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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.
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 you and your
family is very smart, but expect it to be a significant monthly expense.
Medical Emergency:
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Keep in mind that while emergency care here 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. While it is important never to hesitate when
there is a genuine emergency, these services are not intended for situations
where a call to your doctor or a visit to a walk-in clinic would be sufficient.
The United States does not have socialized medical care. If you have no
health insurance coverage, you have to pay for health care out of your own
finances at the time of service. This can run into many thousands of dollars
for serious illnesses
You buy health insurance for the same reason you buy other kinds of
insurance: to protect yourself financially. With health insurance, you protect
yourself and your family in case you need medical care
that could be very expensive.
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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.
The information presented here will help you choose a plan that is right for
you. If you are married or single, have children or no children, this
information will help you to find out how to choose a health insurance plan
that best meets your needs and your financial circumstances. Definitions of
the health insurance terms used are included in the section called
Understanding Health Insurance Terms.
The two main ways that people obtain health coverage are by paying into a
group or buying individual insurance.
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.
it yourself. This will certainly cost you 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 you work for a business of 20 or more employees and leave
your job or are laid off, you can continue to get health coverage for at least
18 months. You will be charged a higher premium than when you were
working.
You also will be able to get insurance under COBRA if your spouse was
covered but now you are widowed or divorced. If you were covered under
your parents' group plan while you were in school, you can also continue in
the plan for up to 18 months under COBRA until you find a job that offers you
your own health insurance.
Not all employers offer health insurance. You might find this to be the case
with your job, especially if you work for a small business or work part-time. If
your employer does not offer health insurance, you might be able to get
group insurance through membership in a labor union, professional
association, club, or other organization.
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 you use. Almost all
plans have some sort of managed care program to help
control costs. For example, if you need to go to the
hospital, one form of managed care requires that you receive approval from
your insurance company before you are admitted to make sure that the
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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.
You can choose any doctor you wish and change doctors any time. You can
go to any hospital in any part of the country.
With fee-for-service, the insurer only pays for part of your doctor and hospital
bills. You pay a monthly fee, called a premium.
A certain amount of money each year, known as the deductible, is paid for by
you before the insurance payments begin. In a typical plan, the deductible
might be $250 for each person in your 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 expenses you have count toward your deductible. Only those
covered by the policy do. You need to check the insurance policy to find out
which ones are covered.
After you have paid your deductible amount for the year, you share the bill
with the insurance company. For example, you might pay 20 percent while
the insurer pays 80 percent. Your portion is called "coinsurance".
To receive payment for fee-for-service claims, you may have to fill out forms
and send them to your insurer. Sometimes your doctor's office will do this for
you. You also need to keep receipts for drugs and other medical costs. You
are responsible for keeping track of your own medical expenses.
There are limits as to how much an insurance company will pay for your claim
if both you and your 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 you will have to pay for
medical bills in any one year. You reach the cap when your out-of-pocket
expenses (for your deductible and your 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 your policy says
it will cover. The cap does not include what you pay for your monthly
premium.
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Some services are limited or not covered at all. You need to check on
preventive health care coverage such as immunizations and well-child care.
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 you
are 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 your 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." Check your policy to make sure
you have both kinds of protection.
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, your 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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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 you may have to wait
longer for an appointment than you 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 your 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. You select a doctor from a list of
participating physicians that make up the IPA network. If you are thinking of
switching into an IPA-type of HMO, ask your doctor if he or she participates in
the plan.
In almost all HMOs, you either are assigned or you choose one doctor to
serve as your primary care doctor. This doctor monitors your health and
provides most of your medical care, referring you to specialists and other
health care professionals as needed. You usually cannot see a specialist
without a referral from your primary care doctor who is expected to manage
the care you receive. This is one way that HMOs can limit your choice.
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 you refer yourself to a provider outside the network and the service
is covered by the plan, you will have to pay coinsurance.
As with an HMO, a PPO requires that you choose a primary care doctor to
monitor your health care. Most PPOs cover preventive care. This usually
includes visits to the doctor, well-baby care, immunizations, and
mammograms.
In a PPO, you can use doctors who are not part of the plan and still receive
some coverage. At these times, you will pay a larger portion of the bill
yourself (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.
FFS advantages:
You may visit any specialist without getting permission from a primary
care physician.
FFS disadvantages:
FFS plans pay only for "reasonable and customary" medical expenses. If
your doctor charges more than the average for your area, you will have to
pay the difference.
HMO
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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:
HMO disadvantages:
HMOs require that you see only network doctors, or they won't pay.
POS
POS plans are more flexible than HMOs, but they also require you to select a
PCP.
POS advantages:
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:
While you may choose to see a physician outside the network, if you don't
receive permission from your PCP, you're likely to wind up submitting the
bills yourself and receiving only a nominal reimbursement — if any.
PPO
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PPO advantages:
The standard co-payment is $10 for a routine office visit during regular
hours.
PPO disadvantages:
If you see an out-of-network doctor, you may have to pay the entire bill
yourself, then submit it for reimbursement.
You may have to pay a deductible if you choose to go outside the network,
or pay the difference between what network doctors vs. out-of-network
doctors 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 you are eligible for Social
Security or Railroad Retirement benefits and are age 65, you and your spouse
automatically qualify for Medicare.
Medicare will pay for many of your 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 your bills that apply if you have employer group
health insurance coverage through your own job or the employment of a
spouse.
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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 you can choose (some
States may have fewer than 10.) If you buy a Medigap policy, make sure you
do not purchase more than one.
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
Children;
Pregnant Women;
Disability Insurance
Disability insurance replaces income you lose if you have a long-term illness
or injury and cannot work. This is an important type of coverage for working-
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age people to consider. Disability insurance does not cover the cost of
rehabilitation if you are injured.
Some employers offer group disability insurance and this may be one of the
benefits where you work. Or you might be eligible for some government-
sponsored programs that provide disability benefits. Many different kinds of
individual policies are also available.
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.
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.
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
This insurance offers limited coverage. It pays a fixed amount for each day,
up to a maximum number of days. You may use it for medical or other
expenses. Usually, the amount you receive will be less than the cost of a
hospital stay.
Some hospital indemnity policies will pay the specified daily amount even if
you have other health insurance. Others may coordinate benefits, so that the
money you receive does not equal more than 100 percent of the hospital bill.
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Coinsurance
Coordination of Benefits
Co-payment
Another way of sharing medical costs. You pay a flat fee every time you
receive a medical service (for example, $5 for every visit to the doctor). The
insurance company pays the rest.
Covered Expenses
Customary Fee
Most insurance plans will pay only what they call a reasonable and customary
fee for a particular service. If your doctor charges $1,000 for a hernia repair
while most doctors in your area charge only $600, you will be billed for the
$400 difference. This is in addition to the deductible and coinsurance you
would be expected to pay.
Deductible
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The amount of money you must pay each year to cover your medical care
expenses before your insurance policy starts paying.
Exclusions
Specific conditions or circumstances for which the policy will not provide
benefits.
Prepaid health plans. You pay a monthly premium and the HMO covers your
doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests,
x-rays, and therapy. You 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.
The most money you 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.
Pre-existing Condition
A health problem that existed before the date your insurance became
effective.
Premium
The amount you or your employer pays in exchange for insurance coverage.
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Provider
Any person (doctor, nurse, dentist) or institution (hospital or clinic) that
provides medical care.
Third-Party Payer
Any payer for health care services other than you. This can be an insurance
company, an HMO, a PPO, or the Federal Government.
♫♫♫♫
MEDICAL BILLING – AN INTRODUCTION
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insurance company on behalf of the doctors. The insurance company pays for
the treatments billed by the billing office.
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.
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
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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 HCFA)
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.
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?
The insurance bills are sent out on claims. 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.
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.
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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Billing office is a link between the Doctor and the insurance company. The
billing office in India has four departments put together, they are:
Scanning Department
Charge Entry Department
Cash Department
Accounts receivable department
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.
The scanning department receives and allocates all the data received by them
to the respective departments.
The registration details involves the patients name, address, social security
number, birth date, sex, rendering & referring doctors name, phone numbers,
insurance company details, employer details etc, and once these details are
entered into the system the treatment charges can be entered into the
particular patients account. 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.
PD & 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.
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. EOB will be used to verify any
discrepancies from the expected payment.
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:
EOB’s are the only hard copy evidence the billing office has of the insurance
company receiving and processing the claims sent to them and so will have to
be filled carefully for future references.
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:
Correct details may not have been provided to the insurance companies.
Claims were sent correctly but Insurance Company may not have received
the claims.
The checks issued might have been sent to the wrong address.
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.
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
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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.
Quality Department:
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.
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In general, the basic tools needed by health care providers for optimizing
reimbursement are:
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The following brief outline would give the workflow process from the time a
patient is seen by a physician.
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)
12. 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
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13. All denied the rejected/denied claims group, which will determine the
reason for denial, researches codes in the EOB’s or Explanation of Benefits
received 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.
14. 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. 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.
16. 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 & Charge sheets received from all All the Scanned documents are received,
four facilities are received, batched & checked with Scan logs and forwarded to
Scanned to Back Office respective entry departments
Claim Not
Claim Paid Low paid Claim Claim
In System
Claim Denied Pended
Claims needs to be
Cash resubmitted after proper Analyst needs to review each situation and
posting verification take appropriate actions to settle claims
If secondary or tertiary
Insurance available, submit Client Adjustment Other
claims Appeals Assistance actions
s
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If Claim needs to be
submitted in paper
RAPIDCARE MEDICAL BILLING MANUAL
If Claims needs to be
submitted electronically
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 a 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.
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Coding Systems:
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:
CDT-3 codes
ABC codes
SNOMED codes
NDC codes
Home Healthcare (saba) codes
DRG systems.
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In US, the coding is still based on ICD-9-CM, which contains more detailed
codes.
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-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.
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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,
Unspecified
- 003.21 Salmonella Meningitis
- 003.22 Salmonella Pneumonia
- 003.23 Salmonella Arthritis
- 003.24 Salmonella Osteomyelitis
003.29 Other Localized Salmonella
-
Infections
- 003.8 Other Specified Salmonella
Infections
- 003.9 Salmonella Infections,
Unspecified
The U.S. National Center for Health Statistics published a set of clinical
modifications to ICD-9, 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.
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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, 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, HCFA 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, HCFA 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
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NCCI Manual
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Charge sheets that must be coded are, upon receipt by the billing account,
forwarded to the coding department for diagnosis and CPT coding.
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.
Coding policies and guidelines, if any, established by the client, the coding
supervisor, or insurer are followed wherever applicable during the process of
coding.
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.
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.
Upon completion of coding, the coded charge sheets are forwarded to the
charge entry department of the respective billing account.
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.
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.
CODING GUIDELINES
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.
V codes are used to identify encounters for reasons other than illness or
injury. V codes are used as principal diagnoses for newborn admissions
(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.
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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.
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 co morbid condition or
complication should be included in the diagnoses which may be submitted
to Medicare. All complications are reported for calculating severity of
illness.
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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.
20. Diagnostic statements expressed in terms of a malignant
neoplasm with “spread to...” or “extension to...” are to be coded as
primary site with metastases.
21. If no site is stated in the diagnosis but he morphologic types is
identified as metastatic, code as primary site unknown and also assign the
code for secondary neoplasm or unspecified site.
22. Code fractures as closed unless they are specified as open.
23. Code only the most severe degree of burn when different
degrees of burns occur at the same site.
24. 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.
25. 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.
26. 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.
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the policy which was in effect during their last visit. Photocopy of insurance
cards is always a help.
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.
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They are:
Patient Information
Patient employer information
Patient guarantor information
Physician information
Insurance information.
Patient Information
They are:
Account #
Patient Name
Patient Sex
Patient Date of Birth
Marital Status
Patient Address
Patient phone number
Example:
Account #: 24584951, 3205215 …
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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 HCFA-1500 claim form in
Last Name, First Name Middle Initial format.
Example:
Patient Name: Jones, Brenda K; Brenda K Jones; Miller John Jr.;
…
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 HCFA-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 …
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 HCFA-1500 claim form along
with the Date of the Birth.
Example:
Sex: Male; Female; M; F.
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This number is for the internal purpose of the Billing Office and the
Hospital. It is mainly helpful to follow-up with the patients or insurance on
their outstanding balances. This number does not appear on the HCFA-1500
claim form.
Example:
SSN: 245-19-0124; 245190124
About SSN
The President Franklin Roosevelt signed the Social Security Act on August 14,
1935. Taxes were collected for the first time in January 1937 and the first
one-time, lump-sum payments were made that same month. Regular ongoing
monthly benefits started in January 1940.
What is
the
origin of
the term
‘Social
Security’?
Abraham Epstein in connection with his group, the American Association first
used the term in the U.S. 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.
Who assigns the SSNs and how many SSNs have been assigned?
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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.
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.
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
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
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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.
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 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.
SSA can assign new SSNs in the following situations, provided all of the
documentation requirements are met:
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
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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.
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.
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.
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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
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:
- 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 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.
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:
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No SSNs with an area number in the 800 or 900 series, or "000" area
number, have been assigned.
No SSNs with an area number above 728 have been assigned in the 700
series, except for 729 through 733 and 764 through 772.
No SSNs with a "00" group number or "0000" serial number have been
assigned.
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.
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).
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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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 self-employment 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 SSNs are
permanently part of SSA's records.
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 HCFA-1500 claim form.
Example:
Marital Status: Single; Married; Divorced; Widow …
This field is printed in the 5th field of the HCFA-1500 claim form.
Example:
Address: 1067 Orange Grove Blvd.
Apt. # 194
Los Angeles, CA 90001
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-
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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 HCFA-1500 claim form along
with the address.
Example:
Phone Number: 626-843-2846; (626)357-5496 …
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
Employer Code
Employer Name
Employer Address & Phone #
Designation/Occupation
Contact Person
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 …
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 HCFA-1500 claim form.
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Example:
Employer: Verizon Wireless; Microsoft Corp.; SUN Microsystems
…
Example:
Address: PO Box 1954
Los Angeles, CA 90001-1954
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 …
Guarantor Account #
Guarantor Name
Guarantor Address
Guarantor phone #
Guarantor/patient relationship
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
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Emergency Contact or follow-up of pending balances and hence does not form
part of the HCFA-1500 claim form.
Example:
245818A; 6252315; 421154; …
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 …
Relationship: This field contains the relationship of the Guarantor with the
patient, such as Spouse, Parent, Others etc.
Example:
Relationship: Spouse; Parent; Grand Parent …
Example:
102 West 35th Street
Heathsville, GA 65418
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.
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Example:
(517)373-1820; 517-374-5857 …
Physician Information
Example:
Adm. Phy.: Mileski MD, William
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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 33 rd 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 HCFA-1500 claim
form.
Example:
Att. Phy.: Pendridge MD, Dayton
Insurance Information
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
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Insurance Code/Name
Effective Date
Subscribers Name
Relationship Code
Pre-Certification/Pre-Authorization
Referral Number
Primary Insurance Group #
Primary Insurance Policy #
Date of Injury/Accident
Claim Number
Example:
Insurance: Medicare, Medicaid, Blue Cross, Blue Shield …
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
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date is used for the internal purpose of the Billing office and Hospitals. This
does not form part of the HCFA-1500 claim form.
Example:
Eff. Date: 7-1-66; 07/01/1976; 07 01 66 …
Example:
Subscriber: John Q. Public; Public, John Q …
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 11 th field and the Secondary
insurance ID is printed in the 9a field of the HCFA-1500 claim form.
Example:
Policy ID: 123-54-5478A; 215543251W1; 215-47-6491 …
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.
The Group ID is printed along with the Policy ID on the HCFA-1500 claim
form.
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.
This is mentioned in the attached documents while submitting the claim.
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Batch No
Found
?
Yes
Any
Incomplet Yes
e/Missing
Info?
Enter the Issue in the
Problem Log
No
No Batch
Complete
d?
Yes
Entry Process
Completed
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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.
For our easy understanding now let us see each of the information found in
patient charge sheet. Information found in patient charge sheet is 1.
Attending Physician 2. Referring Physician 3. Admit Date 4. Date of Service
5. Type of Service 6. Place of Service 7. Prior Authorization Number 8.
Modifiers 9. Procedure code 10. Diagnosis Code 11. # Of days/ units, 12.
Location Details 13. Physician Name, Address, Provider id
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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 32nd field and the corresponding Federal Tax ID of the
Provider is printed in the 25th field of HCFA.
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
known of the condition and its relationship to the employee's employment,
whichever is the later.
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. DOS must be greater than or equal to
admit date.
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45378 – Colonoscopy
This field is printed along with the CPT/HCPCS Code in 24d field of
the HCFA-1500 Claim Form.
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Modifiers that are currently approved for hospital outpatient use with CPT
codes as defined by the 2002 AMA CPT manual are:
Modifier Description
-25 Significant, separately identifiable evaluation and management
service by the same physician on the same day of the procedure
or other service
-50 Bilateral procedure
-76 Repeat procedure by same physician
-77 Repeat procedure by another physician
Modifiers that are currently approved for use with HCPCS Level II codes as
defined by the 2002 AMA CPT manual are:
Modifier Description
-LT Left side
-RT Right side
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NO
Post co pay amount to patient
account if specified.
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here, receives the checks along with the claim details. The details, which are
received with the checks are known as the EOB (Explanation of Benefits).
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
cash poster who gives the file reference numbers based on the date on which
the file was received then collects the received files. 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:
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.
General Terms associated with Cash posting and their definitions:
Claim:
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EOB:
For Example: -
Billed amount:
Allowed amount:
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: -
Paid amount:
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: -
Co-pay:
The fixed dollar amount that patient’s policy requires to pay as patient
share of the cost of certain services each time when a service is rendered. It
is only patient responsibility, which the patient has to pay out of his pocket.
Usually it is paid during the time of the visit. It generally ranges from $5.00
to $25.00. The amount depends upon the visit / plan. Co-pay’s are usually
associated with the HMO plan. The co-pay amount is usually specified in the
insurance card copy.
Co-insurance:
For Example: -
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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: -
Deductible:
The amount patient has to pay for health care, before the health plan
begins to pay. It is the annual amount payable by the beneficiary for covered
services before Insurance makes reimbursement. There is a deductible for
each benefit period - usually a year. Deductibles can change every year. It is
mostly patient responsibility and very rarely another payor pays this amount.
For Example: -
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.
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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:-
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:
For Example:-
Let the billed amount of a claim be $100.00 and the charge be an incorrect
one. In this case the whole of $100.00 is adjusted off and a new charge with
correct details is keyed in.
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:
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:
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 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 payor 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: -
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Now let us see the diagrammatic representation of the cash posting process:
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YES
Post the amount in the software.
NO
Verify whether the amount
received and the amount
posted equals.
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.
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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.
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 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.
From the above report, the analyst selects claims that remain unpaid beyond
30-45 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.
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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.
Following are some of the situations the analyst may encounter & suggested
remedial actions:
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.
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.
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.
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.
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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.
Examples of the kind of situations that the analyst may come across and the
action initiated are given below:
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.
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.
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.
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.
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
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client, depending on the nature of the issue. Complete resolution of an issue may
require inputs or actions from more than one department.
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:
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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 in collections using the tools and documents
mentioned above. The objective is to minimize AR and maximize the collection
rate.
SCOPE:
Calls to be made to the following entities by an AR representative:
Insurance carriers
Hospitals
Physicians office
Patients
Insurance carriers:
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Calls are made to the insurance carrier to confirm on the provider enrollment
details. To check as to whether the provider is participating with the
insurance and/or to enroll the provider with the insurance carrier.
Claim status:
Calls are made to insurance company to enquire about the status of a claim
that has already been filed to them 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.
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.
CALLING – CLASSIFICATION:
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Inbound:
Calls that the office receives from patients, insurance carriers etc are 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.
Outbound:
Calls that our office makes to the insurance carriers, patients, hospitals,
provider’s office etc are termed as outbound.
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 : Called.
TT : Talked to.
CPT : Current Procedural Terminology.
Dnd : Denied.
DOS : Date Of Service.
PCP : Primary Care Physician.
Auth# : Authorization number.
POS : Place Of Service.
EOB : Explanation of Benefits.
EOMB : Explanation of Medicare Benefits.
Chk : Check.
Pt : Patient.
Proc : Procedure code.
Clm : Claim.
Diag : Diagnosis.
Ins : Insurance
Pd : Paid
Amt : Amount
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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.
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.
Called Insurance…………. . TT …………….. . She said that the DOS ………….. for
the billed amount………….. paid …………. On …………. Chk# is ………………… bulk
chk in the amount of………..
Claim processed on…………. The copay is…….. the co-insurance is ………. And
the patient responsibility is …………. The chk was mailed out to …………….
(address) and the chk is still ………. (out-standing).
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COMMON PHONETICS
A As in Apple
B As in Boy
C As in California
D As in David
E As in Edward
F As in Frank
G As in Girl
H As in Henry
I As in Indiana
J As in Jack
K As in Kite
L As in Larry
M As in Mary
N As in Nancy
O As in Orange
P As in Peter
Q As in Queen
R As in Robert
S As in Sam
T As in Tom
U As in Umbrella
V As in Victory
W As in Whisky
X As in X ray
Y As in Yellow
Z (zee) As in Zebra
HIPAA
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What is HIPAA?
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
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transactions, national code sets, and unique identifiers for providers, health
plans, employers and individuals.
Why Standardize
Electronic Transactions?
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. These
regulations have been finalized and implementation is mandated for October
16, 2002, however approved extensions are available until October 16, 2003.
The privacy rule will affect the day-to-day business operations of all
organizations that provide medical care and maintain personal health
information.
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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 Plans: Includes individual or group plans that provide or pay the cost
of medical care and includes both the Medicare and Medicaid programs
+ 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. These controls include the following
mandatory implementation features:
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Data backup
Data storage
Disposal
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
Maintenance records
Accreditation
Accrediting organizations may require compliance in future
HHS has the final responsibility for determining civil violations
and imposing penalties
Civil money penalties
$100 for each violation of a standard
Maximum of $25,000 per year
Per identical requirement or prohibition
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
###
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