Page Lof 16 MEDICAL BILLING Medical billing & Coding is the process of submitting and following up on claims to insurance companies in order to receive payment... Medical billing translates a health care service into a billing claim. The responsibilty of the ‘medical biller in a health care facilty is to follow that claim to ensure the practice receives reimbursement for the work the providers perform. A knowedgeable biller ean oplimize revenue performance for the practica, Although a medical biller’s duties vary with the size of the work facility, the biller typically assembles all data conceming the bill. This can include charge entry, claims transmission, payment posting, insurance {follow-up and patient follow-up. Medical billers regularly communicate with physicians and other health care professionals to clarity ‘ro obtain additional information, Therefare, the medical biller must understand how to read the medical record and, like the medical coder, be familiar with CPT®, HCPCS Level Il and ICD-9-CM codes. {TRODUCTION OF GOVT. IN! Tricare RR Medicare (RR-Rail Road) Administrated by administered directly the federal government. 1 People 65 Years above 2 People Under 65 with certain Disabilities For People with Disabilities and Ilinesses No matter how old you are, if you have Lou Gehrig's disease) kidney failure, or certain other disabilities, you are eligible for Medicare. But you might have a waiting period before you get Medicare benefits, Here are the detail Lou Gehrig's disease (ALS). As soon as you get Social Security Disability benefits for ALS, you should be automatically enrolled in Medicare, There is no waiting period. Kidney failure. To qualify, you must have end-stage renal disease and need dialysis or a kidney transplant, Usually, you can't get Medicare until three months after you start dialysis, OncePage Zot 16 MEDICAL BILLING you've been diagnosed with kidney failure, call the Social Security administration at (800) 772. 1213 to enroll in Medicare, Other disabilities for whieh you get Social Security Disability benefits. You can't get Medicare until two years after you qu s isability, At that point, the Social urity Administeation should sign you up Note: Patignt must be Tax Paid in order to get Medicare benefits, ifferent parts of Medicare Part A Part B Part C Part D A (Hospital Insurance ‘Only Covered with Hospital Services. Ex. Bed Charges & Equipment charges) ‘Cover Inpatient care in Hospital cover Skilled Nursing facility, hospice and home health care Claims billing to UB92 & UBO04 forms, Part B (Medical Insurance) Its Covered with Doctors* Services, hospital outpatient care and home health care. ‘cover some Preventive services to help maintain your health and to keep certain ill geiting worse Claims Billing to HCFA-1500& CMS 1500 forms, Part C (Parta+PartB+PartD} Medicare Advantage plans (like an HMQ or PPO) are health plans run by Medicare-approved private insurance companies, Medicare Advantage plans (also called Part C) include Part A, Part B and usually other coverage like Medicare prescription drug coverage (Part D), sometimes for anextra cost Part D ( Medicare prescription Drug Coverage) Only Covered with Drug Programmed supply for Medicine) Ex: Sugar Patient Here's what the letters behind the Medicare number mean: "A= relired worker B = wile of retired worker B1 = husband of retired workerPage 3of 16 MEDICAL BILLING BG = divorced wife B9 = divorced second wife. € = child of retired or deceased worker; numbers after C denote order of children claiming benefit D = widow D1 = widower D6 = surviving divorced wife E = mother of a child of a deceased worker E1 = divorced mother of a child of a deceased worker F1 = aged dependent father F2 = aged dependent mother “HA = disabled worker HB = wile of disabled worker HC = child of disabled worker *J1 = special “over 72” benefit, has A and B K1 = wife of “over 72” benefit, has A and B *M = has Part B Medicare only, no SSA benefit *T=has A and 8 Medicare, no SSA benefit w ibied widow WA = railroad retirement "denotes the recipient's own social security number. Medicaid: = Covered with below Poverty people (or) Low income people, It’s monthly month basic, Administrated by Each State Law. Dual Eligible Medicare Beneficiary Groups Dual Eligible Income Medicare Criteria Beneficiary Groups Benefits Eligibie for Medicaid payment of Medicare premium, deductible, coinsurance and ‘copayment amounts (except for Medicare Part D). $ 100% of the Federal Poverty Line (FPL) Entitled to all benefits available to 2 MB, QM Plus** as well as.all benefits available under the State Medicaid plan,Page 4of 16 MEDICAL BILLING Suma Only* ‘Specified tow. Income Medicare Beneficiaries > 100% of ie Eligible for payment of the FPL but ‘Medi Part B €120% of vekite sah the FPL poy me Entitled to all benefits > 100% of available to an SLMB, as the FPL but i ‘well as all benefits < 120% of EL available under the State Medicaid plan, SLMB Plus** ‘ible for payment of Medicare Part B a Rte si premiums only; however, Qualifying ne LaeK oF ‘expenditures are 100% Individuals the FPL federally funded and total expenditures are limited by statute aowr Qualified Eligible for Medicaid Disabled payment of Medicare Part Working A premiums only. Individuals Eligible for Medicaid either categorically or through optional coverage groups, such as Medically Needy or special income levels for institutionalized ‘or home and community based waivers. ‘Tricare I's covered with Army people. Tricare Two Types: 1. CHAMPVA ( Civilian Health and Medical program for Veteran affairs) 2. CHAMPUS ¢ Civilian Health and Medical program for Uniformed services) RR Medica It’s covered with Railway Department, Transport Department & Highway’ s Department,Page Sof 16 MEDICAL BILLING Worker's Compensatio It’s covered with Work related injury and work relevant accident, Auto Accident: t's Covered with Vehicle Accident ‘Two types af Auto Accidents 1. No fault Auto Accident To provid 1.HMO (Health Maintenance Organization) Patient must goes to in-network Provider. PCP Must. (Low pi coins). PCP means Primary care Physician. Pt goes to PCP first and PCP Issue Referral for: list visit according to Diagnose, 2. PPO(Preferred Provider Organization) Patient may ge to any Healthcare Provider in listed Panel doctors, anywhere; Include out of Network If benefits are available, 3. EPO(Exclusive Provider Organization) Similar to an HMO, with an EPO you must use network providers - doctors, hospitals and other health care providers - that in. The only exception is for emergency eare. Unlike an HMO, you do not need to select a Primary Care Physician, nor do you need to contact your PCP for referrals to specialists 4, POS (Point of Services) It's companied with HMO+PPO Patient goes to any network provider (In or Out). PCP Must. Traditional Indemnit; we billed and repaid for all or part of cach service performed, subject to deductibles on coverige. COBRA: The term COBRA is an acronym for the Consolidated Omnibus Budget Reconciliation Act of 1986—federal legislation that governs the operation of group-sponsored health plans ofPage 6of 16 MEDICAL BILLING businesses with twenty of more eniplayees. The COBRA Plan will offer continuing healthes coverage fo you and your dependents if you leave your job. ‘You will have to pay the entite COBRA premiam on your own, however It's possible to extend COBRA's Coverage for up to 18 months and a surviving dependent receive further extensions HSA: Health savings accounts (HSAs) are like personal savings accounts, but the money in them is used to pay for health care expenses. You — not your employer or insurance company — own and control the money in your health savings aecount. The money you deposit into the account is not taxed. To be eligible to-open an HSA, you must have a special type of health insurance catled a high-deductible plan. PAR Provider: (Participating Provider) Who agrees and accept Insurance fees schedule and willing to contract with Insurance company. Rolling Capitation 1. Fixed Capitation: Provider will be get fixed amount for every month’year. 2, Rolling Capitatio Provider will be get the fixed amount for every patient, Non-PAR Provider ( Non-Participating Provider) ‘Who does not contract with any Insurance company. (no write off) ixed Percentage of the Allowed amount, insured/subseriber/Patient has to pay to Healthcare Provider. It’s fixed amount payable to provider by insured for each viPage 7 of 16 MEDICAL BILLING Deductible A specified amount of money that the insured must_pay befare an insurance company starts benefits. Medicare & Commereial insurance starts in January of each year ‘Tricare insurance starts in October of each year 2009 PART-B annum Deductible amount - $135.00 2010 PART-B annum Deductible amount - $150.00 2011 PART-B annum Deductible Amount -§ 162.00 2012 PART-B annum Deductible Amount -$140.00 2013 PART-B arinum Deductible Amourt -$ 147.00 Authorization: ‘Two types of Authorization 1, Prior Authorization 2 Retro Authorization Prior Authorization: ‘The process of obtaining permission to performa service from the insurance carrier before the service is performed is called Pre-authorization, Prior authorization only required for certain type of procedures or specialty. However prior Auth is nat guarantee of payment Retro Authorization: Aller rendered the service provider get approval from the insurance company. It’s exceptional only, Mostly insurances do not issue retro Auth Referral: ‘A referral is an authorization provided by the Primary Care Physician referring a patient to a specialist. Submitting a referral along with a claim is necessary to get reimbursement. ABN: (Advance Beneficiary Notice) ‘A notice that hospital/Provider gives the patient before they reeei Medicare/Medicaid is not expected to pay for some or all of the AOB: (Assignment of Benefits) Patient assigned benefits to the provider behalf of the treatment. Coordination of Benefits Its details of Primary and secondary ‘Social Security Number} jumber all US Citizen Must. This Number Given by Social Security Administrator.SSN 3- at, First 3igit-Area Code 2digit-Group no, 4digit-Serial no.Page Bof 16 MEDICAL BILLING surance Company fixed Maximum amount allowed each and every procedure code is called Allowed amount. Refund or Take Back ‘Claim wrongly Process and pay to the provider after the insurance company find the amount and ask refund request from the provider. Offset oF Recoupment a tthe provider not refund the artiount in the insurance company bill be adjusted on the next Claim. Modifier: Modifiers are codes that are used to “ENHANCE OR ALTER THE DESCRIPTION OF A SERVICE OR SUPPLY” UNDER CERTAIN CIRCUMSTANCES. A modifier provides. the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code, The judicious application of modifiers obviates the necessity for separate procedure listings that may deseribe the modifying circumstance, Modifiers may be used under the following circumstances:~ A service or procedure has both a professional and technical component, A service or procedure was performed by more than one physician andor in more than one location. + Assetvice oF procedure has been increased or redu Only part of a service was performed. AA bilateral procedure was performed, A service or procedure was provided more than once, Unusual events occurred, Information Modifier Reimbursement Modifier 1.Information Modifier:Page 9of 16 MEDICAL BILLING oes not Vary the payment just ihtithate the insukince comparly which part of the organ service was rendered eg.LT, RT, Al, KX, KO 2, Reimbursement Modifier: Vary the payment who render the service patient (EX) PC, TC, 2 Commonly User Modifiers: Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period 25:Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day ofa Procedure or Othor Service. adding of Reports, on of Surgery. taged or Related Procedure or Service by the Same Physician During the Postoperative Period, istinet Procedural Service 76:Repeat Procedure or Service by Same Physician: It may be necessary to ind procedure or service was repeated subsequent to the original procedure or service T7:Repeat Procedure by Another Physician: The physician may need ta indicate thai a basic procedure or service performed by another physician had to be repeated 78:Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period 79:Unrelated Procedure by the Same Physician During the Postoperative Periad: The phy: may need to indicate that the performance of « procedure or service during the postoperative period was unrelated! to the original procedure 90:Re ference (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 modifi 90 to the usual procedure number. 94: This modifier may not be used when tests are rerun to confirm initial results; due to te problems with specimens or equipment; or for any other reason when @ normal, one-time, reportable result is all that is requirePage 10 of 16 MEDICAL BILLING cM Centers of Medicare and Medieaid Service is the acronym for the Health Insurance Portability and Accountability Act that was xd by Congress in 1996. HIPAA does the following: Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs: Reduces health care fraud and abuse; Mandates industry-wide standards for health care information on electronic billing and other processes; and Requires the protection and confidential handling of protected health information POS: (Place of Service) It’s Indicate where the service was rendered. (EX) Hospital ,Clinie, Home e Most commonly uscd POSare mentioned below. 11- Office 13-Assisted Living Facility 20-Urgent Care 21-Hospital In P Hospital Out Patient 23-Emergeneey Room 31-Skilled Nursing Facility 32-Nursing 81-Independent Laboratory ROE: (Release of Information) Patients to release their Medical Information DX-Codes: ¢) (ICD9 or ICD10 codes) sation of the nature of an illness or other problem by examination of the symptoms. DX-Codes means Diagnosis Code. 3-5 digit numbers, Ex: 123.45, Fever, Headache CPT: Current Procedure Terminology. Current Procedural Terminology (CPT) is a code set that is used to report medical procedures and services to entities such as physicians, health insurance companies and accreditation organizations ‘There are three types of CPT codes. Category | cavers vaccines, Category 2 deals with performance measurement and Category 3 cavers emerging technologies, services and procedures, The current version is known as CPT 2010. HCPCS level-1 codes CPT Code means Procedure code. 5 digit number Procedure codes include 6 types of Treatmer n Ma nent) Visit, Starting with 99201-99499,Page 11 of 16 MEDICAL BILLING 2. Anesthesiology — Starting with 00100-01999, 99100-99140 3. Surgery Starting with 10021-69990 4 Radiology (Including Nuclear Medicine and Diagnostic Ultrasound (Ex: Exray, CT, MRI) ~ Starting with 70010-79999 5 Pathology (Blood test, Urine test) — Starting with 80048-89356 6 Medicine (except Anesthesiology) (EKG (ECG), EMG) ~ Starting with 90281- 99199, 99500-99602 CPCS Cod calth Care Financing Administration Common Procedure Coding System. (pronounced "hick- picks"), Three level system of eodes, Level I - American Medical Associations Current Procedural Terminology (CPT) codes. Level Il - The alphanumeric cades which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, ete. These are items and services not eovere by CPT (Level 1) procedures, vel III - Local codes used by state Medicaid organizations, Medicare coniraciors, and private insurers for specilie areas or programs. ing Cond Patient already suffered from Some disease before enter the policy, Insurance will not cover some dufation for that disease, that patient responsible... that period called. "Waiting Period”. ‘Once the patient will complete their waiting period, insurance starts to pay their : Heart Disease, High blood pressure, Cancer and Asthma. FECA- Federal Employee's Contribution Act. ‘The Federal Employees’ Compensation Act (FECA) provides federal employees injured in the performance of duty with workers’ compensation benefits, which include wage-loss benefits for total or partial disability, monetary benefits for permanent loss of use of a sched medical benefits, and vocational rehabilitation. This Act also provides survivor benef ble dependents if the injury causes the employce’s death. The FECA is administered by the Office of Workers’ Compensation Programs (OWCP)Page 120f 16 MEDICAL BILLING Work on claim 1, Eligibility verification Pt. id/group number, effective/Termination date, claim mailing address, payer ID or fax, Timely filing limit, Billing entry Reconcile Claim submission... Paper, Electronic, Fax or Oiline on Web partal Call after appropriate days of filing for claim status Ifnot on file verify eligibility again If deny get denial reason argue them about this denial and try to reprocess if you see any possibility Ifpaid get received date. Paid date, check, claims and the address where they mail check. Date of check cleared. Payment posting... and work on denial Appeal on those denials which you feel denied in error/Fault of Insurance company or Medical Necessity Skiils/E xperience: 1. Good communication/Listening Skills.(English) 2-Knowledge of medical billing/co lection practices. 3. Knowledge of computer programs and basic office equipment 4. Knowiedge of business office procedures 3. Knowledge of basic medical coding and third-party eperating procedures and Practices. 6. Ability to operate a multi-line telephone system. 7. Skill in answering a telephone in a pleasant ane! helpful manner. 8. Ability to read, understand and follow oral and written instructions. 9. Ability 10 establish and maintain effective working relationships with patie ‘employees and the public, 10, Must te well organized and detail-oriented,Page 13 of 16 MEDICAL BILLING DAILY USE ABBRIVATI NPI - Nai Provider Id ‘TIN-Tax Identification Number IVR- Interactive Voice response EOB - Explanation of Benefits Durable Medical Equipment HIPAA - Health insurance Portability and Accountability Act cal Laboratory Improvement Amendments, ¢ Data Interchange mployer Group Health Plan, IN - Employer Identification Number. ERISA - Employee Retirement income security Act ESRD - End stage Renal Dis (CPA - Health Care Financial Administration, Health insurance Claim, HCPCS - Healthcare common procedure coding system. ICD9CM-International Classification of Disease 9 the revision of clinical modifier DOS - Date of Serviee. OWCP- Office of Worker's Compensation Program, IN - Provider Identification number. PCP - Primary Care Provider. ERA - Electronic Remittance Advice. RRB - Railroad Retirement Board. SSA - Social Security Administration. SNF - Skilled Nursing Facility, TPA - Third Party Administrator, UPIN - Unique Physician Identification Number.Page 140 16 MEDICAL BILLING EVALULATION AND MANGMENT CODES(Commonly Used) pos | LeveL LEVEL? tever 3 | vevera_| Levels | DESCRIPTION ‘99203 | 99204 [99205 | OFFICENEW Fra 99201 10mins | 99202 20mins | 30mins_| 45mins_| 6omins_| wisiT ‘ga213 | 99214 | 99715 99211 5mins__| 99212 10mins | 20mins_| 30mins_| 45mins_| SUBSEQUENT 99243 | 99244 | 99245 99241 15mins_| 99242 30mins | aQrnins_| 6Omins_| BOmins_| CONSULT 99326 | 99327 | 99328 | ASSISTED LIVING 99324 20mins_| 99325 30mins | aSmins_| 60mins_| 75mins_| HOMENEW ‘99336 | 99337 99334 15mins_| 99335 25mins | 40mins_| 60mins SUBSEQUENT 99223 HOSPITALINITIAL 99221 35mins_| 99222 55mins | 70mins wisi 99233 99231 15mins | 99232 25mins_| 35mins FOLLOW UP 99237 99238 99239 DISCHARGE 99253 99251 20mnins | 99252 -40mins | SSmins CONSULT 99292 toch 99291 30-74 | jaacseionot 30 HOSPITAL mins mine CRITICAL CAL SAME DAY 99238 99235 OBSERVATION INITIAL 99018 99219 OBSERVATION 29224 99225 FOLLOW UPS 9917 DISCHARGE 99281 99282 EMERGENCY SKILLED. NURSING FACILITY INITIAL 99304 2Smins | 99305 35mins vistT 99307 10mins_| $9308 15mins SUBSEQUENT 99215<30mins | 99216>30mins DISCHARGE PHYSICAL EXM 99383'5-11yes_| 99388 12-17 New 99393 99394 Established NEW PATIENT VISIST Required Key Component 3/3_ 99201 | 99202 | 9203 | 99204 | 99205 |Page 15 of 16 MEDICAL BILLING Problem-Facused + Expanded Problem-Focused = Detailed = Comprehensive Medical Decision Making (complexity) = Straightforward stow “Moderate High Contributory Factors Presenting Problem (Severity) + Self-imited or Minor = Low to Moderate “Moderate “Moderate to High ESTABLISHED PATIENT VISIT Required Key Camponent 3/3 goza1 | 99212 99215 + Problem-Focused NA Expanded Problem-Focused x Detailed Comprehensive | Medical Decision Making {complexity} Straightforward NA stow I | + Moderate | 1 | I | x x x = High Contributory Factors Presenting Problem (Severity) + Self-Limited or Minor x Low to Moderate ‘Moderate “Moderate to High x Collector Must Know(After above short training)Page 16 0f 16 MEDICAL BILLING Must Know Basics of Medical Billing Must Know Claim Cycle. Must Know about Timely filing. Must know E/M codes Must Know Place of Services. Must Know about All Boxes of Claim form, Must Know about Main Windows of Software, Must Know about Abbreviations, Must Know about NCCI Must know LCD/Medical Necessity. Musi Know BASIC process of Credentialing. Must Know to work on web portals, Must Dial SOcalls to Hospital/Provider’s, Insurance Companies and Patients.