr’s provider/tax id# is …………. The patient’s ID# id ………………., the patients name is ………………. And the DOS is ………………. For a billed amount of ………………. (If the claim has been denied, ensure all the check points for a denied claim are verified and the reason for the denial is obtained). Thank you for your kind assistance. Have a great day.
Sample format for update Notes: Called Insurance…………. . TT …………….. . She said that the DOS ………….. for the billed amount………….. paid …………. On …………. Chk# is ………………… bulk check in the amount of……….. Claim processed on…………. The copay is…….. the co-insurance is ………. And the
patient responsibility is …………. The check was mailed out to ……………. (address) and the check is still ………. (out-standing).
The AR Process is completed only when the necessary action is taken after the calls has been made and has the claim reprocessed and converts the pending claims into receipts/cash. It has also to be noted that when ever a new update pertaining to claims processing is received, the information should be shared with the other departments so that the speed of the collection is increased and the denials are reduced.
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COMMON PHONETICS
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z (zee) As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in Apple Boy California David Edward Frank Girl Henry Indiana Jack Kite Larry Mary Nancy Orange Peter Queen Robert Sam Tom Umbrella Victory Whisky X ray Yellow Zebra
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ISSUING WORK ORDER
1) 2) 3) 4) Age of the Pending Claim Billed Amount Timely filing limit of the insurance company/carrier. Based on denials received.
Based on the Age the claims are classified in to 5 different age groups. • • • • • • 0-30 days: Claims falling under 30 days from the date of first filing. 31-60 days: Claims greater than 30 days but less than or equal to 60 days from the date of first filing. 61-90 days: Claims greater than 60 days but less than or equal to 90days from the date of first filing. 91-120 days and: Claims greater than 90 days but less than or equal to 120 days from the date of first filing. 120 - 150 days: Claims greater than 120 days but less than or equal to 120 days from the date of first filing. 150 days: Claims greater than 150 days.
The analyst sees that all the claims are followed up and necessary actions are taken and callbacks are set for further course of action. Work-orders issued based on the Billed amount The claims with highest billed amount are identified and the same is placed for calling. And the necessary actions are taken as per the feedback from the night caller. Work-orders issued based on the Timely-filing limit of the carrier The insurance company/carriers with very short span of time for timely filing is identified and the claims pertaining to those carriers are given for calling on priority and necessary actions are taken based on the feedback from the night callers. Work-orders issued based on the Denials The insurance company may send denials alone in their own format to the Providers to know the denial reason for which they denied the claims. Those
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denials will be given for calling and the necessary actions taken based on the feedback from the night callers.
Procedures Followed For Issuing The Work-Orders:
a) The Ledger print outs are given to the night callers for their convenience. b) On the ledger print out the analyst writes in short the previous issues of the claim and also notes down the points that is to be enquired with the carrier. Denials and action to be taken: Callers with the help of the notes given by the analyst, calls the carrier and gets the needed information from the callers. To check for the status of the claim: Analyst: Pending Claims above 30days which is not followed-up is given for Status call. Caller: Gets the status from the carrier, May be a) Payment details b) The denial reason c) Claim Not in system etc., Based on the call the necessary action is taken by the analyst. a) Payment Details: The caller should get the following when he is asking for the payment details. Check # Check Date Check Amount Pay to Address Cashed detail Insurance Verification Analyst: There may be cases were the charge dept/analyst may require to know the correctness of the Member id# or the Mailing address etc of the patient with the carrier. Caller: Gets the mailing address, confirms the id# and other information. The caller should get the following details. Mailing address Member Id# Effective date Authorization # required or not Provider is Par or Non-Par Based on the call information’s are checked and the corrective actions are taken.
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Eligibility of the Patient’s Coverage Analyst: Asks the caller to check for the validity of the coverage with the carrier. Caller: Calls the carrier, confirms the validity of the coverage, and gets the effective date and the termination date wherever possible. Based on the call the necessary action is taken. Check why the Procedure code was not considered Analyst: Would have received the E.O.B wherein one of the line item is not considered for payment, so the analyst asks the caller to check for the reason for having not considered the line-item. Caller: Gets the reason for the procedure code not being considered, say line-item missed from being considered, denied for some reason, but the reason was not specified in the E.O.B or the claim is sent for review and so the same will be paid/denied in due course of time. Based on the feedback the necessary action is taken, say a Callback date is set. Claim Denied stating, “Lacks information needed for Adjudication” Analyst: Receives an E.O.B with a particular procedure code denied with the above reason. Asks the caller to get the exact reason for the denial. Caller: Calls the carrier and gets the exact reason-Reason being “The claim should be submitted along with the additional documents/Medical Notes to process the claim”. Based on the feedback from the caller the analyst sends a mail or Spread Sheet to the Clients office requesting for Medical Notes. Once after receiving the same claim is re-filed along with the medical records to the carrier. Claim Denied stating “Diagnosis inconsistent with the Procedure code billed” Analyst: Based on the denial received the analyst first sends nail/Spread Sheet to the coding department to re-code the charge sheet with the correct Diagnosis, after completion the same is given to the caller to update the new diagnosis in their (carrier) system by telephonic conversation. Caller: If accepted by the Rep, the new diagnosis is updated in the carriers system or else the rep, requests for resubmission of the claim. Based on the call made either the claim is marked for call back or else it is re-filed with the new diagnosis.
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Claim denied stating “No authorization on file” Analyst: If there is authorization # present in the system then, the analyst gives the same to the caller and asks to check if the same is valid for the provider, procedure code, Date of Service and the Diagnosis code billed. Caller: Call the carrier for validity of the authorization#. Based on the feedback the action is taken. Claim Denied for “Medical Necessity” Analyst: The analyst asks the caller to enquire the rep, if the claim will be processed with any additional information, if yes, what sought of additional information is required. Caller: Requests the rep to let them know what information is required in-order to get the claims processed. Based on the in-formation from the carrier the necessary action is taken. Claim Denied stating “Bundled Service” Analyst: Claim is denied stating “Bundled Service” asks the caller to get the information as to, with which procedure code this particular procedure code is bundled”. Caller: The caller gets the info of the bundled service from the insurance representative. If the caller is not able to get the same then the analyst gets the help of the Compliance dept. checks for the Bundled service information and based on this the analyst generates report for that particular procedure code and sends a mail to the client’s office for approval of write off. For Ex. 82948 is bundled with 99213, 99214 and 99215.Here we are to write off the procedure code 82948 with the consent of the Dr. (or) the client office. Claim Denied for Missing or incomplete information in the HCFA Analyst: Asks the caller for claim status. Callers: Get reply from the Rep of the ins stating” Block 33 of the HCFA is missing or incomplete”. Action: The Analyst is supposed to print the HCFA and check for Block 33 to see if there is any missing info or incomplete info, If yes then the analyst checks the form setup and looks into it that the corrections are made and the claim is refiled.
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Claim Denied for Incorrect procedure code Analyst: Asks the caller to check why the particular procedure was not paid. Caller: Gets feedback from the rep that the Procedure code is incorrect and so has to be filed with the correct code. Action: The analyst should update the claim in problem in the Coding SS asking them to correct the same. Once the charge is corrected in the system the claim is refiled to the carrier. Claim Denied for want of Primary EOB Analyst: Asks the caller for the Claims status (primary carrier of the pt). Caller: Gets the feedback from the carrier as “Primary EOB required for processing the claim”. Action: The analyst has to first check if the patient has secondary insurance, if yes, asks the caller to call the secondary ins to check if they are acting as primary ins for this patient, if yes then the analyst sends a mail or updates the Charge SS asking them to archive the primary coverage and refiles the claim to the correct primary carrier. If the call was for Secondary claim, then the analyst should attach the Primary EOB with the secondary claim and sends the same to the carrier by mail. Claim Denied as “Non Covered Service” Analyst: Asks the caller to check under whose plan the Procedure was denied as Non covered service. Caller: Gets the info from the rep as “Non covered under patients plan” or “non covered under providers plan”. a) Non covered under Patient’s plan: Here the Analyst updates the client SS in order to confirm if the claim can be flipped to the patient. b) Non covered under provider plan: Here the analyst updates the Client SS to check if we can Write-off the amount. Claim Denied as “Duplicate Claim” Analyst: Asks the caller to check for claim status. Caller: Gets the reply from the rep as “Duplicate claim”. Action: The analyst has to check in the software if the claim was entered twice with the same DOS, Doctor, and Procedure. If yes, then the charge SS is updated and the duplicate claim is deleted with the consent of the Charge Supervisor. If it is not a duplicate then the analyst should place the call again for calling asking the callers to check for the status of the claim which was submitted previously, either the claim should have got paid or the claim should have got denied, in either case the caller should get the details of the payment made or should get the details of the denial.
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Claim “Not in System” Analyst: Asks for Claim status. Caller: The feedback from the rep is that the claim is not in system. Action: There are 2 steps to be followed The analyst should first check if few claims were transmitted to the carrier on the same date. If yes, then should ask the caller to check with the carrier stating “there were few claims submitted on the same date out of which there are some claims paid and some Denied if so then how this claim cannot be in system, the caller should also give the date of confirmation to the rep. If this was the only claim submitted on that date then the claim has to be refiled. Claim Forwarded to another carrier Analyst: Check for Claim status. Caller: Gets info from the insurance representative that the claim has been forwarded to another carrier. Action: The analyst should ask the caller to call the ins to which the claim was forwarded and check for the status, if claim is not in system then the caller is supposed to enquire the member id # and the ins mailing address ad other details, only then the analyst can take the proper action i.e., after getting the info the analyst updates the charges SS and asks them to archive the coverage with the correct primary coverage and refiles the claim. Claim Denied as “Non-Par provider” Analyst: Asks the caller to get the status of the claims. Caller: Gets the info from the Rep as “denied as Non-par Provider” Action: The analyst should ask the caller to check with the carrier if they will pay @ non-par rates if yes, then the claim can be resubmitted to the carrier. if not, the claim is updated in the client SS for Write off approval. Claim Pending for want of information from the Patient Analyst: Asks for the status of the claim Caller: Gets the feedback as “Claim pending for want of information from the patient”. Action: The call back should be set after 15 days, and on 15th day can ask the caller to call back and check if the carrier has received the needed info from the patient. If no again to set a call back after 15day, can wait for one month, if still the carrier does not receive the info, then with the consent of the client the claim can be flipped to the patient.
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Incorrect Place of Service Analyst: Should check for the correctness of the POS, i.e. for consult the POS should be 11, For Inpatient POS should be 21 and for Outpatient POS is 22.There are different POS for different cases. Callers: Callers can give the correct place of service if they have in their system to reprocess the claim immediately. Claim forwarded to pricing Aid, Pricing Review. Analyst: To place a calling to check for the Mailing address, Fax number and the Timely filing limit. Callers: Callers should ask for the PAPR Mailing address, Ph# once they have been informed that the claim has been forwarded to Pricing Aid Pricing Review. Contractual Obligation, amount for which provider is financially liable. The patient may not be billed for this amount Analyst: Should send a mail or should update the Client SS to get write-off approval. Callers: No need to call Claim/Service denied or reduced because this procedure/service is not paid separately. Analyst: Should first check with the Manual if the denied procedure code is a "Bundled service", if yes has to check with the compliance department for the details and should update the client SS for Approval of write off giving them the reason and referring them the Manuel etc. If the Procedure code is not "Bundled service" then the analyst can place a call with the insurance to check if the claim will be processed if submitted along with the necessary documents. Callers: Callers should ask for the Primary Procedure to which the component code has been included. Charges exceed our Fee schedule or Maximum allowable amount Analyst: The billed amount should be corrected and the claim should be filed again. Medicare has the Maximum Billed beyond which it is fraud. The Procedure codes billed with a Billed amount more than their maximum billed amount will be denied.
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Claim denied for Pre-existing conditions Analyst: The analyst after getting approval from the client will bill the patient, and after getting the copy of the pre-existing condition certificate and medical documents the claim will be submitted to the carrier. Callers: After the submission of Claim with the Pre-existing condition certificate from the Patient along with the medical documents, callers can call and give the date of submission and the ref# which was assigned by the Carrier to the patient. Claim denied for Date of Injury, First Diagnosis Used and for Pre-existing conditions Analyst: The analyst requests for the DOI, first Diagnosis code used and the Preexisting condition from the Client, after getting the same the claim is sent for reprocessing. As this is a paper claim the call back will be placed after 45 days. Callers: After the submission of Claim with the Pre-existing condition certificate from the Patient along with the medical documents, callers can call and give the date of submission and the ref# which was assigned by the Carrier to the patient. Claim denied for “Primary paid more the Allowed Amount Analyst: Write-off will be taken by the Analysts after getting a one time approval from the client. File the itemized bill with Insurance Card Copy Analyst: The claim will be submitted as a itemized bill, i.e. the entries in the claim will be date vice and not a clubbed entry for different date of service, and along with the copy of the insurance card copy. Callers: After the 30 days from the date of submission, the caller has to call and verify the status of the claims. Payment on this service/procedure has been with-held Analyst: Should check if there is any other alternate procedure code existing for the billed procedure code and yes then the same is informed to the charge dept. and the claims with this deleted(from the cpt manual) procedure code is reentered with the alternate procedure after which the claims are resubmitted. Callers: Callers has to ask whether there is an alternative new procedure code for this procedure code with regards to the services rendered.
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File the claim to the Third Party Administrators Analyst: Should file the claims to this Third party as per the information received from the carrier. Once after getting the phone number of the TPA from the carrier a call is made to the TPA. The Fax # and other details are obtained for future calls. Callers: Caller has to call TPA and get the Pricing sheet through fax and place it on the Analyst bay. Confirm that Hospice Patient did not appoint the Rendering Doctor Analyst: Medicare appoints an attending Dr for a Hospice Patient, if we receive a denial from MCR as above, Analyst has to just write down as this in the Block# 19 of the HCFA "Attending Dr was mot appointed by the Patient". Callers: Caller has to call after 20 days from the date of submission stating the "hospice patient" claim status. More than one unit of this service will be discounted Analyst: There may be cases where, 2 units of the same procedure code will not be paid by the carrier, we can check if the 2nd unit will be paid if submitted along with a modifier and medical documents supporting the need for the service. Callers: Callers has to ask why the one unit of the service was not paid. Callers have to ask whether this procedure code can be reprocessed if the additional documents were submitted. Claim denied as Capitated Analyst: Analyst has to first check with the client if we are capitated with the particular carrier. The Rooster report is obtained from the carrier; this contains the details of the claims under capitation. Based on this a capitated adjusted is raised by the analyst to the cash posters. Callers: Callers has to get the list of Procedure codes which are under the capitation and Fee for Services. Claim denied stating Need Corresponding Surgical Code Analyst: When a claim is denied for want of Surgical code, we are to check the Cpt manuals and should take the corresponding 4digit surgical code and the same should be filed with the same to the carrier. Callers: Nil Based on calls the remarks column is updated and after taking necessary actions the issues column is updated segregating the feedbacks under various heads. Callbacks are set for further action. This cycle goes on every month.
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Action to be taken on denial issues:
Issue: Coverage Terminated Action: a) If the patient has only one coverage: In this case the balance can be flipped to the patient. b) If the patient has secondary coverage: Give a work order to Insurance calling team. They need to call the secondary carrier and check if they will be acting as a primary. • If the secondary carrier says yes, then the claim is sent to the secondary. Denial from the primary carrier needs to be attached if we have crossed the timely filing limit of the secondary carrier. This will ensure that the claim will be processed. Otherwise the claim may be denied by the secondary for crossing the timely filing limit. If the secondary says no, then the patient has to be called for information regarding his primary carrier.
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c) If the denial is from Secondary: The primary has already paid and the secondary has been billed for co-insurance. If secondary rejects the claim stating that the coverage has terminated then the balance can be directly flipped to the patient. d) If another balance for same DOS has got paid: Take this case. There are two balances for the patient for the same date of service, a Doctor Balance & a CRNA balance. If the patient has got payment for a Doctor balance and the carrier denies the CRNA balance citing termination of coverage as the reason, then a work order has to be issued for insurance calling to why we got paid for one and rejected for the other. • • If the carrier says that they have paid the Doctor balance in error then a refund has to be initiated and the procedure as stated in point a & b above should be followed. If the carrier has denied the CRNA balance incorrectly then they will reprocess the claim.
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Issue: Invalid or Missing Provider Id# Action: a) If there is no provider number in the system: If the rejection is due to non availability of provider number in the system, the same has to be obtained from the carrier through the enrollment process. b) If there is a provider number in the system: When the rejection states that the provider number is not valid for that particular DOS, the issue should be forwarded to the provider enrollment team for retro activation. When the rejection does not specify anything but simply states invalid provider number, then check if the number has been keyed in correctly in the system by comparing the same with the original records available with the provider enrollment department. Issue: Invalid Procedure code Action: Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry. If yes, correct the same and refile the claim. If not, a) Check whether the carrier requires ASA or CPT code. If the Claim has gone with incorrect code then the claim needs to be refiled with correct code. Forward this issue to claims analyst who will check for errors of the same kind by running a paid & outstanding report for that particular date of filing. This type of error occurs due to lack of knowledge. b) There is one more reason for getting this type of rejection. The carrier may not be paying for some codes. So if point (a) is not applicable, this may be the cause for rejection. A work order can be issued for the insurance calling team. If the carrier says that they do not pay for the procedure then the amount has to be written off. There are some exceptional cases where the primary may not be paying for one code whereas the secondary may consider the same (ex) Medicare won’t pay for dental procedures whereas a secondary, Commercial may pay for the same.
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Issue: Invalid Diagnosis code Action: Two types of rejections are possible Dx not matching with procedure code The Dx reported on the claim is not to the highest level of specificity. Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry. If yes, correct the same and refile the claim. If no, it may be because of incorrect Dx. It is also possible that the 4 or 5 digit Dx is used, which the carrier may consider to be truncated Issue: Invalid or missing modifier Action: a) First check whether modifier has been entered at the time of charge entry. If no, have the same entered and resubmit the claim. b) If modifier has been entered but the carrier rejects the same Check whether the correct modifier has been used If you find that the correct modifier has been used, then give a work order to insurance calling to find out the reason for rejection. Based on the feedback corrective actions are taken. One example, Blue choice (New York) rejected a lot of claims for the reason ‘Invalid or missing modifier’. Carrier was called and it was found that they do not require modifiers henceforth and claims need to be billed without modifiers. Issue: Pre-existing Condition Action: Pre-existing condition refers to the terms & conditions entered into between the carrier and the patient / subscriber before the beginning of the contract. The rejection will usually say that the claim is being denied due to the pre-existing condition. It would not specify what exactly the condition is. So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything. (Ex.) A) There may be a condition that for the first $5000 worth of medical expenses the patient should bear it himself and the carrier would start paying for expenses after crossing that limit. If the patient has not yet exhausted the threshold limit then the claim would be denied for the pre-existing condition. B) There may be a condition that the carrier would not be paying for the same diagnosis more than once in a year. If a same diagnosis code is used on two occasions in the same year then the carrier will deny the claim submitted for the second time stating ‘pre-existing condition. As soon as you receive the denial, work order can be issued to Insurance calling. Check with insurance on the preexisting condition.
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If the patient has secondary coverage: Check whether we can send the entire bill to secondary along with the primary denial. Some carriers may be willing to pay for the same. If the secondary agrees, bill the secondary along with the denial obtained from the primary. If the patient has no Secondary Coverage / Secondary refuses to pay: Flip the balance to patient. Issue: Authorization number required or Invalid Action: Some carriers insist on obtaining prior authorization from them before the surgery. This may be for certain specific procedures or may even be for all procedures. So these are carrier specific and procedure specific. Please note that it is the responsibility of the Surgeon (and not the patient) to obtain the authorization# from the carrier. When you get a denial from the carrier for this reason, give work order to surgeon calling and find out if the surgeon has been paid. If the surgeon has been paid: It is unlikely that a surgeon would have got paid. But if he has got payment, then call carrier and find out why they have denied the anesthesiologist claim when the surgeon has been paid. They will either reprocess the claim or request a refund from the surgeon. If surgeon has not been paid: Take a write off. You cannot flip the balance to the patient. Issue: Anesthesia time not on claim Action: For anesthesia claims it is mandatory to have time printed on the claim. This rule is not applicable for flat fee codes. But we have got quite few denials from the carriers who wanted anesthesia time even for flat fee codes. So wherever anesthesia time is available the same should be noted for claims with flat fee codes. There is one more reason for this denial. If there are more than 4 line items in a balance then the anesthesia time would not get printed on the same claim form but in another. The carrier will treat the two forms separately and deny one for incomplete information and the other for want of anesthesia time. This should be avoided. Whenever you find a denial for this reason take the HCFA(s), staple them and send the same along with a covering letter.
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Issue: Anesthesia Records / Op. Notes / Medical Necessity records required Action: Anesthesia, records are usually requested by W/c (Workmen compensation) carriers for processing of claims. When a carrier requires operative / surgeon notes: a) Give a work order to insurance calling to find out if they have paid for the surgeon’s claim. If they have paid for the same, then the same has to be pointed out since they have processed the surgeon’s claim, why would they require surgeon notes once again for processing the claims? This line of argument can be pursued and the claim processed. b) If the carrier has not (yet) paid for the surgeon’s claim, then the surgeon needs to be called for a copy of the surgeon / operative notes. It should be noted that surgeon notes is a confidential document (i.e.) the request should be substantiated with valid reason. c) MAC B Cases: MAC stands for Monitored Anesthesia care. Certain Medicare (Texas, Ohio, Alabama etc.) requires ‘Medical Necessity’ report for processing MAC category ‘B’ procedure codes. This report needs to be signed by the surgeon. Whenever we receive charge sheets with MAC B procedure codes for MCR in ‘affected sites’ (states which require Medical Necessity letters) then the medical necessity letter for the same should be obtained from the doctor’s office. Once it is received claim should be resubmitted along with the letter. Issue: Exceeded the normal time for filing limit Action: Every carrier has a filing limit within which you have to submit a claim. This filing limit is calculated from the date of service and not from the filing date or the date the claim is sent out. When a carrier rejects the claim for this reason check whether the claim was submitted in the first instance with in the filing limit. If yes, then the claim has to be appealed with proof of timely submission. The proof that is accepted by carriers for timely submission is ‘c’ (carrier confirmation) reports and rejected EOB’s. When no other proof is available send the patient ledger copy as proof. Not many carriers accept patient ledger copies as sufficient evidence for timely submission. But it is worth trying in absence of other documents. If no, find out why the claim was not submitted with in the filing limit. Even If the provider has no identification number issued by the carrier, the normal practice is to submit the claim to the carrier and get a denial so that the same will serve as a proof of timely submission. So if you identify that the claim has not been submitted at all in time highlight the issue immediately.
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Issue: Require W9 form Action: A carrier may require a W9 form in the following circumstances: The tax id# on the claim form differs from what is in the carrier’s record. The ‘pay-to-address on the claim form differs from carrier’s records. Some carriers update the details about provider (like tax id#, pay-to-address) every year. For this reason they will ask for the W9 forms. When W9 form is requested for the above reasons, fill the same carefully and properly and send it to the carrier. Always remember that W9 forms should not be sent to Medicare and Medicaid. Certain BCBS plans and other carriers accept W9 forms.
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SAMPLE W9 FORM
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What is the process of AR analysis?
Step one: Report Execution
At the beginning of each month AR analyst runs an Aged Insurance Report on billing system using required parameters and identifies claims that are unpaid or inappropriately paid. This report provides a list of outstanding claims pending
against each insurance carrier.
Step two: Identification of Accounts to be worked
From the above report, the analyst selects claims that remain unpaid beyond 3045 days from the date of filing. The number of days depend on whether the claims were sent on paper (paper claims) or were transmitted electronically (electronic claims). The number of days depends on the average turnaround time for the claims to get settled, i.e., from the date of filing of the claim to the date of receipt of payment for the claim.
Step three: Identification of the problem - Review
The analyst then reviews patient account ledgers pertaining to the unpaid claims to analyze why the claims are still outstanding. Analyst reviews patient ledger
from all billing angle for possible violation of billing rule.
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Following are some of the situations the analyst may encounter & suggested remedial actions:
(a) If the analyst detects a charge entry, cash posting or claim submission error, he/she informs the concerned department. The error is corrected and claim resubmitted, if necessary.
(b) If the claim has been prepared and submitted correctly according to known rules and guidelines, and the usual turnaround time has passed, the analyst either calls insurance carrier or requests AR caller to call insurance carrier. A note is also made to AR caller indicating the type of information that needs to be obtained from representatives of the insurance company or payer.
(c) When claims are underpaid or denied, the analyst establishes the reasons for the denial or low payment by reviewing the explanations of benefits pertaining to the claim, carrier rejection reports, carrier billing guidelines, or initiating a work order to AR Calling to seek clarifications from the insurance company.
Claim denials or underpayments due to billing errors committed by staff are segregated and the concerned staff instructed to take corrective action.
(d) When claims are denied due to lack of documentation or additional information, the analyst requests for such additional documentation from the provider or billing office, and follows up with the insurance through the AR callers.
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(e) When the analyst is dissatisfied with the adjudication of a claim he/she may appeal with insurance for a review, with supporting documentation obtained from the provider office. The analyst will have to follow the appeals process and if there is a telephonic appeal facility, analyst should explore the same to appeal. A copy of the patient ledger and copies of the relevant EOB should be available with analyst while executing telephonic appeal.
If there is no telephonic appeal facility, then the analyst must an appeal on paper following the insurance company’s appeals process.
Step Four: Identification of the problem – Calling
If the claim has been prepared and submitted correctly as per insurance requirements, and usual turnaround time has passed, call needs to be placed with respective insurance carriers to ascertain the status of outstanding claim.
Analyst or AR Caller obtains the required information from the insurance company and documents the results of the call in the patient notes section of patient account. Appropriate steps needs to be initiated to settle outstanding claims based on the call notes.
Examples of the kind of situations that the analyst may come across and the action initiated are given below:
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(a) The AR night caller may have documented in patient notes that according to the insurance representatives the claim is not in their system, meaning they don’t have a record of the claim. The AR analyst may now check the claim address and review transmission reports to find out if the claim failed to reach the carrier due to a bad address or a transmission error. If the address in the system is incorrect, the analyst first finds out the number of claims that have been affected due to the wrong address. Or if there was a transmission error, how many claims were affected.
(b) Caller patient notes reveal that claims have been denied. Then analyst initiates appropriate action based on the reason for denial as documented in patient notes.
(c) The insurance carrier may state that the claim has been settled. In such cases, the AR caller obtains the payment date and checks details from the carrier and documents them in patient notes. The analyst follows up with the cash department on whether such a payment has been received. If the check the carrier says has been issued has not been received and posted within two weeks from the day of payment, he/she may prepare a report (depending on the policy established by the client) on such missing checks and sends it to the client.
(d) An issue may need feedback from client for proper resolution. If so, the analyst sends a report to the client detailing the issue and seeking clarifications.
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Step Five: Identification and Execution of Corrective Action
Once issues or problems have been identified the AR analyst initiates action to resolve them. Issues may be forwarded to one or more departments, or to the client, depending on the nature of the issue. Complete resolution of an issue may require inputs or actions from more than one department. Analysts issue forward’s request to the concerned departments for issue resolution. Issues that require inputs or actions from the client are forwarded to the client. For instance,
•
To clarify claim issues, check on status of claims or obtain carrier billing
information, the analyst issues work orders to AR Callers. • A corrected claim that must be resubmitted is forwarded to the claims
department.
•
Write-offs, adjustments and actions to resolve overpayments requests are
initiated to the cash department, while charge entry errors are corrected by the charge department.
Step Six: Identification of Uncollectible AR
Details of outstanding claim balances that the analyst considers uncollectible, and which may thus have to be written-off, are forwarded to the client for decision making. Details of outstanding claims, where collections efforts have fail due to non-
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cooperation or lack of response from payers or liable parties, are also forwarded to the client. Such accounts may be moved to a collection account. A collection agency then resumes the collection activity.
What are the tools used by an AR Analyst in Claim Analysis Process?
AR analysts uses the following tools, reports and documents to identify and investigate issues that are affecting cash flow and preventing timely and accurate reimbursement of claims by payers. One or more, and sometimes all, of the following tools, source documents and resources are required for complete and effective AR analysis:
Patient Account Ledger
• • • Explanation of Benefits (EOB) Regular Mail or Correspondences AR calling
System Reports like
1. AR Reports 2. Custom Reports 3. Financial Reports 4. Electronic Transmission Reports The extent to which the above mentioned tools and resources are used will depend on the account receivables situation in the accounts. The AR analyst measures the success of collection efforts by computing the current and past AR and collection’s in the specialty and account he/she is handling, comparing it against industry standards, wherever available. The analyst investigates the reasons for any rise in AR or any fall
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in collections using the tools and documents mentioned above. The objective is to minimize AR and maximize the collection rate.
Information Needed for Assessment of Accounts Receivable
To perform the most basic assessment of A/R, the following three pieces of information are necessary, • • • Monthly Charges Monthly Receipts Total A/R at the end of the month.
Monthly Charges
The charges for the month are the total amount of fees charged for patient care from the first working day through the last working day of the month, whether or not they have been paid. Charges for services that fall outside
regular medical care should not be included. If you have been asked to testify as an expert witness and have just billed the defense attorney for $3,000, that is a charge and will undoubtedly produce income to you or the practice, but it should be considered outside income and for the purpose of analysis should not be included in the A/R. Monthly Receipts 5/4/2010 Page 214 of 310 Healthcare Division
The second piece of required information is the total receipts for the month: the dollars collected for the medical care that was rendered. A receipt must correlate with a charge that was entered for the current month or in a prior month. Month’s-End Accounts Receivable
The third category of information needed to analyze a practice is the total A/R at the end of the month: the total balance that is due to the practice on the last day of the month for patient care. In reality, the total A/R should be the amount of money that can actually be collected eventually. Some factors can over inflate this figure, such as failure to write off balances that are uncollectible. This could involve care for a homeless person who was not
eligible for Medicaid or simply a regulatory balance (the amount disallowed by Medicare in accepting an assignment). Another way A/R can be inflated is by keeping accounts on A/R sent to a collection agency. By turning them over to a collection agency, the practice has classified these accounts as “bad debt”. For the convenience of posting collection agency payments, many practices fail to write off these balances or subtract them from the total A/R. To perform a true analysis, it is essential that the A/R figure reflect the total money owed the practice, which the practice plans to collect.
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If one of these three pieces of information cannot be obtained without a lot of effort, the practice faces a significant challenge because this information is basic and, if missing, indicates a lack of receivables management.
Accounts Receivable Assessment
Once a practice has obtained the total monthly charges and receipts and the total A/R at the end of the month, it can begin assessing the state of it’s A/R. There are three methods of assessing an A/R: days outstanding, A/R ratios, and aged A/R.
Days Outstanding
Days outstanding, or the average number of days it takes for a typical charge to be paid, are the method of accountability most commonly used by hospitals, and the same principles are applicable to a physician practice. There are many ways to figure days outstanding. The simplest method is the following,
1. Take the accounts receivable of the practice on the first day of the month. 2. Add to it the A/R of the practice on the last day of the month and divide by two. This gives you an average of the A/R for the month. 3. Divide this figure by the month’s receipts and then multiply it by the 5/4/2010 Page 216 of 310 Healthcare Division
number of days in the month.
The resulting figure gives you the average number of days a receivable is outstanding, or the days outstanding, for that month. For example, the equation below shows a practice whose A/R on January 1st was $95,000. On January 31st A/R was $105,00, and the receipts for the month of January were $28,000. Then A/R outstanding days is calculated as below, 95,000+105,000 = 200,000/2 = 100,000/28,000 = 3.57 X 31 = 110.7 The average account is 111 days outstanding.
The optimal range of days outstanding is 45 to 60 days. Normally this can be achieved only in a setting where accepting the payment at the time of service is commonplace. For a hospital-based practice such as radiology or anesthesia practice, 60 to 90 days outstanding is not a sterling example of receivable management but is considered acceptable. The real danger zone, whether the practice is hospital-based or not, occurs in practices in which the numbers exceed 120 days unless there is a reasonable explanation, such as a high percentage of Medicaid accounts. As a rule of thumb, any practice with 150 days or more outstanding faces a significant challenge. Accounts Receivables Ratio
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Another method for evaluating a practice involves the use of A/R ratios. These ratios indicate how total A/R relates to a practice’s payments and charges. Accounts Receivable to Receipts Ratio
To find out how quickly your average account is being paid, simply do the following: Take the total A/R on the last day of the month and divide it by the total payments received during that month. ranging from 2.5 to 4. This should produce a number
If the number is 5 or more, you are looking at 150
days (5 X 30 days) from the time when a charge is entered on the books until the time when it is collected.
For example, if a practice has an A/R of $100,000 on January 31st and total receipts for the month are $30,000, the ratio of A/R to payment is 3.3, meaning that it takes an average of 3.3 months, or approximately 100 days, for a charge to be paid ( see the equation below). $100,000 / $30,000 = 3.3 3.3 X 30 days = 100 days on average for an account to be paid. Accounts Receivable to Charges Ratio
It is possible to monitor a practice by keeping track of how the A/R relates to the practice’s charges. Simply divide the A/R at the end of a given month by the charges entered during that month.
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For example, a practice with an A/R of $100,00 on January 31st and $25,000 worth of charges that month has an A/R to charges ratio of 4: $100,000 / $25,000 = 4
This number should be fairly consistent from month to month if there is good A/R management. It also should be somewhat similar to the A/R to receipts ratio. If the numbers vary dramatically, this may indicate that the practice is influenced by seasonal changes, as in the case of an orthopedic surgeon practicing near a ski resort. In the winter the surgeon’s A/R to charges ratio may by lower than it is in the summer, when there aren’t as many broken bones. Of course the A/R to receipts ratio also would be affected. Again, any number above 5 justifies a serious look at the practice’s economic health.
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Duties and Responsibilities
A Charge Entry person The following are the duties and responsibilities of a charge entry person: He/ She should
a) Be aware of all billing rules for his/ her specialty and updates himself/ herself on the latest. b) Ensure that the daily targets of production required of him/ her are met without with he/ she should not leave for the day unless there is nothing left to enter. c) Ensure 100% accuracy of data entered. For this purpose they should take a patient face sheet/ charge summary and completely check the data entered with the demographics/superbills. d) Ensure that proper folders are maintained and are in proper condition and easily retrievable for the charges received and entered. These folders should be properly numbered and a log of all the folders should be maintained separately. e) Forward the charge files for audit immediately after completion. He/ She should also ensure that the files are returned by audit properly and corrections are carried out immediately. f) Ensure that any pending demographics or charges on account of any information which is missing or not clear should be promptly maintained in 5/4/2010 Page 220 of 310 Healthcare Division
an excel spreadsheet and should be forwarded to the client on a daily basis. In case any of the missing or unclear information could be cleared through AR calling, such details should be placed in a folder for AR calling and notified to them properly. It should also be ensured that this is being constantly followed upon to ensure that the issue is cleared. g) Ensure that all e-mails from either the client or from within the group or from the call center should be attended to and replied on the same day. h) Ensure that the pending list is reviewed every week and any items which could be cleared at our end be promptly done. i) Ensure that any special reports required by the client or from the account manager be prepared immediately on request or a proper time frame of the earliest when it can be completed be notified immediately. j) Ensure that all charge files are received in time without any delay or with minimum acceptable delay (transit period between client and Madras). If there any such delays, this should be properly recorded and notified to the client. Also if files are not received for a particular DOS but received for subsequent date of service, then it should be questioned to the client.
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A Cash Poster The following are the duties and responsibilities of a cash poster. He/ She should a) Be aware of all billing rules for his/ her specialty and updates himself/ herself on the latest. b) Ensure that the daily targets of production required of him/ her are met without with he/ she should not leave for the day unless there is nothing left to post. c) Ensure 100% accuracy of data entered. For this purpose they should take a receipt summary/ unposted summary/ cash reconciliation and completely check the data entered with the checks and EOBs. d) Ensure that proper folders are maintained and are in proper condition and easily retrievable for the cash received and posted. These folders should be properly numbered and a log of all the folders should be maintained separately. e) Forward the cash files for audit immediately after completion. He/ She should also ensure that the files are returned by audit properly and corrections are carried out immediately. f) Ensure that the unposted list is reviewed immediately after completion of posting the cash files and the following are identified: Patient Not Found, Not-Our-DOS, Insurance Refunds, Patient Refunds, Others. The Patient Not Found & Not-Our-DOS cases should be properly documented in an excel 5/4/2010 Page 222 of 310 Healthcare Division
spreadsheet, copies of checks and EOBs taken and forwarded on a periodically basis to the client office. The refund requests should be initiated and approved by the manager and forwarded to the client office periodically. g) Ensure that the bank reconciliation, if your specialty/ client is required to do so, is done every month and any discrepancies notified to the client. h) Ensure that small balances if any are written off promptly and periodically. i) Keep their eyes open of any changes in EOBs and notify the AR analyst immediately. For instance, there may be changes in provider #s or changes in the pay-to address or any important information, which needs to be acted upon immediately. These are very vital information and need constant monitoring and action. j) Ensure that all cash deposit files are received in time without any delay or with minimum acceptable delay (transit period between client and Madras). If there any such delays, this should be properly recorded and notified to the client. Also if files are not received for a particular deposit but received for subsequent date of deposits, then it should be questioned to the client. k) Ensure that any special reports required by the client or from the account manager be prepared immediately on request or a proper time frame of the earliest when it can be completed be notified immediately.
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A Regular Mail Person A Regular Mail Person is one who takes care of regular mails i.e. entering the regular mails into the system and taking action on each one of them. This function can be separate or can be attached to one of the other functions. The following are the duties and responsibilities of a regular mail person. He/ She should a) Ensure that all the regular mails received are entered in the system the same day. b) Be aware of all the billing rules for his/ her specialty. c) Ensure that action on all regular mails received is taken on the same day on which it is entered. d) Keep their eyes open on any important announcements in the regular mails received. Sometimes certain changes in rules and regulations of certain carriers are received in regular mails. These should be made note of and appropriate changes in billing rules should be made. e) Be aware that any denial or information received for a single claim, if it applies to all claims for that insurance carrier, should be applied to all claims for that insurance carrier and action taken accordingly. This is called the global rule. f) Also keep watch on the rejections in electronic transmission, review such rejections and along with the AR analyst find out why such rejections occur and what can be done to prevent these rejections. 5/4/2010 Page 224 of 310 Healthcare Division
An AR Analyst An AR Analyst is an important person in the group. He is the one who guides the group by providing lot of inputs in the form of rules and other clarifications. He is the person who reviews the Accounts Receivable and keeps it in control and ensures the billing office meets its objective. The following are the duties and responsibilities of an AR analyst. He/ She should a) Be aware of all the billing rules for his/ her specialty and updates himself/herself on the latest. b) Sets realistic collection targets every month for his/ her specialty. c) Work towards that target by monitoring collections every week of that month. d) Ensure that proper rules are set such that clean claims go in the first place rather than receiving denials and acting on them. e) Coordinate with the charge and cash person to ensure that rules are followed. f) Ensure that his/ her production target of the number of accounts reviewed should be maintained at an acceptable level. g) Ensure that adequate and quality work-orders are given to the night crew for accounts that require follow up.
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h) Ensure that all accounts called during the previous day are reviewed completely and action taken immediately. If global rule is applicable, then it should be applied appropriately. i) Ensure that all denials received have been acted upon and global rules, where applicable, are taken care promptly. j) Ensure that overall AR days for the account meet industry standards is around 70 days whichever is lower. k) Periodically take reports to ensure that AR days, outstanding AR for each patient type/insurance is well within control and as per standards. l) Ensure that proper explanation by carrier/ patient type is available with supporting documentation to prove in case the AR days go above 70. m) Co-ordinate with the call center people and solve problems. n) Constantly keep track of electronic and paper claims and keep his/ her eyes open for any major rejections and ensure that all electronic rejections are taken care promptly. o) Keep his/ her eyes open for EOBs where the pay-to address is different from that of the account’s. p) Work towards ensuring that claims for majority of the carriers go electronically. q) Ensure that any special reports required by the client or from the account manager be prepared immediately on request or a proper time frame of the earliest when it can be completed be notified immediately.
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HOW TO COMPLETE THE CMS-1500
The CMS-1500 is used by physicians, durable medical equipment suppliers, and other providers to bill Medicare, Medicaid, CHAMPUS, VACHAMPUS, Group Health Plan, FECA Black Lung, or other type of insurance. In rare instances, some insurance companies may request free-standing clinics and hospitals to submit charges with the CMS-1500 form. All providers, including nephrologists and oncologists, billing with the CMS-1500 must provide specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and HCPC. The number of services rendered and the charge for these services depends on the facility's charge master.
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Sample CMS 1500 form
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APPENDIX B: ABBREVIATIONS
AMA – American Medical Association BLK Lung – Black Lung CCYY – Year, indicates entry of four digits for the century (CC) and year (YY) CHAMPUS – Civilian Health and Medical Program of the Uniformed Services CHAMPVA – Civilian Health and Medical Program of the Department of Veterans Affairs CLIA – Clinical Laboratory Improvement Amendments CMS – Centers for Medicare & Medicaid Services, formerly HCFA COB – Coordination of Benefits CPT® – Current Procedural Terminology, 4th Edition DD – Day, indicates entry of two digits for the day DME – Durable Medical Equipment EIN – Employer Identification Number EMG – Emergency EPSDT – Early & Periodic Screening, Diagnosis, and Treatment F – Female FECA – Federal Employees’ Compensation Act GTIN – Global Trade Item Number HCFA – Health Care Financing Administration, currently CMS HCPCS – HCFA Common Procedural Coding System HIBCC – Health Industry Business Communications Council HIPAA – Health Insurance Portability and Accountability Act of 1996 HMO – Health Maintenance Organization ICD-9-CM – Internal Classification of Disease - Revision 9 - Clinical Modification I.D. or ID. – Identification ID # or ID. # – Identification Number INFO – Information LMP – Last Menstrual Period M – Male MM – Month, indicates entry of two digits for the month NDC – National Drug Codes No. – Number NUCC – National Uniform Claim Committee NUCC-DS – National Uniform Claim Committee Data Set NPI – National Provider Identifier OMB – Office of Management and Budget OZ – Product number Health Care Uniform Code Council PH # – Phone Number QUAL. – Qualifier REF. – Reference SOF – Signature on File SSN – Social Security Number UPC – Universal Product Code UPIN – Unique Physician Identification Number USIN – Unique Supplier Identification Number VP – Vendor Product Number
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HOW TO COMPLETE THE UB – 92
The UB-92 is the form accepted by CMS for hospitals and free-standing clinics to use when billing Medicare Fiscal Intermediaries (FI). UB-92 forms can be submitted either electronically or on paper ("hard copy"). The UB-92 was adopted in 1992 to replace the UB-82. Providers billing with the UB-92 must supply specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and HCPC. The number of services rendered and the charge for these services depends on the facility's charge master. The following table lists instructions for completing a UB-92 form. Bill fields are also known as locator or location codes.
Locator or Location Code 1 2 3
Instruction Enter the provider's name, address, and telephone number. Leave blank. Enter the Patient Control Number, which is not required by Medicare but can be used by providers for internal patient identification. Enter the appropriate three-digit code. • • First digit—describes your facility type Second digit—describes your facility sub-type
4
Third digit—"1" (admit through discharge claim, encompassing entire services provided for that service period) or "5" (late charge only for standalone late charges omitted from initial bill) or "7" (to designate that this claim replaces a previously submitted claim) or "8" (cancel the entire prior claim). Centers submitting a claim with an "8" as the final digit should indicate why this form is being submitted (ie, duplicate claim) in the Remarks section (location 84). Enter the Federal Tax ID Number for the service provider. Enter the beginning and ending dates of service. For hard copy claims use the format mmddccyy. For electronic claims use the format ccyymmdd. Most statements span a 30- or 31-day period. If there is a break in service days, such as for an inpatient hospitalization, then contact your FI to determine how to designate this on the UB-92 form . Leave blank.
5
6
7–11
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12 13
Enter the patient's name as it appears on his or her Medicare card (last name, first name, middle initial). Enter the patient's full mailing address (including street name, city, state, and ZIP code). Enter the patient's date of birth. For hard copy claims use the format mmddccyy. For electronic claims use the format ccyymmdd. Enter the patient's sex ("M" for male or "F" for female). Leave blank. Enter the patient's admission date. Leave blank. Enter the medical record number. Enter the condition codes if applicable. Leave blank. Check with your intermediary to verify the format for admissions or other breaks in service.
14 15 16 17 18–22 23 24–30 31
32–36
If the patient is within his or her 30-month coordination period, enter "33" in one of these fields. If there is a break in service, such as an admission, enter a date in locator 36 and enter code "74" in the code section.
37 38 39–41
Leave blank. Leave blank. Enter the appropriate code and amount for certain services such as blood and blood products. Enter the appropriate Revenue Code. Revenue Codes are based on type of service provided and billed for. Insert appropriate Revenue Code. Enter the Revenue Code narrative description to match the code in locator 42. Insert appropriate description.
42
43
44
Enter Healthcare Common Procedural Coding System (HCPCS). The Healthcare Common Procedural Codes (HCPC) for certain services are set locally by the Fiscal Intermediary; check with your intermediary for specific information.
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Insert appropriate HCPC code. 45 46 Leave blank. Enter the units of service. Furthermore, most FIs may reimburse an additional $0.50 for the supplies. 47 48 49 50 51 52–57 58 59 60 61 62 63 64 65 66 67 Enter total charges. For hard copy claims enter "Revenue Code 001" to designate the total charges for that claim. Leave blank. Leave blank. Enter up to three payers: "A" "B" and "C." Enter the provider number. Leave blank. Enter up to three individuals who are responsible for insurance coverage: "A" "B" and "C." Enter the patient's relationship to the insured: "A" "B" and "C." Enter the Certificate/Social Security Number/HI Claim/Identification number for "A" "B" and "C." Enter the group name. Enter the group identification number. Leave blank. Leave blank. Leave blank. Leave blank. Enter the Primary Diagnosis Code. All ICD-9-CM codes should correspond to the medical documentation in the patient's chart. Enter the Secondary Diagnosis Code. All ICD-9-CM codes should correspond to the medical documentation in the patient's chart. Leave blank. Enter the attending physician's UPIN. Leave blank.
68–75 76–81 82 83
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84 85
Enter remarks required by your FI. Have the provider representative sign and date this locator.
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Sample UB - 92 form
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HIPAA
The purpose of this document is to assist Medical Billing personnel to understand and plan for the implementation of the HIPAA requirements. The personnel must familiarize themselves with the final HIPAA rules
What is HIPAA?
HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law was to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information, and help the healthcare industry control administrative costs.
HIPAA is divided into five titles or sections. Each title addresses a unique aspect of health insurance reform. Title I is portability and it has been fully implemented. Portability allows
individuals to carry their health insurance from one job to another so that they do not have a lapse in coverage. It also restricts health plans from requiring pre-
existing conditions on individuals who switch from one health plan to another. Title II is called Administrative Simplification and it will have the greatest impact on providers. It is designed to: + + + + Combat health care fraud and abuse; Guarantee security and privacy of health information; Establish standards for health information and transactions; and Reduce the cost of health care by standardizing the way the industry communicates information.
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The remaining titles are:
+ Title III – Tax-Related Health Provisions + Title IV – Application and Enforcement of Group Health Plan Requirements + Title V – Revenue Offsets
What is administrative simplification?
Administrative Simplification is the establishment of a set of standards for receiving, transmitting and maintaining healthcare information and ensuring the privacy and security of individual identifiable information. HIPAA establishes standards for electronic health care
transactions, national code sets, and unique identifiers for providers, health plans, employers and individuals.
The HIPAA electronic data requirements are meant to encourage the healthcare industry to move the handling and transmission of patient information from manual to electronic systems in order to improve security, lower costs, and lower the error rate.
Standardization has been very effective in many industries. Anywhere in America you can plug a US manufactured toaster and it will work because standard voltage was established for small in a
appliances. However, if you take the toaster to Poland, it will only work if you use a special converter. If you go to Sudan you will have to use still another
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converter. The electronic claims process in the United States is like the worldwide electric industry, no standardization. When administrative simplification has been implemented, providers will be able to submit an electronic claim in the same format to any healthcare plan. Transaction and Code Sets: HIPAA mandates the development and use of
standardized transactions for the electronic exchange of data. In addition, the use of standardized national codes sets to identify medical conditions, treatments, providers, individuals, and procedures are required. Implementation Guides for HIPAA Standard Transactions are defined and numbered as follows: Health care claims or coordination of benefits - Transaction Code 837 Payment & remittance advice - Transaction code 835 Health claim status - Transaction code 276/277 Plan enrollment – Transaction code 834 Plan eligibility – Transaction code 270/271
• • • • •
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+ Privacy: Provides for the protection of individually identifiable health
information that is transmitted or maintained in any form or medium. The privacy rule will affect the day-to-day business operations of all organizations information. that provide medical care and maintain personal health
+ Security Standards: Security Standards are designed to protect
health care information as it is being stored and exchanged. It
also includes provisions to verify the identity of those sending and receiving health care information electronically. The security rule has not been finalized; however, some of the security standards will be implemented as part of the privacy rule.
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The HIPAA legislation does not require providers to discontinue submitting paper claims. However, HIPAA may require changes to several aspects of paper billing, such as changes to codes and required data elements. HIPAA requires the following entities to comply:
+ Health Care Providers: Any provider of medical or other health services, who
bills or is paid for healthcare in the normal course of business. Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status of an individual.
+ Health Care Clearinghouse: Entities that process or facilitate the processing of
health information received from other entities. physician and hospital billing services. It includes groups such as
+ Health Plans: Includes individual or group plans that provide or pay the cost of
medical care and includes both the Medicare and Medicaid programs
Providers will be required to: + Guarantee patient privacy rights by:
•
Giving patients clear, written explanations of how the provider may
use and disclose their health information;
•
Ensuring patients can see and get copies of their records, and request
amendments;
•
Making a history of non-routine disclosures accessible to patients;
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•
Obtaining patient consent before sharing their information for
treatment, payment, and health care operations; 1. Obtaining patient authorization for non-routine disclosures and most non-health care purposes; and, 2. Allowing patients to request restrictions on the uses and disclosures of their information.
+
Adopt written privacy procedures, to include: 3. Who has access to protected information, 4. How it will be used within the agency, and 5. When the information may be disclosed;
+
Ensure
that
business
associates
protect
the
privacy
of
health
information; + + Train employees in the provider’s privacy procedures; and, Designate a privacy officer who is responsible for ensuring the privacy procedures are followed. + Assess impact of Transaction Code sets:
Evaluate current business processes to determine what needs to be done to ensure timely compliance. Specific attention should be addressed to: • • • • How claims are submitted How patient records are maintained, released and communicated How patient consent and authorization forms are maintained How referrals are given or received
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+
Assigned Security Responsibility:
The rule requires providers to assign security responsibility to a specific individual or organization and document that assignment. This responsibility includes the management and supervision of:
1. The use of security measures to protect data, and 2. The conduct of personnel in relation to the protection of data.
This assignment is important to provide organizational focus, indicate the importance of security and pinpoint responsibility. + Media Controls: The Billing office must develop formal, documented policies and procedures that govern the receipt and removal of hardware and software (such as diskettes, tapes, and computers). These policies are important to ensure that media
containing personal health information is protected and that those persons who are responsible for hardware/software maintenance are aware of their
responsibilities under HIPAA. implementation features:
These controls include the following mandatory
• • • • •
Controlled access to media Accountability (tracking mechanism) Data backup Data storage Disposal
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+
Physical Access Controls:
The Billing Company must document formal policies and procedures for limiting physical access, while ensuring that properly authorized personnel can work freely. These controls include the following mandatory implementation features: Disaster recovery Emergency mode operation Equipment control (in and out of facility) A facility security plan Procedures for verifying access authorizations prior to physical access Maintenance records Need-to-know procedures for personnel access Sign-in for visitors and escorts, if appropriate Testing and revision
• • • • • • • • •
+
Policy/Guidelines on Workstation Use: These documented
The organization must have a policy on workstation use.
instructions must delineate the proper functions to be performed. This is crucial so that employees understand the manner in which workstations must be used to maximize the security of health information.
•
Accreditation – Accrediting organizations may require compliance in future - HHS has the final responsibility for determining civil violations and imposing penalties
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•
Civil money penalties – – $100 for each violation of a standard Maximum of $25,000 per year - Per identical requirement or prohibition
For each offense of
•
Wrongful disclosures – – Fined not more than $50,000 Imprisoned not more than one year
•
False pretenses – – Fined not more than $100,000 Imprisoned not more than 5 years
•
Intent to sell, transfer or use – – Fined not more than $250,000 Imprisoned not more than 10 years
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Medical Billing Terminologies
COBRA: Consolidated Omnibus Budget Reconciliation Act. It is that if an employee is registered under this Act he/she will be covered by the employer in case of any accidents even after the employee retires or resigns the job. The coverage period will last up to 16 months from the date of retirement/resignation.
OBRA: Omnibus Budget Reconciliation Act. It is special laws that if an employee registers himself under this act it allows him/her to get the health insurance coverage benefits even after COBRA for a period of 11 months. This will come into place only if the patient is suffering from any disabilities.
Roster Billing: It is the process of billing multiple patients A/c's in one single claim for the same TOS (Type of Service) rendered irrespective of the DOS (Date of Service).
Capitation: It is a specified amount paid periodically to the provider for a group of specified health services, regardless of quantity rendered. This is a method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered.
Euthanasia: This is nothing but Mercy Killing which means for E.g.: If someone is in a Coma state the doctor takes the initiative of killing him rather than him being alive and suffers.
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Bench Marks: Since the term Bench marks was discussed and no body could come to a conclusion it was discussed that every individual would search the net and come to a conclusion about what it is and discuss it on Monday.
Medicare Benefits exhausted: When a person takes a treatment for more than the prescribed limit (For E.g.: Mammogram can be taken only once in a year, if taken for more than once in a year in that case Medicare would deny stating as “Mcr benefits exhausted”) Medicare would deny it.
Julian Date: Regardless of the month, it is 1-365 days in a year. It flows periodically (For E.g: After Jan 31st Feb 1st would be considered as 32 and it continuous in the same manner for the coming days). This is used for creating batch numbers irrespective of the department.
Reciprocal Billing: A reciprocal billing arrangement may exist when the patient’s regular physician submits a claim for a covered visit which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis. The requirements for reciprocal billing arrangements are as follows:
• •
The regular physician is unavailable to provide the visit service; The Medicare patient has arranged or seeks to receive the visit
services from the regular physician; • The substitute physician does not provide the visit services to a
Medicare patient over a continuous period of longer than 60 days; and
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•
The regular physician identifies the services as substitute physician
services meeting the requirements by adding modifier Q5 (services furnished by a substitute physician under a reciprocal billing
arrangement) at the end of the procedure.
Under a reciprocal billing arrangement, there is no mention of the regular doctor paying the substitute physician. There is no need for a employer/employee relationship to exist. It is more like an arrangement of "I’ll cover for you, and you cover for me," (on an occasional basis). The substitute physician in a reciprocal billing arrangement usually has a practice of his/her own and is properly enrolled as a Medicare provider.
FROI: First report of Injury/illness, the employer has to send this report to Worker's compensation.
HPSA: Healthcare provider service shortage areas. It may have shortages of primary medical care, dental or mental health providers and may be urban or rural areas, population groups or medical or other public facilities. Health Professional Shortage Area (HPSA) bonuses are a 10 percent incentive payment that is paid to physicians only when their services are covered by Medicare and are performed within the geographic boundaries of a HPSA area. The Incentive is paid only for the professional service. Global services must be billed as two components with separate charges for the professional component (billed with the HPSA modifier)
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and the technical component (billed with no HPSA modifier). Services billed globally with the HPSA modifier will be denied as unprocessable.
Billing requirement for HPSA: To enable Medicare to correctly calculate the incentive payment, report the services with the appropriate modifier for each procedure code: QB Physicians providing services in a rural HPSA QU Physicians providing services in an urban HPSA
If a QB or QU modifier is billed, indicating the service was rendered in a HPSA, the physical location where the service(s) was rendered must be entered if other than home in Item 32 on the CMS 1500 claim form.
HCFAC: Healthcare Fraud and Abuse Control Program, is under Office of Inspector General (OIG) to control fraud and abuse that happening in health care.
HIPDB: Healthcare Integrity and Protection Data Bank is to collecting data’s regarding the fraud and abuse that happening in the health care industry.
Stop loss clause: The explanation for stop loss clause is "a limitation on the amount of loss sustained by the insured without compensation in a given period."
Prosthetic devices: Prosthetic devices are appliances which replace all or part of a function of a permanently. In operative, absent or malfunctioning body part. The
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term "prosthetic devices" includes orthotic devices, rigid or semi-supportive devices that restrict or eliminate motion of a weak or diseased part of the body. Prosthetic Devices helps to overcome injury and is designed to replace, correct or support the function of body. These devices may be rented or purchased. Insurance will cover for the charges if it is covered under subscribers plan.
Placement of false teeth is known as dental prosthetic devices and placement of jawbones are known as maxillofacial prosthetic devices. Examples of prosthetic devices are Communication aids, hearing aids, artificial legs, hands, and limbs.
Factors for calculating Fee Schedule Payment Amounts
Under the formula set forth in section 1848(b) (1) of the Act, the payment amount for each service paid for under the physician fee schedule is the product of three factors: (1) A nationally uniform relative value for the service; (2) a geographic adjustment factor (GAF) for each physician fee schedule area; and (3) a nationally uniform conversion factor (CF) for the service. The CF converts the relative values into payment amounts.
For each physician fee schedule service, there are three relative values: (1) An RVU for physician work; (2) an RVU for practice expense; and (3) an RVU for malpractice expense. For each of these components of the
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fee schedule there is a geographic practice cost index (GPCI) for each fee schedule area. The GPCI’s reflect the relative costs of practice expenses, malpractice insurance, and physician work in an area compared to the national average for each component.
The general formula for calculating the Medicare fee schedule amount for a given service in a given fee schedule area can be expressed as: Payment = [((RVU work x GPCI work) + (RVU practice expense x GPCI practice expense) + (RVU malpractice x GPCI malpractice)) x CF] The CF amount changes for every calendar year.
Catastrophic Limit: The maximum amount of charges that the patient has to pay out-of -Pocket expenses during that year by setting a maximum amount will protect the patient.
Pre-determination: Obtaining estimation from the insurance carrier by the provider before the service is rendered to the patient.
Revenue Codes: This code is used in hospital billing and we have a column in UB92 for printing this revenue code. It is a three-digit code and mainly it is used in care. For ex: If a patient is treated in a intensive care unit for that care will have a revenue code and it is related with the procedure code.
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Free look: Free Look is the 30 days trail period where one tries using the Medigap policy and if he is not satisfied money will be reimbursed.
Hospice: Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is given by a public agency or private company approved by Medicare. It is for all age groups, including children, adults, and the elderly during their final stages of life. The goal of hospice is to care for you and your family not to cure your illness.’
Who is eligible for Medicare Hospice Benefits? Hospice care is covered under Medicare Part A (Hospital insurance) A person is eligible for Medicare hospice benefits when: • • They are eligible for Medicare Part A (Hospital Insurance): and The concerned person’s doctor and the hospice medical director
certify that the patient is terminally ill and probably have less than six months to live: and • The patient sign a statement choosing hospice care instead of routine
Medicare covered benefits for your terminal illness*; and • The patient receives care from a Medicare –approved hospice
program.
What is not covered? The care that you get for your terminal illness must be from a hospice. When you choose hospice care, Medicare will not pay for:
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No-Fault Insurance: This comes in Auto Insurance where the insurance makes the payment irrespective of the mistake on which side.
Referring & Ordering Physician: Referring physician is one who refers a patient for the Professional services. Ordering physician is one who refers or orders the patients for test like Radiology etc.
HCBS: Home and Community based services waivers .It is basically an agency aims at providing high quality, cost effective, consumer directed, home and community based services and support for all persons with all types of disabilities.
Enrolled & Effective date: Enrolled date is the date on which the person gets enrolled with the insurance. Effective date is the date from which the insurance is active and starts covering the insurer.
CHIP: Children's Health Insurance Program. It is a federal program jointly funded by the states and the federal governments, which provides medical insurance coverage for children's who are not covered by Medicaid funded program.
Ambulatory Care: Medical services provided on an outpatient (non-hospitalized) basis. Services may include diagnosis, treatment, surgery, and rehabilitation. In simple we can say a visit, which does not require overnight stay.
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Surrogate
UPIN:
It
is
the
dummy
UPIN
that
has
been
assigned
to
ordering/referring physician for temporary purpose.
Carve-out coverage: Carve-out refers to an arrangement where some benefits (e.g., mental health) are removed from coverage provided by an insurance plan, but is provided through a contract with a separate set of providers.
Experimental Procedures: Any health care services that are determined by the insurance plan to be either, not generally accepted by informed health care professionals in the US, as effective in treating the condition, illness or for which their use is proposed or not proven by scientific evidence to be effective in treating the condition for which it is proposed.
Open Enrollment: Specified period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date.
Balance Billing: The practice of charging full fees in excess of covered amounts, full fees in excess of covered amounts, then billing the patient for that portion of the bill that the payer does not cover.
Multi-specialty Group:
A group of doctors who represent various medical
specialties and who work together in a group practice.
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Insurance Verification:
Is a process of calling Insurance carriers regarding
member (policy holders) information (i.e., Member ID, coverage period etc.)
Telemedicine: The use of telecommunications (i.e., wire, radio, optical or electromagnetic channels transmitting voice, data and video) to facilitate medical diagnosis, patient care, and/or medical learning. Many rural area are finding uses for telemedicine in providing oncology, home health, ER, radiology and psychiatry among others. Medicaid and Medicare provide some limited reimbursement for certain services provided to patients via telecommunication.
CHAMPUS (Civilian Health & Medical Program): Champus is run by the Defence Department. It gives medical care to the active duty members of the military as well as retirees & their eligible dependents. The new name of Champus is Tricare.
Dual Eligible: Persons who are entitled to Medicare (Part A and Part B) and also eligible for Medicaid are termed as dual eligible persons.
Dual Entitlement: An individual who is entitled to Medicare for two different reasons is considered as dually entitled. Medicare entitlement based on ESRD and aged or disability is considered dual entitlement. For example: An individual may be entitled to ESRD and then become entitled based on aged or disability. Or, an individual may be entitled to Medicare based on aged or disability and then develop ESRD.
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ESRD (End Stage Renal Disease): Kidney failure that is severe enough to need life long dialysis or kidney transplantation is termed as ESRD. If a individual is entitled to Medicare through ESRD, Medicare stands as a Secondary Payer (MSP), during the 30 month co-ordination period (COB). The GHP (Group health plan) acts as the primary in the COB period and at the completion of the 30-month COB period, Medicare stands as the primary insurance for that individual.
AAPCC (Adjusted Average Per Capita Cost): An Estimate of how much Medicare will spend in a year for an average Beneficiary.
ASC (Ambulatory Surgical Center): A place other than Hospital that does outpatient surgery. At an ASC you may stay for only a few hours or for one night.
HHA: Home Health Agency-a facility or program licensed, certified or otherwise authorized according to state and federal laws to provide healthcare services in the home.
ALJ: Administrative Law Judge-a person who hears the appeals of the denied claims.
Ancillary Services: Supportive services performed along with the Professional or Technical services are termed as ancillary services.
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EPSDT: Early and Periodic screening, diagnosis and treatment program: Persons under 21 who are receiving Medical Benefits may receive health and dental screenings and follow-up treatment for certain conditions. Providers include physicians, health departments, schools and some local health clinics. These exams are available on a periodic schedule based on the age of the individual.
Peer Review Organization: An organization of practicing doctors and other health care providers who are paid by the Federal government for reviewing the care given to Medicare Patients.
Catastrophic illness: It is a very serious health problem that could be life threatening or cause life-long disability.
Gatekeeper: A primary care physician or managed care entity responsible for determining when and what services a patient can access and receive
reimbursement for. A PCP is involved in overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone that makes the decision of where a patient will receive services.
CORF (Comprehensive Outpatient Rehabilitation Facility): A facility that provides a variety of services including physicians services, physical therapy, social or psychological services and outpatient rehabilitation.
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Sub - Acute Care: Usually described as comprehensive in-patient program for those who have experienced serious illness injury or disease, but when do not require intensive hospital services, the range of services considered as sub- acute. It includes infusion therapy, respiratory care, cancer, strokes and AIDS care.
Residual Market: Residual Market comes in to picture in Workers Compensation. Private insurance companies will not provide coverage for workers where the risk chances are very high. This uncovered area is known as Residual Market, where the state and federal insurance covers this area.
NDC (Nation Drug Code):
NDC is maintained by FDA (Food and Drug
Administration). NDC was originally established as an essential part of an out-ofhospital during reimbursement program under Medicare. NDC serves as a "Universal Product Identifier" for the human drugs. The format is usually 5-4-1. 5Labeler code, 4 - Product code & last one for package code, 1 – Serial Number.
Social Security Number (SSN): It was introduced and provided by Social Security Act of 1935 to the each individual citizen in United States. This is a ninedigit number (For example: 123 45 6789), First 3 Digit refers to Area Number. Second 2 Digit refers to Group Number (01 to 99). The Last 4 Digit refers to Serial Number (0001 to 9999).
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Federal Insurance Compensation Act (FICA): It is a federal policy that provides financial benefits to people when they retired (age sixty-two and older) and/ or if they become disabled. Financial benefits may also be payable to a
worker's family when a worker dies or retires.
Supplemental Security Income (SSI): is a program is administered by the Social Security Administration (SSA). A person who is disabled, blind or a least age sixty-five may receive SSI if he or she meets certain financial eligibility requirements.
PICA: Its is the payer position flag ("p"-primary, "s-secondary", or "t-tertiary") in the first box marked "PICA" on the top left corner of the HCFA 1500 claim forms. This information will be used by proclaim to organize the payer date correctly in the transaction. If the payer position flag is left blank, then the claim will be sent marked as primary.
Qualified Medicare Beneficiary: Designed to help low-income elderly or disabled people on Medicare pay their medical expenses. The Qualified Medicare Beneficiary (QMB) program, administered by the South Dakota Department of Social Services, helps how-income elderly or disabled people on Medicare pay their Medicare premiums, coinsurance and deductibles. The Special Low-income Medicare Beneficiary (SLMB) and Qualifying Individual programs help low-income elderly or disabled people pay their Medicare Part C medical insurance.
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Open Access Plan: • Specialist care without a referral: Open Access plans give you the
freedom to visit a specialist without a referral. You're encouraged to choose a primary care physician (PCP) to coordinate your care and treatment, but you're not required to do so. Your coverage level is highest and there are no claim forms to submit when you visit innetwork providers. Cigna offers three types of Open Access plans, each offering a different level of choice and coverage: • HMO Open Access/Network Open Access: This is a network-only plan-
you can visit any in-network specialist without a referral. There is no out-of-network coverage, except in an emergency or urgent care situation. You may choose a PCP to coordinate your care and treatment, but you're not required to do so. • Point-of-Service Open Access: You can visit any in-network or out-of-
network provider without a referral. Your costs are lower when you choose in-network providers. You may choose a PCP to coordinate your care and treatment, but you're not required to do so. • Open Access Plus: You can visit any in-network or out-of-network
health care provider without a referral, though your coverage is higher when you see in-network providers. We encourage you to use a PCP as a personal health advocate to coordinate your care. With Open Access Plus, you have access to a broad nationwide network of providers.
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Duplicate Coverage Inquiry (DCI): A request to an insurance company or group medical plan by another insurance company or medical plan to find out whether other coverage exists.
Per Diem: Payment to a provider (normally an acute care facility) at an established or negotiated rate per day rather than reimbursement of all hospital charges as billed.
Open Enrollment:
Specified periods of time in which employees may change
insurance plans and medical groups offered by their employer and have the new insurance effective at a later date.
Over the Counter Drug (OTC): A drug product that does not require a prescription under federal or state law.
Medigap: Privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, co-insurance and balance bills, as well as payment for services not covered by Medicare.
Physician
Extenders:
Also
called
mid-level
service
providers.
Physician
extenders include licensed nurse practitioners and/or licensed physician assistants. They coordinate patient care under a doctor’s supervision.
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Global Surgery: A Standard package of pre-operative, intra-operative and postoperative services that is included in the payment for a surgical procedure.
Outlier Payments: Outlier payments are made to hospital to help
offset some
of the financial losses associated with treating extremely high costs Medicare cases.
Shadow Pricing: With in a given employer group, pricing of premiums by HMO based upon the cost of indemnity insurance coverage, rather than strict adherence to community rating or experience rating criteria.
Orphan Drugs: Orphan drugs are those that are so designated under subsection 526 of Federal Food Drug and Cosmetic Act by granting orphan drug status. The FDA grants a manufacturer marketing protection for a particular drug for a particular condition. No other manufacturer may market a generic version of the drug for that indication.
UPIN (Unique Physician Identification Number): UPIN is issued to providers by CMS. Providers who have UPIN only can bill Medicare. The format is 6 digit (3 alpha & 3 numeric).
PIN (Provider Identification Number): PIN is used by all insurance for identifying the provider. The format differs by insurance.
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Preventive Care: An approach to healthcare which emphasis preventive measures and health screenings such as routine physicals, immunizations, diagnostic lab and x-ray tests, mammograms etc., The purpose of offering
coverage for preventive care is to diagnose a problem early, when it is less costly to treat.
Birthday Rule:
The birthday rule related to the coordination of benefits and
determination of the primary payer when a child is covered by both parents health insurance plans. This applies to non-divorced parents. The insurer of the parent whose birthday month falls first in the year is the primary payers.
Chronic Condition: Impaired health status or medical condition that recurs or persists over a long period of time as opposed to an acute or emerged condition.
Participating (par) facility:
A facility that has completed the credentialing
process and signed a contract with the health plan to deliver medical services to members. The facility may be skilled nursing facility, hospital, pharmacy, and nursing home.
Partial Hospitalization: This is a short-term intensive treatment program where individual's experiencing an acute episode of psychiatric illness can receive medically supervised outpatient treatment. It serves an alternative to inpatient care and allows patients who are not a danger to themselves or others to maintain their everyday life without disruption after associated with a hospital stay. It
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reduces the length of psychiatric hospitalization and serves as a step down from an inpatient unit. It is called partial hospitalization because the patient attends
these 5-6 days a week and 6 hours per day, depending on patient’s condition.
Electronic Media Claims: Electronic claim submission is the state-of-the-art method for sending and receiving files, documents, and data. Suppliers who utilize electronic submission of claims to Medicare experience fewer delays than traditional paper billing, plus they save money. If you are not an electronic biller, consider making the switch. Benefits of Electronic Media Claims • Electronic claims allow for faster payment because they can be paid
after 13 days while paper claims cannot be paid for at least 27 days. • Suppliers can trace their claims as they go through the system,
allowing for increased tracking capabilities. This is accomplished through several methods. On-line receipt verification allows for verification after claims transmissions verifying that the transmission was successful. Electronic error reports and receipt listings allow suppliers to download a summary of submitted claims within two days of transmission. This provides the claim control number of claims that were accepted into the system and error explanations of claims that were rejected. • Rejected claims can then be corrected and re-transmitted with almost
no impact on the payment floor. Claim status inquiry allows the supplier to log onto the system and electronically check the status of claims rather then placing a call to a customer service representative.
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•
Lower administrative and postage and handling costs are incurred.
Electronic billing saves valuable production time. Personnel can be used more effectively for other tasks such as customer service or marketing. By using Electronic Remittance Notices (ERNs) and Electronic Funds Transfer (EFT), suppliers can eliminate the tedious process of manually posting to their accounting programs. ERNs can be used to automatically download payment information and then automatically post that
information to accounts receivable. To become an electronic biller, providers must submit an Electronic Data Interchange (EDI) Questionnaire. All suppliers will need to complete a testing process to get started in electronic billing. When this two-phase process is completed, a supplier is assigned a permanent submitter identification number. A supplier needs to only test their software with one DMERC (however they still need to test communications with each DMERC) and the submitter ID assigned to them will be accepted by all DMERCs.
Magnetic resonance imaging (MRI): It is a method of creating images of the inside of opaque organs in living organisms as well as detecting the amount of bound water in geological structures. It is primarily used to visualize pathological or other physiological alterations of living tissues as well as to estimate the permeability of rock to hydrocarbons. It is now a commonly used form of medical imaging.
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Pediatrics: It is the branch of medicine that deals with the medical care of infants and children. Most pediatricians are members of a national body, such as the Canadian Pediatric Society, the British Association of Pediatric Surgeons or the American Academy of Pediatrics.
One of the major challenges facing pediatricians is that the range of body sizes (and weights) that they face in pediatrics is much greater than in adult medicine. For example, a preterm neonate can be less than 2kg in weight while an obese adolescent may be larger than the typical adult. Childhood is the period of greatest growth, development and maturation of the various organ systems in the body.
Another major difference between pediatrics and adult medicine is that children are minors and, in most jurisdictions, cannot make decisions for themselves. The issue of guardianship, legal responsibility and informed consent must always be considered in every pediatric procedure. In a sense, pediatricians often have to treat the parents (and sometimes, the family), not just the child
PACE (Program of All-inclusive Care for Elderly): provides and coordinates all needed preventive, primary, acute and long term care services so that older individuals can continue living in the community. • How do people qualify for PACE?
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In order to be eligible for PACE a person must be aged 55 or older, certified by the state to need nursing home care and live in an area served by a PACE program. • Are prescription drugs covered? Yes. All prescription and non-prescription drugs deemed necessary by the program. • Are people who do not qualify for Medicaid eligible for PACE enrollment? Yes. If a person meets the income and assets limits to qualify for Medicaid, the program pays for a portion of the monthly PACE premium. Medicare pays for the rest. If a person does not qualify for Medicaid, he for the portion of the monthly premium Medicaid help determine a person's Medicaid PACE interdisciplinary care team are paid for by the PACE
or she is responsible
would pay. PACE staff can eligibility.
• What happens if a person wants to leave PACE? A PACE participant is free to cancel the enroll from PACE and resume their benefits in the traditional Medicare and Medicaid programs at any time.
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Table of Contents
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Understanding Healthcare in US
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Health Care in U.S.
Medical care in the United States is generally very high quality. The government closely monitors medically oriented businesses and institutions. Hospitals, clinics, medical schools, and pharmaceutical companies must comply with government standards. Doctors, nurses and other medical personnel must be licensed, and becoming a medical specialist frequently entails fifteen years or more of rigorous schooling and training. The high level of technology available in the U.S. contributes to quality care, and the average hospital contains millions of dollars worth of state-of-the-art equipment. Medical and health care is big business. Hospitals and medical schools also spend substantial amounts on research, knowing that new techniques and discoveries will bring them prestige, patients, and money, while benefiting many people. The result for consumers is ever improving quality and effectiveness of medical care, but at the same time expensive care. When seeking any kind of medical assistance in the United States, there are few free services, and most care is expensive. Unlike other countries, there is little government sponsored health care here, except for those over 65 years of age (Medicare), or for the poor (Medicaid). The insurance industry is a major influence in the business of staying well or regaining one's good health. Obtaining some type of health insurance coverage to protect one self and their family is very smart, but expect it to be a significant monthly expense.
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Medical Emergency
In an emergency, the first thing to remember is "911". This is the telephone number to call from anywhere in the United States for immediate, skilled medical attention. While it is wise to have other important numbers regarding medical assistance (individual’s personal doctor, poison control center, etc.) near telephone, in a genuine emergency it is imperative to dial 911 first. In such situations, time is the most important factor in preventing damage or even loss of life. The operator handling your "911" call will immediately dispense the necessary help, both in terms of sending an ambulance and in routing individual’s call to a counselor who will guide through the situation until the ambulance arrives. Emergency medicine in the U.S. is very high quality. Ambulance attendants, or paramedics, are highly trained in dealing with trauma and making split-second decisions that save lives. And many hospitals are equipped with trauma centers whose single purpose is handling emergency situations, including emergency surgery. In an emergency, individual will begin to receive treatment immediately and will be taken to the facility that can best handle the situation, whether it is a trauma center, a burn treatment center, a cardiac treatment center (heart attacks), a children's hospital or a general hospital. If an individual is conscious, or if there is a family member or a friend with the individual, they will be asked for the name of patient’s doctor, who will be summoned to the hospital to which patient is taken.
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It is important to keep in mind that while emergency care in the U.S. is excellent, it is also expensive. There will be a fee for the ambulance, the emergency room, any medications administered, the services of doctors involved and any tests or special procedures involved. It is important never to hesitate when there is a genuine emergency but these services are not intended for situations where a call to your doctor or a visit to a walk-in clinic would be sufficient. An additional note about "911" This number is also used in police emergencies, and therefore is not limited to medical situations. Any time an individual is in serious danger, witness an accident or a crime in progress, this number is called.
Why Health Insurance is needed?
The United States does not have socialized medical care. If a person does not have health insurance coverage, he / she have to pay for health care out of their own finances at the time of service. This can run into many thousands of dollars for serious illnesses One buy’s health insurance for the same reason one buy’s other kinds of insurance, to protect one self financially. With health insurance, an individual and their family are protected in case of any medical care that could be very expensive. One cannot predict what his medical bills would be. In a good year, costs may be low but if he becomes ill, medical bills could be very high. If he has insurance, many of medical costs are covered by a third-party payer, not by the individual. A
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third-party payer can be an insurance company or, in some cases, it can be the employer. Many people in the United States are enrolled in some sort of managed care plan. This is an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), point-of-service (POS) plans and fee-for-service plans. Individuals enrolled in health care plans pay a monthly or quarterly fee as insurance for the time when they will need medical attention. At the time when a service is provided, the health insurance organization pays part or the entire fee, minimizing the amount an individual have to pay at the time of service. Choosing the right insurance plan that best meets financial circumstances will depend on information like, whether an individual is married or single, have children or no children. Definitions of the health insurance terms used are included in the section called Understanding Health Insurance Terms.
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What are the various types of Health Insurance Coverage?
The two main ways that people obtain health coverage are by paying into a group or buying individual insurance.
Group Health Plans Individual Insurance Plans
Group Insurance Plans
Most Americans get health insurance through their jobs or are covered because a family member has insurance at work. This is called group insurance. Group insurance is generally the least expensive kind. In many cases, the employer pays part or all of the cost. Some employers offer only one health insurance plan. Some offer a choice of plans a fee-for-service plan, a Health Maintenance Organization (HMO), or a Preferred Provider Organization (PPO), for example. Employers with 25 or more workers are required by Federal law to offer employees the chance to enroll in an HMO. What happens if an individual or his family member leaves the job? He will lose employersupported group coverage. It may be possible to keep the same policy, but he will have to pay for it himself. This will certainly cost him more than group coverage for the same, or less, protection. A Federal law makes it possible for most people to continue their group health coverage for a period of time called COBRA (for the Consolidated Omnibus Budget Reconciliation Act of 1985), the law requires that if an individual work’s for a business of 20 or more employees and leave the job or are laid off, he can continue to get health
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coverage for at least 18 months. He will be charged a higher premium than when he was working. He / she also will be eligible to get insurance under COBRA if their spouse was covered but now he /she is widowed or divorced. If an individual was covered under his parents group plan while he was in school, he can also continue in the plan for up to 18 months under COBRA until the individual find a job that offers individual health insurance. Not all employers offer health insurance. Individual might find this to be the case with his job, especially if he work’s for a small business or work part-time. If the employer does not offer health insurance, he might be able to get group insurance through membership in a labor union, professional association, club, or other organization.
Individual Insurance Plans
If the employer does not offer group insurance, or if the insurance offered is very limited, one can buy an individual policy. One can get fee-for-service, HMO, or PPO protection. But an individual should compare the options and shop carefully because coverage and costs vary from company to company. Individual plans may not offer benefits as broad as those in group plans
What Types of Insurance Plans Are There?
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Managed Care: An Explanation
You will hear the term "managed care" quite a lot in the United States. It is a way for insurers to help control costs. Managed care influences how much health care an individual use. Almost all plans have some sort of managed care program to help control costs. For example, if an individual need to go to the hospital, one form of managed care requires that he receive approval from his insurance company before he is admitted to make sure that the hospitalization is needed. If he goes to the hospital without this approval, he may not be covered for the hospital bill.
Fee-for-Service Plans
This is the traditional kind of health care policy. Insurance companies pay fees for the services provided to the insured people covered by the policy. This type of health insurance offers the most choices of doctors and hospitals. An individual can choose any doctor he wishes and change doctors any time. He can go to any hospital in any part of the country. With fee-for-service, the insurer only pays for part of doctor and hospital bills. Individual’s pay a monthly fee, called a premium. A certain amount of money each year, known as the deductible, is paid for by the individual before the insurance payments begin. In a typical plan, the deductible might be $250 for each person in a family, with a family deductible of $500 when at least two people in the family have reached the individual deductible. The deductible requirement applies each year of the policy. Also, not all health
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expenses have count toward the deductible. Only those covered by the policy do. Individuals need to check the insurance policy to find out which ones are covered. After individual has paid deductible amount for the year, he would share the bill with the insurance company. For example, individual might pay 20 percent while the insurer pays 80 percent. Individual’s portion is called "coinsurance". To receive payment for fee-for-service claims, individual may have to fill out forms and send them to insurer. Sometimes doctor's office will do this for Insured. Individual also need to keep receipts for drugs and other medical costs and is responsible for keeping track of his own medical expenses. There are limits as to how much an insurance company will pay for a claim if both individual and his spouse file for it under two different group insurance plans. A coordination of benefit clause usually limits benefits under two plans to no more than 100 percent of the claim. Most fee-for-service plans have a "cap," the most individual will have to pay for medical bills in any one year. He reaches the cap when out-of-pocket expenses (for deductible and coinsurance) total a certain amount. It may be as low as $1,000 or as high as $5,000. The insurance company then pays the full amount in excess of the cap for the items listed in policy. The cap does not include what individual pay for monthly premium. Some services are limited or not covered at all. Insured need to check on preventive health care coverage such as immunizations and well-child care.
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There are two kinds of fee-for-service coverage basic and major medical. Basic protection pays toward the costs of a hospital room and care while patient is in the hospital. It covers some hospital services and supplies, such as x-rays and prescribed medicine. Basic coverage also pays toward the cost of surgery, whether it is performed in or out of the hospital, and for some doctor visits. Major medical insurance takes over where insured basic coverage leaves off. It covers the cost of long, high-cost illnesses or injuries. Some policies combine basic and major medical coverage into one plan. This is sometimes called a "Comprehensive Plan." Insured need to check whether his policy covers both kinds of protection.
Health Maintenance Organizations (HMOs)
Health maintenance organizations are prepaid health plans. As an HMO member, insured pay a monthly premium. In exchange, the HMO
provides comprehensive care for the insured & his family, including doctors' visits, hospital stays, emergency care, surgery, laboratory
(lab) tests, x-rays, and therapy. The HMO arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, patient choices of doctors and hospitals are limited to those that have agreements with the HMO to provide care. However, exceptions are made in emergencies or when medically necessary.
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There may be a small co-payment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Individual total medical costs will likely be lower and more predictable in an HMO than with fee-for-service insurance. Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure patient get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of services covered varies in HMOs, so it is important to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis. Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor's office or hospital. However, in an HMO individual may have to wait longer for an appointment than he would with a fee-for-service plan. In some HMOs, doctors are salaried and they all have offices in an HMO building at one or more locations in individual’s community as part of a prepaid group practice. In others, independent groups of doctors contract with the HMO to take care of patients. These are called individual practice associations (IPAs) and they are made up of private physicians in private offices who agree to care for HMO members. Individual select a doctor from a list of participating physicians that make up the IPA network. If an individual is thinking of switching into an IPA-type of HMO, he needs to check whether doctor participates in the plan.
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In almost all HMOs, individuals are either assigned or choose one doctor to serve as patient’s primary care doctor. This doctor monitors health and provides most of patient’s medical care, referring to specialists and other health care professionals as needed. Patient usually cannot see a specialist without a referral from primary care doctor who is expected to manage the care received by the patient. This is one way that HMOs can limit patient’s choice. In HMO’s there is another part called capitation which is like an agreement between the insurance and the provider. In brief let us see what it is.
Capitation
Many HMO plans and some PPO plans are considering capitated. When a plan is capitated the doctor and treatment center receives a monthly payment from insurance company based on the number of enrollees. The monthly payment may be varying due to increase or decrease and the treatment centers are paid more than the individual doctors. When a doctor or treatment center treats a capitated patient, we go through the charge entry process, but none of the claims are mailed. This is because under a capitated plan, since the doctors and treatment centers are paid monthly regardless if they treat a patient. When they do treat a patient. They can not bill the insurance company for the services rendered. If a claim is accidentally issued to the insurance company, they automatically deny the claim as a provider with a capitated plan, and you hope that none of the enrollees ever became patients
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Point-of-Service Plans (POS)
Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If patient refer themselves to a provider outside the network and the service is covered by the plan then patient will have to pay coinsurance.
Preferred Provider Organizations (PPOs)
The preferred provider organization is a combination of traditional fee-for-service and an HMO. Like an HMO, there are a limited number of doctors and hospitals to choose from. When patient use those providers (sometimes called "preferred" providers, other times called "network" providers), most of his medical bills are covered. When patient goes to doctors in the PPO, he presents a card and do not have to fill out forms. Usually there is a small co-payment for each visit. For some services, patient may have to pay a deductible and coinsurance. As with an HMO, a PPO requires that patient choose a primary care doctor to monitor his health care. Most PPOs cover preventive care. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.
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In a PPO, patient can use doctors who are not part of the plan and still receive some coverage. At these times, patient will pay a larger portion of the bill himself (and also fill out the claims forms). Some people like this option because even if their doctor is not a part of the network, it means they do not have to change doctors to join a PPO.
Features of different Insurance Plans
Whether insured is opting for traditional indemnity fee-for-service plans (FFS), health maintenance organizations (HMOs), point of service plans (POS), and preferred provider organizations (PPO). Each plan has its own features to consider before making a choice.
FFS, Also Called Traditional Indemnity
FFS coverage offers flexibility in exchange for higher out-of-pocket expenses, more paperwork, and higher premiums. FFS advantages: Individual may choose your own doctors and hospitals. Individual may visit any specialist without getting permission from a primary care physician. FFS disadvantages: There's typically a deductible (anywhere from $500 to $1,500) before the insurance company starts paying claims, and then doctors are reimbursed about 80 percent of the bill while patient pick up the remaining 20 percent.
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FFS plans pay only for "reasonable and customary" medical expenses. If patient’s doctor charges more than the average for the area, patient will have to pay the difference.
HMO
HMOs are the least expensive, but also the least flexible of all the health insurance plans. They are geared more toward members of a group seeking health insurance.
HMO advantages: They offer their customers low co-payments, minimal paperwork, and coverage for many preventive-care and health-improvement programs. HMO disadvantages: Individual must choose a primary care physician, also known as a PCP. HMOs require that individual see only network doctors or they won't pay. Individual must get a referral from your PCP to see a specialist.
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POS
POS plans are more flexible than HMOs, but they also require patient to select a PCP.
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POS advantages: Depending on patient insurance company's rules, he may choose to visit a doctor outside the network and still receive coverage — but the amount covered will be substantially less than if patient went to a physician within the network.
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These plans tend to offer more preventive care and well-being services, such as workshops on smoking cessation and discounts to health clubs.
POS disadvantages: Individual must choose a PCP. While individual may choose to see a physician outside the network, if he did not receive permission from PCP, individual is likely to wind up submitting the bills himself and receiving only a nominal reimbursement — if any.
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PPO
PPOs give policyholders a financial incentive — reasonable co-payments (also called co-pays) — to stay within the group's network of practitioners. PPO advantages: The standard co-payment is $10 for a routine office visit during regular hours.
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Individual may go to any specialist without permission, as long as the doctor participates in the network.
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PPO disadvantages: If individual see an out-of-network doctor, he may have to pay the entire bill himself, and then submit it for reimbursement.
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Individual may have to pay a deductible if he chooses to go outside the network, or pay the difference between what network doctors vs. out-ofnetwork doctor’s charge.
Types of Insurance
MEDICARE
Medicare is the federal (national) health insurance program for Americans age 65 and older and for certain disabled Americans. If individual is eligible for Social Security or Railroad Retirement benefits and are age 65, he and his spouse automatically qualify for Medicare. Medicare has two parts hospital insurance, known as Part A, and supplementary medical insurance, known as Part B, which provides payments for doctors and related services and supplies ordered by the doctor. If individual is eligible for Medicare, Part A is free, but insured must pay a premium for Part B. Medicare will pay for many of insured health care expenses, but not all of them. In particular, Medicare does not cover most nursing home care, long-term care services in the home, or prescription drugs. There are also special rules on when Medicare pays patient’s bills that apply if patient have employer group health
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insurance coverage through his own job or the employment of a spouse. Medicare usually operates on a fee-for-service basis. Some people who are covered by Medicare buy private insurance, called "Medigap" policies, to pay the medical bills that Medicare doesn't cover. Some Medigap policies cover Medicare's deductibles; most pay the coinsurance amount. Some also pay for health services not covered by Medicare. There are 10 standard plans from which individual can choose (some States may have fewer than 10.) If an individual buy a Medigap policy, he should make sure that he does not purchase more than one.
MEDICARE PART A
Medicare Part A is also known as Hospital Insurance (HI). The intermediary determines payment to Part A facilities for covered items and services provided by the facility. The following services are covered in Part A, • • • • Inpatient Hospital Care. Inpatient Care in a Skilled Nursing Facility (SNF). Home Health Care. Hospice Care.
The services and coverage limitations for each of Medicare Part A Care: Part A services and coverage for Inpatient Hospital Care: Covered Services for Inpatient Hospital Care:
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• • • • • • • • •
Semi private room All meals, including special diets Regular Nursing services Costs of special care units Blood transfusions Lab tests Medical supplies such as splints and casts Use of appliances such as wheelchairs X-rays and other radiology services, including radiation therapy, billed by
the Hospital. • • Operating and recovery room costs Rehabilitation services, such as physical therapy, occupational therapy and
speech pathology therapy. Non-covered Services for Inpatient Hospital Care: • • • Private duty Nurses Personal convenience items Any extra charges for a private room unless medically necessary.
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Benefit Period for Inpatient Hospital Care: Benefit period begins when the first day (not on the previous benefit period) on which an eligible patient is furnished inpatient hospital or extended care services by a qualified provider. The benefit period with the close of a period of 60
consecutive days (after the date of discharge from the facility) during which the patient was neither an inpatient hospital nor a Skilled Nursing Facility (SNF). Eligible Benefits for Inpatient Hospital Care: A patient is eligible for 90 days of hospital care in a benefit period, as long as medical necessity for the admission and the number of days has been proven. The patient also has a lifetime reserve of 60 days, which could be used once the 90 days have been exhausted. Once the reserve days have been used, they are not replenished. Part A services and coverage for Inpatient Care in a Skilled Nursing Facility (SNF): Covered Medicare Part A SNF services include the following: • • • • • Semi-private room All meals, including special diets Regular Nursing services Physical/occupational therapy and speech-language pathology services Drugs furnished during stay
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Blood transfusions Medical supplies such as splints and casts Use of appliances such as wheelchairs
Non-Covered Medicare Part A SNF services include the following: • • • • Private duty Nurses Personal convenience items Any extra charges for a private room unless medically necessary Any services not provided by the facility and included in its bill.
Duration of Care: Benefit period – A benefit period begins with the first day (not in a previous benefit period) on which an eligible patient is furnished inpatient hospital or extended care services by a qualified provider. The benefit period ends with the close of a period of 60 consecutive days (after the date of discharge from the facility) during which the patient was neither an inpatient of a hospital nor an inpatient of a Skilled Nursing Facility (SNF). Eligible benefits – A patient is eligible for 100 days of care in a SNF during a benefit period, as long as medical necessity for the admission and the number of days has been proven. Part A services and coverage for Inpatient Care in a Home Health Care:
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Covered Medicare Part A home health care services include the following: • • • • • • • Part-time or intermittent skilled nursing care and home health aid services Physical therapy Speech-language pathology services Occupational therapy Medical social services Medical supplies Durable medical equipment (DME)
Non-covered Medicare Part A Home Health Care services include the following: • • • • • 24-hour-a-day nursing care at home Drugs and biologicals Meals delivered to the patient’s home Homemaker services Blood transfusion.
Duration of Care: Eligibility requirements – The eligibility requirements for home health services are:
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The patient must be homebound The home health services must be provided under a plan of care established and approved by a physician
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The patient must be under the care of a physician The patient needs skilled nursing care on an intermittent basis or has a continued need for physical/occupational therapy or speech-language pathology services
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The Home Health Agency (HHA) must be acting upon a physician certification that is part of the plan of care and the agency must meet certain qualification requirements to be certified under the Medicare program.
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Part A services and coverage for Inpatient Care in a Hospice Care: Covered Medicare Part A Hospice care services include the following: • • • • • • • • • Nursing services Doctors services Drugs, including outpatient drugs for pain relief and symptom management Physical/Occupational therapy and speech-language pathology services Home health aide and homemaker services Medical social services Medical supplies and appliances Short-term inpatient care, including respite care Counseling
Non-covered Medicare Part A Hospice Care services include the following: • Treatment other than for pain relief and symptom management of a terminal illness • Regular Medicare can usually help pay for treatment not related to the terminal illness.
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Duration of care: Eligibility requirements – Provided to patients terminally ill with a life expectancy of six months or less who elect to forego traditional medical treatment for the terminal illness and elect to receive only limited (hospice) care. Eligible Benefits – A patient may elect to receive Medicare coverage of four election periods of hospice care. The periods consist of two 90-day periods, one 30-day period and an unlimited fourth extension period.
MEDICARE PART B
Medicare Part B is also known as Supplemental Medical Insurance (SMI). Medicare part B typically thought of as insurance for physician services (in both hospital & non-hospital settings). physician services Medicare Part B coverage: • • • • • Physician Services Non-Physician Services Diagnostic Tests Durable Medical Equipment Ambulance Transportation However, Medicare Part B also covers certain non-
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PHYSICIAN SERVICES
Definition of physician services – For Medicare purposes, a physician is described as a doctor of medicine; doctor of osteopathy; doctor of dental surgery or dental medicine; a chiropractor; a doctor of podiatry or surgical chiropody; or a doctor of optometry legally authorized to practice by a state in which s/he performs this function. Scope of Physician Services – The services performed by a physician within the above definition are subject to any limitations imposed by CMS 1500, the state licensing agency or the local Medicare contractor on the scope of practice. If any limitations are placed on the scope of practice, Medicare will only cover items or services within the limitation. For example, Medicare limits reimbursement for
chiropractors for only spinal manipulation, as long as coverage requirements are met – based on the scope and limitation of the medical license. Requirements for coverage of physician services – In order for a physician service to be potentially covered under Medicare, it must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Covered Medicare Part B physician services include, but are not limited to, the following: • Diagnostic tests and procedures that are part of treatment
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• • • • •
X-rays Medical and surgical services, including anesthesia Drugs and biologicals that cannot be self-administered Physical/occupational therapy and speech-language pathology services Treatment of mental illness.
Non-covered services – Situations in which an item or service would not be covered under Medicare Part B include, but are not limited to the following: • • Program exclusions, as designated by CMS 1500 Medical devices or biologicals which have not been approved by the food and drug administration. • Items and services which are determined to be investigational in nature.
NON-PHYSICIAN SERVICES
In addition to physician services, Medicare Part B also reimburses covered items and services from various non-physician providers. These non-physician providers include the following types: • • • Certified Registered Nurse Anesthetist (CRNA) Certified Nurse Midwife (CNM) Clinical Psychologist (CP)
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• • • • •
Clinical Social Worker (CSW) Physician Assistant (PA) Independent Billing Audiologists Independent Billing Psychologists Independent Practicing independent Physical, occupational and speech therapists
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Nurse practitioner and Clinical Nurse Specialist in collaboration with a physician
Scope of Non-Physician services – The services performed by the above listed nonphysicians are subject to any limitations imposed by CMS 1500, the state licensing agency or the local Medicare contractor on the scope of practice. If any limitations are placed on the scope of practice, Medicare will only cover items or services within the limitation. For example, Medicare limits reimbursement for clinical
psychologists or clinical social workers to services involving treatment of mental illness, as long as coverage requirements are met – based on the scope and limitation of the medical license. Requirements for coverage of non-physician services – In order for a nonphysician service to be potentially covered under Medicare, it must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.
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Covered Medicare Part B non-physician services include, but are not limited to, the following: • • • • • • Diagnostic tests and procedures that are part of treatment X-rays Anesthesia Administration of drugs and biological’s that cannot be self-administered Physical/occupational therapy and speech-language pathology services Treatment of mental illness
Non-covered services – Situations in which an item or service would not be covered under Medicare Part B include, but are not limited to the following: • • Program exclusions, as designated by CMS 1500 Medical devices or biologicals which have not been approved by the Food and Drug Administrations • Items and services which are determined to be investigational in nature
Note: All service(s) which are related to a non-covered item or service is /are also not covered service(s) under the Medicare Program.
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Non-covered Medicare Part B non-physician services include, but are not limited to, the following: • • • Acupuncture Hearing aids Personal comfort items
Note: The local Medicare contractor has the ability and authority to designate an item or service as non-covered for their service area or jurisdiction. For a
complete list of all non-covered items or services for your state, you should contact your local Medicare contractor. Diagnostic Procedures Diagnostic procedures can be performed in a variety of places, such as independent laboratories, Independent Diagnostic Testing Facilities (IDTF),
outpatient x-ray and testing facilities and inpatient hospitals (interpretation only). Keep in mind Diagnostic tests, as with all other services your provide must meet the regular coverage requirements in order for Medicare to make payment. They are the item or service must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. For most diagnostic tests, Medicare contractors develop a list of
diagnoses for which payment will only be allowed. If a claim for a diagnostic test is received and the indicated diagnosis is not on the list of covered diagnosis codes, then Medicare will deny the service as not being medically reasonable and
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necessary. For a list of diagnostic tests and applicable covered diagnosis codes, please contact your local Medicare contractor. Diagnostic Tests Covered diagnostic tests include, but are not limited to the following: • • • • • • • • • • • • X-ray (diagnostic radiology) Magnetic resonance imaging (MRI) Cat scans Diagnostic ultrasound procedures Nuclear medicine Nuclear imaging procedures Organ or disease-oriented panels Drug screens Clinical pathology consultations Individual blood chemistry tests Immunology Transfusion medicine
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•
Surgical pathology
Durable Medical Equipment (DME) include, but are not limited to the following: • • • • • • • Wheelchairs Commode chairs Oxygen equipment Walkers Hospital beds Canes Nebulizers
Non-covered DME include, but are not limited to the following: • • Personal convenience items Bathroom or safety equipment
Duration of care: Claims for DME are processed by regional contractors (DMERC). You should
contact your local DMERC for further information regarding duration of care.
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Note: All DME must be prescribed by a physician. Ambulance Transportation In order for Medicare to reimburse ambulance transportation, several coverage requirements must be met. limited to the following: • The ambulance service must be medically necessary and reasonable. To These coverage requirements include, but are not
meet medical necessity, the patient’s condition must be such that use of any other method of transportation is contraindicated. In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individuals health, whether or not such other transportation is actually available, no Medicare payment may be made for the ambulance service. To meet the
medical reasonableness, the patients diagnosis must warrant ambulance services. The diagnosis requirement still needs to be met, even though the patient’s condition may contraindicate the use of other means of transportation. • The ambulance vehicle and crew must meet Medicare requirements. The average
Medicare covers ambulance transportation either by land or air. requirements for air ambulance are stricter than land transportation.
Duration of care:
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There is no limit to the number of ambulance transports, as long as medical necessity and reasonableness has been determined and proven.
MEDICARE PART C
Medicare Part C coverage includes: • • Part A Medicare Coverage Part B Medicare Coverage
In addition, Part C coverage includes: • • • • • Preventive Care Prescription Drugs Eyeglasses Dental Care Hearing Aids
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What is hospice? Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is given by a public agency or private company approved by Medicare. It is for all age groups, including children, adults, and the elderly during their final stages of life. The goal of hospice is to care for the patient and their family, and not to cure the patient illness. If a patient qualifies for hospice care, he/she gets medical and support services, including nursing care, medical social services, doctor services, counseling, & homemaker services. In many cases, the patient and their family can stay together in the comfort of their home. Depending on the patient’s condition, they may have hospice care in a hospice facility, hospital, or nursing home. Who is eligible for Medicare Hospice Benefits? Hospice care is covered under Medicare Part A (Hospital insurance). A patient is eligible for Medicare hospice benefits when: • • Patient is eligible for Medicare Part A (Hospital Insurance); Patients doctor and the hospice medical director certify that a patient is
terminally ill and probably have less than six months to live; • Patient signs a statement for choosing hospice care instead of routine
Medicare covered benefits for terminal illness;
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How does hospice work? Patient’s doctor and the hospice will work with the patient and their family to set up a plan of care that meets patient’s needs. For a hospice patient, there is a team of people that will help take care of the patient. They are: • • • • • • Patient’s family A doctor A nurse Clergy or other counselors A social worker Trained volunteers
Volunteers are trained to help with every day tasks, such as shopping and personal care services, like bathing and dressing. Speech, physical, and
occupational therapists and other persons who are trained to give care are also there when required. A Family member or other person who cares for the patient will be there every day and members of the hospice team will make regular visits. A nurse and a doctor are on-call 24 hours a day, 7 days a week to give the patient and their family the
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support and care when needed. If a patient should need care in hospital for illness, the hospice team will help arrange the stay.’ Even though a doctor is a part of the hospice team, patient can choose to use his/her regular doctor, who is not a part of the hospice to get care. The hospice will work closely with the patient’s regular doctor to give the care that a patient needs. What does Medicare covers? Medicare covers these hospice services and pays nearly all of their costs: • • • • • • • • • • Doctor services Nursing care Medical equipment (such as a wheelchairs or walkers) Medical supplies (such as bandages and catheters) Drugs for symptom control and pain relief Short-term care in the hospital including respite care Home health aide and homemaker services Physical and occupational therapy Speech therapy Social workers services
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• •
Dietary counseling Counseling to help you and your family with grief and loss
The patient, only have to pay part of the cost for outpatient drugs and inpatient respite cares. What is respite care? Respite care is care given to a hospice patient by another caregiver so that the usual caregiver can rest. As a hospice patient, you may have one person that takes care of you every day. That person might be a family member. Sometimes they need someone to take care of you for a short time while they do other things that need to be done. During a period of respite care, you will be cared for in a Medicare approved facility, such as a hospice facility, hospital or nursing home. What is not covered? The care that you get for your terminal illness must be from a hospice. When you choose hospice care, Medicare will not pay for: • Treatment to cure your terminal illness.
As a hospice patient, you can get comfort care to help you cope with your illness not cure it. Comfort care includes drugs for symptom control and pain relief, pain relief, physical care, and counseling and other hospice services. Hospice uses medicine, equipment, and supplies to make you as comfortable and pain-free as possible. Medicare will not pay for treatment to cure your illness. You should talk
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with your illness; you should talk with your doctor if you are thinking about potential treatment to cure your illness. As a hospice care and go back to your regular doctor health plan. • Care from another hospice that was not set up by your hospice.
You must get hospice care from the hospice provider you chose. You can get hospice care from another hospice provider, unless you change your hospice provider. • Care from another provider that is the same care that you must get from
your hospice. Your hospice team must give all care that you get for your terminal illness. You cannot get the same type of care from a different provider unless you change your hospice provider. What will I have to pay for hospice care? Medicare pays the hospice for your hospice care. You will have to pay: No more that $5 for each prescription drug and other similar products” The hospice can charge up to $5 for each prescription for outpatient drugs or other similar products for pain relief and symptom control. 5% of the Medicare payment amount for inpatient respite care For example, if Medicare pays $100 per day for inpatient respite care, you will pay $5 per day. You can stay in a Medicare – approved hospital or nursing home up to 5 days each
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time you get respite care. There is no limit to the number of times you can get respite care The amount you pay for respite care can change each year. Can I keep my Medicare health plan? Yes. You should use your Medicare health plan (like the Original Medicare Plan or a Medicare managed care plan) to get care for any health problems that are not related to your terminal illness. You may be able to get this care from your own doctor who is not a part of the hospice, or from the hospice doctor. When you use your Medicare health plan, you must pay the deductible and coinsurance amounts (if you have the Original Medicare Plan), or the copayment (if you have a Medicare managed care plan). • Important information about Medicare Supplemental Insurance:
If you are in the Original Medicare Plan, you may have a medicare Supplemental Insurance or “Medigap” policy. Your Medigap policy still helps to cover the costs for the care of health problems that are not related to your terminal illness. How long can I get hospice care? You can get hospice care as long as your doctor certifies that you are terminally ill and probably have less than six months to live. Even if you live longer than six months, you can get hospice care as long as your doctor recertifies that you are terminally ill. Hospice care is given in periods of care. As a hospice patient, you can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods. At
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the start of each period of care, your doctor must certify that you are terminally ill in order for you to continue getting hospice care. A period of care starts the day you begin to get hospice care. It ends when your 90 or 60-day period is up. If your doctor re-certifies that you are terminally ill, your care continues through another period of care. As a hospice patient, why would I stop getting hospice care? Sometimes a terminally ill patient’s health improves or their illness goes into remission. If that happens, your doctor may feel that you no longer need hospice care and will not re-certify you at that time. Also, as a hospice patient you always have the right to stop getting hospice care, for whatever reason. If you stop your hospice care, you will get your health care from your Medicare health plan, (like the Original Medicare Plan or a Medicare managed care plan). If you are eligible, you can go back to hospice care at any time. As a hospice patient, you always have the right to stop getting hospice care and go back to your regular doctor or health plan.
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MEDICAID
The Medicaid Program provides medical assistance for certain individuals and families with low incomes and resources. Medicaid eligibility is limited to individuals who fall into specific categories. Although the Federal government establishes general guidelines for the program, the Medicaid program
requirements are actually established by each State Medicaid eligibility is limited to individuals who fall into specified categories. The federal statute identifies over 25 different eligibility categories for which federal funds are available. These categories can be classified in to five broad coverage groups:
• • • • •
Children; Pregnant Women; Adults in Families with Dependent children; individuals with disabilities; and individuals 65 or over
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BLUE CROSS BLUE SHIELD PLANS
Blue Cross plans were founded originally to cover hospital expenses. Blue shield plans were originally established primarily to cover physician services. In most areas, Blue cross and blue shield plans are a single corporation. In other areas, they are separate organizations and in some case even compete with each other. A person becomes a member by entering into a contract with the local Blue cross and/or Blue shield plan and by paying regular dues. The person becomes a subscriber not a policyholder and retains a certificate not a policy, that tells him what to expect from the contract when medical services are required. When the BCBS plans serve as a Medicare contractor (Medicare HMO), the Blue Cross staff within the plan handle Medicare Part A as the fiscal intermediary and the Blue shield staff within the plan handle Medicare Part B as the carrier.
Types of Blue Cross and Blue Shield contracts
There are two basic types of blue cross and blue shield contracts: -
•
Service Benefit Contracts - Offered by all BCBS plans that offer physician participation agreements. The contract provides the covered services themselves, rather than reimbursing the subscriber for some or all of the expenses incurred in obtaining covered services. Through physician participation agreements, a blue cross or blue shield plan secures the performance of service benefits (i.e. covered services) on behalf of its subscribers.
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•
Indemnity Benefit – contracts cover some or all of the actual expenses of providing covered services but not more than the actual charges for a specific service. An indemnity benefit contract makes not promise to cover the full fee. A professional provider may bill the subscriber an amount in excess of the Plan’s benefit allowance. The subscriber is responsible for any difference between the plan’s allowance and the professional provider’s bill.
TRICARE (CHAMPUS)
Tricare is the Managed healthcare program for Active Duty service members and retirees and their families. Tricare formerly CHAMPUS is the Managed care program for DoD beneficiaries. Through the 3 tricare programs Standard, Extra and Prime, Military Treatment Facilities MTF and Civilian providers work as partners to help control the overall cost of healthcare. TRICARE is administered by regional Managed care Contractors to provide you with an appropriate balance of cost, access and quality. The TRICARE programs are available to family members of active duty military service members and also to military retirees and their dependents. These dependents include spouses, unmarried children under age 21, unmarried children who are full-time students under age 23 and stepchildren adopted by the sponsor. Those who are eligible must be listed in the Defense Department's worldwide, computerized database DEERS (Defense Enrollment Eligibility Reporting System). The following are not eligible for TRICARE benefits: • People age 65 or older who are eligible for Medicare (with some exceptions)
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• •
Parents and parents-in-law of active duty service members or retirees People who are eligible for health benefits under CHAMPVA (Civilian Health
and Medical Program of the Department of Veterans Affairs) The Defense Enrollment Eligibility Reporting System (DEERS) is a military database that lists everyone who is eligible for TRICARE benefits. Make sure your DEERS record is up-to-date. This will help us process your claims quickly and accurately.
RAILROAD MEDICARE
The Railroad Retirement Board’s mission is to administer retirement/survivor and unemployment/sickness insurance benefit programs for railroad workers and their families under the Railroad Retirement Act and the Railroad Unemployment Insurance Act. These programs provide income protection during old age and in the event of disability, death or temporary unemployment and sickness. The Railroad Retirement Board also administers aspects of the Medicare program and has administrative responsibilities under the Social Security Act and the Internal Revenue Code. The ID format is one or two alpha’s followed by 8 numeric. Medicare - Blue Cross and Blue Shield Plans have served as partners to the federal government in administering the Medicare program since its inception in 1966. Blue Plans helped design the original infrastructure for tracking and processing Medicare payments. Today, the Blue System collectively is the largest single processor of Medicare claims - handling more than 90 percent of claims
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from hospitals and institutions (Part A) and nearly 60 percent of claims from physicians and other health care practitioners (Part B). National Accounts – This is a program that covers the employees of a company that has offices, plans and people in several states and whose employees travel a great deal or change location frequently. The Identification number on the subscriber’s card indicates this is a National account. Claims are filed and paid by the local plan where the treatment was rendered.
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DISABILITY INSURANCE
Disability insurance replaces incomes which individual lose if he has a long-term illness or injury and cannot work. This is an important type of coverage for working-age people to consider. Disability insurance does not cover the cost of rehabilitation if an individual is injured. Some employers offer group disability insurance and this may be one of the benefits where individual work. Or the individual might be eligible for some government-sponsored programs that provide disability benefits. Many different kinds of individual policies are also available.
WORKMEN’S COMPENSATION INSURANCE
This insurance policy protects the insured party from legal liabilities against injury or death of any of his employees who is a "workman" as defined by the Workmen's Compensation Act. Workers hurts on-the-job are protected by workers’ compensation employees. With rare exceptions, Oregon has a "no fault" system, which means both workers and employers are protected from the time and expense of determining who caused an on-the-job accident. It is the workers responsibility, however, to prove that an injury or disease is job related rather than substantially related to a diagnosed pre-existing condition. insurance. Oregon law requires employers to insure their
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This insurance policy is necessary for every employer since it indemnifies him against his legal liability as an "employer" towards accidental or fatal injuries sustained by his work men during work. The actual cost of workers’ compensation insurance coverage is paid totally by employers to the insurance company the employer selects. The amount the employer pays depends primarily upon a worker’s job. A hazardous job costs more to insure than a less hazardous job. For example, a roofing company may pay $14.31 for workers’ compensation insurance for every $100 earned by each of its roofers, but just 18 cents for every $100 earned by its bookkeeper. On extra payment of premium, medical, surgical and hospitalization expenses including transportation costs are also covered. Liabilities that may arise owing to diseases mentioned in Section III (C) of Workmen's Compensation Act during the course of employment are also covered.
Some common things regarding Workers CompensationA worker's paycheck shows a deduction for "workers’ compensation." What is this for? The payroll deduction is the Department of Consumer and Business Services’ cents-per-hour assessment. Both workers and employers are assessed equal amounts for each hour the employee works. The money is collected by the Department of Revenue and is passed on to the Department of Consumer and Business Services (DCBS) -- the state agency that oversees the Oregon workers’ compensation system. The assessment goes to special funds the DCBS
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administers and is used to provide incentives to rehire injured workers and to ensure that benefits paid to injured workers and workers’ beneficiaries keep pace with the cost of living. Why do employers care about on-the-job injuries, if insurance covers those injuries? Employer’s care for several reasons: No employer wants to see anyone get sick, hurt or injured on-the-job. Employers don’t want to lose valuable, trained employees. The most valuable resource a business has is the people who work there. Injuries cause rates to increase. Individuals may have to pay more for car insurance if they are in an automobile accident. Similarly, employers may have to pay more for insurance or may even have coverage canceled, if there are too many injuries in the workplace. There are many indirect costs associated with accidents. For example, there may be lost production time and damage to machinery, which are costs not covered by insurance.
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What are workers supposed to do if they are hurt on-the-job? They should report their injury to their employers or supervisors immediately. They will help their workers get appropriate medical treatment, if necessary. The worker and employer must then file a workers’ compensation claim for benefits if the worker sees a doctor for medical treatment or missed time from work. The claim is filed by completing a Report of Occupational Injury or Disease (Form 801) available from the employer. Workers must complete page 2, then give the form to the employer who will complete page 1. The employer will send both pages to the insurance company. If the worker is in the hospital or cannot complete the form due to injury, the employer can send it to the insurer without the worker’s signature. The employer should give the worker a copy of the completed form. Workers should be sure to tell their doctors that the injury happened on the job and the name of the company that insures the employer. The doctor is required to file a report and will ask the worker to sign a portion of the form. If the employer is enrolled in a managed care organization (MCO) service area, he or she provides the worker with a list of doctors who are authorized to treat injured workers under the contract. A worker’s family doctor or authorized nurse practitioner may also be permitted to treat by the MCO. Employers will provide workers with additional information, if necessary.
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What kinds of injuries or illnesses qualify for workers’ compensation benefits? Generally, any injury that occurs while working (or illness due to work) that requires the worker to see a doctor or results in disability or death may qualify for workers’ compensation benefits. An injury could be traumatic (caused by an accident), cumulative (caused by repetitive motion) or an occupational disease (such as loss of hearing). A doctor must be able to verify that there is objective medical evidence showing that an injury or disease exists and that work exposure was the major cause. How does a worker get benefits when hurt on-the-job? If SAIF is the employer’s workers' compensation insurance company, we will begin evaluating the claim as soon as it is received. We will notify the worker and employer in writing when the claim has been accepted or denied. A claim number will be assigned to the claim. A claims adjuster may contact the worker by telephone or in writing to ask questions about the claim. Workers should have their claim number with them when they complete any forms, see the doctor or call SAIF. Having the claim number available will also help workers get their questions answered quickly.
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What does "deferred" mean? It means the claim has not been accepted or denied. No decision has been made yet. A claim is considered to be "deferred" while it is being evaluated. While a claim is deferred (and also when a claim is accepted), workers will receive wage replacement benefits, if the doctor states that the worker cannot work, and the worker is unable to work for more than three days. These benefits will not be paid if the claim is denied within 14 days of the day the injury was reported to the employer. Who pays for medical expenses if the claim is deferred? No one should pay for medical expenses while the claim is in a deferred status. If SAIF accepts the claim, we will pay for medical care related to the claim. If the claim is denied, the worker or the worker’s private health insurance carrier will be responsible for medical expenses. However, as of January 1, 2002, a claim that is denied and is on appeal will be processed by the health insurance company, provided the worker has coverage. However, if there is a balance remaining, the medical provider can bill the workers compensation carrier, who will pay up to the fee schedule for certain types of medical services prescribed to reduce pain, diagnose the condition or prevent disability. If the claim denial is ultimately upheld, the amount paid to the medical provider can be held as an overpayment and deducted from future workers’ compensation benefits with the same insurer.
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By law, if the worker is receiving medical care in Oregon, the doctor may not seek payment from the worker for the medical treatment related to the claim during the time the claim is being evaluated or if the claim is accepted. It is also important to know that during the time the claim is being evaluated (deferred), SAIF will not make payment for any medication the doctor may prescribe or for any other expenses such as transportation costs for visits to the doctor’s office. Workers should keep receipts for these expenses, as they will be paid by SAIF, in addition to related medical bills, if the worker’s claim is accepted. If SAIF sends a worker for an evaluation during this "deferred" period, we will reimburse expenses to attend the appointment(s). How do workers get reimbursed for prescriptions that they pay for? Workers may send their prescription receipts to their claims adjusters for reimbursement. Pharmacies can direct bill SAIF for most future prescriptions. Workers may contact us to verify whether a pharmacy participates in our pharmacy program. When will the worker receive a wage replacement check? If SAIF has received notification of the injury, the initial check will be mailed no later than 14 days from the date the worker informed the employer of the injury or became unable to work because of the injury, unless the claim is denied by the 14th day. Subsequent checks are mailed about every two weeks. An attending physician or authorized nurse practitioner must authorize these benefits.
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How long do wage replacement checks continue? The wage replacement benefit checks will continue until one of the following occurs: The worker returns to regular work; The worker’s doctor releases him/her to return to regular work; or The doctor approves a written offer of modified work by the employer, but the worker refuses to take it, and the wage offered is equal to or greater than the wage at injury. The worker returns to modified work and receives the equivalent of a regular wage. The claim is closed. SAIF may ask the worker to verify earnings after returning to modified work to ensure that he/she is receiving the correct amount of wage replacement. A prompt response will ensure there is no interruption in benefits. What is the amount of the wage replacement check? In most cases, the check will be for two-thirds of the worker’s weekly wage up to a maximum. For dates of injury on or after January 1, 2002, the maximum is 133% of the Oregon average weekly wage. There is usually a deduction for the three-day wait that is not paid in the first check.
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Why is there a three-day wait? The three-day wait is required by state law and acts as a form of "deductible." If the worker’s physician authorizes temporary total disability for 14 consecutive days or if the worker is hospitalized as an inpatient during the first period of disability, wage replacement benefits are paid back to the first day the worker missed work. How much is the maximum compensation? Wage replacement checks will generally be equal to two-thirds of the worker’s weekly wage, up to the maximum that is 133% of Oregon’s average weekly wage. (If your date of injury is prior to January 1, 2002, your maximum is 100% of the Oregon average weekly wage.) This maximum is calculated annually using figures from the state Employment Department. The minimum for any injured worker is $50 per week or 90 percent of the worker’s weekly wage, whichever is less. When will the claim be accepted or denied? A claim is evaluated and accepted or denied as quickly as possible. Sometimes your adjuster may need additional medical information or must request an investigation. This may cause a delay in the decision to accept or deny a claim. By law, insurers have 60 days from the time your employer knew of the injury to make this decision. (If your date of injury is prior to January 1, 2002 we have up to 90 days.)
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What are the worker's responsibilities if a claim is denied? The worker has 60 days to appeal a denial. If a claim is denied and that denial becomes final, the worker will be responsible for payment of all medical bills. The worker may bill his/her private health insurance company for medical treatment if the claim is denied by sending a copy of the denial to them. According to Oregon workers’ compensation law, it is up to the injured worker to prove that an injury occurred on-the-job or that an illness was due to job-related factors. Workers who file a workers’ compensation claim for an injury that they know occurred off-the-job or attempt to collect wage replacement and benefits for one job while failing to report earnings at another may be committing fraud and could be prosecuted. For dates of injury after January 1, 2002, some medical benefits may be paid while the claim is on appeal. Contact your adjuster if you need more information on these benefits. What are the worker's responsibilities if a claim is accepted? A SAIF claims adjuster is available to assist the worker with his/ her claim. Workers should be sure to ask questions if they don’t understand something or receive any forms or letters that are confusing. Workers should also keep their claims adjusters up to date on their recovery progress. The adjuster is there to help. It is the worker’s responsibility to do all he/she can to return to work. Workers should cooperate fully with those who are helping to return them to work. They
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should keep their medical appointments and follow their doctor’s instructions and treatment plan. They should avoid any activities that will slow or stop recovery. It is important for workers to keep their employers informed about their condition. Employers need to know what the worker’s doctor reports after each medical visit. When the doctor releases the worker for work, the worker must contact the employer immediately. Workers should be sure to obtain a written copy of the work release to give to the employer. What happens to the worker’s job if he/she can’t work? The intent of the workers’ compensation system is to help injured workers get back to work. Workers have a responsibility to make every effort to return to work once they are able. Employers may also ask an injured worker to return to a different job while they are healing. Studies show that most injured workers recover more quickly when they can return to the workplace. If the worker is unable to return to his/her old job and has a permanent disability, he/she may be eligible for the Preferred Worker Program that provides financial incentives to employers who hire injured workers with permanent disabilities. The Department of Consumer and Business Services will notify workers if they are eligible or they can contact the Department directly at 1-800-445-3948 to inquire about this program.
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Will the worker get retrained? Retraining is one of the last options exercised to get an injured worker back to work. In most cases, re-employment depends upon the worker’s existing skills and physical capabilities. If a worker believes his/her injury will prevent him/her from returning to any employment he/she has held in the past, the worker should contact SAIF to review eligibility for vocational benefits. Why do insurers send out all that paperwork inquiring about a worker’s medical and work history? This information is needed to ensure that the benefits the worker receives are appropriate and to determine his/her eligibility for vocational assistance or permanent partial disability. Who should a worker call if he/she has questions about workers’ compensation? Employers can certainly help answer questions workers may have. Any worker who has filed a claim with SAIF should contact us at 1-800-285-8525. They can also call the Department of Consumer and Business Services Injured Workers' Hotline at 1-800-452-0288 or the Ombudsman for Injured Workers at 1-800-9271271.
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HOSPITAL INDEMNITY INSURANCE
This insurance offers limited coverage. It pays a fixed amount for each day, up to a maximum number of days. An individual may use it for medical or other expenses. Usually, the amount the individual receive will be less than the cost of a hospital stay. Some hospital indemnity policies will pay the specified daily amount even if patient has other health insurance. Others may coordinate benefits, so that the money patient /insured receive is not equal / more than 100 percent of the hospital bill.
LONG-TERM CARE INSURANCE
Long-term care insurance is designed to cover the costs of nursing home care, which can be several thousand dollars each month. Long-term care is usually not covered by health insurance except in a very limited way. Medicare covers very few long-term care expenses. There are many plans and they vary in costs and services covered, each with its own limits
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Understanding Health Insurance Terms
Coinsurance
The amount patient / insured is required to pay for medical care in a fee-for-service plan, after deductible have been met. as a The coinsurance For rate is usually if the
expressed
percentage.
example,
insurance company pays 80 percent of the claim, patient / insured pay 20 percent.
Coordination of Benefits
It is a system to eliminate duplication of benefits, when an individual is covered under more than one group plans. Benefits under the two plans usually are limited to no more than 100 percent of the claim.
Co-payment
It is another way of sharing medical costs. Here Individuals pay a flat fee every time he receives medical service. (For example, $5 is paid for every visit to the doctor). The insurance company pays the rest.
Covered Expenses
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Most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures the insurer agrees to pay for. They are listed in the policy. Customary Fee Most insurance plans will pay only what they call a reasonable and customary fee for a particular service. If patient’s doctor charges $1,000 for a hernia repair while most doctors in that area charge only $600, patient will be billed for the $400 difference. This is in addition to the deductible and coinsurance which patient is expected to pay. Deductible The amount of money insured must pay each year to cover medical care expenses before insurance policy starts paying. Exclusions Specific conditions or circumstances for which the policy will not provide benefits.
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HMO (Health Maintenance Organization)
Prepaid health plans. Insured pay a monthly premium and the HMO covers doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, xrays, and therapy. Insured must use the doctors and hospitals designated by the HMO.
Managed Care
Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care. Maximum Out-of-Pocket Expenses The most money insured will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
PPO (Preferred Provider Organization)
A combination of traditional fee-for-service and HMO. When patient use the doctors and hospitals that are part of the PPO, he can have a larger part of medical bills covered. Patient can use other doctors, but at a higher cost. Pre-existing Condition A health problem that existed before the date insurance became effective. Premium
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The amount which insured or his employer pays in exchange for insurance coverage. Primary Care Doctor Usually patient’s first contact for health care. This is often a family physician or internist, but some women use their gynecologist. A primary care doctor monitors health and diagnoses and treats minor health
problems, and refers the patient to specialists if another level of care is needed. In many plans, care by specialists is only paid for if the patient is referred by primary care doctor. An HMO or a POS plan will provide a list of doctors from which patient will choose primary care doctor (usually a family physician, internists, obstetriciangynecologist, or pediatrician). This could mean patient might have to choose a new primary care doctor if his current one does not belong to the plan. PPOs allow members to use primary care doctors outside the PPO network (at a higher cost). Indemnity plans allow any doctor to be used.
Provider Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care is called an provider. Third-Party Payer Any payer for health care services other than the patient / insured. This can be an insurance company, an HMO, a PPO, or the Federal Government.
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MEDICAL BILLING – AN INTRODUCTION
What Is Medical Billing?
Medical billing is better described as full medical practice management and a doctor's key to getting paid. Full medical practice management," meaning that billing office handle all the bookkeeping and
accounting functions for their doctor-clients, including patient statements, recording
payments, preparing financial reports, and even consulting the physicians on issues such as how to negotiate contracts with the growing number of managed care companies such as HMOs and PPOs that are trying to reign in doctors' fees.
Medical billing involves preparation of medical bills on behalf of the doctor for the treatments performed on the patients. The work also involves sending the
medical bills to the respective insurance company with whom the patient is a beneficiary. The billing department also collects the money from the insurance
company on behalf of the doctors. The insurance company pays for the treatments billed by the billing office.
The Medical Billing industry is a subsidiary of the Health care industry. Medical Billing is the financial-data management of a physician or a group of physicians’ practices. This means maintaining all of the physician’s non-medical records and keeping track of and collecting all money due to him.
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What are the basic differences between US & Indian medical payment collections?
To understand “Medical Billing”, it is important to first understand the difference between medical payment collections in India as opposed to the collections policies in the U.S. There are two basic differences 1. The first difference is that few people in India have a medical insurance
policy. They pay their medical fee out of their pockets immediately after their visit to the doctor. On the other hand, a large percentage of the American population had Medical Insurance Policies to cover their medical bills. In addition, most physicians extend credit. In short, insurance companies pay most medical bills, and they do this, at an extended period from the date of treatment. 2. Even if a person has a medical insurance policy in India, and if his policy
covers his treatment, he has to pay the medical bill out of his pocket at the time of his treatment. His insurance company then later reimburses him. In the U.S, the patient undergoes his treatment, gives all relevant information regarding his insurance policy or policies at the physician’s office and leaves. According to American law, it is the physician’s responsibility to collect the money from the government insurance programs. Most physicians take the responsibility of collecting payments due from the private insurance companies also as an added service to their patients.
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The client of a Billing Office may be one physician, a group of physicians working in the same hospital practicing different specialties (Ophthalmology, Anesthesia, etc.) or a group of physicians practicing the same specialty.
Why Physicians go for Medical Billing Companies to do billing?
America has more than 3000 insurance companies, each with a number of plans. This posed a problem to the physicians. Every insurance company required the medical claims filed to them according to their own rules and formats. Also, when physicians sent out claims to these insurance companies the explanation of the diagnosis and the treatment, necessary to every claim, were voluminous and time consuming. The forms and codes developed by Center for Medicare and Medicaid Services (CMS – formerly known as HealthCare Financing Administration CMS) reduced the volume of the information to be transferred to the insurance companies but the volume was still considerable and required skill and time. The medical treatment performed still had to be encoded. These codes, with the patients’ demographic information, still had to be entered into specific medical billing software’s. This process was again time consuming and the extra personnel and infrastructure meant extra costs. They could not handle the volume and turned to specialist billing offices for assistance. It was easier for a physician to source their non-medical, accounting work to a billing office so that he could concentrate on his practice. Thus the medical billing office became an intermediary between the physician and the insurance companies.
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The billing office collects information relevant to the patients’ treatment from the physicians’ office. Using these codes and forms, the billing office bills the insurance companies and patients on behalf of the physicians. Until recently, medical billing was usually done by typing out and mailing claims to various insurance companies. Now the objective of the medical billing industry is to offer fast, efficient, and error-free claims processing using computers to log and transmit claims to the insurance companies.
What is a Claim?
A claim is a request made to the insurance company, by the billing office on behalf of the insured person or the physician, for reimbursement of services rendered by the physician. A claim is sent out on standardized forms that contain information regarding the patient, his insurance coverage, the physician, the diagnosis and the treatment. A claim is either mailed or electronically transmitted to an insurance company. In a small family practice or suburban clinic this task may be simple and assigned to the medical assistant or nurse but in bigger practices and clinics this is the medical biller's job! When a physician treats a patient, the doctor’s office must file an insurance claim to get paid. This claim is usually filed on paper and sent by mail. These paper claims are notoriously slow, often taking 60-90 days or more for the doctor to get paid. Now, these claims can be processed electronically, saving healthcare provider’s time and money. With electronic claims processing, payment time is drastically reduced to just 7 to 21 days on average. This dramatic improvement in cash flow
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is exactly why medical billing is in such demand. Physicians are constantly seeking remedies to their medical billing difficulties.
A brief study on working of Medical billers?
Medical billers and coders usually work forty regular office hours from Monday through Friday on a desk in the billing office or billing department of the professional healthcare office. They must know the different methods of billing patients, understand various collection methods, ethical and legal implications have a good working knowledge of medical terminology, anatomy, medical billing and claims form completion, and coding. They also must understand database management, spreadsheets, electronic mail, and possess state-of-the-art word processing and accounting skills, be proficient in bookkeeping, and be able to type at a speed of at least 45 words-per-minute. The work area of medical billers and coders usually is in a separate area away from the patients and public eye. However, even though they are not involved in the actual process of doctors and healthcare professionals providing medical care they need to possess excellent customer service skills when it comes to making contact with clients, insurance companies, and often patients. Medical billers must know how to explain charges, deal with criticism, give and receive feedback, be assertive, and communicate effectively without becoming confused as the person is asking questions. Patients can quickly become frustrated when trying to deal with healthcare providers and bills over the phone.
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While an increasing amount of patient care is being funded through HMO (Health Managed Organizations) related insurance, where the patient makes a small copayment at the time of service and the doctor bills the managed care company for the balance, a number of patients still need to make arrangements to pay for their medical services over a period of time. Part of the medical biller and coder's job is to contact some of these patients from time to time regarding a past due bill. Incoming calls from patients who have questions regarding a bill are also directed to the medical billers office. The way s/he communicates over the phone can make or break business relationships. Other specialties closely related to the medical billing profession are: • • • • • • • • • • Medical Coders/Coding Specialists Patient Account Representatives Electronic Claims Processors Billing Coordinators Reimbursement Specialists Claims Assistant Professionals Medical Claims Analysts Medical Claims Processors Medical Claims Reviewers Medical Collectors
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What are the various departments in an Indian billing office?
Billing office is a link between the Doctor and the insurance company. The billing office in India has four departments put together, they are: 1. Scanning Department 2. Charge Entry Department 3. Cash Department 4. Accounts receivable department 5. Quality Department
Scanning Department
This department is responsible for collecting the data scanned from the US billing office. The US office in turn receives the data from the physician’s office,
insurance companies, and patients. The data received in US is scanned to back office in India. The data sent to us involves the details of the patients and
treatments taken at the hospitals. (Patient Demographic & charge sheets). These data are handled by the charge entry department. The second form of data is the data sent to us by the insurance companies. The data contains the benefit paid to the respective patient’s by the insurance companies and this data is handled by the cash department. The third form of data is called the regular mails and this comes from the insurance companies and this is handled by the accounts receivables.
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The scanning department receives and allocates all the data received by them to the respective departments.
Charge Entry Department
This department is responsible for registering the patients in the system before entering the charges. Each type of ailment or disease has a unique diagnosis code called ICD-9 code (International Classification of Diseases 9th Edition Clinical Modification) and each type of ailment requires different modes of treatment procedures. The procedures involved in the treatments are noted by unique codes called the CPT (Current Procedural Terminology). code (Procedure code) The charge sheets notify the various treatments performed on a patient. The
charge entry department enters these procedures into the respective patient account. These details are collected and entered by the billing office and the
copies of these claims are sent to the insurance companies. The mode of sending the claims to the insurance companies can be by mail or by electronic transmission. Insurance companies take on an average time period of 30 days to process the claims. Patient Demographics & charge entry is the first step of the billing process and an error here will prompt errors in the subsequent steps. In some cases this error can be discovered only after the claims reach the insurance carriers. This will
result in lost accounts receivables time. Hence utmost care should be taken while entries are being made.
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Cash Department
This department is responsible for entering the cash details into a particular account. The check and the explanation of benefits (EOB) are sent to us by the insurance companies. Check contains the providers or group name, amount paid and the insurance company’s name. EOB contains the detailed description of the payments made for the type of procedures involved in the treatment. In case of a denial, an EOB alone is sent and it explains which charge has been denied and for what reason. payment. EOB will be used to verify any discrepancies from the expected
When a claim has been processed and paid, the amount paid will have to be applied to the amount charged for individual patient’s treatment in the Medical billing software. This makes it possible for the billing office to track the payments received from different angles. Some examples of how a billing office would want to track the payments received are: a) All insurance payments for a doctor or a group b) All patient payments for the doctor or group c) Total payments made for all patients or any group of patients (grouped by insurance company, date etc) d) Payment made for any specific treatment for a patient e) Payments made by an individual patient or insurance company
f) All payments made for one particular treatment that the physician renders.
(total revenue earned from heart operations alone for an cardiologist)
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Cash posting or the correct application of payments to their respective charges in the medical billing software is very important as any wrong posting may result in wrong accounting. If there are any mistakes in posting, the reports that are run to assess a physician’s practice or judge the billing office’s performance will be incorrect. EOB’s are the only hard copy evidence the billing office have to check how the
insurance company had processed the claims sent to them and it has to be filed carefully for future references.
Accounts Receivables Department
This department has to check for the steady inflow of money from the insurance company. The main motive of this department is to collect money for all the
treatments taken by the patients. Usually the turn around period for the payment by the insurance company is 30 – 45 days. Once the limit is exceeded AR
department has to make an enquiry for the delay. There are various reasons for the delay like: a) Correct details may not have been provided to the insurance companies. b) Claims were sent correctly but Insurance Company may not have received the claims. c) The checks issued might have been sent to the wrong address. d) The insurance company may delay the payments if they have a backlog and they would inform us by a letter that they have received the claims and would be making the payments shortly.
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AR department acts as a hub around which other departments have to revolve. This department can gather & update lot of billing information which is required to settle a claim. There are instances where insurance company does not make a 100% payment and we would have received a low payment, in such case AR analyst have to work on such claims & settle the claim. The Medical billing software is capable of running reports that pull out claims that are unpaid for greater than 30 days. These are calling aging reports and show pending payments in slots such as 0 – 30 days, 31-60 days and 61-90 days. Claims filed within the last 30 days will find themselves in the first slot (0-30days). Claims that are more than 30 days but less than 60 days old will be found in the 31-60 days slot. A glance at this report will show the AR personnel the claims that need to be followed up on with the insurance company. Claims will be followed up over the telephone or by written correspondence. It
would be necessary to find out why the claims are yet to be paid and what needs to be done to have these claims paid. The delay and denials will be corrected by the billing office in coordination with the physician’s office and the insurance carriers. The same applies when patient billing statements are sent out. The
patient is given 3-4 weeks to pay the bill and if the payment is not received with in that time, the billing office will follow up with the patient. Communication is very important between the three departments. There will be a number of circumstances where these departments will have to work with each other to troubleshoot problem claims. Only good coordination between these
departments will assure correct and quick payments from both the insurance companies and the patients.
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Quality Department
Quality in Health care business can be defined in two words first “
Accuracy “ ( Defect free transaction ) where in data captured in the software is accurate with the information received, this will also enable the claim to be paid within the given time period. Next comes “Timely Response i.e., work received
has to be completed within the stipulated time period as agreed with the client. In the competitive world of Healthcare BPO Environment today, Quality Process plays a vital role to ensure that a clean claim is being transmitted/forwarded to the Insurance carrier. Quality check is done based on General rules and specific rules given by the client from time to time. Quality check is maintained in all departments of Medical Billing by laying down rules for each department and thereby arresting the errors to minimum level. In the absence of correct checks and balances, companies can run the risk of jeopardizing their relationship with customers through the inability to provide continuously good service.
The project is initiated with formal identification of the Project Manager, allocation of project resources, and overall establishment of the project environment and preparation of Project Development and Quality Plan. Continuous Project
monitoring is done through various levels of quality reviews. The project manager ensures a smooth interaction with the customer through e-mails, teleconferences and Weekly Progress Reports.
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Quality Check List
Demos: Patient Details: 1. 2. 3. 4. 5. 6. 7. Patient Account Number. Patient Name: Last name, First name Middle Initial Patient DOB: MM/DD/YYYY Patient SSN: 9 Digits Numeric Patient Sex: Male/Female Patient Marital Status: Married/Single/Others Patient Address: Physical Address/Mailing Address City, State, Zip Code 8. Patient Ph#: 10 digits 9. Employer Details.
Guarantor Details: 1. 2. 3. Guarantor Name. Guarantor Address Guarantor Phone#.
Insurance Details: Primary Insurance: 1. 2. 3. Plan Name. Insurance Address Policy Number
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4. 5. 6.
Group Number Subscriber Relationship code
Secondary/ Tertiary same details need to be checked.
Charges: 1. 2. 3. 4. 5. 6. 7. 8. 9. Date of Service (From Date; To Date) Place of Service Facility Referring Doctor Provider Procedure Modifiers Diagnosis Units
10. Billed Amount
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What are the problems faced by US providers or physicians?
Constantly US physicians face the problems of insurance coding & payment reimbursement on their insurance claims. Optimizing reimbursement is like trying to piece together a puzzle with a lot of pieces. Not only is there a lot of complexity, but change is continuously occurring. important factors, few are outlined below. 1. Providers are using invalid, obsolete or deleted codes while submitting claims to respective insurance carriers. 2. The code and fees may be okay, but providers may be losing charge information, missing super bill fees or billing insurance carriers wrongly or irregularly. 3. The practice is not well-informed about current coding and billing issues. 4. The practice doesn't have and/or doesn't follow written policies and procedures which support the billing, coding and collections processes. 5. Not participating in Medicare may allow providers to bill higher fees to patients, but this may not be in the best interests of their practices. 6. Poor understanding of how insurance carriers work and ineffective strategies and systems for dealing with them. 7. The practice is not using forms and documents which are current. In general, the basic tools needed by health care providers for optimizing reimbursement are: 1. A thorough understanding of the billing process and related terminology. There are a number of
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2. Procedure coding and diagnostic expertise.
3. A well-designed super bill. 4. A fee schedule based on relative values.
5. Current and accurate forms and documents.
6. Current reference materials (such as code books).
7. Written policies and procedures covering billing guidelines.
What is the normal work flow process in Medical billing?
The following brief outline would give the workflow process from the time a patient is seen by a physician. 1. The doctor sees the patient. Demographics, super bills/charge sheets,
insurance verification data and a copy of the insurance card i.e. all the information pertaining to the patient is sent to the Billing office. 2. Billing office scans the source documents and saves the image file to an FTP
site or on to their server under pre-determined directory paths. 3. Scanning department retrieves the files and prints them and ties up with
the control log for number of files and pages. (This process is absent if a billing office opts for data entry thru electronic source documents) 4. Illegible /missing documents are identified and a mail is sent to the Billing
office for rescanning. 5. Documents are batched, numbered and sent to the appropriate departments
for action 6. Coding and pre-coding of the super bill/charge sheet and demographics for
insurance, doctors, modifiers, CPT and diagnosis are done wherever required.
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7.
The claims data entry operator creates a charge, according to the billing
rules pertaining to the specific carriers and locations .All charges are accomplished within the agreed turnaround time with the client. 8. Charges are checked for accuracy and again verified by audit department
for accuracy and compliance with rules.
9.
Claims are filed and information sent to the Transmission department. the electronic media. Once claims are transmitted electronically,
Transmission department prepares a list of claims that go out on paper and through confirmation reports are obtained and filed after verification. Paper claims are printed and attachments done, if necessary, stuffed into envelopes and sent to the US for postage and mailing. Transmission rejections are analyzed and appropriate corrective action is taken.
10.
Cash Application team receives the cash files and the deposit control log is
prepared. This helps to reconcile the deposits at the end of each month. During cash application overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Also underpayments/denials are highlighted for further research by the denied claims team. 11. All denied codes in the EOB’s or Explanation of Benefits received are
researched by the rejected/denied claims group, which will determine the reason for denial, and appropriate action is initiated for resolving the issue. This group also researches the regular mail received from the insurance companies and appropriate actions are taken on the refund request, newsletters, rejection reports etc. 12. AR analysts are the key to any group. They record the processing time of
each insurance companies and identify all claims falling above the processing time.
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Then the claims are researched for completeness and accuracy and insurance carriers are called if required. AR analysts are responsible for the cash collection and resolving all problems to enable the account to have clean AR.
13.
Insurance calling team initiates calls to the insurance companies to establish
reasons for non-payment of the claims. All reasons are passed on to the Analysts for resolution. Calling team works during the American Time zones. 14. Patient calling team calls up the patients to confirm receipt of bill and when
they are going to pay. Based on client’s approvals budget plans and discounts for immediate payments are also undertaken. Below chart will clearly demonstrate the actual flow of medical billing process. Process starts right from the stage of patient demographic entry at the physician’s office by the patients.
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PD & Charges from Facility I
PD & Charges from Facility II
PD & Charges from Facility III
PD & Charges from Facility IV
PD & Charge sheets received from all four facilities are received, batched & Scanned to Back Office
All the Scanned documents are received, checked with Scan logs and forwarded to respective entry departments
Patient Demographics and Charges are entered as per rules
Patient Demographics & Charges are coded in Coding Department
Entered demographics & Charges are quality checked based on entry guidelines.
Entries are updated and Claims are filed to Insurance Carriers
Paper Claims Submiss ion
Claims are sent to Insurance Carriers via U.S Mail After 45 Days
Electronic Claims Submission
Claims are sent to Insurance Carriers via Clearing house
A
If a claim is still outstanding, calls are placed to Insurance Carriers to check status of the claims
After 30 Days
B
Claim Paid
Claim Not In System
Low paid Claim
Claim Denied
Claim Pended
Cash posting
Claims needs to be resubmitted after proper verification
Analyst needs to review each situation and take appropriate actions to settle claims
If secondary or tertiary Insurance available, submit claims If Claim needs to be submitted in paper
Appeals
Client Assistance
Adjustments If Claims needs to be submitted electronically
Other actions
A
B
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MEDICAL BILLING FLOW CHART
Front Office Provider
Medical transcription
Patient
Medical Coding
Billing office in U.S
Billing office in India
Eligibility Verification Clearing House Patient registration & Charge entry Cash Posting A/R Department Insurance Company
Preliminary screening
Conversion in to ins. Specific format
Dispatch
Communication of Decision
Claim Adjudicatio n
Pre-edit/Audit
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MEDICAL CODING
What is Medical Coding?
Every Healthcare Provider that delivers a Service receives money for these services by filing a claim with patient’s Health Insurance Carrier. This is also referred as an encounter. An encounter is defined as “a face to face contact between a healthcare professional and an eligible beneficiary.”
Codes exist for all types of encounters, services, tests, treatments, and procedures provided in a Medical office, clinic or hospital. Even patient complaints such as headaches, upset Stomach, etc have codes which consist of a set of numbers and a combination of set of numbers. The Combination of these codes tells the payer what was wrong with patient and what service was performed. This makes it easier to handle these claims and identify the provider on a predetermined basis.
Reason for the Visit /Encounter – Diagnosis Code
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Service rendered - Procedure Code
Coding Systems
The two major coding systems are
1. International Classification of Diseases – Clinical Modification – 9th Revision
(ICD-9-CM) 2. Current Procedural Terminology (CPT)
CPT and ICD-9-CM are not the only coding systems. Here are few more coding systems that are used to code a variety of coding information:
1. CDT-3 codes 2. ABC codes 3. SNOMED codes 4. NDC codes 5. Home Healthcare (saba) codes 6. DRG systems.
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ICD coding system
ICD (International Classification of Disease) is a coding system for which the first edition was published in 1900, and it is being revised at approximately 10-year intervals. The most recent version is ICD-10, which was published in 1992. WHO is responsible for its maintenance. In US, the coding is still based on ICD-9-CM, which contains more detailed codes. ICD consists of a core classification of three-digit codes, which are the minimum requirement for reporting the reason for the encounter. An optional fourth digit provides an additional level of detail. At all levels, the numbers 0 to 7 are used for further detail, whereas the number 8 is reserved for all other cases and the number 9 is reserved for unspecified coding. The basic ICD is meant to be used for coding diagnostic terms, but ICD-9 as well as ICD-10 also contains a set of expansions for other families of medical terms. For instance, ICD-9also contains a list of codes starting with the letter “V” for reasons for encounter or other factors that are related to someone’s health status. A list of codes starting with the letter “E” is used to code external causes of death. The nomenclature of the morphology of neoplasms is coded by the “M” list. The disease codes of both ICD-9 and ICD-10 are grouped into chapters. For example, in ICD-9, infectious and parasitic diseases are coded with the three-digit codes 001 to 139, and in ICD-10 the codes are renumbered and extended as codes starting with the letters A or B; for tuberculosis the three-digit codes 010 to 018 are used in ICD-9, and the codes A16 to A19 are used in ICD-10. The four-
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digit levels and optional five-digit levels enable the encoder to provide more detail. Table below gives examples of some codes in the ICD-9 system.
Example of a Four-Digit Code Level in ICD-9 and the Five-Digit Code Level as Extended by the ICD-9-CM Code Disease 001 - 139 Infectious and parasitic diseases 001 - 009 Infectious diseases of the digestive tract 003 Other Salmonella Infections - 003.0 Salmonella gastroenteritis 003.1 Salmonella Septicemia 003.2 Localized Salmonella Infections 003.20 Localized Salmonella Infection, 003.21 003.22 003.23 003.24 003.29 Unspecified Salmonella Meningitis Salmonella Pneumonia Salmonella Arthritis Salmonella Osteomyelitis Other Localized Salmonella Infections Other Specified
003.8
Salmonella
-
003.9
Infections Salmonella Infections, Unspecified
The U.S. National Center for Health Statistics published a set of clinical modifications to ICD9, known as ICD-9-CM. It is fully compatible with ICD-9, but it contains an extra level of detail where needed. In addition, ICD-9-CM contains a volume III on medical procedures. CPT Coding System
Current Procedural Terminology (CPT), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an
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effective means for reliable nationwide communication among physicians, patients, and third parties.
The American Medical Association (AMA) first developed and published CPT in 1966. The first edition helped encourage the use of standard terms and descriptors to document procedures in the medical record; helped communicate accurate information on procedures and services to agencies concerned with insurance claims; provided the basis for a computer-oriented system to evaluate operative procedures; and contributed basic information for actuarial and statistical purposes. The first edition of the CPT code book contained primarily surgical procedures, with limited sections on medicine, radiology, and laboratory procedures. The second edition was published in 1970, and presented an expanded work of terms and codes to designate diagnostic and therapeutic procedures in surgery, medicine, and the specialties. At that time, five-digit coding was introduced,
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replacing the former four-digit classification. Another significant change was a listing of procedures relating to internal medicine. In the mid- to late 1970s, the third and fourth editions of the CPT code were introduced. The fourth edition, published in 1977, represented significant updates in medical technology, and a procedure of periodic updating was introduced to keep pace with the rapidly changing medical environment. In 1983, the CPT code was adopted as part of the HealthCare Common Procedure Coding System (HCPCS) (Formerly called as HealthCare Financing Administration's (HCFA) Common Procedure Coding System). With this adoption, CMS mandated the use of HCPCS to report services for Part B of the Medicare Program. In October 1986, CMS also required State Medicaid agencies to use HCPCS in the Medicaid Management Information System. In July 1987, as part of the Omnibus Budget Reconciliation Act, CMS mandated the use of CPT for reporting outpatient hospital surgical procedures. Today, in addition to use in federal programs (Medicare and Medicaid), CPT is used extensively throughout the United States as the preferred work of coding and describing health care services
Tools of the Trade
1. CPT Book – Procedural Coding Medical services provided by physicians are identified using the AMA Current Procedure Terminology or CPT codes. The AMA CPT book provides descriptors for each of the 8,000 codes listed. Frequently there are additional instructions for code use in
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each section of the book. These CPT rules should be followed when choosing the correct code to describe the service provided
2. ICD-9-CM - Medical Diagnosis Coding The ICD-9-CM coding system contains three "volumes" of coding information although the volumes come in one book. Volume 1 contains the diagnosis codes that every provider needs for billing. index of Volume 1. Volume 2 is an alphabetical
Outpatient diagnostic or treatment centers, like
physician offices, need only Volumes 1 and 2. Thus, books that contain only Volumes 1 and 2 are often referred to as physician, office, or outpatient editions. Volume 3 contains procedure codes, not diagnosis codes. Volume 3 codes are used for billing inpatient hospital stays in the DRG system so books that contain Volume 3 are called hospital, payer, or inpatient editions
3. HCPCS – CPT Level II codes HCPCS Level II codes are used to bill Medicare for supplies, materials, injections, DME, rehab, and other services.
4. NCCI Manual
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National Correct Coding Initiative guide will help us code our service for reimbursement in compliance with CMS’s policies to prevent claim rejection, delays, and audits.
Coding department functions
1. Charge sheets that must be coded are, upon receipt by the billing account, forwarded to the coding department for diagnosis and CPT coding.
2. Medical coders code the diagnosis description given in the charge sheets according to established guidelines, using the ICD-9-CM (International
Classification of Diseases, Revision 9, Clinical Modification, and Volumes 1 & 2) diagnosis coding system and CPT/HCPCS codes according to the procedure performed.. The published diagnosis/CPT coding rules under the ICD-9-CM/CPT coding system are observed.
3. Codes are selected strictly based on documentation provided by the client,
and to the highest specificity as indicated in the submitted documents. When documentation is insufficient or unclear, the charges are returned to the client for clarifications.
4. Coding policies and guidelines, if any, established by the client, the coding
supervisor, or insurer are followed wherever applicable during the process of
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coding.
5. When coders identify procedure coding or other errors in the charge information given to them, such errors are corrected with an explanatory note written on the concerned charge sheet. If the coding department decides that the errors are of such a type that will require client authorization or clarification, then such authorization or clarification is obtained from the client by the concerned billing account.
6. When a coder finds that the information on the charge sheet is insufficient to select the appropriate diagnosis or procedure code, the coder writes a note in the charge sheet stating what additional information is needed to supply the code.
7. When a given diagnosis code is not in the list of covered diagnosis codes listed in the state Medicare carrier’s LMRP (Local Medical Review Policy), the coder will code the diagnosis as documented and write “Not in LMRP” in the charge sheet. A policy can be arrived on handling denials by the operation team and client can be alerted on the same.
8. Coders, where ever possible, advise billing departments on the appropriateness of the diagnosis codes and procedure codes documented in a charge sheet, toward ensuring accurate health care claim submission.
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9. Coders should not alter codes or change information documented in the charge sheet, or any other medical document, unless authorized by the client, except when there are definite errors, such as typographical errors. No attempt will be made to alter the procedure or diagnosis documented by the physician or medical service provider. (See also point 6 above)
10.
Upon completion of coding, the coded charge sheets are forwarded to the charge entry department of the respective billing account.
11.
The work of new coders who join the department will be fully audited before file submission, until such time the coders gain the required level of accuracy.
12. A hundred percent audit of all coding work can be conducted during project
transition, until such time the coders gain the required experience and accuracy levels.
13.
Account specific coding policies, if applicable, will be documented
Coding guidelines
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Use all codes necessary to completely code all diseases and procedures, including underlying diseases. Refer all medical records of patients treated for multiple trauma and patients hospitalized over thirty days to the coding supervisor to verify selection of principal diagnosis before abstracting. E codes are used whenever appropriate to identify external codes.
2. Consult the following sources to identify all diagnoses and procedures requiring coding and to increase the accuracy and specificity of coding. Face Sheet-code diagnoses and complications appearing on the face sheet. Progress Notes-Scan to detect complications and/or secondary diagnoses for which the patient was treated and/or procedures performed. History and Physical-scan to identify any additional conditions; such as history of cancer or a pacemaker in situ. coded. Discharge Summary-read if available and compare listed diagnoses with face sheet. Code diagnoses and procedures listed on discharge These conditions should be
summary but not specified on face sheet.. Operative Reports-scan to identify additional procedures requiring coding. Consult previous medical records in patients admitted for follow-up of neoplasm to determine the primary and secondary sites.
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X-ray and laboratory-use reports as guides to identify diagnoses (e.g. types of infections) or more detail (e.g. type of fractures). Physician’s Orders-scan to detect treatment for unlisted diagnoses-the administration of insulin, antibiotics, and sulfonamides may indicate treatment of diabetes, respiratory or urinary infections which should be confirmed by checking other medical record forms.
3. Code incomplete face sheets by reviewing the above items. Record codes assigned in pencil on the fact sheet. Request supervisor’s assistance if difficulty is encountered in identifying codable data by scanning record. Call physician for diagnostic information only if instructed to do so by supervisor.
4. Exercise discretion in coding diagnostic conditions not identified on the face sheet or discharge summary. Query physician on the deficiency report if the coding question influences Identification of most specific code.. Review all alcohol/drug abuse cases to confirm prior to coding.
5. Process special diagnostic coding situations as follows:
V codes are used to identify encounters for reasons other than illness or injury. V codes are used as principal diagnoses for newborn admissions
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(V30.0-V37.0), Chemotherapy session (V58.0), Radiotherapy session (V58.1), Removal of fixation devices (V54.0), and Attention to Artificial openings (V55). For inpatient coding, avoid the use of V codes as the principal diagnosis where a diagnosis of a condition can be made. V codes are used in outpatient coding when a person who is not currently ill obtains health services for a specific purpose, such as, to act as a donor, or when a circumstance influences the person’s health status but is not in itself a current illness or injury. Patients receiving
preoperative evaluations receive a code from category V72.8. Avoid using codes that lack specificity. These vague codes should not be used if it is possible to obtain the information required to assign a more specific code. Inpatient coding requires that signs and symptoms are coded when a specific diagnosis cannot be made or when the etiology of a sign or symptom is unknown. Do not code symptoms if the etiology is known and the symptom is usually present with a specific disease process. Example: Do not code convulsions with the diagnosis of epilepsy. Outpatient coding requires that diagnoses documented as “probable, suspected, questionable, rule out or working”, should not be coded. Code the condition for that visit, i.e., signs or symptoms or abnormal test results. Chronic conditions may be coded as many times as the patient receives treatment.
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Code abnormal laboratory tests only when noted on the face sheet by the attending physician. When there are more diagnoses for a hospitalization, acute conditions take precedence over chronic and at least one comorbid condition or complication should be included in the diagnoses which may be submitted to Medicare. All complications and comorbitities should be
reported for calculating severity of illness.
6. Sequence
diagnoses
and
procedures
according
to
the
“Guidelines
for
Sequencing and Designating Principal Diagnosis and Principal Procedure Codes.”
Essentials of accurate coding
1. Identify all main terms or procedures included in the diagnostic/procedural statements(s). 2. Locate each main term/procedure in the Alphabetical Index. A main term may be followed by a series of terms in parentheses. The presence or
absence of these parenthetical terms in the diagnosis has no effect upon the selection of the code listed for the main term. 3. Refer to any sub terms indented under the main term. These sub terms for individual line entries and describe essential differences by site, etiology or clinical type.
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4. Follow cross reference instructions if the needed code is not located under the first main entry consulted. 5. Verify code selected from the Index in the Tabular List. 6. Read and be guided by any instructional terms in the Tabular List. 7. Fourth and fifth digit sub classification codes must be used where provided. 8. Continue coding diagnostic and procedural statements until all of the component elements are fully identified. This instruction applies even when no “use” statement appears. 9. Use both codes when a specific condition is stated as both acute (or sub acute) and chronic and the Alphabetic Index provides unique codes at the third, fourth, or fifth digit level. 10. The term hypertensive means “due to”, but the presence of words such as “and or with hypertension” does not imply causality. 11. If the cause of a sign or symptom is specified in the diagnosis, code the cause but do not assign a code for the sign or symptom. 12. For inpatient coding, when a diagnosis statement consists of a symptom followed by comparative or contrasting diagnoses, assign codes for the symptom as well as for the diagnoses. When coding outpatient
services, do not code diagnoses documented as “probable, suspected, questionable, rule out or working diagnosis”. Code the condition
necessitating that visit, such as signs or symptoms, abnormal test, or other reasons.
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13.
Do not confuse V codes which provide for classifying the reason for visit with procedure codes documenting the performance of a procedure.
14.
V codes are found in the Alphabetic Index under references such as Admission, Examination, History of, Problem, Observation, Status,
Screening, Aftercare, etc. 15. When an endoscopic approach is utilized to accomplish another procedure (such as biopsy, excision of lesion or removal of foreign body), assign codes for both the endoscopy and the procedure unless the code books contain instructions to the contrary or the code identifies the endoscopic/laparoscopic approach. 16. No procedure code is assigned if an incision was not made. Code
canceled surgeries to V64.1, V64.2 and V64.3. use code V64.1 if a closed fracture reduction was attempted but not accomplished. 17. Consult the Alphabetical Index first to code neoplasm in order to determine whether a specific histological type of neoplasm has been assigned a specific code. 18. Do not assign the code for primary malignancy or unspecified site if the primary site of the malignancy is no longer present. Instead, identify the previous primary site by assigning the appropriate code in category V10 “Personal history of malignant neoplasm.” 19. Cancer “metastatic from” a site should be interpreted as primary of that site and cancer described as “metastatic to” a site should be interpreted as secondary of that site.
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20.
If no site is stated in the diagnosis but he morphologic type is identified as metastatic, code as primary site unknown and also assign the code for secondary neoplasm or unspecified site.
21. 22.
Code fractures as closed unless they are specified as open. Code only the most severe degree of burn when different degrees of burns occur at the same site.
23.
Assign separate codes for multiple injuries unless the coding books contain instructions to the contrary or sufficient information is not available to assign separate codes.
24.
Poisoning by drugs includes drugs given in error, suicide and homicide, adverse effects of medicines taken in combination with alcohol, or taking a prescribed drug in combination with self prescribed drugs.
25.
Adverse
reactions
to
correct
substances
properly
administered
include: allergic reaction, hypersensitivity, intoxication, etc. The poisoning codes 960-979 are never used to identify adverse reactions to correct substances properly administered. 26. Complications of medical and surgical care are located in the Alphabetical; Index under Complication or the name of the condition. 27. The causes or residual illnesses or injuries are located in the Alphabetical Index under Late Effect. 28. When the late effect of an illness or injury is coded in the main classification, the E code assignment must also be one for late effect.
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MEDICAL BILLING – PATIENT DEMOGRAPHICS
Patient demographics – an overview
•
What is Patient Demographics and what does it contain?
Patient Demographics sheet contains all the basic demographic information about an individual or patient. Patient demographics ( PD ) include Patient name, Date of birth, Address, Phone number, Doctor information, Social security number (SSN) and Sex. Patient Demographic also contains Guarantors or emergency
contact information, Health insurance information. Each piece of information is important because correct and quality entry of such information will directly impact physician’s monthly revenue. This sheet is also called as face sheet of a charge or claim.
A good patient demographic form is the key to obtaining accurate information which is required for claim submission. Providing as much information as possible will reduce the insurance company’s need to contact billing office. Avoiding unnecessary contact will reduce the costs of claims processing and delay in payments. Obtaining all the required demographic information will often determine how willing the patient is to complete the form. If the request is firm and
professional without being offensive, we have great chances of getting the information’s which we need to settle a claim.
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Ideally a patient’s insurance coverage should be verified before any service is rendered with the common exception of emergency treatment. shouldn’t apply exclusively to new patients. This policy
Established patients may have
changed employers, gotten married or divorced or are no longer covered by the policy which was in effect during their last visit. Photocopy of insurance cards is always a help.
•
How Patient demographics originate and reach us?
Patient Demographic sheets also known as face sheet are distributed to patients when they visit physician’s office for treatment. Before the services are rendered, front office staff ensures that patient demographic sheets are filled in by the patient or some one in patient’s family. This process ensures that all necessary patient’s demographic information are gathered accurately which would facilitate in timely reimbursement of physicians charges. In most of the physician’s front office, copies of insurance identification card are also taken. This is to ensure that all the information’s available in insurance identification card are captured. Insurance ID card contains very valuable information which would be very helpful in settling the claim.
These patient demographics are batched together at physician’s office and are forwarded to our office for patient demographics entry.
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•
For our easy understanding now let us see each of the information found in patient demographics. Information found in patient demographics have been
classified into five major headings. They are:
I.
II.
Patient Information. Patient Employer Information. Patient Guarantor Information. Physician Information. Insurance Information.
III. IV. V.
I. Patient Information
This segment in face sheet consists of basic demographic information. They are: 1. Account # 2. Patient Name 3. Patient Sex 4. Patient Date of Birth 5. Marital Status 6. Patient Address 7. Patient phone number
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Each patient record is assigned a patient account number. This is how a patient is identified in the system. Before filing any claim we would need to obtain clear,
accurate information from the patients. A good patient information sheet is the key to this aspect of claims submission. Let us now see few more things about items listed below.
1. Account Number [Visit Number]: In case of a New Patient this field in almost
all the Medical Billing software’s is updated automatically. In cases where it does not get updated automatically the billing office enters the Medical Record Number/Account Hospital/Provider. In case of an Established Patient the Billing Office runs a query to search for the patient record with the help of the Medical Record Number/Account Number or using the Last Name or using the Date of Birth of the patient. If the software has a Visit Number concept then a new visit with the same Account number and the next visit number is created if not then the same Account is edited with the new details as on the Encounter Form. This number is for the internal purpose of the Billing Office and the Hospitals. This field is usually in numeric format but may differ from software to software. This number does not form part of the CMS-1500 claim form. Example: Account #: 24584951, 3205215 … Account # and Visit #: 24584951-01, 24584951-02 … Number as on the Encounter Form submitted by the
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2. Patient Name: This field is entered in the Last Name, First Name Middle Initial
format. However in some software’s this field is split as Last Name First Name and Middle Initial fields. The patient name may also contain title (Junior, Senior, I, II, III …) and suffix (M.D. …) this information also needs to be entered along with the name. The title must be entered with the last name and the suffix should be entered with the first name or after the middle initial. The Name on the Encounter Form may not be given in above said format but still it should be entered as per the Billing Software specifications. Checking the spelling of patient name is a very important step. Simple errors such as transposition of letters or misspelled names can result in denial or suspension of the claim. Patient name is printed in the 2nd field of the CMS1500 form in Last Name, First Name Middle Initial format. Example: Patient Name: Jones, Brenda K; Brenda K Jones; Miller John Jr.; …
3. Date of Birth: This field contains the Date of Birth of the patient. It is entered
in the MM/DD/YYYY or MMDDYYYY as per the Billing Software specification. This field is printed in the 3rd field of the CMS-1500 claim form in MM DD YY format. If Date of Birth detail is not available then generic DOB format have to be entered i.e., 01/01/1901. Example: Date of Birth: 02/12/1979; 02/12/79; 02-Dec-1979 …
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4. Sex: This field contains the Gender of the patients. i.e., M for Male, F for
Female, and U for Unknown when the gender of the patient is not specified on the patient encounter Form. This field is printed in the 3rd field of the CMS-1500 claim form along with the Date of the Birth. Example: Sex: Male; Female; M; F.
5. Social Security Number: This field contains a 9 digit number which is allotted
to the patient by the Social Security Administration. If SSN is missing from patient encounter form then this field is usually left blank or any 9 digit dummy number (000-00-0000/999-99-9999) is entered as per the Billing Software specifications. Example: SSN: 245-19-0124; 245190124
i.
When did Social Security start?
The Social Security Act was signed by President Franklin Roosevelt on August 14, 1935. Taxes were collected for the first time in January 1937 and the first onetime, lump-sum payments were made that same month. Regular ongoing monthly benefits started in January 1940.
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ii. What is the origin of the term ‘Social Security’?
The term was first used in the U.S. by Abraham Epstein in connection with his group, the American Association for Social Security. Originally, the Social Security Act of 1935 was named the Economic Security Act, but this title was changed during Congressional consideration of the bill. Under the 1935 law, Social Security only paid retirement benefits to the primary worker. A 1939 change in the law added survivor’s benefits and benefits for the retiree's spouse and children. In 1956 disability benefits were added.
iii. Who assigns the SSNs and how many SSNs have been assigned?
Social Security numbers are assigned by Social Security Administration. SSNs were first issued in November 1936. By December 1, 2002 more than 418 million numbers had been assigned.
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iv. Is it true that Social Security was originally just a retirement program?
Yes. Under the 1935 law, Social Security only paid retirement benefits to the primary worker. A 1939 change in the law added survivor’s benefits and benefits for the retiree's spouse and children. In 1956 disability benefits were added.
v. Is Social Security just a program for the elderly and disabled?
Social Security is not just a program for the elderly and disabled. Survivors of deceased workers and the families of retired or disabled workers also qualify for benefits. In fact, about 3.8 million children are currently receiving such benefits and 9 out of 10 would be eligible to receive benefits if a parent retires, becomes disabled, or dies. They need a Social Security number (SSN) before they can receive benefits. The SSN is also needed for reasons not connected with Social Security benefits. For example, to be claimed as a dependent on a tax return, to open a bank account and buy Savings Bonds, your child needs an SSN.
vi. Is there any significance to the numbers assigned in the Social Security Number?
The digits in the Social Security number allow for the orderly assignment of numbers. The number is divided into three parts: the area, group, and serial
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numbers. The first three (3) digits (area) of a person's social security number are determined by the ZIP Code of the mailing address shown on the application for a social security number. Generally, numbers were assigned beginning in the northeast and moving westward. So people on the east coast have the lowest numbers and those on the west coast have the highest numbers. The remaining six digits in the number are more or less randomly assigned and were organized to facilitate the early manual bookkeeping operations associated with the creation of Social Security in the 1930s.
Within each area, the group number (middle two (2) digits) range from 01 to 99 but are not assigned in consecutive order. For administrative reasons, group numbers issued first consist of the Odd numbers from 01 through 09 and then Even numbers from 10 through 98, within each area number allocated to a State. After all numbers in group 98 of a particular area have been issued, the Even Groups 02 through 08 are used, followed by Odd Groups 11 through 99.
Within each group, the serial numbers (last four (4) digits) run consecutively from 0001 through 9999.
vii. Are Social Security Numbers re-assigned after a person dies?
SSA does not reissue SSNs after someone dies. When someone dies their number is simply removed from the active files and is not reused. In theory, the time might come someday when SSA would need to consider "recycling" numbers in
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this way--but not for a long time to come. SSA does not have to face reissuing numbers since the 9-digit Social Security number allows about 1 billion possible combinations, and to date SSA have issued a little over 400 million numbers.
viii.
How can one get a different Social Security number assigned to
himself?
Generally, an individual is assigned only one Social Security number (SSN) which is used to record the individual’s earnings for future benefit purposes and to keep track of benefits paid under that number. However, under certain circumstances, SSA may assign an individual a new (different) SSN. When they assign a new number, the original number is not voided or deleted. For integrity reasons, they cross-refer in the records all the numbers assigned to the same individual.
SSA can assign new SSN in the following situations, provided all of the documentation requirements are met:
• Sequential SSN are assigned to members of the same family
• Certain scrambled earnings situations • Certain wrong number cases • Religious or cultural objection to certain numbers/digits in the SSN • Misuse by a third party of the number holder’s SSN and the number holder has been disadvantaged by that particular misuse
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• Harassment, abuse or life endangerment situations (including domestic violence)
To apply for a new (different) SSN, you need to complete Form SS-5 (Application for a Social Security Card)
You will also need to submit evidence age, identity, and U.S. citizenship or lawful alien status. Form SS-5 explains what documents will satisfy these requirements. You will also need to submit evidence to support your need for a new number.
If you are age 18 or over, you must submit your request for a new SSN in person at your local Social Security office.
ix. When
did
Social
Security
cards
bear
the
legend
"NOT
FOR
IDENTIFICATION"?
The first Social Security cards were issued starting in 1936; they did not have this legend. Beginning with the sixth design version of the card, issued starting in 1946, SSA added a legend to the bottom of the card reading “FOR SOCIAL SECURITY PURPOSES -- NOT FOR IDENTIFICATION”. This legend was removed as part of the design changes for the 18th version of the card, issued beginning in 1972. The legend has not been on any new cards issued since 1972.
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x. How to get a Social Security number for my baby? The easiest way to apply for a baby's Social Security number (SSN) is at the hospital. Both parents’ Social Security numbers are required when applying for a baby’s SSN. When a parent requests a Social Security number (SSN) for his/her newborn as part of the birth registration process in the hospital, the State Vital Statistics Office forwards to the Social Security Administration (SSA) data we need to assign an SSN to the child and issue a card. This is known as the Enumeration at Birth (EAB) process. Once SSA receives the data, the process of assigning the number and issuing the card is the same as if the application were taken in a Social Security office. In most States, the birth registration process is electronic. Hospitals submit birth registration information through local registrars to the State, where the
information is entered into an automated database. In most States this process is completed and EAB data is sent to the Social Security Administration within 60 days of birth. EAB is a good service for most parents who have no immediate need for their child's SSN because they do not have to submit an application and evidentiary documents to a Social Security office.
xi. What types of Social Security cards does SSA issue?
SSA issues three types of Social Security cards depending on an individual's citizen or non-citizen status and whether or not a non-citizen is authorized by the Department of Homeland Security (DHS) to work in the United States.
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The first type of card shows the individual's name and Social Security number only. This is the card most people have and reflects the fact that the holder can work in the U.S. without restriction. SSA issues this card to: - U.S. citizens, or - Non-citizens who are lawfully admitted to the U.S. for permanent residence, or who have permission from the Department of Homeland Security (DHS) record to work permanently in the U.S., such as refugees, asylees and citizens of Compact of Free Association countries.
The second type of card bears, in addition to the individual's name and Social Security number, the legend, "NOT VALID FOR EMPLOYMENT". SSA issues this card to non-citizens who: - don't have DHS permission to work, but are receiving a federally-funded benefit; or - are legally in the U.S. and don't have DHS permission to work but, are subject to a state or local law which requires him or her to provide a SSN to get general assistance benefits or a State driver's license for which all other requirements have been met.
The third type of card bears, in addition to the individual's name and Social Security number, the legend, "VALID FOR WORK ONLY WITH INS (or DHS) AUTHORIZATION". SSA issues this card to people who have DHS permission to work temporarily in the U.S. If you’re a non-citizen, SSA must verify your documents with DHS before SSA issues a SSN card. SSA will issue the card within two days of receiving
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verification from DHS. Most of the time, they can quickly verify your documents online with DHS. If DHS can’t verify your documents online, it may take several weeks or up to three months to respond to Social Security's request.
xii. Which Social Security numbers are invalid (impossible)? An invalid (or impossible) Social Security number (SSN) is one which has not yet been assigned. The SSN is divided as follows: the area number (first three digits), group number (fourth and fifth digits), and serial number (last four digits). To determine if an SSN is invalid consider the following:
•
No SSN with an area number in the 800 or 900 series, or "000" area number, have been assigned.
•
No SSN with an area number above 728 have been assigned in the 700 series, except for 729 through 733 and 764 through 772.
•
No SSN with a "00" group number or "0000" serial number have been assigned.
•
No SSN with an area number of "666" have been or will be assigned.
xiii.
Is it legal to laminate your Social Security card?
SSA discourages the lamination of Social Security number (SSN) cards because lamination would prevent detection of certain security features. To deter potential fraud and misuse involving SSN, SSA currently issues SSN cards that are both counterfeit-resistant and tamper-resistant. (For example, the card contains a
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marbleized light blue security tint on the front, with the words "Social Security" in white; intaglio printing in some areas on the front of the card; and yellow, pink, and blue planchets--small discs--on both sides). SSA cannot guarantee the validity of a laminated card. You may, however, cover the card with plastic or other material if the material could be removed without damaging the card.
SSA would also recommend that as a security precaution, you carry your Social Security card only when you expect to need it, for example, to show to an employer or other third party.
xiv.
Is there any charge for replacing a Social Security card?
Social Security does not charge a fee for either an original or replacement Social Security card. A replacement card can be a duplicate card (one with the same name and number) or a corrected card (one with different name but the same number).
xv. Can metal or plastic versions of Social Security cards be used? The official verification of your Social Security number is the card issued by the Social Security Administration. Third parties who request your Social Security card as verification of your number will want to see the card SSA issues. Although Social Security has no authority to prevent use of metal or plastic replicas of Social Security cards, SSA considers them an unauthorized use of the Social Security number and discourages their use.
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xvi.
Can Social Security number be canceled?
No. When someone has applied for and been assigned a Social Security number (SSN) based on a validly signed application, the Social Security Administration (SSA) may not cancel or destroy that record. The Privacy Act of 1974 authorizes agencies to maintain in their records any information about an individual that is relevant and necessary to accomplish a purpose of the agency that is required by law. SSA is required by law to establish and maintain records of wages and selfemployment income for each individual whose work is covered under the program. The SSN is considered relevant and necessary for that record keeping purpose. Consequently, valid SSN are permanently part of SSA's records.
6. Marital Status: This field contains the Marital Status of the patient. It is
usually entered as ‘S’ for Single, ‘M’ for Married, ‘D’ for Divorced, ‘W’ for Widow/Widower, ‘X’ for Separated and ‘O’ for Others. It marital status is missing from patient encounter form, we need to enter ‘O’ in the marital status field. This field is printed in the 8th field of the CMS-1500 claim form. Example: Marital Status: Single; Married; Divorced; Widow …
7. Address: Patient’s address is split into 5 different fields. It is usually entered
as Address1 (PO Box#/Door#/Appt. #), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. This field can not be left blank. Patient address is a
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important field to file a claim & send patient statement. Following are the general abbreviations found in patient encounter forms:
a) Apt. # - Apartment number b) Ave. Avenue number
c) Blvd. - Boulevard d) Ste. e) Dr. - Suite/Street - Drive
This field is printed in the 5th field of the CMS-1500 claim form. Example: Address: 1067 Orange Grove Blvd. Apt. # 194 Los Angeles, CA 90001
8. Patient Phone Number: This field contains the contact number of the patient
including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code, and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. This field is printed in the 5th field of the CMS-1500 claim form along with the address. Example: Phone Number: 626-843-2846; (626)357-5496 …
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II.Patient Employer information
This segment in the face sheet contains employer information of the patient. The entry person needs to enter this information if available in face sheet. Employer information is a must for worker’s comp claims. Non-worker’s comp claims do not require employer name to process claims but it is advisable to update employer information during entry. Following information’s are found in this segment 1. Employer Code 2. Employer Name 3. Employer Address & Phone # 4. Designation/Occupation 5. Contact Person
1. Employer Code: This field is used in most of the Billing Software’s to reduce
the time of PD entry. The Names and Addresses of the major Employers are stored in the Employer database with a unique code assigned to each employer. Hence it is enough to just enter the code and skip to the next block. Example: Employer Code: IBM; A0012; MS024 …
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2. Employer Name: This field contains the name of the patients Employer. If the
patient is a Student or Not Employed or Retired then it can be entered as Student or Not employed or Retired in this field. This field is printed in the 11b field of the CMS-1500 claim form. Example: Employer: Verizon Wireless; Microsoft Corp.; SUN Microsystems …
3. Employer Address: The address of the patients Employer is split into 5
different fields. It is usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. Example: Address: PO Box 1954 Los Angeles, CA 90001-1954
4. Employer Phone Number (Ext No.): This field contains the contact number
of the patients Employer including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. Some software’s may also require you to enter the Extension number if given on the encounter form. Example: 818-245-7849 [5478]; (818)-245-7849 …
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III. Patient Guarantor Information
This segment in face sheet consists of guarantor or emergency contact information. They are:
1. Guarantor Account # 2. Guarantor Name 3. Guarantor Address 4. Guarantor phone # 5. Guarantor/patient relationship 6. Guarantor employer & SSN This block is mostly entered only in the case of the patient being a minor or if the patient is not responsible for the payment. This information is for the internal purpose of the Billing Office and the Hospitals for the purpose of Emergency Contact or follow-up of pending balances and hence does not form part of the CMS-1500 claim form.
1. Guarantor Account #: This field is used to enter the guarantor account #. If
the guarantor is already stored in the database then the stored information can be pulled up using this number. This information is not part of the encounter form. The account number of the guarantor is pulled using search engine.
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Example: 245818A; 6252315; 421154; …
2. Guarantor Name: This field is entered in the Last Name, First Name Middle
Initial format. However in some software’s this field is split as Last Name First Name and Middle Initial fields. The guarantor name may also contain title (Junior, Senior, I, II, III …) and suffix (M.D. …) this information also needs to be entered along with the name. The title must be entered with the last name and the suffix should be entered with the first name or after the middle initial. The Name on the Encounter Form may not be given in above said format but still it should be entered as per the Billing Software specifications. Example: Joseph Warowes Sr.; Warowes, Virginia E M.D …
3. Relationship: This field contains the relationship of the Guarantor with the
patient, such as Spouse, Parent, Others etc. Example: Relationship: Spouse; Parent; Grand Parent …
4. Address: The address of the Guarantor is split into 5 different fields. It is
usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. Example: 102 West 35th Street Heathsville, GA 65418
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5. Phone Number: This field contains the contact number of the Guarantor
including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. Example: (517)373-1820; 517-374-5857 …
6. Guarantor
Employer:
This
field
contains
the
guarantor’s
employer
information. Basically the guarantor’s employer name, address, and contact details are entered here.
7. Emergency Contact: This field is used to enter the Emergency Contact details
of the patients relative or next of kin. Contact information such as Name, Address Phone # and relation to the patient are entered here.
IV. Physician Information
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This segment contains the following information.
1. Admitting physician code: The physician responsible for admission of a
patient to a hospital or other inpatient health facility. Some facilities have all admitting decisions made by a single physician (typically a rotating responsibility), called an admitting physician. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. This field is optional; if the Admitting physician info is not given it can be left blank. This field does not form part of the CMS-1500 claim form. Example: Adm. Phy.: Mileski MD, William
2. Attending or Rendering physician code: The physician rendering the major
portion of care or having primary responsibility for the care of the patient's major condition or diagnosis. In other words the doctor or supplier who actually renders the service (also referred to as a "rendering physician"). All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. The Name of the rendering physician is printed in the 33rd field along with the Address and Phone #. The rendering physician’s Federal tax ID stored in the database is automatically printed in the 25th field of the CMS-1500 claim form.
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Example: Att. Phy.: Pendridge MD, Dayton
3. Referring Physician/Primary Care physician code: The physician who has
sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is called a referring Physician or Primary Care Physician (PCP). The name of the facility may be reflected in this area if the patient has not identified a unique physician, but has identified a facility. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. The name of the referring physician is printed in the 17th field and the corresponding UPIN stored in the database is printed in the 17a field of the CMS1500 claim form.
V.Insurance Information
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This segment of face sheet contains all active insurance information of the patient. This segment includes primary, secondary, and/or tertiary insurance information. This segment is the most important field in patient demographic
sheet. Information found in this field should always be the updated & correct one. If not, we would be submitting claims to incorrect insurance. Entry persons should always match this information with copy of insurance id cards. (if provided). This will reduce the risk of entering incorrect insurance information. Following information are found in this segment 1. Insurance Code/Name 2. Effective Date 3. Subscribers Name 4. Relationship Code 5. Pre-Certification/Pre-Authorization 6. Referral Number
7. Primary Insurance Group & Policy #
8. Date of Injury/Accident 9. Claim Number Sample Medicare Insurance Card copy:
1.
Insu
rance
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Code/Name: This field is used to enter the insurance code or name of the coverage that the patient has. The insurance code is assigned by the Billing office for its internal purpose to reduce the PD entry time. Each Insurance company’s name, billing address, contact person, etc… are assigned a unique code. The entry person should be very careful while selecting the insurance code and should always verify the billing address with the given card copy or with the billing address given on the encounter form. The Primary insurance name is printed in the 11c field and the Secondary insurance name is printed in the 9d field of the CMS-1500 claim form. Example: Insurance: Medicare, Medicaid, Blue Cross, Blue Shield …
2. Effective Date: This field contains the effective date of coverage. This date
should not be after the Date of Service. The date format is MMDDYYYY. This date is used for the internal purpose of the Billing office and Hospitals. This does not form part of the CMS-1500 claim form. Example: Eff. Date: 7-1-66; 07/01/1976; 07 01 66 …
3. Subscribers Name: This field contains the Subscribers name of the insurance
policy. If the patient is a dependant who is covered under someone else’s policy then the name of the person who pays the premium is entered in this field. If patient is the subscriber then we need to enter the patient name itself. The name is entered in the Last Name, First Name MI format.
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The Primary insurance subscribers name is printed in the 4 th field and the Secondary insurance subscribers name is printed in the 9th field of the CMS-1500 claim form. Example: Subscriber: John Q. Public; Public, John Q …
4. Relationship Code: This field contains the relationship of the subscriber to the
patient. The code is usually 1 – Self, 2 – Spouse, 3 – Parent, 4 – others etc…This field does not form part of the CMS-1500 claim form.
5. Policy ID: This field contains the Policy number given by the insurance
company to the subscriber and the dependants of the policy. This does not have any standard format across the insurance company but each insurance company has a unique format such as for Medicare the policy number is given as SSN + Alpha or Alphanumeric. The policy ID should be entered as given in the scanned card copy or as mentioned on the Encounter form. The Primary insurance ID is printed in the 11th field and the Secondary insurance ID is printed in the 9a field of the CMS-1500 claim form. Example: Policy ID: 123-54-5478A; 215543251W1; 215-47-6491 …
6. Group ID: This field contains the Group ID as given by the insurance company
for the policy. Not all the insurance companies have the Group ID hence if not given then this field can be left blank.
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The Group ID is printed along with the Policy ID on the CMS-1500 claim form.
7. Pre-Auth. / Pre-Cert. Number: Review of "need" for inpatient care or other
care before admission. This refers to a decision made by the payer, Managed Care Organization, or insurance company prior to admission. Most managed care plans require pre-cert. This is a method of controlling and monitoring utilization by evaluating the need for service prior to the service being rendered. The practice of reviewing claims for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. The third party usually reviews the treatment plan, monitoring one or more of the following: patient's eligibility, covered service, amounts payable, application of appropriate deductibles, co-payment factors, and maximums. Under some programs, for instance, pre-determination by the third party is required when covered charges are expected to exceed a certain amount. This number should be attached with the respective claim; otherwise the claim will be rejected. There is no standard format for Auth and Pre-Cert. number across all the insurance companies. Each insurance company has its own unique format of Auth and Pre-Cert. numbers.
8. Referral Number: A Referral number is provided by a PCP (Primary Care
Physician) when he refers a patient to a specialist. Without the Referral number a patient cannot get a specialist’s service if he has a HMO plan. This number is printed on the CMS-1500 claim form or entered in the attached documents as per the Insurance company requirements.
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9. Date of Injury/Accident: This field is used to enter the Date of
Injury/Accident when the claim is filed to Work Comp/Auto Accident insurance. This date is useful for the insurance companies to verify if the coverage was active or not. This date is mentioned in the documents attached while filing the claim.
10. Claim Number: This field is used to enter the Claim number for a particular
claim given by the Work Comp/Auto Accident insurance company. Failing to mention this number on the claim form will result in the rejection of the claim.
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MEDICAL BILLING – PATIENT CHARGES
Patient charges – an overview
•
What are Patient Charges and what does it contain?
Patient charge is nothing but the fees claimed by the physician who rendered the services to the patient. Charges can be either based upon demographic evaluation or a flat fee rate as prescribed by the physician’s office. Each piece of information is important because correct and quality entry of such information will directly impact physician’s monthly revenue. This sheet is also called as face sheet of a charge or claim.
•
How Charge Sheets originate and reach us?
Once patient /spouse completes Pd sheet, patient is then referred to physician in the appointed time. After preliminary investigation physician provides the services required by the patient. In the super-bill, kind of treatment is denoted by procedure code and diagnosis code denotes the nature of illness for which services were administered. Super bills or charge sheets contain information like Date of Service, Kind of Service, Diagnosis Code, Attending Doctor, Modifier details. Super bills are usually completed by physician or their assistant. Sometimes Coding of diagnosis & procedures are done by coding specialists.
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Once Charge sheets are completed, they are batched with PD at physician’s office and are forwarded to our office for charge entry. Mode of transfer of data may vary from client to client. But most preferred mode is thru FTP. Here patient
demographics are scanned & captured as image file. These image files are placed in FTP site. begins. These image scan files are retrieved at our office & charge entry
Information found in patient charge sheet •
For our easy understanding now let us see each of the information found in patient charge sheet 1. Attending Physician 2. Referring Physician 3. Admit Date 4. Date of Service 5. Type of Service 6. Place of Service 7. Prior 10. Diagnosis Code 11.
Authorization Number 8. Modifiers 9. Procedure code
# Of days/ units, 12. Location Details 13. Physician Name, Address, Provider id
1. Attending Physician: Attending physician is also referred as rendering
physician. A physician who renders the service to patients is called
attending or rendering physician. Each Rendering/Attending Physician of a particular facility is assigned a unique code with the Name of the Physician, Address of the Clinic/Facility, PIN (Provider Identification Number), License number, Federal TaxID#.
The Rendering Physician Name, Address, and PIN are printed in the 33rd field and if the Address of the Facility where the service was rendered differs from the Physicians location then that address is printed in the 32 nd
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field and the corresponding Federal Tax ID of the Provider is printed in the 25th field of CMS-1500 form.
2. Referring Physician:
Physician who refers patient to specialists is
called referring Physician or Primary Care Physician (PCP) information is integral to continuity of care, reimbursement and community relations. In simple words, the physician who has sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is known as a Referring Physician. Each Referring Physician is allotted a unique code in the Medical Billing software which stores the Name of the Physician, Address of the Clinic/Facility, UPIN (Unique Physician Identification Number). The Referring Physician Name is printed in the 17th field of the CMS-1500 claim form. The UPIN which is stored along with the code is printed in the 17a field of the CMS-1500 claim form.
3. Admit Date: Admit date refers to the date in which patient was admitted
into the Hospital. For workers compensation Date of Injury (DOI) is very important for processing the claim. For the purpose of determining the date of injury for an occupational disease, the date of injury shall be taken to be the last date of injurious exposure to the hazards of such disease or the date on which the employee first knew or reasonably should have
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known of the condition and its relationship to the employee's employment, whichever is the later.
4. Date of Service: DOS is the date in which services were rendered to
patient by attending physician. In certain cases we have thru date of service and also it will be in the single date format. Standard format for entering DOS is mm/dd/yyyy. admit date. DOS must be greater than or equal to
5. Type of Service:
We need to input the type of service which was Broadly we have two digit TOS codes which
administered to patient.
needs to be entered in block 24C of CMS-1500 form. The type of service defines what type of service it is like radiology, cardiology and etc.
6. Place of Service:
Two digit place of service needs to be entered in
block 24b of CMS-1500 form while submitting claims to insurance carriers. POS can be for inpatient, Outpatient & ER. Health care that you get when you are admitted to a hospital is an inpatient. Medical or surgical care that does not include an overnight hospital stay is an outpatient. Care given for a medical emergency when you believe that your health is in serious danger when every second counts is an Emergency care. This field consists of the place or the location where services were provided to the patient. Location details are printed in block 32 of CMS-1500 form. Where services are
Details like location name, address are printed.
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rendered in patient’s home & physician’s office location details in CMS1500 form can be blank.
7. Preauthorization: An insurance plan requirement in which you or your
primary care physician must notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense. Preauthorization are of two types. 1) Requesting authorization of date of services that have not been previously requested or the request was previously rejected. 2) Requesting authorization for increase or decrease units for previously approved dates of service. In other words, Preauthorization means Insurance is notified in advance about specific procedures. This allows for a review of medical necessity, efficiency, and quality of proposed care. It is also an opportunity to inform patient/physician about benefits, including length-of-stay
guidelines and plan limitations. This will help to understand the costs if patient receive the proposed care.
8. Procedure Code:
Procedure codes are used to indicate the kind of
treatment or service was administered in patient. Utmost care should be given while entering the procedure code. We need to first know what kind of procedure code each insurance accepts to process claims. Healthcare
Common Procedure Coding System (HCPCS) is a coding system that is composed of Level I codes (Current Procedural Terminology (CPT) codes), Level II codes (national codes), and Level III codes (local codes). Level I (CPT) codes are five digit numeric codes that describe procedures and tests.
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CPT codes are developed and maintained by the AMA with annual updates. Level II (national) codes are five digit alpha numeric codes that describe pharmaceuticals, supplies, procedures, tests and services. Level II codes are developed and maintained by CMS with quarterly updates. Level III (local) codes are five digit alpha numeric codes that are being phased out by the fiscal intermediaries. Examples of CPT codes: 85025 – CBC with automated differential 71020 – Chest x-ray 2 views 45378 – Colonoscopy 93501 – Right heart catheterization In other words, this field contains the Code of the procedure done (CPT/HCPCS Code). The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties. All the Procedure codes are stored in a Master database of the Medical Billing software with the description of the code and the dollar amount. This helps the charge entry person to cross verify the procedure before saving the claim. This field is printed in the 24d field and the corresponding dollar amount of the procedure stored in the Medical Billing Software is printed in the 24f field of the CMS-1500 claim form
•
•
•
•
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9.
Modifiers:
A modifier indicates that a service or procedure was altered
by specific circumstances, but not changed in its definition or code. Modifiers are two digit numeric or alpha numeric codes that are appended to the end of CPT/HCPCS codes. Modifiers may be used to indicate that:
•
A service or procedure has both a professional and technical component
• • • • • •
A service or procedure was performed by more than one physician A service or procedure has been increased or reduced Only part of a service was performed An additional service was performed A bilateral procedure was performed more than once Unusual events occurred This field is printed along with the CPT/HCPCS Code in 24d field of the
CMS-1500 Claim Form. A list of the most frequently used CPT (Current Procedural Terminology) modifiers, HCPCS (HealthCare Financing Administration's Common
Procedure Coding System) modifiers, and local modifiers has been compiled for reference.
These modifiers and associated nomenclature emanated from three different sources.
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Physician's Current Procedure Terminology, CPT 1999 was used for the definition of CPT-4 numeric modifiers with one modification. The five digit modifiers identified in the CPT are not included in these definitions since the Medicare program does not recognize reporting modifiers in this format. The HCPCS (Health Care Financing Administration's Common Procedure Coding System) alpha modifiers were developed by the Health Care Financing Administration for use in the Medicare program. Local alpha modifiers were developed by Pennsylvania Blue Shield to address situations not included in CPT-4 or HCPCS. For some of these modifiers, additional clarification (shown as indented text) has been added, as well as examples. Other modifiers are selfexplanatory; no additional comment is provided. Modifiers provide the means by which the reporting provider can indicate a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.
Modifiers may be used to indicate that:
•
a service or procedure has both a professional and technical component
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•
• • • •
a service or procedure was performed by more than one physician a service or procedure has been increased or reduced only part of a service was performed an adjunctive service was performed a bilateral procedure was performed a service or procedure was provided more than once unusual events occurred Anesthesia One of the following modifiers must be reported with anesthesia services to indicate who performed the anesthesia service:
•
•
AA - Anesthesia services performed personally by anesthesiologist AD - Medical supervision by a physician: more than four concurrent anesthesia procedures
•
•
QJ - Medically directed by a physician: two concurrent procedures (for services prior to January 1, 1995)
•
QK - Medically directed by a physician: two, three, or four concurrent procedures (effective for services on or after January 1, 1995)
•
QO - Medically directed by a physician: three concurrent procedures (for services prior to January 1, 1995)
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•
QQ - Medically directed by a physician: four concurrent procedures (for services prior to January 1, 1995)
• • •
QY - Anesthesiologist medically directs one CRNA QX - CRNA service: with medical direction by a physician QZ - CRNA service: without medical direction by a physician
The following modifier is reported in addition to one of the above modifiers to indicate that monitored anesthesia care was provided:
•
QS - Monitored anesthesia care service
Global Surgery The following modifiers are used by physicians to indicate a billed service is not part of a global surgical package and is eligible for separate reimbursement: 24 - Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.
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An excision of a malignant lesion on the left arm is performed in the office on May 10, 1998. The ICD-9-CM diagnosis code reported is 171.2. The postoperative period designated for excision code 11606 is 10 days. The patient returns to the office on May 15, 1998 and is treated for contact dermatitis, ICD-9-CM code 692.0. The physician should report the
appropriate evaluation and management code followed by the 24 modifier, e.g., 9921224. In order for the evaluation and management service to be payable in the post-operative period with the 24 modifier, the diagnosis code supporting the E/M service must be different from the diagnosis code reported for the previously performed surgery. Modifier 24 should not be used for the medical management of a patient by the surgeon following surgery. Medicare recognizes modifier 24 only for the care following a discharge under these circumstances: The care is for immunotherapy management furnished by the transplant surgeon; The care is for critical care (99291, 99292) for a burn or trauma patient under diagnosis codes 800.0-929.9, 940.0-959.9; or
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The
documentation
demonstrates
that
the
visit
occurred
during
a
subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery. 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of thre E/M services on the same date. This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed with the 25 modifier in addition to billing for suturing a scalp wound if a full neurological examination was made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures
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and confirmed allergy and immunization status. In the circumstance when the decision to perform a minor procedure is typically done immediately before the service, (e.g., whether or not sutures are needed to close a wound, whether or not to remove a mole or wart, etc.) it is considered a routine preoperative service and a visit or consultation should not be reported in addition to the procedure. Effective immediately for dates of service on or after January 1, 1997, separate payment may be made for an initial hospital visit (CPT codes 99221-99223), an initial inpatient consultation (CPT codes 99251-99255) and a hospital discharge service (CPT codes 99238 and 99239) when billed by the same physician for the same date as an inpatient dialysis service (CPT code 90935-90947). It is no longer required that these evaluation and management services be unrelated to the treatment of the patient's ESRD in order for payment to be made. However, the 25 modifier must still be reported with these evaluation and management services in order to indicate that they are significant and separately identifiable services. Physicians may request reviews of previously denied services. 57 - Decision for Surgery. An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.
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E/M services on the day before or on the day of major surgery ( 90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment. These E/M services may be billed separately and identified with the 57 modifier. This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period ) unless the purpose of the visit is a decision for major surgery. This modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure. See modifier 25. 58 - Staged Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was planned prospectively at the time of the original procedure. This
circumstance may be reported by adding the modifier 58 to the staged procedure. Note: Medicare policy limits the use of this modifier to staged procedures. The CPT-4 definition of this modifier is broader in scope. This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier 78.
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It would not be appropriate to report this modifier for codes which indicate in the terminology "one or more sessions", e.g., 66761, 67141, 67227. These codes are defined by CPT-4 as consisting of one or more sessions. The relative value units represent the work for the total number of sessions necessary for completion of the procedure. Therefore, subsequent sessions performed within the global period of the initial surgery are included in the global fee. 59 - Distinct Procedural Service: Under certain circumstances, a provider may need to indicate that a procedure or service was independent from the services performed on the same day. See Appendix C (Correct Coding Initiative) for more information regarding the use of modifier 59. 78 - Return to the Operating Room for a Related Procedure During the Postoperative Period: The Physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the 78 modifier to the related procedure. When treatment for complications requires a return trip to the operating room, physicians must bill the CPT-4 code that describes the procedure (s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, e.g., 47999 or 64999. In this situation,
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you must include operative notes with the claim or a narrative description which will allow us to understand the extent of the service performed. The procedure code for the original surgery is not used except when the identical procedure is repeated. An operating room for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit ( unless the patient's condition was so critical there would be insufficient time for transportation to an operating room). A partial colectomy is performed in the hospital on March 1, 1999. The postoperative designation for this procedure (code 44140) is 90 days. On March 15, 1999, the patient is returned to the operating room for a secondary suture of the abdominal wall. This procedure should be reported as 4990078. 79 - Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79.
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A repair of a femoral hernia (49550) is performed on January 5, 1999. The postoperative period designation for this procedure code is 90 days. On February 12, 1999, the same physician performs an appendectomy. The physician should report the appendectomy as 4495079. Surgical 50 - Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier 50to the appropriate five digit code. Report such procedures as a single line item with a unit of 1. For example, when procedure code 19180 (Mastectomy, simple, complete) is performed bilaterally, report the service as 1918050. If a procedure is identified by the terminology as bilateral ( or unilateral or bilateral), do NOT report the procedure code with modifier 50. For example, procedure code 68810 to 68815, (probing of nasolacrimal duct, with or without irrigation, unilateral or bilateral) includes terminology which indicates the procedure is performed either unilaterally or bilaterally. Therefore it's not appropriate to report this modifier with this code. Additionally some procedure codes, i.e., 52000 (Cystourethroscopy,
separate procedure) should NOT be reported with the 50 modifier since anatomy does not permit this procedure to be performed bilaterally.
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51 - Multiple Procedures: When multiple procedures, other than evaluation and management services, are performed on the same day or at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated "add-on" codes (e.g., 22612, 22614). For more information, please reference chapter 22, section 22.1 53 - Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure. Use modifier 53 (discontinued procedure) to report a failed or terminated colonoscopy, or a failed or discontinued procedure. Documentation
describing the circumstances requiring the discontinuation of a procedure should be provided with the claim submission. If this information is NOT included, your claim may be denied.
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Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled f
procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 54 - Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative
management, surgical services may be identified by adding the modifier 54 to the usual procedure code. Services billed with a 54 modifier will be reimbursed at the intraoperative allowance for the surgical procedure. The intraoperative allowance includes the one day preoperative care, the intraoperative service, as well as any inhospital visits that are performed. 55 - Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number.
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This modifier is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient's postoperative care by reporting the
appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. 62 - Two surgeons: Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances the separate services may be identified by adding the modifier 62 to the procedure number used by each surgeon for reporting his services. Under some circumstances the individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and /or the patient's condition.
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If two surgeons, usually with different skills, are required to perform a single surgical procedure, each surgeon bills for the procedure with modifier 62. Co-surgery also refers to single surgical procedures involving two surgeons performing the parts of the procedure simultaneously, e.g., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified by the Health Care Financing Administration. 66 Surgical Team: Under some circumstances, highly complex
procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier 66 to the basic procedure number used for reporting services. Documentation establishing that a surgical team was medically necessary is required for certain services identified by the Health Care Financing Administration. All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing "by report". 73 - Discontinued out-patient hospital/ambulatory surgical center (ASC) procedure prior to the administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when
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provided, and being taken to the room where the procedre is to be preformed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier 73. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical reparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53. 74 - Discontinued out-patient hospital/ambulatory surgical center (ASC) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, incubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier 74. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.
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80 - Assistant Surgeon: Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number (s). This modifier should be reported to identify surgical assistant services performed in a non-teaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare. When the surgical services are performed in a non-teaching setting, report "Non-teaching" in the narrative section of an electronic claim submission, or in Block 24D for paper claims. Note: Please reference Chapter 22 for more information on assistant surgery reporting requirements. 82 - Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number (s). This modifier is used in teaching hospitals if there is no approved training program related to the medical specialty required for the surgical procedure or no qualified resident was available.
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Health Professional Shortage Area (HPSA) These modifiers are used by physicians to indicate the services reported were rendered in a qualified Health Professional Shortage Area (HPSA) and are eligible for the 10% incentive payment.
• •
QB - Physician providing service in a rural HPSA QU - Physician providing service in an urban HPSA
Additional CPT Modifiers 22 - Unusual Procedural Services: When the service(s) provided is greater than what is usually required for the listed procedure, indicate this by adding modifier 22 to the procedure code. A report is also required. For services on the physician fee schedule, modifier 22 is applicable only to those procedure codes for which the global surgery concept applies, whether the procedure code is surgical in nature or not. Supportive documentation, e.g., operative reports, progress notes, order sheets, pathology reports, etc., must be submitted with the claim. Note: Modifier 22 will be removed when reported with procedures that do not have a global surgery period of 0, 10, or 90 days.
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26 - Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. 52 - Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Use modifier 52 (reduced service) to indicate a service or procedure is partially reduced or eliminated at the physician’s election. When you report modifier 52, include office records, test results, operative notes, or hospital records to substantiate the reason for reporting a reduced service. If this information is NOT included, your claim may be denied. Note: Effective January 1, 1999, for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the wellbeing of a patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 76 - Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original
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service. This circumstance may be reported by adding the modifier 76 to the repeated service. Note: When it is medically necessary to repeat a service, the first service should be reported in the usual manner. The repeat service should be reported on the next line with modifier 76 appended to the procedure code. In the event it is medically necessary to repeat a procedure more than twice, report the second line with the 76 modifier and the appropriate number of units in the units field. If a service is repeated more than once, additional documentation should be provided in the narrative field of the claim to support the medical necessity of the repeat services. The patient's medical records must always document the medical necessity of performing repeat procedures and be available to the carrier upon request. 77 - Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated service. 90 - Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier 90 to the usual procedure number. For the Medicare program, this modifier is used by independent clinical laboratories when referring tests to a reference laboratory for analysis.
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91 - Repeat clinical diagnostic laboratory test: In the same course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. (Note: Effective for dates of service 1/1/2000 and after.) 99 - Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure and other applicable modifiers may be listed as part of the description of the service. Note: This modifier should be used by providers submitting claims electronically when it is necessary to report more than two modifiers. In this situation, other applicable modifiers should be reported in the narrative portion of the electronic claim.
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Additional HCPCS Modifiers
• • •
AH - Clinical Psychologist AJ - Clinical Social Worker AM - Physician, team member service EJ - Subsequent claims for a defined course of therapy, e.g., EPO, Sodium Hyaluronate, Infliximab.
•
• • • •
E1 - Upper left, eyelid E2 - Lower left, eyelid E3 - Upper right, eyelid E4 - Lower right, eyelid
Note: These modifiers can be used to specify on which eyelid services were performed. Comprehensive and component code combinations performed on different eyelids are separately payable.
• • •
FA - Left Hand, thumb F1 - Left hand, second digit F2 - Left hand, third digit F3 - Left hand, fourth digit F4 - Left hand, fifth digit F5 - Right hand, thumb F6 - Right hand, second digit F7 - Right hand, third digit F8 - Right hand, fourth digit
•
• • • • •
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•
F9 - Right hand, fifth digit
Note: These modifiers can be used to indicate that rebundled services were performed on different digits. Separate payment will be allowed when column I & II services are performed on different digits. See Appendix C for comprehensive and component code combinations.
•
G6 - ESRD patient for whom less than six dialysis sessions have been provided in a month
•
G7 - Pregnancy resulted from rape or incest or pregnancy certified by physicians as life threatening
•
GA - Beneficiary authorization
Effective for dates of service on and after October 1, 1995, report this modifier to indicate that advance written notice was provided to the beneficiary of the likelihood of denial of a service as being not reasonable and necessary under Medicare guidelines. See chapter 6, page 6-6.1 for example of written notice. GC - This service has been performed in part by a resident under the direction of a teaching physician. GE - This service has been performed by a resident without the presence of a teaching physician under the primary care exception. Note: GE, for this purpose, is for use on all services except ambulance.
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GH - Diagnostic mammogram converted from screening mammogram on the same day GN - Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care GO - Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care GP - Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care GT - Via interactive audio and video telecommunication systems GX - Service not covered by Medicare Note: Effective January 1, 1999, when a beneficiary refuses to have an xray, the claim must be billed using the correct chiropractic HCPCS code (98940, 89841, or 98942) along with the new GX modifier. QA: - FDA investigational device exemption. FDA-approved investigational devices and/or services incident to the use of such devices should be billed using the appropriate HCPCS code and the QA modifier. When billing a service with the QA modifier, you are certifying FDA approval of a clinical trial or the device and that the device was approved at the time the service was rendered.
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The FDA will issue an investigational device exemption (IDE) number that corresponds to each FDA-approved device that has been granted an investigational device exemption. Providers must obtain the investigational device exemption number from the manufacturer supplying the device in the clinical trial. LT - Left side (used to identify procedures performed on the left side of the body) If used to substantiate different body sites, this modifier can exclude services from rebundling. Q1 - Documentation on file for ambulatory or non-ambulatory patients that indicates mycosis/dystrophy of the toenail causing secondary infection and/or pain which results or would result in marked limitation of ambulation and require the professional skills of a provider. Note: This modifier is applied to ambulatory as well as non-ambulatory patients. Documentation that these conditions exist must be maintained in the patient's file. Q3 - Live kidney donor: services associated with postoperative medical complications directly related to the donation. This modifier is effective for services furnished on or after January 1, 1995.
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These postoperative services will be reimbursed at 100% of the allowed charge as required in Section 1881 (d) of the Social Security Act. The following bullets are some reporting notes and tips for submitting kidney donor services: In the event that more than two modifiers are required when reporting postoperative physician services furnished to live kidney donors, it is important that the Q3 modifier is reported in the first modifier position. This is necessary to ensure that these services are reimbursed at 100%. Services are to be reported under the name and HIC number of the recipient of the kidney donation. Procedure code 50320, Donor nephrectomy from living donor, should continue to be reported with the YA modifier to be reimbursed at 100% of the allowed charge.
•
Q4 - Service for ordering/referring physician qualifies as a service exemption for laboratory services
•
Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement
•
• • • •
Q6 - Service furnished by a locum tenant physician Q7 - One Class A Finding Q8 - Two Class B Findings Q9 - One Class B and Two Class C Findings Note: Modifiers Q7, Q8, and Q9 are effective for dates of service on and after October 1, 1995 and are to be used to bill podiatric services.
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•
QP: - Documentation is on file showing that the lab test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes 80002-80019, G0058, G0059 and G0060.
•
QR - Repeat clinical diagnostic laboratory test performed on the same day to obtain subsequent reportable test value(s) (separate
specimens taken in separate encounters.) (This modifier should not be used for dates of service after 12/31/1999. See modifier -91.) • QW - CLIA Waived Tests (Please reference appendix Ha for additional information.) • QY - Medical Direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist. • RT - Right side (used to identify procedures performed on the right side of the body) If used to substantiate different body sites, this modifier can exclude services from rebundling.
•
SF - Second opinion ordered by a Professional Review Organization (PRO) per section 9401, P.L.
•
99-272
(100
%
reimbursement
-
no
Medicare
deductible
or
coinsurance)
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SG - Ambulatory surgical center (ASC) facility service This modifier is only used by the ASC for identifying the facility charge. It should not be reported by the physician when reporting his/her professional service rendered in an ASC.
• •
TA - Left foot, great toe T1 - Left foot, second digit T2 - Left foot, third digit T3 - Left foot, fourth digit T4 - left foot, fifth digit T5 - Right foot, great toe T6 - Right foot, second digit T7 - Right foot, third digit T8 - Right foot, fourth digit T9 - Right foot, fifth digit
•
• • • • • • •
Note: These modifiers can be used to indicate that comprehensive or component code combinations were performed on different digits. Separate payment will be allowed when column I & II services are performed on different digits. See Appendix C (New Correct Coding Combinations). TC - Technical component: Under certain circumstances a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure code number.
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W7 - Kidney Donor (see modifier Q3 for more information) XJ - Course of treatment has ended (radiation therapy) This modifier is used to indicate the course of treatment for radiation therapy has ended. If this modifier is not reported, additional fractions will be denied. YR - Services performed by another provider but billed as services performed "incident to" the personal professional services of the billing physician/non-physician. Beginning January 1, 1997, services provided `incident to' the personal professional services of a physician/non-physician must be billed using the YR modifier. The YR modifier is intended to be attached to all personal professional services performed `incident to' which may be identified by a CPT or HCPCS level I or II code. In general, `incident to' services are services performed by a physician's or non-physician provider's employee, but reported on the claim as if the billing physician or non-physician provider has provided the service. YY - Second surgical opinion (See modifier SF for PRO-ordered services) ZD - Routine non-covered services Services reported with this modifier will be denied as non-covered.
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ZP - No purchased services (*) DO NOT REPORT THIS MODIFIER * Effective with claims received on or after June 23, 1998, do not report the ZP modifier with diagnostic service. If the technical portion of the diagnostic services was NOT purchased block 20 (or electronic equivalent) should be checked “NO”. If the technical portion of the diagnostic service was purchased, blocks 20 and 32 of the CMS 1500 claim form (or electronic equivalent) must be completed to meet purchased service criteria. ZX - Medical necessity for portable Xray suppliers and independent physiological laboratories DO NOT REPORT THIS MODIFIER Note: Providers/Suppliers are required to maintain medical necessity documentation on file. ZZ - Third surgical opinion.
10. Diagnosis Code: Diagnosis code is used to indicate the health problem
that a patient have. The first of these codes is the ICD-9-CM diagnosis code describing the principal diagnosis (i.e. the condition established after study to be chiefly responsible for causing this hospitalization). The remaining codes are the ICD-9-CM diagnosis codes corresponding to additional conditions that coexisted at the time of admission, or developed
subsequently, and which had an effect on the treatment received or the length of stay. Medicare requires physicians to include a complete diagnosis code (or codes) on each claim submitted for payment. The first of these codes is the ICD-9-CM (International Classification of Diseases Ninth
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Revision Clinical Modification) diagnosis code describing the principal diagnosis (i.e. the condition established after study to be chiefly responsible for causing this hospitalization). A Maximum of 4 diagnosis codes can be printed on the CMS-1500 claim form.
This field is printed in the 21st field of the CMS-1500 claim form.
11.
Number of days/Units: This field contains the length of service performed. We need to enter number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service was performed the numerical 1 should be entered.
12. Billed Amount: It is the amount charged by a provider for a specific
service. In other words it is the total charge value of the claim. The billed amount for a specific procedure code is based on the provider.
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MEDICAL BILLING – CASH POSTING
What is Cash Posting?
Cash posting is a process by which the payments received from insurance companies, patients and other entities, towards settlement of claims, applied to the respective claims / patient accounts or other accounts in the billing system. Cash team receives the cash files (Check copy and EOB) and applies the payments in the billing software against the appropriate patient account. During cash posting, overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Also underpayments/denials are informed to the Analysts.
How the cash is generated, received and posted?
The charges submitted to the insurance will be processed payment is made according to the fee schedule. The insurance pays the cash through checks which is deposited in the specified banks date-wise. Each check has its own unique number and date on which the check was issued. The checks along with the claim details are received by the Billing Office in U.S who in turn groups a certain amount together and sends to the billing office here. The details which are received with the checks are known as the EOB (Explanation of Benefits).
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The Billing office in U.S scans the Checks and EOB details to the Billing Office here. The Billing Office here receives the scanned documents as files. The received files are then collected by the cash poster who gives the file reference numbers based on the date on which the file was received. Then the cash poster matches the checks with the EOB details. This process is termed as file sorting or Check matching. Now the file had been sorted and the details are posted in the Software which is called as the Cash Posting.
Electronic Posting
Cash posting can be done either manually or electronically. During manual posting the above said methods are carried on whereas in case of electronic posting the amounts deposited in the bank gets transmitted electronically to the billing office here. The transmitted details are known as Electronic File Transfer i.e. EFT’s. This Eft’s are received by the cash poster with the insurance reference
number. Then the Cash poster retrieves the transmitted details and starts posting the cash electronically. In this posting the amounts that are allotted to the claims get identified by the software itself and the respective amounts are posted, for which the detailed EOB’S will be received later.
Once the posting is over the amount posted in the software is tallied with the amount received. Then a detailed report containing the claim and its posting details are taken which is helpful for any future references.
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General Terms associated with Cash posting and their definitions:
•
Claim: Forms submitted for payment of physician services, other medical
services and supplies provided to Insurance beneficiaries. It is an itemized statement of healthcare services and their costs provided by hospital, physician's office or other healthcare facility. A charge when filed to insurance becomes a claim.
•
Insurance Claim number: It is the number given by the insurance to the claim in order to identify
the claim in case of reference. Some insurance companies address the claim with the help of the claim number. It can be of the combination of any numeric values along with the alphabetical values. It is insurance specific and no general format is there for this. For Example: - 12345ABXCQ78.
•
EOB: It is defined as Explanation of Benefits. This contains the claim details,
the amount paid by the insurance, Co-pay / Co-insurance amount and write-off amount. It also contains the patient name, patient address, patient account number, SSN, insurance name, insurance address, insurance contact numbers and it’s customer care numbers (if any). If insurance does not pay the claim then the reason for which the claim was not paid i.e. the denial reason is also mentioned in
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EOB. In simple words it can be defined as the detailed explanation of the benefits provided by the insurance for the claim. Some insurance like Medicare have their own format of EOB. For Example:EOMB (Explanation of Medicare Benefits) contains a statement detailing the amount of benefits paid or denied for services under the Medicare program.
•
Billed amount: It is the Amount charged for each service performed by the provider.
In other words it is the total charge value of the claim. The billed amount for a specific procedure code is based on the provider. It may vary from place to place. It is not common across all the states.
•
Allowed amount: The maximum reimbursement the member's health policy allows for a
specific service. It is the maximum dollar amount assigned for a procedure based on various pricing mechanisms. Allowed amounts are generally based on the rate specified by the insurance. This amount may be: -a fee negotiated with participating providers. -an allowance established by law. -an amount set on a Fee Schedule of Allowance. For Example:If the billed amount is $100.00 and the insurance allows $80.00 then the allowed amount is $80.00 and the balance $20.00 is the write-off amount.
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Formula: Allowed amount = Amount paid + co-pay / co-insurance + Deductible • Paid amount: It is the amount which the insurance originally pays to the claim. It is the balance of allowed amount – Co-pay / Co-insurance – deductible. The paid amount may be either full or partial. i.e. Full allowed amount being paid or a certain percentage of the allowed amount being paid. For Example:If the billed amount is $100.00 and the insurance allows $80.00 but the payment amount is $60.00. Here $60.00 is the actual amount paid for the claim. Formula: Paid amount = Allowed amount – (Co-pay / Co-insurance + Deductible) • Co-pay: The fixed dollar amount that patient requires to pay as patient’s share each time out of his pocket when a service is rendered. This is paid during the time of the visit. Co-pay ranges from $5.00 to $25.00. Co-pay’s are usually associated with the HMO plan. The Co-pay amount is usually specified in the insurance card copy.
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•
Co-insurance: Co-insurance is the portion or percentage of the cost of covered services to be paid either by insurance or patient. After the primary insurance making payment the balance of the cost covered (Co-insurance) will be sent to secondary insurance if the patient has one or to the patient.
For Example:If the billed amount is $100.00 and the insurance allows @80%. The payment amount is $60.00 then the remaining $20.00 is the co-insurance amount. Formula: Co-insurance = Allowed amount – Paid amount – Write-off amount.
•
Deductible: Deductible is the amount the patient has to pay for his health care
services, whereas only after the patient meets the deductible the health insurance plan starts its coverage. The patient has to meet the Deductibles every year. It is mostly patient responsibility and very rarely another payor pays this amount.
•
Posting Reference Number:
This is the number which is given by the operator to the claims posted in order to keep track of the payment posted details. This is generally given in a specified format as per the client requirement.
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For Example:01.3651.123103 here the 01 refers to the serial number, 3651 refers to the batch number and 123103 refer to the date and the year on which the file was received by us.
•
Offset: This is a kind of an adjustment which is made by the insurance when
excess payments and wrong payments are made. If insurance pays to a claim more than the specified amount or pays incorrectly it asks for a refund or adjusts / offsets the payment against the payment of another claim. This is called as Offset.
For example:Let the total billed amount of two claims is $100.00 each and the specified payment for this is $80.00. The insurance pays $90.00 for the first claim. Here $10.00 is paid in excess. Now while making payment for the second claim the insurance pays $70.00 and sets $10.00 as offset. Now the insurance payment becomes normal as the excess payment had been adjusted off.
•
Refund: This is the process of returning back the excess money paid by the
insurance / patient on request. If payment is received in excess than the specified amount, insurance / patient request for a refund. The process of Refund is usually done as per the client specifications. For example:-
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Let the total billed amount of a claim be $100.00 and the specified payment for this is $80.00. The insurance pays $90.00 for the claim. Here $10.00 is paid in excess. Now the insurance requests for a refund of $10.00 which will be done as per the client specifications.
•
Adjustment: An adjustment is an amount which had been adjusted for some reason
and may be recoverable. It can be an additional payment or correction of records on a previously processed claim. Adjustments are done based on the client instructions. One specific type of adjustment is the write-off.
For Example:Let the billed amount of a claim be $100.00 and the paid amount is given as $70 and $ 30 is given as participating providers adjustment. So this $ 30 has to be adjusted.
•
Write-Off:- It is an amount which cannot be recovered at all. This writeoff is usually done when the insurance payments are made. It is the balance of what the insurance have allowed on a particular charge i.e. Total Billed amount – Allowed amount. The main difference between an adjustment and write-off is that Adjustment may be recovered whereas write-off cannot be recovered at all.
For Example:-
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If the billed amount is $100.00 and the insurance allowed amount is $80.00. The payment amount is $80.00 then the remaining $20.00 is the write-off amount.
•
Denial :
Denial is the technical term used for the non-payment of a claim by the insurance. The insurance usually pays the claim if the details presented to them are sufficient enough for processing. If there is any lack of information then the insurance quotes a reason for which the claim is not considered for payment which is known to be the denial reason. These reasons are found in the EOB. Some insurance like Medicare follow a general set of denial codes which is uniform across all the states. But some commercial insurance follow their own set of reasons codes for the denials which will be clearly mentioned in the EOB. For Example:If the claim has gone to the insurance without the patient date of birth then the insurance will not pay the claim stating a denial reason code to it.
•
Balance Billing:
It is the difference between the billed amount and the amount approved by insurance. Once the claim payment had been made by the primary insurance and if there is any balance pending for the claim then the balance is either sent to the secondary payor or to the patient. If the patient is enrolled with the secondary payor then the balance is billed to it. Generally for secondary billing the claim must be submitted
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along with the primary payor’s EOB. Only then the secondary payor will pay for the claim. In secondary billing primary payor EOB is the most important document. Some insurance like Medicare automatically transfers the pending balance to the secondary payer (Medicare Supplementary) if the patient has any. This procedure is termed as Crossover which reduces the work of the billing office. If the patient is not enrolled with the secondary payor then the balance is billed to the patient. Patient billing cannot be done at all the cases. For certain cases we need the client’s approval for patient billing. Periodic
patient statements are sent to the patient in order to intimate the balance which is pending from patient.
•
Capitation Payment
Specified amount paid periodically to the provider for a group of specified health services, regardless of quantity rendered. This is a method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered. The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. It is a payment system where managed care plans pay the health care providers a fixed amount to care for a patient over a given period. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member.
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MEDICAL BILLING – ACCOUNTS RECEIVABLES
What is Account Receivables?
Receivables are defined as amounts due and expected to be collected by billing / provider’s office for the services provided to individuals. In Medical Billing, receivables are handled by Account Receivables Department. Account Analyst
plays a crucial role in identifying and resolving issues which helps to reduce or clear receivables.
What is the purpose of Claims review & AR Analysis?
The purpose of claim analysis is to identify and resolve medical claims billing and reimbursement issues toward maximizing collections and minimizing accounts receivables. It helps to ensure timely, accurate and final settlement of health insurance claims and patient bills by insurers or patients as appropriate. The scope of claim analysis is applicable to all health insurance claims and patient bills that have not been fully and finally settled by liable party or parties comprising health insurers, patients and others. It is the responsibility of the Accounts Receivables Analyst to ensure that AR is under control & acceptable by industry standards.
What is the scope of AR Department?
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AR Department has to ensure steady inflow of money from the insurance company. The main motive of this department is to collect money for all the Usually the turn around
treatments taken by the patients in a timely fashion.
period for the payment by the insurance company is 30 – 45 days. Once the limit is exceeded AR department has to make an enquiry for the delay. various reasons for the delay like: e) Correct details may not have been provided to the insurance companies. f) Claims were sent correctly but Insurance Company may not have received the claims. g) The checks issued might have been sent to the wrong address. h) The insurance company may delay the payments if they have a backlog and they would inform us by a letter that they have received the claims and would be making the payments shortly. There are
AR department acts as a hub around which other departments revolve.
This
department can gather & update lot of billing information which is required to settle a claim. Account analyst uses various reports available in billing software to identify claims which have not been settled.
The Medical billing software is capable of running reports that pull out claims that are unpaid for greater than 30 days. These are called aging reports and these reports show pending payments in slots such as 0 – 30 days, 31-60 days and 6190 days. Claims filed within the last 30 days will find themselves in the first slot (0-30days). Claims that are more than 30 days but less than 60 days old will be
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found in the 31-60 days slot. A glance at this report will show the AR personnel the claims that need to be followed up on with the insurance company.
Claims will be followed up over the telephone or by written correspondence.
It
would be necessary to find out why the claims are yet to be paid and what needs to be done to have these claims paid. The delay and denials will be corrected by the billing office in coordination with the physician’s office and the insurance carriers. The same applies when patient billing statements are sent out. The
patient is given 3-4 weeks to pay the bill and if the payment is not received with in that time, the billing office will follow up with the patient
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Accounts receivables - calling
Medical accounts receivable follow-up involves following up with entities such as Insurance carriers, Physicians, Hospitals and patients for information required to resolve the pending accounts at the earliest. Calling is a support media for A/R Analyst to close an outstanding account. Calling is done on accounts which are outstanding for more than 40 days and for which no correspondence has been obtained.
Calls are made to the following entities by an AR representative:
Insurance carriers Hospitals Physicians office Patients
Insurance carriers
Calls are made to insurance carriers for the following reasons:
1. Patient eligibility verification
Calls are made to the insurance carrier to confirm on the eligibility of the insured, the type of insurance the subscriber has with the respective insurance and/or the benefits that are covered by the insurance.
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2. Provider enrollment department Calls are made to the insurance carrier to confirm on the provider enrollment details. In order to check whether the provider is participating with the insurance and/or to enroll the provider with the insurance carrier.
3. Claim status Calls are made to insurance company to enquire about the status of a claim that has already been filed to them, but for which there has been no correspondence from the insurance company for over 40 days.
Hospitals
Calls are made to the hospitals to check on the pre-authorization, pre-certification, to confirm on medical records and also to check on patient’s coverage information in case a contact cannot be established with the patient.
Physician’s office
Calls are made to the physician’s office/PCP office to obtain and confirm on the referrals, to confirm on the patient’s coverage information incase a contact cannot be established with the patient.
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Patients
Calls are made to the patient to confirm on the insurance policy details, to obtain and confirm on the patient’s other insurance details or to inform the patient about their responsibility that is due from them to the doctor. Under whose name do we call carriers & patient’s? Calls are made to patients and insurance companies, hospitals, physician’s office under the client’s name. Thus the carriers and patients would have no way of knowing that they are being called from an outside firm, but rather the clients’ in house collections department. Who receives the payment collected by the ar representative? The accounts receivables would be managed under the client’s name, therefore the payments would be made directly to the client account as specified.
Calling – classification
Inbound: Calls that the office receives from patients, insurance carriers etc is termed as inbound. Patients call the billing office to check on the payments and on clarifications when statements are sent to them periodically. Insurance carriers call the billing office when a message is left for them to call us back and/or for clarifications on claims that have been filed with them.
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Outbound: Calls that our office makes to the insurance carriers, patients, hospitals, provider’s office etc are termed as outbound.
Calls are made to insurance carriers to check on patient eligibility, provider enrollment details and/or to check the status of the claim that is filed. Calls are made to the patient to follow-up on the payments, to confirm if the statements sent have been received by them and also to check on their insurance coverage information Calls are made to the hospitals, provider’s office to check on the authorization details.
Abbreviations to update patient notes
Cld TT CPT Dnd DOS PCP Auth# POS EOB EOMB : Called. : Talked to. : Current Procedural Terminology. : Denied. : Date Of Service. : Primary Care Physician. : Authorization number. : Place Of Service. : Explanation of Benefits. : Explanation of Medicare Benefits.
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Chk Pt Proc Clm Diag Ins Pd Amt NIS
: Check. : Patient. : Procedure code. : Claim. : Diagnosis. : Insurance : Paid : Amount : Not in system
Script on how to call insurance for status of a claim
Sample 1 Good morning, this is ……… calling from ………………. (name of the physicians office) to check the status of the claim. (If the rep asks for the provider/ tax id #)…… The Dr’s provider/tax id# is …………. The patient’s ID# id ………………., the patients name is ………………. And the DOS is ………………. For a billed amount of ……………… (If the claim has been paid, ensure all the check points for a paid claim is verified and confirmed.) Thank you for your kind assistance. Have a great day.
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Sample 2 Good morning, this is ……… calling from ………………. (name of the physicians office) to check the status of the claim. (if the rep asks for the provider/ tax id #)…… The Dr’s provider/tax id# is …………. The patient’s ID# id ………………., the patients name is ………………. And the DOS is ………………. For a billed amount of ………………. (If the claim has been denied, ensure all the check points for a denied claim are verified and the reason for the denial is obtained). Thank you for your kind assistance. Have a great day.
Sample format for update Notes: Called Insurance…………. . TT …………….. . She said that the DOS ………….. for the billed amount………….. paid …………. On …………. Chk# is ………………… bulk check in the amount of……….. Claim processed on…………. The copay is…….. the co-insurance is ………. And the
patient responsibility is …………. The check was mailed out to ……………. (address) and the check is still ………. (out-standing).
The AR Process is completed only when the necessary action is taken after the calls has been made and has the claim reprocessed and converts the pending claims into receipts/cash. It has also to be noted that when ever a new update pertaining to claims processing is received, the information should be shared with the other departments so that the speed of the collection is increased and the denials are reduced.
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COMMON PHONETICS
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z (zee) As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in As in Apple Boy California David Edward Frank Girl Henry Indiana Jack Kite Larry Mary Nancy Orange Peter Queen Robert Sam Tom Umbrella Victory Whisky X ray Yellow Zebra
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ISSUING WORK ORDER
1) 2) 3) 4) Age of the Pending Claim Billed Amount Timely filing limit of the insurance company/carrier. Based on denials received.
Based on the Age the claims are classified in to 5 different age groups. • • • • • • 0-30 days: Claims falling under 30 days from the date of first filing. 31-60 days: Claims greater than 30 days but less than or equal to 60 days from the date of first filing. 61-90 days: Claims greater than 60 days but less than or equal to 90days from the date of first filing. 91-120 days and: Claims greater than 90 days but less than or equal to 120 days from the date of first filing. 120 - 150 days: Claims greater than 120 days but less than or equal to 120 days from the date of first filing. 150 days: Claims greater than 150 days.
The analyst sees that all the claims are followed up and necessary actions are taken and callbacks are set for further course of action. Work-orders issued based on the Billed amount The claims with highest billed amount are identified and the same is placed for calling. And the necessary actions are taken as per the feedback from the night caller. Work-orders issued based on the Timely-filing limit of the carrier The insurance company/carriers with very short span of time for timely filing is identified and the claims pertaining to those carriers are given for calling on priority and necessary actions are taken based on the feedback from the night callers. Work-orders issued based on the Denials The insurance company may send denials alone in their own format to the Providers to know the denial reason for which they denied the claims. Those
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denials will be given for calling and the necessary actions taken based on the feedback from the night callers.
Procedures Followed For Issuing The Work-Orders:
a) The Ledger print outs are given to the night callers for their convenience. b) On the ledger print out the analyst writes in short the previous issues of the claim and also notes down the points that is to be enquired with the carrier. Denials and action to be taken: Callers with the help of the notes given by the analyst, calls the carrier and gets the needed information from the callers. To check for the status of the claim: Analyst: Pending Claims above 30days which is not followed-up is given for Status call. Caller: Gets the status from the carrier, May be a) Payment details b) The denial reason c) Claim Not in system etc., Based on the call the necessary action is taken by the analyst. a) Payment Details: The caller should get the following when he is asking for the payment details. Check # Check Date Check Amount Pay to Address Cashed detail Insurance Verification Analyst: There may be cases were the charge dept/analyst may require to know the correctness of the Member id# or the Mailing address etc of the patient with the carrier. Caller: Gets the mailing address, confirms the id# and other information. The caller should get the following details. Mailing address Member Id# Effective date Authorization # required or not Provider is Par or Non-Par Based on the call information’s are checked and the corrective actions are taken.
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Eligibility of the Patient’s Coverage Analyst: Asks the caller to check for the validity of the coverage with the carrier. Caller: Calls the carrier, confirms the validity of the coverage, and gets the effective date and the termination date wherever possible. Based on the call the necessary action is taken. Check why the Procedure code was not considered Analyst: Would have received the E.O.B wherein one of the line item is not considered for payment, so the analyst asks the caller to check for the reason for having not considered the line-item. Caller: Gets the reason for the procedure code not being considered, say line-item missed from being considered, denied for some reason, but the reason was not specified in the E.O.B or the claim is sent for review and so the same will be paid/denied in due course of time. Based on the feedback the necessary action is taken, say a Callback date is set. Claim Denied stating, “Lacks information needed for Adjudication” Analyst: Receives an E.O.B with a particular procedure code denied with the above reason. Asks the caller to get the exact reason for the denial. Caller: Calls the carrier and gets the exact reason-Reason being “The claim should be submitted along with the additional documents/Medical Notes to process the claim”. Based on the feedback from the caller the analyst sends a mail or Spread Sheet to the Clients office requesting for Medical Notes. Once after receiving the same claim is re-filed along with the medical records to the carrier. Claim Denied stating “Diagnosis inconsistent with the Procedure code billed” Analyst: Based on the denial received the analyst first sends nail/Spread Sheet to the coding department to re-code the charge sheet with the correct Diagnosis, after completion the same is given to the caller to update the new diagnosis in their (carrier) system by telephonic conversation. Caller: If accepted by the Rep, the new diagnosis is updated in the carriers system or else the rep, requests for resubmission of the claim. Based on the call made either the claim is marked for call back or else it is re-filed with the new diagnosis.
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Claim denied stating “No authorization on file” Analyst: If there is authorization # present in the system then, the analyst gives the same to the caller and asks to check if the same is valid for the provider, procedure code, Date of Service and the Diagnosis code billed. Caller: Call the carrier for validity of the authorization#. Based on the feedback the action is taken. Claim Denied for “Medical Necessity” Analyst: The analyst asks the caller to enquire the rep, if the claim will be processed with any additional information, if yes, what sought of additional information is required. Caller: Requests the rep to let them know what information is required in-order to get the claims processed. Based on the in-formation from the carrier the necessary action is taken. Claim Denied stating “Bundled Service” Analyst: Claim is denied stating “Bundled Service” asks the caller to get the information as to, with which procedure code this particular procedure code is bundled”. Caller: The caller gets the info of the bundled service from the insurance representative. If the caller is not able to get the same then the analyst gets the help of the Compliance dept. checks for the Bundled service information and based on this the analyst generates report for that particular procedure code and sends a mail to the client’s office for approval of write off. For Ex. 82948 is bundled with 99213, 99214 and 99215.Here we are to write off the procedure code 82948 with the consent of the Dr. (or) the client office. Claim Denied for Missing or incomplete information in the HCFA Analyst: Asks the caller for claim status. Callers: Get reply from the Rep of the ins stating” Block 33 of the HCFA is missing or incomplete”. Action: The Analyst is supposed to print the HCFA and check for Block 33 to see if there is any missing info or incomplete info, If yes then the analyst checks the form setup and looks into it that the corrections are made and the claim is refiled.
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Claim Denied for Incorrect procedure code Analyst: Asks the caller to check why the particular procedure was not paid. Caller: Gets feedback from the rep that the Procedure code is incorrect and so has to be filed with the correct code. Action: The analyst should update the claim in problem in the Coding SS asking them to correct the same. Once the charge is corrected in the system the claim is refiled to the carrier. Claim Denied for want of Primary EOB Analyst: Asks the caller for the Claims status (primary carrier of the pt). Caller: Gets the feedback from the carrier as “Primary EOB required for processing the claim”. Action: The analyst has to first check if the patient has secondary insurance, if yes, asks the caller to call the secondary ins to check if they are acting as primary ins for this patient, if yes then the analyst sends a mail or updates the Charge SS asking them to archive the primary coverage and refiles the claim to the correct primary carrier. If the call was for Secondary claim, then the analyst should attach the Primary EOB with the secondary claim and sends the same to the carrier by mail. Claim Denied as “Non Covered Service” Analyst: Asks the caller to check under whose plan the Procedure was denied as Non covered service. Caller: Gets the info from the rep as “Non covered under patients plan” or “non covered under providers plan”. a) Non covered under Patient’s plan: Here the Analyst updates the client SS in order to confirm if the claim can be flipped to the patient. b) Non covered under provider plan: Here the analyst updates the Client SS to check if we can Write-off the amount. Claim Denied as “Duplicate Claim” Analyst: Asks the caller to check for claim status. Caller: Gets the reply from the rep as “Duplicate claim”. Action: The analyst has to check in the software if the claim was entered twice with the same DOS, Doctor, and Procedure. If yes, then the charge SS is updated and the duplicate claim is deleted with the consent of the Charge Supervisor. If it is not a duplicate then the analyst should place the call again for calling asking the callers to check for the status of the claim which was submitted previously, either the claim should have got paid or the claim should have got denied, in either case the caller should get the details of the payment made or should get the details of the denial.
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Claim “Not in System” Analyst: Asks for Claim status. Caller: The feedback from the rep is that the claim is not in system. Action: There are 2 steps to be followed The analyst should first check if few claims were transmitted to the carrier on the same date. If yes, then should ask the caller to check with the carrier stating “there were few claims submitted on the same date out of which there are some claims paid and some Denied if so then how this claim cannot be in system, the caller should also give the date of confirmation to the rep. If this was the only claim submitted on that date then the claim has to be refiled. Claim Forwarded to another carrier Analyst: Check for Claim status. Caller: Gets info from the insurance representative that the claim has been forwarded to another carrier. Action: The analyst should ask the caller to call the ins to which the claim was forwarded and check for the status, if claim is not in system then the caller is supposed to enquire the member id # and the ins mailing address ad other details, only then the analyst can take the proper action i.e., after getting the info the analyst updates the charges SS and asks them to archive the coverage with the correct primary coverage and refiles the claim. Claim Denied as “Non-Par provider” Analyst: Asks the caller to get the status of the claims. Caller: Gets the info from the Rep as “denied as Non-par Provider” Action: The analyst should ask the caller to check with the carrier if they will pay @ non-par rates if yes, then the claim can be resubmitted to the carrier. if not, the claim is updated in the client SS for Write off approval. Claim Pending for want of information from the Patient Analyst: Asks for the status of the claim Caller: Gets the feedback as “Claim pending for want of information from the patient”. Action: The call back should be set after 15 days, and on 15th day can ask the caller to call back and check if the carrier has received the needed info from the patient. If no again to set a call back after 15day, can wait for one month, if still the carrier does not receive the info, then with the consent of the client the claim can be flipped to the patient.
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Incorrect Place of Service Analyst: Should check for the correctness of the POS, i.e. for consult the POS should be 11, For Inpatient POS should be 21 and for Outpatient POS is 22.There are different POS for different cases. Callers: Callers can give the correct place of service if they have in their system to reprocess the claim immediately. Claim forwarded to pricing Aid, Pricing Review. Analyst: To place a calling to check for the Mailing address, Fax number and the Timely filing limit. Callers: Callers should ask for the PAPR Mailing address, Ph# once they have been informed that the claim has been forwarded to Pricing Aid Pricing Review. Contractual Obligation, amount for which provider is financially liable. The patient may not be billed for this amount Analyst: Should send a mail or should update the Client SS to get write-off approval. Callers: No need to call Claim/Service denied or reduced because this procedure/service is not paid separately. Analyst: Should first check with the Manual if the denied procedure code is a "Bundled service", if yes has to check with the compliance department for the details and should update the client SS for Approval of write off giving them the reason and referring them the Manuel etc. If the Procedure code is not "Bundled service" then the analyst can place a call with the insurance to check if the claim will be processed if submitted along with the necessary documents. Callers: Callers should ask for the Primary Procedure to which the component code has been included. Charges exceed our Fee schedule or Maximum allowable amount Analyst: The billed amount should be corrected and the claim should be filed again. Medicare has the Maximum Billed beyond which it is fraud. The Procedure codes billed with a Billed amount more than their maximum billed amount will be denied.
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Claim denied for Pre-existing conditions Analyst: The analyst after getting approval from the client will bill the patient, and after getting the copy of the pre-existing condition certificate and medical documents the claim will be submitted to the carrier. Callers: After the submission of Claim with the Pre-existing condition certificate from the Patient along with the medical documents, callers can call and give the date of submission and the ref# which was assigned by the Carrier to the patient. Claim denied for Date of Injury, First Diagnosis Used and for Pre-existing conditions Analyst: The analyst requests for the DOI, first Diagnosis code used and the Preexisting condition from the Client, after getting the same the claim is sent for reprocessing. As this is a paper claim the call back will be placed after 45 days. Callers: After the submission of Claim with the Pre-existing condition certificate from the Patient along with the medical documents, callers can call and give the date of submission and the ref# which was assigned by the Carrier to the patient. Claim denied for “Primary paid more the Allowed Amount Analyst: Write-off will be taken by the Analysts after getting a one time approval from the client. File the itemized bill with Insurance Card Copy Analyst: The claim will be submitted as a itemized bill, i.e. the entries in the claim will be date vice and not a clubbed entry for different date of service, and along with the copy of the insurance card copy. Callers: After the 30 days from the date of submission, the caller has to call and verify the status of the claims. Payment on this service/procedure has been with-held Analyst: Should check if there is any other alternate procedure code existing for the billed procedure code and yes then the same is informed to the charge dept. and the claims with this deleted(from the cpt manual) procedure code is reentered with the alternate procedure after which the claims are resubmitted. Callers: Callers has to ask whether there is an alternative new procedure code for this procedure code with regards to the services rendered.
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File the claim to the Third Party Administrators Analyst: Should file the claims to this Third party as per the information received from the carrier. Once after getting the phone number of the TPA from the carrier a call is made to the TPA. The Fax # and other details are obtained for future calls. Callers: Caller has to call TPA and get the Pricing sheet through fax and place it on the Analyst bay. Confirm that Hospice Patient did not appoint the Rendering Doctor Analyst: Medicare appoints an attending Dr for a Hospice Patient, if we receive a denial from MCR as above, Analyst has to just write down as this in the Block# 19 of the HCFA "Attending Dr was mot appointed by the Patient". Callers: Caller has to call after 20 days from the date of submission stating the "hospice patient" claim status. More than one unit of this service will be discounted Analyst: There may be cases where, 2 units of the same procedure code will not be paid by the carrier, we can check if the 2nd unit will be paid if submitted along with a modifier and medical documents supporting the need for the service. Callers: Callers has to ask why the one unit of the service was not paid. Callers have to ask whether this procedure code can be reprocessed if the additional documents were submitted. Claim denied as Capitated Analyst: Analyst has to first check with the client if we are capitated with the particular carrier. The Rooster report is obtained from the carrier; this contains the details of the claims under capitation. Based on this a capitated adjusted is raised by the analyst to the cash posters. Callers: Callers has to get the list of Procedure codes which are under the capitation and Fee for Services. Claim denied stating Need Corresponding Surgical Code Analyst: When a claim is denied for want of Surgical code, we are to check the Cpt manuals and should take the corresponding 4digit surgical code and the same should be filed with the same to the carrier. Callers: Nil Based on calls the remarks column is updated and after taking necessary actions the issues column is updated segregating the feedbacks under various heads. Callbacks are set for further action. This cycle goes on every month.
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Action to be taken on denial issues:
Issue: Coverage Terminated Action: a) If the patient has only one coverage: In this case the balance can be flipped to the patient. b) If the patient has secondary coverage: Give a work order to Insurance calling team. They need to call the secondary carrier and check if they will be acting as a primary. • If the secondary carrier says yes, then the claim is sent to the secondary. Denial from the primary carrier needs to be attached if we have crossed the timely filing limit of the secondary carrier. This will ensure that the claim will be processed. Otherwise the claim may be denied by the secondary for crossing the timely filing limit. If the secondary says no, then the patient has to be called for information regarding his primary carrier.
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c) If the denial is from Secondary: The primary has already paid and the secondary has been billed for co-insurance. If secondary rejects the claim stating that the coverage has terminated then the balance can be directly flipped to the patient. d) If another balance for same DOS has got paid: Take this case. There are two balances for the patient for the same date of service, a Doctor Balance & a CRNA balance. If the patient has got payment for a Doctor balance and the carrier denies the CRNA balance citing termination of coverage as the reason, then a work order has to be issued for insurance calling to why we got paid for one and rejected for the other. • • If the carrier says that they have paid the Doctor balance in error then a refund has to be initiated and the procedure as stated in point a & b above should be followed. If the carrier has denied the CRNA balance incorrectly then they will reprocess the claim.
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Issue: Invalid or Missing Provider Id# Action: a) If there is no provider number in the system: If the rejection is due to non availability of provider number in the system, the same has to be obtained from the carrier through the enrollment process. b) If there is a provider number in the system: When the rejection states that the provider number is not valid for that particular DOS, the issue should be forwarded to the provider enrollment team for retro activation. When the rejection does not specify anything but simply states invalid provider number, then check if the number has been keyed in correctly in the system by comparing the same with the original records available with the provider enrollment department. Issue: Invalid Procedure code Action: Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry. If yes, correct the same and refile the claim. If not, a) Check whether the carrier requires ASA or CPT code. If the Claim has gone with incorrect code then the claim needs to be refiled with correct code. Forward this issue to claims analyst who will check for errors of the same kind by running a paid & outstanding report for that particular date of filing. This type of error occurs due to lack of knowledge. b) There is one more reason for getting this type of rejection. The carrier may not be paying for some codes. So if point (a) is not applicable, this may be the cause for rejection. A work order can be issued for the insurance calling team. If the carrier says that they do not pay for the procedure then the amount has to be written off. There are some exceptional cases where the primary may not be paying for one code whereas the secondary may consider the same (ex) Medicare won’t pay for dental procedures whereas a secondary, Commercial may pay for the same.
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Issue: Invalid Diagnosis code Action: Two types of rejections are possible Dx not matching with procedure code The Dx reported on the claim is not to the highest level of specificity. Check the charge sheet as to whether the rejection is due to wrong keying in at the time of charge entry. If yes, correct the same and refile the claim. If no, it may be because of incorrect Dx. It is also possible that the 4 or 5 digit Dx is used, which the carrier may consider to be truncated Issue: Invalid or missing modifier Action: a) First check whether modifier has been entered at the time of charge entry. If no, have the same entered and resubmit the claim. b) If modifier has been entered but the carrier rejects the same Check whether the correct modifier has been used If you find that the correct modifier has been used, then give a work order to insurance calling to find out the reason for rejection. Based on the feedback corrective actions are taken. One example, Blue choice (New York) rejected a lot of claims for the reason ‘Invalid or missing modifier’. Carrier was called and it was found that they do not require modifiers henceforth and claims need to be billed without modifiers. Issue: Pre-existing Condition Action: Pre-existing condition refers to the terms & conditions entered into between the carrier and the patient / subscriber before the beginning of the contract. The rejection will usually say that the claim is being denied due to the pre-existing condition. It would not specify what exactly the condition is. So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything. (Ex.) A) There may be a condition that for the first $5000 worth of medical expenses the patient should bear it himself and the carrier would start paying for expenses after crossing that limit. If the patient has not yet exhausted the threshold limit then the claim would be denied for the pre-existing condition. B) There may be a condition that the carrier would not be paying for the same diagnosis more than once in a year. If a same diagnosis code is used on two occasions in the same year then the carrier will deny the claim submitted for the second time stating ‘pre-existing condition. As soon as you receive the denial, work order can be issued to Insurance calling. Check with insurance on the preexisting condition.
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If the patient has secondary coverage: Check whether we can send the entire bill to secondary along with the primary denial. Some carriers may be willing to pay for the same. If the secondary agrees, bill the secondary along with the denial obtained from the primary. If the patient has no Secondary Coverage / Secondary refuses to pay: Flip the balance to patient. Issue: Authorization number required or Invalid Action: Some carriers insist on obtaining prior authorization from them before the surgery. This may be for certain specific procedures or may even be for all procedures. So these are carrier specific and procedure specific. Please note that it is the responsibility of the Surgeon (and not the patient) to obtain the authorization# from the carrier. When you get a denial from the carrier for this reason, give work order to surgeon calling and find out if the surgeon has been paid. If the surgeon has been paid: It is unlikely that a surgeon would have got paid. But if he has got payment, then call carrier and find out why they have denied the anesthesiologist claim when the surgeon has been paid. They will either reprocess the claim or request a refund from the surgeon. If surgeon has not been paid: Take a write off. You cannot flip the balance to the patient. Issue: Anesthesia time not on claim Action: For anesthesia claims it is mandatory to have time printed on the claim. This rule is not applicable for flat fee codes. But we have got quite few denials from the carriers who wanted anesthesia time even for flat fee codes. So wherever anesthesia time is available the same should be noted for claims with flat fee codes. There is one more reason for this denial. If there are more than 4 line items in a balance then the anesthesia time would not get printed on the same claim form but in another. The carrier will treat the two forms separately and deny one for incomplete information and the other for want of anesthesia time. This should be avoided. Whenever you find a denial for this reason take the HCFA(s), staple them and send the same along with a covering letter.
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Issue: Anesthesia Records / Op. Notes / Medical Necessity records required Action: Anesthesia, records are usually requested by W/c (Workmen compensation) carriers for processing of claims. When a carrier requires operative / surgeon notes: a) Give a work order to insurance calling to find out if they have paid for the surgeon’s claim. If they have paid for the same, then the same has to be pointed out since they have processed the surgeon’s claim, why would they require surgeon notes once again for processing the claims? This line of argument can be pursued and the claim processed. b) If the carrier has not (yet) paid for the surgeon’s claim, then the surgeon needs to be called for a copy of the surgeon / operative notes. It should be noted that surgeon notes is a confidential document (i.e.) the request should be substantiated with valid reason. c) MAC B Cases: MAC stands for Monitored Anesthesia care. Certain Medicare (Texas, Ohio, Alabama etc.) requires ‘Medical Necessity’ report for processing MAC category ‘B’ procedure codes. This report needs to be signed by the surgeon. Whenever we receive charge sheets with MAC B procedure codes for MCR in ‘affected sites’ (states which require Medical Necessity letters) then the medical necessity letter for the same should be obtained from the doctor’s office. Once it is received claim should be resubmitted along with the letter. Issue: Exceeded the normal time for filing limit Action: Every carrier has a filing limit within which you have to submit a claim. This filing limit is calculated from the date of service and not from the filing date or the date the claim is sent out. When a carrier rejects the claim for this reason check whether the claim was submitted in the first instance with in the filing limit. If yes, then the claim has to be appealed with proof of timely submission. The proof that is accepted by carriers for timely submission is ‘c’ (carrier confirmation) reports and rejected EOB’s. When no other proof is available send the patient ledger copy as proof. Not many carriers accept patient ledger copies as sufficient evidence for timely submission. But it is worth trying in absence of other documents. If no, find out why the claim was not submitted with in the filing limit. Even If the provider has no identification number issued by the carrier, the normal practice is to submit the claim to the carrier and get a denial so that the same will serve as a proof of timely submission. So if you identify that the claim has not been submitted at all in time highlight the issue immediately.
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Issue: Require W9 form Action: A carrier may require a W9 form in the following circumstances: The tax id# on the claim form differs from what is in the carrier’s record. The ‘pay-to-address on the claim form differs from carrier’s records. Some carriers update the details about provider (like tax id#, pay-to-address) every year. For this reason they will ask for the W9 forms. When W9 form is requested for the above reasons, fill the same carefully and properly and send it to the carrier. Always remember that W9 forms should not be sent to Medicare and Medicaid. Certain BCBS plans and other carriers accept W9 forms.
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SAMPLE W9 FORM
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What is the process of AR analysis?
Step one: Report Execution
At the beginning of each month AR analyst runs an Aged Insurance Report on billing system using required parameters and identifies claims that are unpaid or inappropriately paid. This report provides a list of outstanding claims pending
against each insurance carrier.
Step two: Identification of Accounts to be worked
From the above report, the analyst selects claims that remain unpaid beyond 3045 days from the date of filing. The number of days depend on whether the claims were sent on paper (paper claims) or were transmitted electronically (electronic claims). The number of days depends on the average turnaround time for the claims to get settled, i.e., from the date of filing of the claim to the date of receipt of payment for the claim.
Step three: Identification of the problem - Review
The analyst then reviews patient account ledgers pertaining to the unpaid claims to analyze why the claims are still outstanding. Analyst reviews patient ledger
from all billing angle for possible violation of billing rule.
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Following are some of the situations the analyst may encounter & suggested remedial actions:
(a) If the analyst detects a charge entry, cash posting or claim submission error, he/she informs the concerned department. The error is corrected and claim resubmitted, if necessary.
(b) If the claim has been prepared and submitted correctly according to known rules and guidelines, and the usual turnaround time has passed, the analyst either calls insurance carrier or requests AR caller to call insurance carrier. A note is also made to AR caller indicating the type of information that needs to be obtained from representatives of the insurance company or payer.
(c) When claims are underpaid or denied, the analyst establishes the reasons for the denial or low payment by reviewing the explanations of benefits pertaining to the claim, carrier rejection reports, carrier billing guidelines, or initiating a work order to AR Calling to seek clarifications from the insurance company.
Claim denials or underpayments due to billing errors committed by staff are segregated and the concerned staff instructed to take corrective action.
(d) When claims are denied due to lack of documentation or additional information, the analyst requests for such additional documentation from the provider or billing office, and follows up with the insurance through the AR callers.
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(e) When the analyst is dissatisfied with the adjudication of a claim he/she may appeal with insurance for a review, with supporting documentation obtained from the provider office. The analyst will have to follow the appeals process and if there is a telephonic appeal facility, analyst should explore the same to appeal. A copy of the patient ledger and copies of the relevant EOB should be available with analyst while executing telephonic appeal.
If there is no telephonic appeal facility, then the analyst must an appeal on paper following the insurance company’s appeals process.
Step Four: Identification of the problem – Calling
If the claim has been prepared and submitted correctly as per insurance requirements, and usual turnaround time has passed, call needs to be placed with respective insurance carriers to ascertain the status of outstanding claim.
Analyst or AR Caller obtains the required information from the insurance company and documents the results of the call in the patient notes section of patient account. Appropriate steps needs to be initiated to settle outstanding claims based on the call notes.
Examples of the kind of situations that the analyst may come across and the action initiated are given below:
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(a) The AR night caller may have documented in patient notes that according to the insurance representatives the claim is not in their system, meaning they don’t have a record of the claim. The AR analyst may now check the claim address and review transmission reports to find out if the claim failed to reach the carrier due to a bad address or a transmission error. If the address in the system is incorrect, the analyst first finds out the number of claims that have been affected due to the wrong address. Or if there was a transmission error, how many claims were affected.
(b) Caller patient notes reveal that claims have been denied. Then analyst initiates appropriate action based on the reason for denial as documented in patient notes.
(c) The insurance carrier may state that the claim has been settled. In such cases, the AR caller obtains the payment date and checks details from the carrier and documents them in patient notes. The analyst follows up with the cash department on whether such a payment has been received. If the check the carrier says has been issued has not been received and posted within two weeks from the day of payment, he/she may prepare a report (depending on the policy established by the client) on such missing checks and sends it to the client.
(d) An issue may need feedback from client for proper resolution. If so, the analyst sends a report to the client detailing the issue and seeking clarifications.
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Step Five: Identification and Execution of Corrective Action
Once issues or problems have been identified the AR analyst initiates action to resolve them. Issues may be forwarded to one or more departments, or to the client, depending on the nature of the issue. Complete resolution of an issue may require inputs or actions from more than one department. Analysts issue forward’s request to the concerned departments for issue resolution. Issues that require inputs or actions from the client are forwarded to the client. For instance,
•
To clarify claim issues, check on status of claims or obtain carrier billing
information, the analyst issues work orders to AR Callers. • A corrected claim that must be resubmitted is forwarded to the claims
department.
•
Write-offs, adjustments and actions to resolve overpayments requests are
initiated to the cash department, while charge entry errors are corrected by the charge department.
Step Six: Identification of Uncollectible AR
Details of outstanding claim balances that the analyst considers uncollectible, and which may thus have to be written-off, are forwarded to the client for decision making. Details of outstanding claims, where collections efforts have fail due to non-
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cooperation or lack of response from payers or liable parties, are also forwarded to the client. Such accounts may be moved to a collection account. A collection agency then resumes the collection activity.
What are the tools used by an AR Analyst in Claim Analysis Process?
AR analysts uses the following tools, reports and documents to identify and investigate issues that are affecting cash flow and preventing timely and accurate reimbursement of claims by payers. One or more, and sometimes all, of the following tools, source documents and resources are required for complete and effective AR analysis:
Patient Account Ledger
• • • Explanation of Benefits (EOB) Regular Mail or Correspondences AR calling
System Reports like
1. AR Reports 2. Custom Reports 3. Financial Reports 4. Electronic Transmission Reports The extent to which the above mentioned tools and resources are used will depend on the account receivables situation in the accounts. The AR analyst measures the success of collection efforts by computing the current and past AR and collection’s in the specialty and account he/she is handling, comparing it against industry standards, wherever available. The analyst investigates the reasons for any rise in AR or any fall
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in collections using the tools and documents mentioned above. The objective is to minimize AR and maximize the collection rate.
Information Needed for Assessment of Accounts Receivable
To perform the most basic assessment of A/R, the following three pieces of information are necessary, • • • Monthly Charges Monthly Receipts Total A/R at the end of the month.
Monthly Charges
The charges for the month are the total amount of fees charged for patient care from the first working day through the last working day of the month, whether or not they have been paid. Charges for services that fall outside
regular medical care should not be included. If you have been asked to testify as an expert witness and have just billed the defense attorney for $3,000, that is a charge and will undoubtedly produce income to you or the practice, but it should be considered outside income and for the purpose of analysis should not be included in the A/R. Monthly Receipts 5/4/2010 Page 214 of 310 Healthcare Division
The second piece of required information is the total receipts for the month: the dollars collected for the medical care that was rendered. A receipt must correlate with a charge that was entered for the current month or in a prior month. Month’s-End Accounts Receivable
The third category of information needed to analyze a practice is the total A/R at the end of the month: the total balance that is due to the practice on the last day of the month for patient care. In reality, the total A/R should be the amount of money that can actually be collected eventually. Some factors can over inflate this figure, such as failure to write off balances that are uncollectible. This could involve care for a homeless person who was not
eligible for Medicaid or simply a regulatory balance (the amount disallowed by Medicare in accepting an assignment). Another way A/R can be inflated is by keeping accounts on A/R sent to a collection agency. By turning them over to a collection agency, the practice has classified these accounts as “bad debt”. For the convenience of posting collection agency payments, many practices fail to write off these balances or subtract them from the total A/R. To perform a true analysis, it is essential that the A/R figure reflect the total money owed the practice, which the practice plans to collect.
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If one of these three pieces of information cannot be obtained without a lot of effort, the practice faces a significant challenge because this information is basic and, if missing, indicates a lack of receivables management.
Accounts Receivable Assessment
Once a practice has obtained the total monthly charges and receipts and the total A/R at the end of the month, it can begin assessing the state of it’s A/R. There are three methods of assessing an A/R: days outstanding, A/R ratios, and aged A/R.
Days Outstanding
Days outstanding, or the average number of days it takes for a typical charge to be paid, are the method of accountability most commonly used by hospitals, and the same principles are applicable to a physician practice. There are many ways to figure days outstanding. The simplest method is the following,
1. Take the accounts receivable of the practice on the first day of the month. 2. Add to it the A/R of the practice on the last day of the month and divide by two. This gives you an average of the A/R for the month. 3. Divide this figure by the month’s receipts and then multiply it by the 5/4/2010 Page 216 of 310 Healthcare Division
number of days in the month.
The resulting figure gives you the average number of days a receivable is outstanding, or the days outstanding, for that month. For example, the equation below shows a practice whose A/R on January 1st was $95,000. On January 31st A/R was $105,00, and the receipts for the month of January were $28,000. Then A/R outstanding days is calculated as below, 95,000+105,000 = 200,000/2 = 100,000/28,000 = 3.57 X 31 = 110.7 The average account is 111 days outstanding.
The optimal range of days outstanding is 45 to 60 days. Normally this can be achieved only in a setting where accepting the payment at the time of service is commonplace. For a hospital-based practice such as radiology or anesthesia practice, 60 to 90 days outstanding is not a sterling example of receivable management but is considered acceptable. The real danger zone, whether the practice is hospital-based or not, occurs in practices in which the numbers exceed 120 days unless there is a reasonable explanation, such as a high percentage of Medicaid accounts. As a rule of thumb, any practice with 150 days or more outstanding faces a significant challenge. Accounts Receivables Ratio
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Another method for evaluating a practice involves the use of A/R ratios. These ratios indicate how total A/R relates to a practice’s payments and charges. Accounts Receivable to Receipts Ratio
To find out how quickly your average account is being paid, simply do the following: Take the total A/R on the last day of the month and divide it by the total payments received during that month. ranging from 2.5 to 4. This should produce a number
If the number is 5 or more, you are looking at 150
days (5 X 30 days) from the time when a charge is entered on the books until the time when it is collected.
For example, if a practice has an A/R of $100,000 on January 31st and total receipts for the month are $30,000, the ratio of A/R to payment is 3.3, meaning that it takes an average of 3.3 months, or approximately 100 days, for a charge to be paid ( see the equation below). $100,000 / $30,000 = 3.3 3.3 X 30 days = 100 days on average for an account to be paid. Accounts Receivable to Charges Ratio
It is possible to monitor a practice by keeping track of how the A/R relates to the practice’s charges. Simply divide the A/R at the end of a given month by the charges entered during that month.
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For example, a practice with an A/R of $100,00 on January 31st and $25,000 worth of charges that month has an A/R to charges ratio of 4: $100,000 / $25,000 = 4
This number should be fairly consistent from month to month if there is good A/R management. It also should be somewhat similar to the A/R to receipts ratio. If the numbers vary dramatically, this may indicate that the practice is influenced by seasonal changes, as in the case of an orthopedic surgeon practicing near a ski resort. In the winter the surgeon’s A/R to charges ratio may by lower than it is in the summer, when there aren’t as many broken bones. Of course the A/R to receipts ratio also would be affected. Again, any number above 5 justifies a serious look at the practice’s economic health.
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Duties and Responsibilities
A Charge Entry person The following are the duties and responsibilities of a charge entry person: He/ She should
a) Be aware of all billing rules for his/ her specialty and updates himself/ herself on the latest. b) Ensure that the daily targets of production required of him/ her are met without with he/ she should not leave for the day unless there is nothing left to enter. c) Ensure 100% accuracy of data entered. For this purpose they should take a patient face sheet/ charge summary and completely check the data entered with the demographics/superbills. d) Ensure that proper folders are maintained and are in proper condition and easily retrievable for the charges received and entered. These folders should be properly numbered and a log of all the folders should be maintained separately. e) Forward the charge files for audit immediately after completion. He/ She should also ensure that the files are returned by audit properly and corrections are carried out immediately. f) Ensure that any pending demographics or charges on account of any information which is missing or not clear should be promptly maintained in 5/4/2010 Page 220 of 310 Healthcare Division
an excel spreadsheet and should be forwarded to the client on a daily basis. In case any of the missing or unclear information could be cleared through AR calling, such details should be placed in a folder for AR calling and notified to them properly. It should also be ensured that this is being constantly followed upon to ensure that the issue is cleared. g) Ensure that all e-mails from either the client or from within the group or from the call center should be attended to and replied on the same day. h) Ensure that the pending list is reviewed every week and any items which could be cleared at our end be promptly done. i) Ensure that any special reports required by the client or from the account manager be prepared immediately on request or a proper time frame of the earliest when it can be completed be notified immediately. j) Ensure that all charge files are received in time without any delay or with minimum acceptable delay (transit period between client and Madras). If there any such delays, this should be properly recorded and notified to the client. Also if files are not received for a particular DOS but received for subsequent date of service, then it should be questioned to the client.
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A Cash Poster The following are the duties and responsibilities of a cash poster. He/ She should a) Be aware of all billing rules for his/ her specialty and updates himself/ herself on the latest. b) Ensure that the daily targets of production required of him/ her are met without with he/ she should not leave for the day unless there is nothing left to post. c) Ensure 100% accuracy of data entered. For this purpose they should take a receipt summary/ unposted summary/ cash reconciliation and completely check the data entered with the checks and EOBs. d) Ensure that proper folders are maintained and are in proper condition and easily retrievable for the cash received and posted. These folders should be properly numbered and a log of all the folders should be maintained separately. e) Forward the cash files for audit immediately after completion. He/ She should also ensure that the files are returned by audit properly and corrections are carried out immediately. f) Ensure that the unposted list is reviewed immediately after completion of posting the cash files and the following are identified: Patient Not Found, Not-Our-DOS, Insurance Refunds, Patient Refunds, Others. The Patient Not Found & Not-Our-DOS cases should be properly documented in an excel 5/4/2010 Page 222 of 310 Healthcare Division
spreadsheet, copies of checks and EOBs taken and forwarded on a periodically basis to the client office. The refund requests should be initiated and approved by the manager and forwarded to the client office periodically. g) Ensure that the bank reconciliation, if your specialty/ client is required to do so, is done every month and any discrepancies notified to the client. h) Ensure that small balances if any are written off promptly and periodically. i) Keep their eyes open of any changes in EOBs and notify the AR analyst immediately. For instance, there may be changes in provider #s or changes in the pay-to address or any important information, which needs to be acted upon immediately. These are very vital information and need constant monitoring and action. j) Ensure that all cash deposit files are received in time without any delay or with minimum acceptable delay (transit period between client and Madras). If there any such delays, this should be properly recorded and notified to the client. Also if files are not received for a particular deposit but received for subsequent date of deposits, then it should be questioned to the client. k) Ensure that any special reports required by the client or from the account manager be prepared immediately on request or a proper time frame of the earliest when it can be completed be notified immediately.
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A Regular Mail Person A Regular Mail Person is one who takes care of regular mails i.e. entering the regular mails into the system and taking action on each one of them. This function can be separate or can be attached to one of the other functions. The following are the duties and responsibilities of a regular mail person. He/ She should a) Ensure that all the regular mails received are entered in the system the same day. b) Be aware of all the billing rules for his/ her specialty. c) Ensure that action on all regular mails received is taken on the same day on which it is entered. d) Keep their eyes open on any important announcements in the regular mails received. Sometimes certain changes in rules and regulations of certain carriers are received in regular mails. These should be made note of and appropriate changes in billing rules should be made. e) Be aware that any denial or information received for a single claim, if it applies to all claims for that insurance carrier, should be applied to all claims for that insurance carrier and action taken accordingly. This is called the global rule. f) Also keep watch on the rejections in electronic transmission, review such rejections and along with the AR analyst find out why such rejections occur and what can be done to prevent these rejections. 5/4/2010 Page 224 of 310 Healthcare Division
An AR Analyst An AR Analyst is an important person in the group. He is the one who guides the group by providing lot of inputs in the form of rules and other clarifications. He is the person who reviews the Accounts Receivable and keeps it in control and ensures the billing office meets its objective. The following are the duties and responsibilities of an AR analyst. He/ She should a) Be aware of all the billing rules for his/ her specialty and updates himself/herself on the latest. b) Sets realistic collection targets every month for his/ her specialty. c) Work towards that target by monitoring collections every week of that month. d) Ensure that proper rules are set such that clean claims go in the first place rather than receiving denials and acting on them. e) Coordinate with the charge and cash person to ensure that rules are followed. f) Ensure that his/ her production target of the number of accounts reviewed should be maintained at an acceptable level. g) Ensure that adequate and quality work-orders are given to the night crew for accounts that require follow up.
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h) Ensure that all accounts called during the previous day are reviewed completely and action taken immediately. If global rule is applicable, then it should be applied appropriately. i) Ensure that all denials received have been acted upon and global rules, where applicable, are taken care promptly. j) Ensure that overall AR days for the account meet industry standards is around 70 days whichever is lower. k) Periodically take reports to ensure that AR days, outstanding AR for each patient type/insurance is well within control and as per standards. l) Ensure that proper explanation by carrier/ patient type is available with supporting documentation to prove in case the AR days go above 70. m) Co-ordinate with the call center people and solve problems. n) Constantly keep track of electronic and paper claims and keep his/ her eyes open for any major rejections and ensure that all electronic rejections are taken care promptly. o) Keep his/ her eyes open for EOBs where the pay-to address is different from that of the account’s. p) Work towards ensuring that claims for majority of the carriers go electronically. q) Ensure that any special reports required by the client or from the account manager be prepared immediately on request or a proper time frame of the earliest when it can be completed be notified immediately.
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HOW TO COMPLETE THE CMS-1500
The CMS-1500 is used by physicians, durable medical equipment suppliers, and other providers to bill Medicare, Medicaid, CHAMPUS, VACHAMPUS, Group Health Plan, FECA Black Lung, or other type of insurance. In rare instances, some insurance companies may request free-standing clinics and hospitals to submit charges with the CMS-1500 form. All providers, including nephrologists and oncologists, billing with the CMS-1500 must provide specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and HCPC. The number of services rendered and the charge for these services depends on the facility's charge master.
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Sample CMS 1500 form
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APPENDIX B: ABBREVIATIONS
AMA – American Medical Association BLK Lung – Black Lung CCYY – Year, indicates entry of four digits for the century (CC) and year (YY) CHAMPUS – Civilian Health and Medical Program of the Uniformed Services CHAMPVA – Civilian Health and Medical Program of the Department of Veterans Affairs CLIA – Clinical Laboratory Improvement Amendments CMS – Centers for Medicare & Medicaid Services, formerly HCFA COB – Coordination of Benefits CPT® – Current Procedural Terminology, 4th Edition DD – Day, indicates entry of two digits for the day DME – Durable Medical Equipment EIN – Employer Identification Number EMG – Emergency EPSDT – Early & Periodic Screening, Diagnosis, and Treatment F – Female FECA – Federal Employees’ Compensation Act GTIN – Global Trade Item Number HCFA – Health Care Financing Administration, currently CMS HCPCS – HCFA Common Procedural Coding System HIBCC – Health Industry Business Communications Council HIPAA – Health Insurance Portability and Accountability Act of 1996 HMO – Health Maintenance Organization ICD-9-CM – Internal Classification of Disease - Revision 9 - Clinical Modification I.D. or ID. – Identification ID # or ID. # – Identification Number INFO – Information LMP – Last Menstrual Period M – Male MM – Month, indicates entry of two digits for the month NDC – National Drug Codes No. – Number NUCC – National Uniform Claim Committee NUCC-DS – National Uniform Claim Committee Data Set NPI – National Provider Identifier OMB – Office of Management and Budget OZ – Product number Health Care Uniform Code Council PH # – Phone Number QUAL. – Qualifier REF. – Reference SOF – Signature on File SSN – Social Security Number UPC – Universal Product Code UPIN – Unique Physician Identification Number USIN – Unique Supplier Identification Number VP – Vendor Product Number
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HOW TO COMPLETE THE UB – 92
The UB-92 is the form accepted by CMS for hospitals and free-standing clinics to use when billing Medicare Fiscal Intermediaries (FI). UB-92 forms can be submitted either electronically or on paper ("hard copy"). The UB-92 was adopted in 1992 to replace the UB-82. Providers billing with the UB-92 must supply specific information about the patient, the patient's insurance, and about themselves as service providers. The service provided is described by revenue codes, revenue code descriptions, and HCPC. The number of services rendered and the charge for these services depends on the facility's charge master. The following table lists instructions for completing a UB-92 form. Bill fields are also known as locator or location codes.
Locator or Location Code 1 2 3
Instruction Enter the provider's name, address, and telephone number. Leave blank. Enter the Patient Control Number, which is not required by Medicare but can be used by providers for internal patient identification. Enter the appropriate three-digit code. • • First digit—describes your facility type Second digit—describes your facility sub-type
4
Third digit—"1" (admit through discharge claim, encompassing entire services provided for that service period) or "5" (late charge only for standalone late charges omitted from initial bill) or "7" (to designate that this claim replaces a previously submitted claim) or "8" (cancel the entire prior claim). Centers submitting a claim with an "8" as the final digit should indicate why this form is being submitted (ie, duplicate claim) in the Remarks section (location 84). Enter the Federal Tax ID Number for the service provider. Enter the beginning and ending dates of service. For hard copy claims use the format mmddccyy. For electronic claims use the format ccyymmdd. Most statements span a 30- or 31-day period. If there is a break in service days, such as for an inpatient hospitalization, then contact your FI to determine how to designate this on the UB-92 form . Leave blank.
5
6
7–11
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12 13
Enter the patient's name as it appears on his or her Medicare card (last name, first name, middle initial). Enter the patient's full mailing address (including street name, city, state, and ZIP code). Enter the patient's date of birth. For hard copy claims use the format mmddccyy. For electronic claims use the format ccyymmdd. Enter the patient's sex ("M" for male or "F" for female). Leave blank. Enter the patient's admission date. Leave blank. Enter the medical record number. Enter the condition codes if applicable. Leave blank. Check with your intermediary to verify the format for admissions or other breaks in service.
14 15 16 17 18–22 23 24–30 31
32–36
If the patient is within his or her 30-month coordination period, enter "33" in one of these fields. If there is a break in service, such as an admission, enter a date in locator 36 and enter code "74" in the code section.
37 38 39–41
Leave blank. Leave blank. Enter the appropriate code and amount for certain services such as blood and blood products. Enter the appropriate Revenue Code. Revenue Codes are based on type of service provided and billed for. Insert appropriate Revenue Code. Enter the Revenue Code narrative description to match the code in locator 42. Insert appropriate description.
42
43
44
Enter Healthcare Common Procedural Coding System (HCPCS). The Healthcare Common Procedural Codes (HCPC) for certain services are set locally by the Fiscal Intermediary; check with your intermediary for specific information.
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Insert appropriate HCPC code. 45 46 Leave blank. Enter the units of service. Furthermore, most FIs may reimburse an additional $0.50 for the supplies. 47 48 49 50 51 52–57 58 59 60 61 62 63 64 65 66 67 Enter total charges. For hard copy claims enter "Revenue Code 001" to designate the total charges for that claim. Leave blank. Leave blank. Enter up to three payers: "A" "B" and "C." Enter the provider number. Leave blank. Enter up to three individuals who are responsible for insurance coverage: "A" "B" and "C." Enter the patient's relationship to the insured: "A" "B" and "C." Enter the Certificate/Social Security Number/HI Claim/Identification number for "A" "B" and "C." Enter the group name. Enter the group identification number. Leave blank. Leave blank. Leave blank. Leave blank. Enter the Primary Diagnosis Code. All ICD-9-CM codes should correspond to the medical documentation in the patient's chart. Enter the Secondary Diagnosis Code. All ICD-9-CM codes should correspond to the medical documentation in the patient's chart. Leave blank. Enter the attending physician's UPIN. Leave blank.
68–75 76–81 82 83
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84 85
Enter remarks required by your FI. Have the provider representative sign and date this locator.
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Sample UB - 92 form
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HIPAA
The purpose of this document is to assist Medical Billing personnel to understand and plan for the implementation of the HIPAA requirements. The personnel must familiarize themselves with the final HIPAA rules
What is HIPAA?
HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law was to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information, and help the healthcare industry control administrative costs.
HIPAA is divided into five titles or sections. Each title addresses a unique aspect of health insurance reform. Title I is portability and it has been fully implemented. Portability allows
individuals to carry their health insurance from one job to another so that they do not have a lapse in coverage. It also restricts health plans from requiring pre-
existing conditions on individuals who switch from one health plan to another. Title II is called Administrative Simplification and it will have the greatest impact on providers. It is designed to: + + + + Combat health care fraud and abuse; Guarantee security and privacy of health information; Establish standards for health information and transactions; and Reduce the cost of health care by standardizing the way the industry communicates information.
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The remaining titles are:
+ Title III – Tax-Related Health Provisions + Title IV – Application and Enforcement of Group Health Plan Requirements + Title V – Revenue Offsets
What is administrative simplification?
Administrative Simplification is the establishment of a set of standards for receiving, transmitting and maintaining healthcare information and ensuring the privacy and security of individual identifiable information. HIPAA establishes standards for electronic health care
transactions, national code sets, and unique identifiers for providers, health plans, employers and individuals.
The HIPAA electronic data requirements are meant to encourage the healthcare industry to move the handling and transmission of patient information from manual to electronic systems in order to improve security, lower costs, and lower the error rate.
Standardization has been very effective in many industries. Anywhere in America you can plug a US manufactured toaster and it will work because standard voltage was established for small in a
appliances. However, if you take the toaster to Poland, it will only work if you use a special converter. If you go to Sudan you will have to use still another
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converter. The electronic claims process in the United States is like the worldwide electric industry, no standardization. When administrative simplification has been implemented, providers will be able to submit an electronic claim in the same format to any healthcare plan. Transaction and Code Sets: HIPAA mandates the development and use of
standardized transactions for the electronic exchange of data. In addition, the use of standardized national codes sets to identify medical conditions, treatments, providers, individuals, and procedures are required. Implementation Guides for HIPAA Standard Transactions are defined and numbered as follows: Health care claims or coordination of benefits - Transaction Code 837 Payment & remittance advice - Transaction code 835 Health claim status - Transaction code 276/277 Plan enrollment – Transaction code 834 Plan eligibility – Transaction code 270/271
• • • • •
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+ Privacy: Provides for the protection of individually identifiable health
information that is transmitted or maintained in any form or medium. The privacy rule will affect the day-to-day business operations of all organizations information. that provide medical care and maintain personal health
+ Security Standards: Security Standards are designed to protect
health care information as it is being stored and exchanged. It
also includes provisions to verify the identity of those sending and receiving health care information electronically. The security rule has not been finalized; however, some of the security standards will be implemented as part of the privacy rule.
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The HIPAA legislation does not require providers to discontinue submitting paper claims. However, HIPAA may require changes to several aspects of paper billing, such as changes to codes and required data elements. HIPAA requires the following entities to comply:
+ Health Care Providers: Any provider of medical or other health services, who
bills or is paid for healthcare in the normal course of business. Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status of an individual.
+ Health Care Clearinghouse: Entities that process or facilitate the processing of
health information received from other entities. physician and hospital billing services. It includes groups such as
+ Health Plans: Includes individual or group plans that provide or pay the cost of
medical care and includes both the Medicare and Medicaid programs
Providers will be required to: + Guarantee patient privacy rights by:
•
Giving patients clear, written explanations of how the provider may
use and disclose their health information;
•
Ensuring patients can see and get copies of their records, and request
amendments;
•
Making a history of non-routine disclosures accessible to patients;
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•
Obtaining patient consent before sharing their information for
treatment, payment, and health care operations; 1. Obtaining patient authorization for non-routine disclosures and most non-health care purposes; and, 2. Allowing patients to request restrictions on the uses and disclosures of their information.
+
Adopt written privacy procedures, to include: 3. Who has access to protected information, 4. How it will be used within the agency, and 5. When the information may be disclosed;
+
Ensure
that
business
associates
protect
the
privacy
of
health
information; + + Train employees in the provider’s privacy procedures; and, Designate a privacy officer who is responsible for ensuring the privacy procedures are followed. + Assess impact of Transaction Code sets:
Evaluate current business processes to determine what needs to be done to ensure timely compliance. Specific attention should be addressed to: • • • • How claims are submitted How patient records are maintained, released and communicated How patient consent and authorization forms are maintained How referrals are given or received
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+
Assigned Security Responsibility:
The rule requires providers to assign security responsibility to a specific individual or organization and document that assignment. This responsibility includes the management and supervision of:
1. The use of security measures to protect data, and 2. The conduct of personnel in relation to the protection of data.
This assignment is important to provide organizational focus, indicate the importance of security and pinpoint responsibility. + Media Controls: The Billing office must develop formal, documented policies and procedures that govern the receipt and removal of hardware and software (such as diskettes, tapes, and computers). These policies are important to ensure that media
containing personal health information is protected and that those persons who are responsible for hardware/software maintenance are aware of their
responsibilities under HIPAA. implementation features:
These controls include the following mandatory
• • • • •
Controlled access to media Accountability (tracking mechanism) Data backup Data storage Disposal
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+
Physical Access Controls:
The Billing Company must document formal policies and procedures for limiting physical access, while ensuring that properly authorized personnel can work freely. These controls include the following mandatory implementation features: Disaster recovery Emergency mode operation Equipment control (in and out of facility) A facility security plan Procedures for verifying access authorizations prior to physical access Maintenance records Need-to-know procedures for personnel access Sign-in for visitors and escorts, if appropriate Testing and revision
• • • • • • • • •
+
Policy/Guidelines on Workstation Use: These documented
The organization must have a policy on workstation use.
instructions must delineate the proper functions to be performed. This is crucial so that employees understand the manner in which workstations must be used to maximize the security of health information.
•
Accreditation – Accrediting organizations may require compliance in future - HHS has the final responsibility for determining civil violations and imposing penalties
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•
Civil money penalties – – $100 for each violation of a standard Maximum of $25,000 per year - Per identical requirement or prohibition
For each offense of
•
Wrongful disclosures – – Fined not more than $50,000 Imprisoned not more than one year
•
False pretenses – – Fined not more than $100,000 Imprisoned not more than 5 years
•
Intent to sell, transfer or use – – Fined not more than $250,000 Imprisoned not more than 10 years
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Medical Billing Terminologies
COBRA: Consolidated Omnibus Budget Reconciliation Act. It is that if an employee is registered under this Act he/she will be covered by the employer in case of any accidents even after the employee retires or resigns the job. The coverage period will last up to 16 months from the date of retirement/resignation.
OBRA: Omnibus Budget Reconciliation Act. It is special laws that if an employee registers himself under this act it allows him/her to get the health insurance coverage benefits even after COBRA for a period of 11 months. This will come into place only if the patient is suffering from any disabilities.
Roster Billing: It is the process of billing multiple patients A/c's in one single claim for the same TOS (Type of Service) rendered irrespective of the DOS (Date of Service).
Capitation: It is a specified amount paid periodically to the provider for a group of specified health services, regardless of quantity rendered. This is a method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered.
Euthanasia: This is nothing but Mercy Killing which means for E.g.: If someone is in a Coma state the doctor takes the initiative of killing him rather than him being alive and suffers.
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Bench Marks: Since the term Bench marks was discussed and no body could come to a conclusion it was discussed that every individual would search the net and come to a conclusion about what it is and discuss it on Monday.
Medicare Benefits exhausted: When a person takes a treatment for more than the prescribed limit (For E.g.: Mammogram can be taken only once in a year, if taken for more than once in a year in that case Medicare would deny stating as “Mcr benefits exhausted”) Medicare would deny it.
Julian Date: Regardless of the month, it is 1-365 days in a year. It flows periodically (For E.g: After Jan 31st Feb 1st would be considered as 32 and it continuous in the same manner for the coming days). This is used for creating batch numbers irrespective of the department.
Reciprocal Billing: A reciprocal billing arrangement may exist when the patient’s regular physician submits a claim for a covered visit which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis. The requirements for reciprocal billing arrangements are as follows:
• •
The regular physician is unavailable to provide the visit service; The Medicare patient has arranged or seeks to receive the visit
services from the regular physician; • The substitute physician does not provide the visit services to a
Medicare patient over a continuous period of longer than 60 days; and
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•
The regular physician identifies the services as substitute physician
services meeting the requirements by adding modifier Q5 (services furnished by a substitute physician under a reciprocal billing
arrangement) at the end of the procedure.
Under a reciprocal billing arrangement, there is no mention of the regular doctor paying the substitute physician. There is no need for a employer/employee relationship to exist. It is more like an arrangement of "I’ll cover for you, and you cover for me," (on an occasional basis). The substitute physician in a reciprocal billing arrangement usually has a practice of his/her own and is properly enrolled as a Medicare provider.
FROI: First report of Injury/illness, the employer has to send this report to Worker's compensation.
HPSA: Healthcare provider service shortage areas. It may have shortages of primary medical care, dental or mental health providers and may be urban or rural areas, population groups or medical or other public facilities. Health Professional Shortage Area (HPSA) bonuses are a 10 percent incentive payment that is paid to physicians only when their services are covered by Medicare and are performed within the geographic boundaries of a HPSA area. The Incentive is paid only for the professional service. Global services must be billed as two components with separate charges for the professional component (billed with the HPSA modifier)
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and the technical component (billed with no HPSA modifier). Services billed globally with the HPSA modifier will be denied as unprocessable.
Billing requirement for HPSA: To enable Medicare to correctly calculate the incentive payment, report the services with the appropriate modifier for each procedure code: QB Physicians providing services in a rural HPSA QU Physicians providing services in an urban HPSA
If a QB or QU modifier is billed, indicating the service was rendered in a HPSA, the physical location where the service(s) was rendered must be entered if other than home in Item 32 on the CMS 1500 claim form.
HCFAC: Healthcare Fraud and Abuse Control Program, is under Office of Inspector General (OIG) to control fraud and abuse that happening in health care.
HIPDB: Healthcare Integrity and Protection Data Bank is to collecting data’s regarding the fraud and abuse that happening in the health care industry.
Stop loss clause: The explanation for stop loss clause is "a limitation on the amount of loss sustained by the insured without compensation in a given period."
Prosthetic devices: Prosthetic devices are appliances which replace all or part of a function of a permanently. In operative, absent or malfunctioning body part. The
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term "prosthetic devices" includes orthotic devices, rigid or semi-supportive devices that restrict or eliminate motion of a weak or diseased part of the body. Prosthetic Devices helps to overcome injury and is designed to replace, correct or support the function of body. These devices may be rented or purchased. Insurance will cover for the charges if it is covered under subscribers plan.
Placement of false teeth is known as dental prosthetic devices and placement of jawbones are known as maxillofacial prosthetic devices. Examples of prosthetic devices are Communication aids, hearing aids, artificial legs, hands, and limbs.
Factors for calculating Fee Schedule Payment Amounts
Under the formula set forth in section 1848(b) (1) of the Act, the payment amount for each service paid for under the physician fee schedule is the product of three factors: (1) A nationally uniform relative value for the service; (2) a geographic adjustment factor (GAF) for each physician fee schedule area; and (3) a nationally uniform conversion factor (CF) for the service. The CF converts the relative values into payment amounts.
For each physician fee schedule service, there are three relative values: (1) An RVU for physician work; (2) an RVU for practice expense; and (3) an RVU for malpractice expense. For each of these components of the
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fee schedule there is a geographic practice cost index (GPCI) for each fee schedule area. The GPCI’s reflect the relative costs of practice expenses, malpractice insurance, and physician work in an area compared to the national average for each component.
The general formula for calculating the Medicare fee schedule amount for a given service in a given fee schedule area can be expressed as: Payment = [((RVU work x GPCI work) + (RVU practice expense x GPCI practice expense) + (RVU malpractice x GPCI malpractice)) x CF] The CF amount changes for every calendar year.
Catastrophic Limit: The maximum amount of charges that the patient has to pay out-of -Pocket expenses during that year by setting a maximum amount will protect the patient.
Pre-determination: Obtaining estimation from the insurance carrier by the provider before the service is rendered to the patient.
Revenue Codes: This code is used in hospital billing and we have a column in UB92 for printing this revenue code. It is a three-digit code and mainly it is used in care. For ex: If a patient is treated in a intensive care unit for that care will have a revenue code and it is related with the procedure code.
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Free look: Free Look is the 30 days trail period where one tries using the Medigap policy and if he is not satisfied money will be reimbursed.
Hospice: Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is given by a public agency or private company approved by Medicare. It is for all age groups, including children, adults, and the elderly during their final stages of life. The goal of hospice is to care for you and your family not to cure your illness.’
Who is eligible for Medicare Hospice Benefits? Hospice care is covered under Medicare Part A (Hospital insurance) A person is eligible for Medicare hospice benefits when: • • They are eligible for Medicare Part A (Hospital Insurance): and The concerned person’s doctor and the hospice medical director
certify that the patient is terminally ill and probably have less than six months to live: and • The patient sign a statement choosing hospice care instead of routine
Medicare covered benefits for your terminal illness*; and • The patient receives care from a Medicare –approved hospice
program.
What is not covered? The care that you get for your terminal illness must be from a hospice. When you choose hospice care, Medicare will not pay for:
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No-Fault Insurance: This comes in Auto Insurance where the insurance makes the payment irrespective of the mistake on which side.
Referring & Ordering Physician: Referring physician is one who refers a patient for the Professional services. Ordering physician is one who refers or orders the patients for test like Radiology etc.
HCBS: Home and Community based services waivers .It is basically an agency aims at providing high quality, cost effective, consumer directed, home and community based services and support for all persons with all types of disabilities.
Enrolled & Effective date: Enrolled date is the date on which the person gets enrolled with the insurance. Effective date is the date from which the insurance is active and starts covering the insurer.
CHIP: Children's Health Insurance Program. It is a federal program jointly funded by the states and the federal governments, which provides medical insurance coverage for children's who are not covered by Medicaid funded program.
Ambulatory Care: Medical services provided on an outpatient (non-hospitalized) basis. Services may include diagnosis, treatment, surgery, and rehabilitation. In simple we can say a visit, which does not require overnight stay.
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Surrogate
UPIN:
It
is
the
dummy
UPIN
that
has
been
assigned
to
ordering/referring physician for temporary purpose.
Carve-out coverage: Carve-out refers to an arrangement where some benefits (e.g., mental health) are removed from coverage provided by an insurance plan, but is provided through a contract with a separate set of providers.
Experimental Procedures: Any health care services that are determined by the insurance plan to be either, not generally accepted by informed health care professionals in the US, as effective in treating the condition, illness or for which their use is proposed or not proven by scientific evidence to be effective in treating the condition for which it is proposed.
Open Enrollment: Specified period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date.
Balance Billing: The practice of charging full fees in excess of covered amounts, full fees in excess of covered amounts, then billing the patient for that portion of the bill that the payer does not cover.
Multi-specialty Group:
A group of doctors who represent various medical
specialties and who work together in a group practice.
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Insurance Verification:
Is a process of calling Insurance carriers regarding
member (policy holders) information (i.e., Member ID, coverage period etc.)
Telemedicine: The use of telecommunications (i.e., wire, radio, optical or electromagnetic channels transmitting voice, data and video) to facilitate medical diagnosis, patient care, and/or medical learning. Many rural area are finding uses for telemedicine in providing oncology, home health, ER, radiology and psychiatry among others. Medicaid and Medicare provide some limited reimbursement for certain services provided to patients via telecommunication.
CHAMPUS (Civilian Health & Medical Program): Champus is run by the Defence Department. It gives medical care to the active duty members of the military as well as retirees & their eligible dependents. The new name of Champus is Tricare.
Dual Eligible: Persons who are entitled to Medicare (Part A and Part B) and also eligible for Medicaid are termed as dual eligible persons.
Dual Entitlement: An individual who is entitled to Medicare for two different reasons is considered as dually entitled. Medicare entitlement based on ESRD and aged or disability is considered dual entitlement. For example: An individual may be entitled to ESRD and then become entitled based on aged or disability. Or, an individual may be entitled to Medicare based on aged or disability and then develop ESRD.
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ESRD (End Stage Renal Disease): Kidney failure that is severe enough to need life long dialysis or kidney transplantation is termed as ESRD. If a individual is entitled to Medicare through ESRD, Medicare stands as a Secondary Payer (MSP), during the 30 month co-ordination period (COB). The GHP (Group health plan) acts as the primary in the COB period and at the completion of the 30-month COB period, Medicare stands as the primary insurance for that individual.
AAPCC (Adjusted Average Per Capita Cost): An Estimate of how much Medicare will spend in a year for an average Beneficiary.
ASC (Ambulatory Surgical Center): A place other than Hospital that does outpatient surgery. At an ASC you may stay for only a few hours or for one night.
HHA: Home Health Agency-a facility or program licensed, certified or otherwise authorized according to state and federal laws to provide healthcare services in the home.
ALJ: Administrative Law Judge-a person who hears the appeals of the denied claims.
Ancillary Services: Supportive services performed along with the Professional or Technical services are termed as ancillary services.
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EPSDT: Early and Periodic screening, diagnosis and treatment program: Persons under 21 who are receiving Medical Benefits may receive health and dental screenings and follow-up treatment for certain conditions. Providers include physicians, health departments, schools and some local health clinics. These exams are available on a periodic schedule based on the age of the individual.
Peer Review Organization: An organization of practicing doctors and other health care providers who are paid by the Federal government for reviewing the care given to Medicare Patients.
Catastrophic illness: It is a very serious health problem that could be life threatening or cause life-long disability.
Gatekeeper: A primary care physician or managed care entity responsible for determining when and what services a patient can access and receive
reimbursement for. A PCP is involved in overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone that makes the decision of where a patient will receive services.
CORF (Comprehensive Outpatient Rehabilitation Facility): A facility that provides a variety of services including physicians services, physical therapy, social or psychological services and outpatient rehabilitation.
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Sub - Acute Care: Usually described as comprehensive in-patient program for those who have experienced serious illness injury or disease, but when do not require intensive hospital services, the range of services considered as sub- acute. It includes infusion therapy, respiratory care, cancer, strokes and AIDS care.
Residual Market: Residual Market comes in to picture in Workers Compensation. Private insurance companies will not provide coverage for workers where the risk chances are very high. This uncovered area is known as Residual Market, where the state and federal insurance covers this area.
NDC (Nation Drug Code):
NDC is maintained by FDA (Food and Drug
Administration). NDC was originally established as an essential part of an out-ofhospital during reimbursement program under Medicare. NDC serves as a "Universal Product Identifier" for the human drugs. The format is usually 5-4-1. 5Labeler code, 4 - Product code & last one for package code, 1 – Serial Number.
Social Security Number (SSN): It was introduced and provided by Social Security Act of 1935 to the each individual citizen in United States. This is a ninedigit number (For example: 123 45 6789), First 3 Digit refers to Area Number. Second 2 Digit refers to Group Number (01 to 99). The Last 4 Digit refers to Serial Number (0001 to 9999).
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Federal Insurance Compensation Act (FICA): It is a federal policy that provides financial benefits to people when they retired (age sixty-two and older) and/ or if they become disabled. Financial benefits may also be payable to a
worker's family when a worker dies or retires.
Supplemental Security Income (SSI): is a program is administered by the Social Security Administration (SSA). A person who is disabled, blind or a least age sixty-five may receive SSI if he or she meets certain financial eligibility requirements.
PICA: Its is the payer position flag ("p"-primary, "s-secondary", or "t-tertiary") in the first box marked "PICA" on the top left corner of the HCFA 1500 claim forms. This information will be used by proclaim to organize the payer date correctly in the transaction. If the payer position flag is left blank, then the claim will be sent marked as primary.
Qualified Medicare Beneficiary: Designed to help low-income elderly or disabled people on Medicare pay their medical expenses. The Qualified Medicare Beneficiary (QMB) program, administered by the South Dakota Department of Social Services, helps how-income elderly or disabled people on Medicare pay their Medicare premiums, coinsurance and deductibles. The Special Low-income Medicare Beneficiary (SLMB) and Qualifying Individual programs help low-income elderly or disabled people pay their Medicare Part C medical insurance.
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Open Access Plan: • Specialist care without a referral: Open Access plans give you the
freedom to visit a specialist without a referral. You're encouraged to choose a primary care physician (PCP) to coordinate your care and treatment, but you're not required to do so. Your coverage level is highest and there are no claim forms to submit when you visit innetwork providers. Cigna offers three types of Open Access plans, each offering a different level of choice and coverage: • HMO Open Access/Network Open Access: This is a network-only plan-
you can visit any in-network specialist without a referral. There is no out-of-network coverage, except in an emergency or urgent care situation. You may choose a PCP to coordinate your care and treatment, but you're not required to do so. • Point-of-Service Open Access: You can visit any in-network or out-of-
network provider without a referral. Your costs are lower when you choose in-network providers. You may choose a PCP to coordinate your care and treatment, but you're not required to do so. • Open Access Plus: You can visit any in-network or out-of-network
health care provider without a referral, though your coverage is higher when you see in-network providers. We encourage you to use a PCP as a personal health advocate to coordinate your care. With Open Access Plus, you have access to a broad nationwide network of providers.
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Duplicate Coverage Inquiry (DCI): A request to an insurance company or group medical plan by another insurance company or medical plan to find out whether other coverage exists.
Per Diem: Payment to a provider (normally an acute care facility) at an established or negotiated rate per day rather than reimbursement of all hospital charges as billed.
Open Enrollment:
Specified periods of time in which employees may change
insurance plans and medical groups offered by their employer and have the new insurance effective at a later date.
Over the Counter Drug (OTC): A drug product that does not require a prescription under federal or state law.
Medigap: Privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, co-insurance and balance bills, as well as payment for services not covered by Medicare.
Physician
Extenders:
Also
called
mid-level
service
providers.
Physician
extenders include licensed nurse practitioners and/or licensed physician assistants. They coordinate patient care under a doctor’s supervision.
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Global Surgery: A Standard package of pre-operative, intra-operative and postoperative services that is included in the payment for a surgical procedure.
Outlier Payments: Outlier payments are made to hospital to help
offset some
of the financial losses associated with treating extremely high costs Medicare cases.
Shadow Pricing: With in a given employer group, pricing of premiums by HMO based upon the cost of indemnity insurance coverage, rather than strict adherence to community rating or experience rating criteria.
Orphan Drugs: Orphan drugs are those that are so designated under subsection 526 of Federal Food Drug and Cosmetic Act by granting orphan drug status. The FDA grants a manufacturer marketing protection for a particular drug for a particular condition. No other manufacturer may market a generic version of the drug for that indication.
UPIN (Unique Physician Identification Number): UPIN is issued to providers by CMS. Providers who have UPIN only can bill Medicare. The format is 6 digit (3 alpha & 3 numeric).
PIN (Provider Identification Number): PIN is used by all insurance for identifying the provider. The format differs by insurance.
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Preventive Care: An approach to healthcare which emphasis preventive measures and health screenings such as routine physicals, immunizations, diagnostic lab and x-ray tests, mammograms etc., The purpose of offering
coverage for preventive care is to diagnose a problem early, when it is less costly to treat.
Birthday Rule:
The birthday rule related to the coordination of benefits and
determination of the primary payer when a child is covered by both parents health insurance plans. This applies to non-divorced parents. The insurer of the parent whose birthday month falls first in the year is the primary payers.
Chronic Condition: Impaired health status or medical condition that recurs or persists over a long period of time as opposed to an acute or emerged condition.
Participating (par) facility:
A facility that has completed the credentialing
process and signed a contract with the health plan to deliver medical services to members. The facility may be skilled nursing facility, hospital, pharmacy, and nursing home.
Partial Hospitalization: This is a short-term intensive treatment program where individual's experiencing an acute episode of psychiatric illness can receive medically supervised outpatient treatment. It serves an alternative to inpatient care and allows patients who are not a danger to themselves or others to maintain their everyday life without disruption after associated with a hospital stay. It
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reduces the length of psychiatric hospitalization and serves as a step down from an inpatient unit. It is called partial hospitalization because the patient attends
these 5-6 days a week and 6 hours per day, depending on patient’s condition.
Electronic Media Claims: Electronic claim submission is the state-of-the-art method for sending and receiving files, documents, and data. Suppliers who utilize electronic submission of claims to Medicare experience fewer delays than traditional paper billing, plus they save money. If you are not an electronic biller, consider making the switch. Benefits of Electronic Media Claims • Electronic claims allow for faster payment because they can be paid
after 13 days while paper claims cannot be paid for at least 27 days. • Suppliers can trace their claims as they go through the system,
allowing for increased tracking capabilities. This is accomplished through several methods. On-line receipt verification allows for verification after claims transmissions verifying that the transmission was successful. Electronic error reports and receipt listings allow suppliers to download a summary of submitted claims within two days of transmission. This provides the claim control number of claims that were accepted into the system and error explanations of claims that were rejected. • Rejected claims can then be corrected and re-transmitted with almost
no impact on the payment floor. Claim status inquiry allows the supplier to log onto the system and electronically check the status of claims rather then placing a call to a customer service representative.
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•
Lower administrative and postage and handling costs are incurred.
Electronic billing saves valuable production time. Personnel can be used more effectively for other tasks such as customer service or marketing. By using Electronic Remittance Notices (ERNs) and Electronic Funds Transfer (EFT), suppliers can eliminate the tedious process of manually posting to their accounting programs. ERNs can be used to automatically download payment information and then automatically post that
information to accounts receivable. To become an electronic biller, providers must submit an Electronic Data Interchange (EDI) Questionnaire. All suppliers will need to complete a testing process to get started in electronic billing. When this two-phase process is completed, a supplier is assigned a permanent submitter identification number. A supplier needs to only test their software with one DMERC (however they still need to test communications with each DMERC) and the submitter ID assigned to them will be accepted by all DMERCs.
Magnetic resonance imaging (MRI): It is a method of creating images of the inside of opaque organs in living organisms as well as detecting the amount of bound water in geological structures. It is primarily used to visualize pathological or other physiological alterations of living tissues as well as to estimate the permeability of rock to hydrocarbons. It is now a commonly used form of medical imaging.
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Pediatrics: It is the branch of medicine that deals with the medical care of infants and children. Most pediatricians are members of a national body, such as the Canadian Pediatric Society, the British Association of Pediatric Surgeons or the American Academy of Pediatrics.
One of the major challenges facing pediatricians is that the range of body sizes (and weights) that they face in pediatrics is much greater than in adult medicine. For example, a preterm neonate can be less than 2kg in weight while an obese adolescent may be larger than the typical adult. Childhood is the period of greatest growth, development and maturation of the various organ systems in the body.
Another major difference between pediatrics and adult medicine is that children are minors and, in most jurisdictions, cannot make decisions for themselves. The issue of guardianship, legal responsibility and informed consent must always be considered in every pediatric procedure. In a sense, pediatricians often have to treat the parents (and sometimes, the family), not just the child
PACE (Program of All-inclusive Care for Elderly): provides and coordinates all needed preventive, primary, acute and long term care services so that older individuals can continue living in the community. • How do people qualify for PACE?
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In order to be eligible for PACE a person must be aged 55 or older, certified by the state to need nursing home care and live in an area served by a PACE program. • Are prescription drugs covered? Yes. All prescription and non-prescription drugs deemed necessary by the program. • Are people who do not qualify for Medicaid eligible for PACE enrollment? Yes. If a person meets the income and assets limits to qualify for Medicaid, the program pays for a portion of the monthly PACE premium. Medicare pays for the rest. If a person does not qualify for Medicaid, he for the portion of the monthly premium Medicaid help determine a person's Medicaid PACE interdisciplinary care team are paid for by the PACE
or she is responsible
would pay. PACE staff can eligibility.
• What happens if a person wants to leave PACE? A PACE participant is free to cancel the enroll from PACE and resume their benefits in the traditional Medicare and Medicaid programs at any time.
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